Endometriosis of the large bowel: a report of 11 cases

Colorectal endometriosis - a challenging, often overlooked cause of colorectal pathology: a clinicopathological review of 114 cases

The colon is the most common site for endometriosis outside the genital tract. It has a varied presentation and can mimic numerous other conditions, both clinically and pathologically. We investigated the clinicopathological features of a series of colorectal endometriosis with a particular emphasis on the features seen in cases with colonic mucosal involvement. A total of 114 consecutive cases of colorectal endometriosis were reviewed. Forty-eight percent did not have a prior diagnosis of endometriosis and in 34 patients (30%) the endometriosis was determined as the cause for the presentation. Mucosal involvement was present in 31 specimens. Features of chronic colitis were seen in the adjacent mucosa in 90% of cases whilst there were glandular changes mimicking adenocarcinoma in two cases (1.8%). Fifty percent of cases with mucosal involvement also showed glands with a hybrid intestinal-endometrial phenotype by morphology and/or by immunohistochemistry. Endometriosis is an important mimic of other conditions.

Sonographer-acquired ultrasound protocol for deep endometriosis

Endovaginal sonographic imaging has been shown to reliably identify pelvic endometriosis, but most United States imaging practices do not adequately assess locations and features of endometriosis beyond ovarian endometrioma. In this article, we propose a protocol for sonographer-acquired images and maneuvers to be interpreted subsequently by sonologists (radiologists or gynecologists). The purpose is to improve the sensitivity of endovaginal sonography for the detection of endometriosis in imaging practices that involve the non-physician sonographer as part of their workflow.

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

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion

Purpose

To evaluate magnetic resonance (MR) imaging morphologic- and signal intensity abnormalities of deep infiltrating endometriosis (DIE) of the bowel wall and to assess its value in predicting depth and extent of bowel wall infiltration.

Materials and methods

This single-center study was performed in a tertiary referral center for endometriosis. All patients (n = 28) who underwent segmental bowel resection (2004–2010) were retrospectively studied. MR images were analyzed by two experienced readers independently (number of lesions, location, size, signal intensity, and depth of bowel wall infiltration) and this was correlated with histopathology.

Results

The sensitivity, specificity, positive and negative predictive values, and accuracy for diagnosis of endometriosis infiltrating the muscular layer of the bowel were 100%, 75%, 96%, 100%, and 96%, respectively. The inter-rater agreement was 0.84. “Fan shaped” configurations with hypointensity on T2- and T1-weighted imaging were characteristic for thickening of indigenous smooth muscle and smooth muscle hyperplasia at histopathology, as a consequence of infiltration by endometriosis. Thickening of the (sub)mucosa corresponded to edema with or without infiltration of endometriosis.

Conclusion

MR imaging at 1.5 Tesla is useful to predict muscular infiltration of the bowel in endometriosis, whereas it is of limited value in diagnosis of (sub)mucosal infiltration.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging

BACKGROUND

The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard.

METHODS

Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology.

RESULTS

Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%.

CONCLUSION

DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

An Unusual Rectosigmoid Mass: Endometrioid Adenocarcinoma Arising in Colonic Endometriosis: Case Report and Literature Review

Malignant transformation is an infrequent complication of endometriosis. The ovary is the primary site in 79 per cent of cases, and extragonadal sites are identified in 21 per cent. Primary involvement of these types of tumors with the colon and/or rectum is a rare clinical entity. Endometrioid carcinoma is a common histologic type that remains a diagnostic challenge–the main differential diagnosis includes colorectal carcinomas. We report a case of malignant transformation arising in colonic endometriosis. The patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy 10 years before she presented with hematochezia. The patient was ultimately treated by surgical resection. Immunohistochemical staining in addition to the usual histopathology was critical for accurate diagnosis of this endometriosis-associated intestinal tumor.

Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis

OBJECTIVE

To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE).

METHODS

This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall.

RESULTS

Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%.

CONCLUSION

The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

Diagnosis and misdiagnosis of inflammatory bowel disease

Several diseases can mimic IBD clinically, but careful and repeated evaluations, if necessary, will dramatically decrease the likelihood of misdiagnosis. A careful consideration of patient's clinical, radiographic, endoscopic, and histopathologic features will establish the correct diagnosis in the majority of cases.

Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation

Endometriosis of the intestinal tract may mimic a number of diseases both clinically and pathologically. The authors evaluated 44 cases of intestinal endometriosis in which endometriosis was the primary pathologic diagnosis, and evaluated them for a variety of gross and histologic changes. Cases with preneoplastic or neoplastic changes were excluded specifically because they were the subject of a previous study. The patients ranged in age from 28 to 56 years (mean age, 44 years), and presenting complaints included abdominal pain (n = 15), an abdominal mass (n = 12), obstruction (n = 8), rectal bleeding (n = 2), infertility (n = 3), diarrhea (n = 2), and increasing urinary frequency (n = 1). The clinical differential diagnoses included diverticulitis, appendicitis, Crohn's disease, tubo-ovarian abscess, irritable bowel syndrome, carcinoma, and lymphoma. Forty-two patients underwent resection of the diseased intestine and two patients underwent endoscopic biopsies. In 13 patients there were predominantly mural masses, which were multiple in two patients (mean size, 2.6 cm). In addition, 11 cases had luminal stenosis or strictures, six had mucosal polyps, four had submucosal masses that ulcerated the mucosa (sometimes simulating carcinoma), three had serosal adhesions, one had deep fissures in the mucosa, and one was associated with appendiceal intussusception. Involvement of the lamina propria or submucosa was identified in 29 cases (66%) and, of these, 19 had features of chronic injury including architectural distortion (n = 19), dense lymphoplasmacytic infiltrates (n = 7), pyloric metaplasia of the ileum (n = 1), and fissures (n = 1). Three cases had features of mucosal prolapse (7%), ischemic changes were seen in four (9%), and segmental acute colitis and ulceration were seen in four and six cases (9% and 13%) respectively. In 14 patients, endometriosis formed irregular congeries of glands involving the intestinal surface epithelium, mimicking adenomatous changes. Mural changes included marked concentric smooth muscle hyperplasia and hypertrophy, neuronal hypertrophy and hyperplasia, and fibrosis of the muscularis propria with serositis. Follow-up of 20 patients (range, 1-30 years; mean, 7.8 years) revealed that only two patients had recurrent symptoms. None of the patients developed inflammatory bowel disease. Endometriosis can involve the intestinal tract extensively, causing a variety of clinical symptoms, and can result in a spectrum of mucosal alterations. Because the endometriotic foci may be inaccessible to endoscopic biopsy or may not be sampled because of their focality, clinicians and pathologists should be aware of the potential of this condition to mimic other intestinal diseases.

Neoplastic and pre-neoplastic changes in gastrointestinal endometriosis: a study of 17 cases

The clinicopathologic features of neoplasms arising in gastrointestinal endometriosis have not been well characterized. In this series, we report 17 cases of gastrointestinal endometriosis complicated by neoplasms (14 cases) or precancerous changes (three cases). Four patients, one of whom also had hypermenorrhea, presented with chronic abdominal pain and five had obstructive symptoms; one of these also had rectal bleeding. One patient presented with an acute abdomen and fecal peritonitis, one had vaginal bleeding, and one had a progressive change in bowel habits. Nine patients had a long history of endometriosis, 11 patients had had hysterectomies, and eight of these had also received unopposed estrogen therapy. The lesions involved the rectum (6), sigmoid (6), colon, unspecified (2), and small intestine (3), and comprised 8 endometrioid adenocarcinomas (EA), 4 mullerian adenosarcomas (MAS), 1 endometrioid stromal sarcoma (ESS), 1 endometrioid adenofibroma of borderline malignancy (EBA) with carcinoma in situ, 2 atypical hyperplasias (AH), and one endometrioid adenocarcinoma in situ (ACIS). The tumors ranged in size from 2 to 15 cm and all involved the serosa and muscularis propria. Two tumors extended into the mucosa, with mucosal ulceration in one. Follow-up was available in 11 cases. One patient with EA was dead of disease at 1 year, one had two recurrences at 1 and 2 years, and three were alive with no evidence of disease (ANED) at 9 months to 13 years (mean, 68 mos). The patient with the EBA was ANED at 3 months. Two patients with MAS were ANED at 2 and 3 years. The patient with ESS had a recurrence at 3 years and was ANED 6 years after her original diagnosis. One woman with AH was ANED at 60 months and the patient with ACIS was ANED at 16 months. One of the carcinomas was originally misdiagnosed as a primary intestinal adenocarcinoma. The pathologist should be aware of the possibility of a tumor of genital tract type when evaluating intestinal neoplasms in females, particularly if they have a history of endometriosis and have received unopposed estrogen therapy.

Extrapelvic endometriosis

This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.

Expression of E-cadherin, alpha- and beta-catenin mRNAs in ovarian endometriosis

To establish the mechanism of development of ovarian endometriosis from the biological function of the adherens junction, we have investigated the expression of E-cadherin, alpha- and beta-catenin mRNAs in ovarian endometriosis in comparison with that in normal uterine endometrium. The expression of E-cadherin, alpha- and beta-catenin mRNAs in ovarian endometriosis was not altered during the menstrual cycle. On the other hand, the expression in normal uterine endometrium significantly was increased at the secretory phase, and was significantly higher than that in ovarian endometriosis. In conclusion, the expression of E-cadherin, alpha- and beta-catenin mRNAs for adherens junction in ovarian endometriosis appeared to be decreased after ovulation, which might, at least in part, contribute to detachment as the first step of development of endometriotic cells.

Mucosal changes in the large bowel with endometriosis: a possible cause of misdiagnosis of colitis?

Endometriotic deposits are not uncommon in the large bowel of women. Because the symptoms produced by endometriosis may lead to investigation by colorectal endoscopic biopsy, the aims of this study were to assess the range of mucosal abnormalities that may occur and to determine whether this could represent a significant potential diagnostic problem. We found mucosal changes in eight of 10 cases of colorectal endometriosis; however, the abnormalities (ulceration, gland architectural disturbance, crypt abscess formation, increased inflammatory cell presence, and smooth muscle fibers between glands in the mucosa) were focal and directly related to endometrial deposits. In one case an abnormal colonic biopsy specimen from a patient with endometriosis supported the erroneous clinical diagnosis of Crohn's disease. Comparing a group of women with endometriosis to a group with adenomyosis of the uterus showed that although more women with endometriosis have endoscopic large bowel biopsies, there was no significant excess of biopsy specimens showing inflammatory changes. Our conclusion is that the endometriosis of the large bowel can masquerade as inflammatory bowel disease or ischemic changes and the possibility should be borne in mind, particularly in cases with atypical clinical features or very focal histological changes.

Aggressive surgical management for advanced colorectal endometriosis

PURPOSE

The aim of this study was to evaluate the results of aggressive surgical management in patients with advanced colorectal endometriosis.

METHODS

The medical records of 130 women who had undergone aggressive surgical management of advanced colorectal endometriosis were reviewed. They were then interviewed a mean of 60 months following surgery and asked to rank relief of their symptoms.

RESULTS

The most common symptoms before surgery were pelvic pain, dyspareunia, rectal pain, change in bowel habit, and cyclic rectal bleeding. Colorectal operations included low anterior resection, sigmoid resection, disc excision of the rectal wall, right colectomy, appendectomy, and small bowel resection. At follow-up symptom relief was high, ranging from 100 percent in cyclic bleeding to 91 percent for rectal pain. Mortality and clinical leakage rates were 0 percent, small bowel obstruction 3 percent, and abscess 1 percent. The crude pregnancy rate following surgery was 49 percent.

CONCLUSIONS

These findings strongly support the use of aggressive surgical extirpation of all visible colorectal endometriosis for patients with advanced disease.

Small bowel endometriosis masquerading as regional enteritis

A 35-year-old female presented with recurrent right lower quadrant pain, nausea, and vomiting. She was afebrile with diffuse abdominal tenderness. Plain x-ray of abdomen revealed small bowel obstruction. A barium x-ray of the small bowel showed stricture of the terminal ileum. A CT scan of the abdomen showed a 6-cm mass in right lower quadrant. She was empirically managed as having Crohn's disease. She underwent laparotomy after failure of medical management with high-dose steroids. There was ulceration and narrowing of terminal ileum. Frozen sections revealed endometriosis. Ileocecectomy was performed. Histopathology of resected specimen confirmed the diagnosis of endometriosis, and there was no evidence of chronic inflammatory bowel disease or neoplasia. Ileal endometriosis should be considered in the differential diagnosis of Crohn's disease in menstruating females presenting with perimenstrual symptoms.