Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Case report: A rare cause of intestinal perforation in a third-trimester pregnant woman

Background

An acute abdomen is a medical emergency that requires early diagnosis and treatment. In pregnancy, this process is significantly more challenging, and radiological findings are sometimes unclear due to the enlarged uterus displacing other structures. Moreover, endometriosis-related complications are rare, and the disease is often undiagnosed.

Case presentation

We report a case of acute perforation of the cecum and appendix during pregnancy (35 weeks of gestation) caused by a previously unknown, deep infiltrating endometriosis with focal ulceration of the affected bowel wall, which sonographically seemed to be acute appendicitis.

Conclusion

Despite the relatively low risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).

Multidisciplinary surgical management of severe posterior compartment endometriosis

BACKGROUND

Endometriosis is a chronic, inflammatory, and hormone-dependent disease that affects approximately 10% of women in reproductive age. Endometriosis is categorized into different types, as superficial, deep, and ovarian endometriosis. When deep endometriosis occurs, the sigmoid and rectum are often affected (Becker et al. in Hum Reprod Open, 2022, https://doi.org/10.1093/hropen/hoac009 ). In the following article, we aim to demonstrate stepwise surgery for stage IV endometriosis involving the anterior rectosigmoid.

METHODS

We present the case of a 26-year-old obese (BMI 35.87) woman with severe posterior pelvic compartment endometriosis, persistent abdominal pain, and constipation. On preoperative MRI of the pelvis, a 13 cm conglomerate incorporating both ovaries (kissing ovaries), uterine serosa, and the anterior rectosigmoid was observed (Fig. 1). Accordingly, interdisciplinary laparoscopic surgery with a gynecologist and colorectal surgeon was planned.

RESULTS

The total laparoscopic approach is demonstrated step by step in the video.

CONCLUSIONS

Deep endometriosis is a rare condition. When involvement of other organs (e.g., the bowel) is suspected, preoperative endometriosis-specific imaging should be performed for optimal surgical planning. Experienced endometriosis multidisciplinary surgical teams can provide specialized and high-quality care for patients suffering from this debilitating disease (Luna Russo et al. in Minerva Ginecol, 2020, https://doi.org/10.23736/S0026-4784.20.04544-X ).

Exploring the feasibility of indocyanine green fluorescence for intraoperative ureteral visualisation in robotic transvaginal natural orifice transluminal endoscopy surgery during endometriosis resection

BACKGROUND

To assess the feasibility of use of indocyanine green (ICG) in identifying and minimising urinary tract injury during surgical resection of endometriosis through robotic transvaginal natural orifice transluminal endoscopy surgery (RvNOTES).

METHODS

We conducted a retrospective case series in two academic tertiary care hospitals. We examined 53 patients who underwent RvNOTES hysterectomy with planned endometriosis resection.

RESULTS

The study involved 53 patients undergoing RvNOTES with ICG fluorescence for endometriosis resection. Mean patient age was 37.98 ± 6.65 years. Operative time averaged 181.32 ± 53.94 min, with estimated blood loss at 45.57 ± 33.62 mL. Postoperative stay averaged 0.23 ± 0.47 days. No ICG-related complications occurred.

CONCLUSION

No complications occurred with ICG fluorescence in RvNOTES. It appears to be a safe option for ureteral localisation and preservation. ICG fluorescence is widely used in diverse medical specialities for identifying ureters during complex surgeries. Larger studies are needed to firmly establish its advantages in intraoperative ureteral visualisation during RvNOTES for deep infiltrative endometriosis.

Abdominal Wall Endometriosis: Early Diagnosis of a Rare Iatrogenic Complication Following Cesarean Section

Abdominal wall endometriosis is a rare form of extrapelvic endometriosis, frequently diagnosed with delay in most cases. It is typically iatrogenic and primarily associated with procedures such as cesarean sections or other gynecological surgeries. In our patient, endometriosis at the laparotomy scar was diagnosed relatively early, approximately two months after the onset of symptoms, which manifested 10 months after the last cesarean section. The patient, who had an obstetric history of three cesarean sections, presented at the Gynecology outpatient clinic of the General Hospital of Trikala, complaining of pain associated with menstruation located in the lower abdomen, near the surgical scar. Based on clinical and imaging findings, abdominal wall endometriosis was suspected, leading to a decision for wide excision of the endometriotic lesion. Histological examination of the surgical specimen confirmed the diagnosis. The postoperative course was uneventful, and three months after the surgery, the patient reported complete resolution of symptoms. This case report emphasizes the importance of integrating advanced diagnostic methods alongside classic clinical findings for the accurate diagnosis of abdominal wall endometriosis. It also highlights the contribution of surgical treatment through wide excision of the endometriotic lesion, in facilitating early diagnosis, achieving cure, and minimizing the risk of disease recurrence in the future.

Role of ultrasonography in the diagnosis of endometriosis in infertile women: Ovarian endometrioma, deep endometriosis, and superficial endometriosis

Endometriosis is a complex chronic inflammatory process characterised by the presence of endometrial-like glandular tissue outside the uterine cavity, typically within the pelvic structures. This condition affects up to 10-15 % of women and those assigned female at birth, and can result in chronic pelvic pain and in/subfertility. Treatment goals include medical, surgical options and alternative therapies. Transvaginal ultrasound (TVUS) is the currently recommended first line investigation for endometriosis with magnetic resonance imaging (MRI) reserved for those with equivocal ultrasound findings. In this paper, we aim to outline the commonly seen sonographic appearances of endometriosis divided into anterior, middle and posterior pelvic compartments. Limitations to ultrasound imaging include high operator dependence and patient factors. New imaging techniques and research into the utility of artificial intelligence (AI) into the detection of endometriosis is currently underway, with possibility of reduced diagnostic delay and better patient outcomes.

Extrapelvic Endometriosis Mimicking Peritoneal Surface Malignancy: Case Report and a Review of Literature

Extrapelvic endometriosis is a rare presentation of endometriosis with atypical clinical symptoms. It can mimic peritoneal surface malignancy, as well as some abdominal infectious diseases. A 29-year-old Moroccan woman presented with abdominal pain, progressive abdominal distention, and an intermittent inflammatory syndrome. Imaging revealed multiple, progressively growing abdominal cysts. She had elevated tumor markers CA125 and CA19.9. Despite thorough investigation, several differential diagnoses persisted for a long time. Definitive pathological diagnosis could only be established after debulking surgery. Literature review on malignant and benign conditions causing multicystic abdominal distention is provided. When definitive diagnosis is not established, but suspicion for peritoneal malignancy remains, a debulking procedure can be undertaken. Organ preservation can be pursued whenever benign disease is still considered. In case of malignancy, short-term (curative) debulking procedure with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed.

Appendiceal Endometriosis Presenting As Chronic Appendicitis: A Case Report

The origin of endometriosis has multiple theories, with controversy over which may demonstrate the prominent pathophysiology. The most common extra-pelvic organ system affected by endometriosis is the gastrointestinal tract. Gastrointestinal endometriosis (GE) accounts for 3 to 37% of all endometriosis cases, and appendiceal endometriosis is present in around 3% of GE cases, therefore constituting less than 1% of all endometriosis cases. In this report, we present a 24-year-old female with a past medical history significant for endometriosis status post two excisional laparoscopies who presented with eight months' duration of right lower quadrant pain, constant and stabbing, with rebound tenderness. Appendectomy and histopathology demonstrated focal endometriosis, diffuse serosal fibrovascular adhesions involving the appendiceal serosa/subserosa, as well as a dilated lumen filled with hemorrhagic content. When the appendix is not considered in endometriosis pathology, patients are at increased risk for unresolved pain and further laparoscopic procedures. Prophylactic appendectomy appears to be a worthwhile consideration in patients with chronic pelvic pain, given the high frequency of appendiceal pathology.

Aberrant epigenetic regulation of estrogen and progesterone signaling at the level of endometrial/endometriotic tissue in the pathomechanism of endometriosis

Endometriosis is a term referring to a condition whereby the endometrial tissue is found outside the uterine cavity. This progressive and debilitating condition affects up to 15% of women of reproductive age. Due to the fact that endometriosis cells may express estrogen receptors (ERα, Erβ, GPER) and progesterone (P4) receptors (PR-A, PR-B), their growth, cyclic proliferation, and breakdown are similar to the processes occurring in the endometrium. The underlying etiology and pathogenesis of endometriosis are still not fully explained. The retrograde transport of viable menstrual endometrial cells with the retained ability to attach within the pelvic cavity, proliferate, differentiate and invade into the surrounding tissue explains the most widely accepted implantation theory. Endometrial stromal cells (EnSCs) with clonogenic potential constitute the most abundant population of cells within endometrium that resemble the properties of mesenchymal stem cells (MSCs). Accordingly, formation of the endometriotic foci in endometriosis may be due to a kind of EnSCs dysfunction. Increasing evidence indicates the underestimated role of epigenetic mechanisms in the pathogenesis of endometriosis. Hormone-mediated epigenetic modifications of the genome in EnSCs or even MSCs were attributed an important role in the etiopathogenesis of endometriosis. The roles of excess estrogen exposure and P4 resistance were also found to be crucial in the development of epigenetic homeostasis failure. Therefore, the aim of this review was to consolidate the current knowledge regarding the epigenetic background of EnSCs and MSCs and the changed properties due to estrogen/P4 imbalances in the context of the etiopathogenesis of endometriosis.

Therapeutic effects of melatonin on endometriosis, targeting molecular pathways: Current knowledge and future perspective

Endometriosis, the very serious disease in women creates a huge financial burden worldwide, which is comparable to diabetes mellitus. In addition to the typical pelvic pain, endometriosis is related to low life quality and decreased work efficiency; clinical consequences include mood complaints, metabolic impairments, inflammation, immunologic problems, and elevated malignancy risks. Several risk factors are correlated with endometriosis including elevated oxidative and nitrosative stress, long-lasting inflammation, raised immune tolerance, as well as autoimmunity. Melatonin is a natural molecule present throughout both the plant and animal kingdoms. It has numerous functions as an antioxidant and anti-inflammatory agent. Due to the anti-proliferative, antioxidant, anti-inflammatory, and anti-invasive features of melatonin, it performances as a beneficial agent to limit endometriosis; this involves several pathways including antiestrogenic, antioxidant, anti-inflammatory, and anti-apoptosis effects, as well as reducing the growth of E2-induced endometriotic tissue. Moreover, melatonin can favor sleep quality and decrease the unwanted signs in the patients. However, most of the data on melatonin accured from experimental works and additional clinical trials are needed. This review summarizes what is currently known regarding the influence of melatonin on endometriosis. AVAILABILITY OF DATA AND MATERIAL: Not applicable.

Prevalence of urinary dysfunction after minimally invasive surgery for deep rectosigmoid endometriosis

PURPOSE

This study aimed to assess the prevalence and progression of lower urinary tract symptoms following laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid and identify preoperative factors associated with worse postoperative outcomes.

METHODS

Prospective, observational study.

SETTINGS

single-center, referral hospital for endometriosis. Patients undergoing laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid colon between October 2016 and October 2018.

MAIN OUTCOME MEASURES

urinary function was assessed with the validated Portuguese language version of the International Prostate Symptom Score, which is also used in women. The score was collected before and after surgery. The Wilcoxon signed-rank test was used to compare pre and postoperative scores and the chi-square test compared symptoms categorized by severity.

RESULTS

Fifty-three patients were assessed and 44 were included. Concerning urinary symptoms after surgery, the irritative symptoms prevailed over the obstructive ones. Additionally, 58.8% and 54.5% of the women reported moderate or severe symptoms at pre and postoperative, respectively. In at least one questionnaire category, the postoperative questionnaire scores increased in ten (22.7%) participants. A statistically significant difference was found comparing the changes from absent/mild to moderate/severe IPSS categories (P = 0.039). No significant changes were identified in any of the International Prostate Symptom Score pre and postoperatively (P = 0.876).

CONCLUSIONS

There was a high prevalence of pre and postoperative urinary symptoms. Patients with preoperative moderate/severe International Prostate Symptom Score are at risk of persisting urinary dysfunction after surgery for rectosigmoid deep endometriosis.

Paraurethral Endometriosis as a Common Pathology in an Uncommon Location: A Case Report and a Review of the Literature

Paraurethral endometriosis is an extremely rare condition. To the best of our knowledge, only seven cases with details on variable risk factors have been reported in the English literature. Herein, we present the case of a third nulliparous patient described in the literature at the time of diagnosis. A 30-year-old woman presented with mild urinary symptoms. A well-defined 2.3 cm paraurethral cystic lesion was found on clinical examination, and MRI findings were suggestive of hemorrhagic content, with no evidence of pelvic endometriosis. Complete surgical excision was performed, and the patient's symptoms improved. The patient experienced no recurrence for 10 months postoperatively. The histopathological findings were suggestive of endometriosis. These findings might indicate that embryonic remnants are possible causes of the pathogenesis of paraurethral endometriosis.

Nieuwenhuizen K, Bronsgeest K, Rhemrev J, Smeets M, English J, Jansen F, Both S, Twijnstra A. Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Deep endometriosis classification in relation to pain

Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation. Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score. Materials and Methods: A prospective multi-centre study was conducted with data from university and non-university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (www.equsum.org). Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected. Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01). Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients. What’s new? Dyschezia might have a predictive value in detecting ureteric involvement.

Epigenetic regulation and T-cell responses in endometriosis – something other than autoimmunity

Endometriosis is defined as the presence of endometrial-like glands and stroma located outside the uterine cavity. This common, estrogen dependent, inflammatory condition affects up to 15% of reproductive-aged women and is a well-recognized cause of chronic pelvic pain and infertility. Despite the still unknown etiology of endometriosis, much evidence suggests the participation of epigenetic mechanisms in the disease etiopathogenesis. The main rationale is based on the fact that heritable phenotype changes that do not involve alterations in the DNA sequence are common triggers for hormonal, immunological, and inflammatory disorders, which play a key role in the formation of endometriotic foci. Epigenetic mechanisms regulating T-cell responses, including DNA methylation and posttranslational histone modifications, deserve attention because tissue-resident T lymphocytes work in concert with organ structural cells to generate appropriate immune responses and are functionally shaped by organ-specific environmental conditions. Thus, a failure to precisely regulate immune cell transcription may result in compromised immunological integrity of the organ with an increased risk of inflammatory disorders. The coexistence of endometriosis and autoimmunity is a well-known occurrence. Recent research results indicate regulatory T-cell (Treg) alterations in endometriosis, and an increased number of highly active Tregs and macrophages have been found in peritoneal fluid from women with endometriosis. Elimination of the regulatory function of T cells and an imbalance between T helper cells of the Th1 and Th2 types have been reported in the endometria of women with endometriosis-associated infertility. This review aims to present the state of the art in recognition epigenetic reprogramming of T cells as the key factor in the pathophysiology of endometriosis in the context of T-cell-related autoimmunity. The new potential therapeutic approaches based on epigenetic modulation and/or adoptive transfer of T cells will also be outlined.

Peritoneal Pathology Review: Mullerian, Mucinous and Mesothelial Lesions

This review provides an overview of the pathology of selected benign and malignant lesions of the female peritoneum and their often-encountered differential diagnoses. It includes endometriosis and its related lesions, endosalpingiosis, pseudomyxoma peritonei (PMP) and related ovarian/appendiceal pathology, and malignant and benign mesothelial tumors. The current terminology associated with PMP is also discussed.

Extragenital Endometriosis in the Differential Diagnosis of Non- Gynecological Diseases

BACKGROUND

Endometriosis is a chronic, benign disease that affects approximately 10% of women of childbearing age. Its characteristic clinical features are dysmenorrhea, dyschezia, dysuria, dyspareunia, and infertility. The manifestations of extragenital endometriosis (EE) are a diagnostic challenge, as this disease can mimic other diseases due to its unusual location with infiltration of various organs and corresponding symptoms.

METHODS

This review is based on publications retrieved by a selective search of the literature on the commonest extragenital sites of endometriosis, including the relevant current guideline.

RESULTS

Current evidence on the treatment of extragenital endometriosis consists largely of cohort studies and cross-sectional studies. The treatment is either surgical and/or conservative (e.g., hormonal therapy). Gastrointestinal endometriosis is the most common form of EE, affecting the rectum and sigmoid colon in nearly 90% of cases and typically presenting with dyschezia. Urogenital endometriosis is the second most common form of EE. It affects the bladder in more than 85% of cases and may present with dysuria, hematuria, or irritable bladder syndrome. The diaphragm is the most common site of thoracic endometri - osis, potentially presenting with period-associated shoulder pain or catamenial pneumothorax. Endometriosis affecting a nerve often presents with sciatica. In abdominal wall endometriosis, painful nodules arise in scars from prior abdominal surgery.

CONCLUSION

There is, as yet, no causally directed treatment for chronic endometriosis. The treatment is decided upon individually in discussion with the patient, in consideration of risk factors and after assessment of the benefits and risks. Timely diagnosis is essential.

[S2k guidelines for the diagnosis and treatment of endometriosis-Recommendations for pathology]

Die vorliegende Übersicht fasst die relevanten Aspekte der S2k-Leitlinie Endometriose zusammen. Die Empfehlungen umfassen die Aufarbeitung und Befunderhebung bei Biopsien und Resektaten, die bei der klinischen Diagnose einer Endometriose entnommen wurden. Die Leitlinie berücksichtigt neben praktischen Aspekten der Pathologie ebenso die klinischen Notwendigkeiten an die Histopathologie für eine optimale Diagnostik und Therapie der Patientinnen.

Basierend auf der in der pathologischen Literatur gebräuchlichsten Definition der Endometriose des Corpus uteri (Adenomyosis uteri) wurde diese in der Leitlinie definiert als der Nachweis des Endometrioseherdes im Myometrium in einem Abstand zur endomyometranen Grenze von einem mittelgroßen Gesichtsfeld (100fache Vergrößerung), was metrisch rund 2,5 mm entspricht. Bei Darmresektaten soll zum Status der Resektionsränder Stellung genommen werden.

Ebenso definiert werden Anforderungen im Kontext endometrioseassoziierter Karzinome (z. B. Hormonrezeptorbestimmungen, immunhistochemische Untersuchung auf Ausfall der DNA-Mismatch-Reparaturproteine).

Rectal endometriosis presenting as toxic megacolon

Background

The bowel is the most common site of extragenital endometriosis, with involvement of the locoregional sigmoid colon and anterior rectum seen most often. The clinical presentation varies depending on how soon patients seek medical care, thus requiring changes in management strategies. Endometriosis can cause a life-threatening surgical emergency with progressive obliteration of the bowel lumen leading to obstruction and late complications including toxic megacolon and transmural necrosis.

Case presentation

We report the case of a 41-year-old woman presenting with an acute abdomen and complete large bowel obstruction complicated by sepsis and toxic megacolon. The patient underwent emergency total colectomy with ileostomy. Medical history was significant for chronic, vague, and episodic lower abdominal pain self-medicated with herbal tea and laxatives. Pathologic examination demonstrated colonic endometriosis within the bowel wall as the cause of obstruction, ischemia, and transmural necrosis.

Conclusions

Although a rare clinical entity, this case highlights two important points. First, it demonstrates the value of performing proper and complete clinical work up to rule out or in all possible causes of colonic obstruction, including intestinal endometriosis. Second, it suggests a potential benefit of a formalized multidisciplinary approach, including surgery, in the management of medically unresponsive endometriosis. In conclusion, this case shows that endometriosis can cause life-threatening colonic obstruction in women of childbearing age. Prompt early intervention is warranted, particularly when obstruction is only partial and ischemia has not supervened, to conceivably prevent the development of a toxic megacolon requiring colectomy and avoid late complications.

Isolated Bladder Endometriosis in a Patient With Previous Cesarean Sections

Urological endometriosis is rare and accounts for approximately 1% of women with endometriosis. The pathophysiology of bladder endometriosis may be divided into two different causes, namely primary and secondary. The primary form occurs spontaneously and manifests in a form of a generalized pelvic disease whereas the secondary form is thought to be iatrogenic and typically occurs after pelvic surgery such as Cesarean section or hysterectomy. We present a case report on a patient presenting with an invasive bladder mass initially thought to be from a pelvic malignancy. The final histology showed isolated bladder endometriosis. She had a significant past medical history of two previous Cesarean sections. A review of her magnetic resonance imaging (MRI) images demonstrated the presence of a Cesarean scar niche which may be linked to her bladder endometriosis. There is a need to improve awareness of the possible link between Cesarean scar niche with bladder endometriosis. This is important as it raises the clinical question of whether appropriate repair of Cesarean scar niches can prevent future complications such as bladder endometriosis which can potentially be associated with significant morbidity.

Estrogen- and Progesterone (P4)-Mediated Epigenetic Modifications of Endometrial Stromal Cells (EnSCs) and/or Mesenchymal Stem/Stromal Cells (MSCs) in the Etiopathogenesis of Endometriosis

Endometriosis is a common chronic inflammatory condition in which endometrial tissue appears outside the uterine cavity. Because ectopic endometriosis cells express both estrogen and progesterone (P4) receptors, they grow and undergo cyclic proliferation and breakdown similar to the endometrium. This debilitating gynecological disease affects up to 15% of reproductive aged women. Despite many years of research, the etiopathogenesis of endometrial lesions remains unclear. Retrograde transport of the viable menstrual endometrial cells with retained ability for attachment within the pelvic cavity, proliferation, differentiation and subsequent invasion into the surrounding tissue constitutes the rationale for widely accepted implantation theory. Accordingly, the most abundant cells in the endometrium are endometrial stromal cells (EnSCs). These cells constitute a particular population with clonogenic activity that resembles properties of mesenchymal stem/stromal cells (MSCs). Thus, a significant role of stem cell-based dysfunction in formation of the initial endometrial lesions is suspected. There is increasing evidence that the role of epigenetic mechanisms and processes in endometriosis have been underestimated. The importance of excess estrogen exposure and P4 resistance in epigenetic homeostasis failure in the endometrial/endometriotic tissue are crucial. Epigenetic alterations regarding transcription factors of estrogen and P4 signaling pathways in MSCs are robust in endometriotic tissue. Thus, perspectives for the future may include MSCs and EnSCs as the targets of epigenetic therapies in the prevention and treatment of endometriosis. Here, we reviewed the current known changes in the epigenetic background of EnSCs and MSCs due to estrogen/P4 imbalances in the context of etiopathogenesis of endometriosis. Graphical Abstract.

An Unusual Cause of Large Bowel Obstruction in a Patient With Ulcerative Colitis

Endometriosis is a rare cause of large bowel obstruction and has been infrequently reported in patients with inflammatory bowel disease. We present an unusual case of a young woman with ulcerative colitis, who presented with a large bowel obstruction with colonic stricture and peripancreatic mass concerning for malignancy. The evaluation revealed endometriosis, and her large bowel obstruction was successfully managed with leuprolide and colonic stenting.

Two Cases of Endometriosis in the Cecum Detected by Contrast-enhanced Computed Tomography with Air/Carbon Dioxide Insufflation

We herein report two patients with endometriosis in the cecum. Both patients presented with a protruding, subepithelial tumor on colonoscopy and were diagnosed with cecal endometriosis after surgical resection. It is notable that the cecal lesions were not initially identified on computed tomography (CT), while CT colonography with air/carbon dioxide insufflation resulted in the detection of the cecal tumor. These cases highlight the possibility of false-negative results on conventional CT in patients with cecal endometriosis. We consider CT colonography with air/carbon dioxide insufflation useful for detecting cecal tumors in such cases.

The Importance of a Multi-Disciplinary Approach to the Endometriotic Patients: The Relationship between Endometriosis and Psychic Vulnerability

Endometriosis is a chronic inflammatory condition, which is distinguished by the presence of the endometrial-like glands and stroma outside the uterine cavity. Pain and infertility are the most commonly expressed symptoms, occurring in 60% and 40% of cases, respectively. Women with endometriosis, especially those with pelvic pain, also have a greater vulnerability to several psychiatric disorders. There is, in particular, a tendency to contract affective or anxiety disorders as well as panic-agoraphobic and substance use disorders. Endometriosis with pelvic pain, infertility and psychic vulnerability usually leads to disability and a markedly lower quality of life for women of reproductive age. Thus, the burden of endometriosis is not limited to the symptoms and dysfunctions of the disease; it extends to the social, working and emotional spheres, leading to a severe impairment of global functioning. An analysis of scientific literature revealed a close relationship between specific temperamental traits, the expression of several psychiatric symptoms, chronicity of pain, risk of substance use and lower probability of a positive outcome. Endometriosis symptoms and the impact of related psychological consequences, increased vulnerability and the possible onset of psychiatric symptoms may influence coping strategies and weaken resilience, so triggering a vicious cycle leading to a marked deterioration in the quality of life. A multidisciplinary approach consisting of a medical team composed of gynecologists, psychologists, psychiatrists, experts in Dual Disorder, algologists and sexologists, would guarantee the setting of a target and taking the best decision on a personalized treatment plan. That approach would allow the prompt detection of any psychopathological symptoms and improve the endometriosis-related physical symptoms, bringing a healthier quality of life and a greater likelihood of a positive outcome.

Small Bowel Obstruction Caused by Ileal Endometriosis with Appendiceal and Lymph Node Involvement Treated with Single-Incision Laparoscopic Surgery: A Case Report and Review of the Literature

Patient: Female, 40-year-old

Final Diagnosis: Intestinal endometriosis

Symptoms: Abdominal pain

Medication:—

Clinical Procedure: —

Specialty: Surgery

Incidental appendiceal mass as the only manifestation of endometriosis

Appendiceal endometriosis is a rare condition that remains difficult to diagnose preoperatively. Herein, we present a case of appendiceal endometriosis presenting as a neuroendocrine tumor. A 34-year-old Caucasian woman was found to have an appendiceal mass with a small fluid collection on routine transvaginal ultrasound. The patient denied any symptoms. Features were consistent with those of a neuroendocrine tumour of the appendix. Laparoscopic appendectomy followed by histopathology revealed endometriosis with negative cytology for malignant cells. Preoperative characteristics of appendiceal tumours in women of childbearing age should be further investigated. Establishing clinical and surgical guidelines is the key to avoid invasive procedures and related adverse outcomes.

Reflex anuria causing acute kidney injury following myomectomy: A case report

Reflex anuria is a rare cause of acute renal failure, which may occur following ureteric manipulation or painful stimuli to adjacent organs during pelvic surgery. This condition, relatively unfamiliar to the general gynecologist, should be considered even when no obvious cause of anatomical obstruction is found. We present a case of reflex anuria in a 28-year-old woman for two large intramural fibroids. Evaluation did not reveal any organic obstruction of the urinary tract. Bilateral ureteric stenting and other supportive measures resulted in diuresis and improvement of renal function. Stents were removed after 10 days and patient was discharged on the 15th postoperative day with normal renal parameters. Intrarenal arteriolar spasm or ureteric spasm following pelvic manipulation can cause reflex anuria and should be considered in the differential diagnosis of acute renal failure in cases following pelvic surgery.

Diagnosis, surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment. Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion. A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively. Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.

Ileal obstruction caused by transmural endometriosis in a patient with simultaneous C. difficile colitis and Influenza AH1N1. Case report

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Bowel obstruction or intestinal occlusion caused by endometriosis is very rare.

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Endometriotic nodules induce luminal stenosis and ileal obstruction.

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Transmural endometriosis infiltrates the four layers of the intestinal wall.

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Diagnosis is established through pathological and immunohistochemical analysis.

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The treatment of choice is bowel resection via laparoscopy or laparotomy.

Introduction

Small bowel obstruction secondary to endometriosis is extremely rare. This etiology is reported in 0.10% of cases and diagnosed incidentally.

Case presentation

32-year old female, critically ill patient was diagnosed with small bowel obstruction. After medical stabilization of multiple comorbidities, diagnostic laparoscopy was done and converted to open right ileocolectomy with ileo-transverse anastomosis. Definite diagnosis was ileal obstruction caused by transmural endometriosis. The patient's recovery was uneventful. At one-year follow-up, she remains asymptomatic.

Discussion

We present the uncommon case of ileal obstruction due to transmural endometriosis that was treated surgically. We also present current literature review focusing on diagnostic and treatment methods of this rare disease.

Conclusion

Endometriosis should be included in the differential diagnosis of small bowel obstruction. The treatment of choice is bowel resection.

Endometriosis Associated Infertility: A Critical Review and Analysis on Etiopathogenesis and Therapeutic Approaches

Endometriosis represents a frequently diagnosed gynecological affliction in the reproductive timespan of women, defined by symptoms ranging from pelvic pain to infertility. A complex interplay between the genetic profile, hormonal activity, menstrual cyclicity, inflammation status, and immunological factors define the phenotypic presentation of endometriosis. To date, imaging techniques represent the gold standard in diagnosing endometriosis, of which transvaginal ultrasonography and magnetic resonance imaging bring the most value to the diagnostic step. Current medical treatment options for endometriosis-associated infertility focus on either stimulating the follicular development and ovulation or on inhibiting the growth and development of endometriotic lesions. Techniques of assisted reproduction consisting of superovulation with in vitro fertilization or intrauterine insemination represent effective treatment alternatives that improve fertility in patients suffering from endometriosis. Emerging therapies such as the usage of antioxidant molecules and stem cells still need future research to prove the therapeutic efficacy in this pathology.

One-stage, radical laparoscopic endometriosis excision involving three different organ systems: A case report from tertiary referral center

Introduction:

We present a case of an extensive endometriosis involving left paracolpium and left parametrium, rectovaginal septum, urinary bladder, left interiliac region between artery and vein, left ureter and rectum, presenting as dysmenorrhoea, alternating bouts of diarrhea and constipation and hydronephrosis.

Methods:

Laparoscopic surgery made by a multidisciplinary team consist of gynecologic, abdominal surgeon and urologist.

Results:

Successfully managed deep infiltrated endometriosis.

Conclusion:

The aim of this report is to demonstrate benefit of one-stage, minimally invasive radical surgical procedure performed in a tertiary referral center. To the best of our knowledge, this report presents an extremely complex case because we successfully managed deep infiltrating endometriosis in three different organ systems at the same time, using minimally invasive nerve-sparing technique. A case with the same constellation has not been published yet since reported cases of extrapelvic endometriosis chiefly address one organ system involvement.

Benign Mimickers of Urinary Bladder Cancer: a Case Series

Bladder cancer is one of the leading malignancies in the world associated with significant morbidity and mortality. However, several benign lesions of the bladder can mimic urothelial carcinoma clinically and radiologically owing to overlapping signs and symptoms. Thus, rendering a correct diagnosis is imperative as it will have a significant impact on the management of patients. We present an amalgamation of five cases having a high suspicion of urothelial malignancy, which were subsequently diagnosed as benign entities with better prognosis and thus warranted a different therapeutic approach.

Endometriosis of the Paralumbar Muscles: A Case Report and Literature Review

The objective of this study is to report a case of deep endometriosis of the paralumbar muscles (psoas, multifidus, and erector spinae) and review existing literature on its management. A 34-year-old female with a history of endometriosis was seen for infertility. Paralumbar muscle masses seen on computed tomography (CT) scan were sampled, confirming endometriosis. Gonadotropin-releasing hormone agonist was given for 2 months. The patient was primed for assisted reproduction. A literature review was conducted to provide an understanding of paralumbar muscle endometriosis. To our knowledge, this is the first reported case of multifidus and erector spinae muscle endometriosis and fifth case of psoas muscle endometriosis. Because the available information is scarce, data from the existing literature on deep endometriosis may aid in the diagnosis and management. Magnetic resonance imaging and CT scan are essential imaging techniques to map lesions. Excision seems prudent, but the approach should be individualized depending on the patient's presentation and her preferences.

Non-neoplastic conditions mimicking peritoneal carcinomatosis at CT imaging

The general appearance of peritoneal carcinomatosis at abdominal CT and other cross-sectional imaging modalities consists of varying amounts of peritoneal-based soft tissue implants (mass-forming or infiltrative), peritoneal fluid, and occasionally calcification. However, a wide variety of common and uncommon neoplastic and non-neoplastic conditions can closely mimic peritoneal carcinomatosis at imaging. Neoplastic mimics of peritoneal carcinomatosis include primary peritoneal and sub peritoneal tumors, as well as peritoneal lymphomatosis and sarcomatosis.Broad categories of non-neoplastic mimics of peritoneal carcinomatosis include tumor-like conditions, systemic processes, atypical infections, and fat-based conditions. For many entities, suggestive or specific patient information and/or CT imaging findings exist that may allow the radiologist to narrow the differential diagnosis. In this article, we review the salient clinical and cross-sectional imaging features of non-neoplastic mimics of peritoneal carcinomatosis and malignancy, with emphasis on the CT findings and the additional clues that may suggest the correct benign diagnosis.

Genitourinary manifestations of endometriosis with emphasis on the urinary tract

Endometriosis is a common benign condition affecting women. The disease has a broad spectrum of presentations from incidental lesions in asymptomatic women to causing significant and debilitating morbidity in others. Ectopic endometrial glands are located in predictable locations throughout the pelvis, including implantation on the ovaries and in the rectouterine cul-de-sac. Less commonly, the urinary tract may be involved. As genitourinary manifestations may remain symptomatically occult or masquerade as other diagnoses, it is essential for the radiologist to be aware of the imaging features, consider this diagnosis, and potentially save the patient from delayed treatment.

Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Clinical management of endometriosis

Endometriosis is a disease of reproductive age women that is commonly characterized by symptoms that often negatively impact quality of life. The clinical management of endometriosis remains highly variable and mostly influenced by geographic location, practice patterns, and breadth of clinician experience. This variability in treatment has inspired a trend towards multidisciplinary and specialized care of patients suffering from this disease. Surgical sampling, followed by histologic confirmation of endometrial-like tissue, remains the standard for the definitive diagnosis of endometriosis. However, the high sensitivity and specificity of MRI and ultrasound has shed light on the path towards non-surgical diagnosis of deep infiltrating endometriosis. Molecular variability and intricacy of this disease has limited the development of biologic markers to target for non-invasive diagnosis and pharmacologic therapies. Surgical management of advanced-stage endometriosis can be difficult, mostly secondary to the invasive nature of the disease, and anatomical distortion requiring advanced surgical skills to manage. The high prevalence of chronic pelvic pain and other complex pain syndromes in patients with endometriosis also requires knowledge in the management of these types of issues in order to provide comprehensive care. Menopausal endometriosis, extrapelvic presentation, and potential malignant transformation of lesions are infrequent, requiring a high index of suspicion for timely diagnosis and treatment.

Endometriosis-It is not just benign

Endometriosis is a common disease, not uncommonly debilitating with severe negative impact on all domains of life for women. The long-standing approach is that endometriosis is one of many gynecological benign conditions. Nevertheless, there is a growing body of evidence linking endometriosis and invasiveness. The aim of this commentary is to address the topic of the attitude toward endometriosis as a benign disease while summarizing the current literature regarding the debate that surrounds this topic.

Endometriosis in Menopause-Renewed Attention on a Controversial Disease

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

Endometriosis of the duplex appendix: A case report and review of the literature

BACKGROUND

Duplication of the appendix is an infrequent congenital malformation with a complex classification. The horseshoe appendix is a subtype of the duplex appendix and is rarely reported in the literature. Endometriosis is a common gynecological disease that rarely occurs in the appendix. Moreover, horseshoe appendix combined with endometriosis has not been previously reported.

CASE SUMMARY

Here, we describe a 44-year-old woman who was admitted with a 1-d history of migratory lower right quadrant pain. Physical examination was consistent with the signs of acute appendicitis. The patient underwent an emergency exploratory laparotomy. The distal tip of the appendix was in contact with the cecum by another base, or "horseshoe appendix". In addition, a small intestinal mass and an ovarian mass were identified. Subsequently, appendectomy, partial resection of the small intestine, and right oophorectomy were successively performed. The histopathology confirmed the diagnosis of acute inflammation of the duplex appendix with endometriosis, small intestine endometriosis, and ovarian endometriosis.

CONCLUSION

Surgeons need to be aware of the possibility of the duplex appendix when performing an appendectomy, and this study emphasizes the importance of exploring the entire abdomen.

Endometrioma of the Liver: A Case Report and Review of the Literature

Hepatic endometriosis is a rare form of endometriosis first described by Finkel in 1986. A thorough review of the literature revealed 28 cases of hepatic endometriosis. This unusual condition offers several diagnostic challenges due to its variable appearance on imaging and need for histologic analysis to establish a definitive diagnosis. We present a 42-year-old female initially treated for presumed hydatid cyst that was later found to be endometriosis in the liver. The case highlights the importance of considering endometriosis in the differential for a patient presenting with a solitary liver mass regardless of age and previous history of endometriosis.

Appendiceal endometriosis invading the sigmoid colon: a rare entity

PURPOSE

We report an unusual case of endometriosis of the appendix with simultaneous invasion of the sigmoid colon.

METHODS

Clinical, radiological, surgical, and histological data of the patient were reviewed, as well as the current literature on gastrointestinal endometriosis.

RESULTS

A 41-year-old woman presented to the emergency department of our hospital with acute right lower quadrant pain, pronounced tenderness elevated white blood cell count, and increased C-reactive protein. Abdominal CT scan suggested a mucocele of the appendix. The patient was first treated with antibiotics, followed by en bloc resection of the appendix and of the sigmoid colon 2 months later. Histological examination revealed an endometriotic nodule of the appendix filling the appendiceal lumen and resulting in a mucocele which invaded the sigmoid colon wall.

CONCLUSIONS

The diagnosis of gastrointestinal endometriosis can be challenging due to the variety of symptoms it can produce. Although extremely rare, a concomitant double gastrointestinal location of endometriosis may be possible and should be considered in women of reproductive age.