Intestinal endometriosis:Diagnostic ambiguities and surgical outcomes
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摘要
BACKGROUND Endometriosis is a common disease for women of reproductive age. However,when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.AIM To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.METHODS We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.RESULTS Twenty-three(76.6%) patients showed symptoms associated with endometriosis,with dysmenorrhea being the most common(n = 9, 30.0%). Thirteen patients(43.3%) had a history of pelvic surgeries. Ten patients(33.3%) had a history of treatment for endometriosis. Only 4 patients(13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients(43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients(56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine(n = 8, 26.7%),followed by malignancies of the colon/rectum(n = 3, 10.0%) and ovary(n = 3,10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9(0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.CONCLUSION Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings,intestinal endometriosis should be included in the differential diagnosis.
BACKGROUND Endometriosis is a common disease for women of reproductive age. However,when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.AIM To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.METHODS We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.RESULTS Twenty-three(76.6%) patients showed symptoms associated with endometriosis,with dysmenorrhea being the most common(n = 9, 30.0%). Thirteen patients(43.3%) had a history of pelvic surgeries. Ten patients(33.3%) had a history of treatment for endometriosis. Only 4 patients(13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients(43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients(56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine(n = 8, 26.7%),followed by malignancies of the colon/rectum(n = 3, 10.0%) and ovary(n = 3,10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9(0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.CONCLUSION Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings,intestinal endometriosis should be included in the differential diagnosis.
BACKGROUND Endometriosis is a common disease for women of reproductive age. However,when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.AIM To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.METHODS We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.RESULTS Twenty-three(76.6%) patients showed symptoms associated with endometriosis,with dysmenorrhea being the most common(n = 9, 30.0%). Thirteen patients(43.3%) had a history of pelvic surgeries. Ten patients(33.3%) had a history of treatment for endometriosis. Only 4 patients(13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients(43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients(56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine(n = 8, 26.7%),followed by malignancies of the colon/rectum(n = 3, 10.0%) and ovary(n = 3,10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9(0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.CONCLUSION Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings,intestinal endometriosis should be included in the differential diagnosis.
引文
1 Wolthuis AM,Meuleman C,Tomassetti C,D'Hooghe T,de Buck van Overstraeten A,D'Hoore A.Bowel endometriosis:colorectal surgeon's perspective in a multidisciplinary surgical team.World J Gastroenterol2014;20:15616-15623[PMID:25400445 DOI:10.3748/wjg.v20.i42.15616]
2 Ferrero S,Camerini G,Maggiore ULR,Venturini PL,Biscaldi E,Remorgida V.Bowel endometriosis:Recent insights and unsolved problems.World J Gastrointest Surg 2011;3:31-38[DOI:10.4240/wjgs.v3.i3.31]
3 Remorgida V,Ferrero S,Fulcheri E,Ragni N,Martin DC.Bowel endometriosis:presentation,diagnosis,and treatment.Obstet Gynecol Surv 2007;62:461-470[PMID:17572918 DOI:10.1097/01.ogx.0000268688.55653.5c]
4 Campagnacci R,Perretta S,Guerrieri M,Paganini AM,De Sanctis A,Ciavattini A,Lezoche E.Laparoscopic colorectal resection for endometriosis.Surg Endosc 2005;19:662-664[PMID:15759190DOI:10.1007/s00464-004-8710-7]
5 Meuleman C,Tomassetti C,D'Hoore A,Van Cleynenbreugel B,Penninckx F,Vergote I,D'Hooghe T.Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.Hum Reprod Update2011;17:311-326[PMID:21233128 DOI:10.1093/humupd/dmq057]
6 Seaman HE,Ballard KD,Wright JT,de Vries CS.Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease:findings from a national case-control study--Part 2.BJOG2008;115:1392-1396[PMID:18715239 DOI:10.1111/j.1471-0528.2008.01879.x]
7 Yantiss RK,Clement PB,Young RH.Endometriosis of the intestinal tract:a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation.Am J Surg Pathol 2001;25:445-454[PMID:11257618 DOI:10.1097/00000478-200104000-00003]
8 Goncalves MO,Podgaec S,Dias JA,Gonzalez M,Abrao MS.Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis,defining surgical strategy.Hum Reprod 2010;25:665-671[PMID:20023291 DOI:10.1093/humrep/dep433]
9 Rousset P,Peyron N,Charlot M,Chateau F,Golfier F,Raudrant D,Cotte E,Isaac S,Réty F,Valette PJ.Bowel endometriosis:preoperative diagnostic accuracy of 3.0-T MR enterography--initial results.Radiology 2014;273:117-124[PMID:24828001 DOI:10.1148/radiol.14132803]
10 Demirel F,Koca G,Demirel K,Aydogmus H,Korkmaz M,Gokmen B.Labeled red blood cell scintigraphy in the non-invasive diagnostics of endometriosis.Fertil Steril 2010;94:S202[DOI:10.1016/j.fertnstert.2010.07.784]
11 Kim KJ,Jung SS,Yang SK,Yoon SM,Yang DH,Ye BD,Byeon JS,Myung SJ,Kim JH.Colonoscopic findings and histologic diagnostic yield of colorectal endometriosis.J Clin Gastroenterol 2011;45:536-541[PMID:21030871 DOI:10.1097/MCG.0b013e3181fd297b]
12 Bergqvist A.Different types of extragenital endometriosis:a review.Gynecol Endocrinol 1993;7:207-221[PMID:8291459 DOI:10.3109/09513599309152504]
13 Peterson CM,Johnstone EB,Hammoud AO,Stanford JB,Varner MW,Kennedy A,Chen Z,Sun L,Fujimoto VY,Hediger ML,Buck Louis GM;ENDO Study Working Group.Risk factors associated with endometriosis:importance of study population for characterizing disease in the ENDO Study.Am J Obstet Gynecol 2013;208:451.e1-451.11[PMID:23454253 DOI:10.1016/j.ajog.2013.02.040]
14 Rizk B,Fischer AS,Lotfy HA,Turki R,Zahed HA,Malik R,Holliday CP,Glass A,Fishel H,Soliman MY,Herrera D.Recurrence of endometriosis after hysterectomy.Facts Views Vis Obgyn 2014;6:219-227[PMID:25593697]
15 Sel?uk?,Bozda?G.Recurrence of endometriosis;risk factors,mechanisms and biomarkers;review of the literature.J Turk Ger Gynecol Assoc 2013;14:98-103[PMID:24592083 DOI:10.5152/jtgga.2013.52385]
16 Guo SW.Recurrence of endometriosis and its control.Hum Reprod Update 2009;15:441-461[PMID:19279046 DOI:10.1093/humupd/dmp007]
17 Randall GW,Gantt PA,Poe-Zeigler RL,Bergmann CA,Noel ME,Strawbridge WR,Richardson-Cox B,Hereford JR,Reiff RH.Serum antiendometrial antibodies and diagnosis of endometriosis.Am J Reprod Immunol 2007;58:374-382[PMID:17845208 DOI:10.1111/j.1600-0897.2007.00523.x]
18 Landi S,Ceccaroni M,Perutelli A,Allodi C,Barbieri F,Fiaccavento A,Ruffo G,McVeigh E,Zanolla L,Minelli L.Laparoscopic nerve-sparing complete excision of deep endometriosis:is it feasible?Hum Reprod 2006;21:774-781[PMID:16449312 DOI:10.1093/humrep/dei324]
19 Chopin N,Vieira M,Borghese B,Foulot H,Dousset B,Coste J,Mignon A,Fauconnier A,Chapron C.Operative management of deeply infiltrating endometriosis:results on pelvic pain symptoms according to a surgical classification.J Minim Invasive Gynecol 2005;12:106-112[PMID:15904612 DOI:10.1016/j.jmig.2005.01.015]
20 Fedele L,Bianchi S,Zanconato G,Bettoni G,Gotsch F.Long-term follow-up after conservative surgery for rectovaginal endometriosis.Am J Obstet Gynecol 2004;190:1020-1024[PMID:15118634 DOI:10.1016/j.ajog.2003.10.698]
21 Seong SJ,Kim D,Lee KH,Kim TJ,Chung HH,Chang SJ,Lee EJ.Role of Hormone Therapy After Primary Surgery for Endometrioma:A Multicenter Retrospective Cohort Study.Reprod Sci 2016;23:1011-1018[PMID:26763524 DOI:10.1177/1933719115625841]
22 Heaps JM,Nieberg RK,Berek JS.Malignant neoplasms arising in endometriosis.Obstet Gynecol 1990;75:1023-1028[PMID:2188180]
23 Takeuchi M,Matsuzaki K,Uehara H,Nishitani H.Malignant transformation of pelvic endometriosis:MRimaging findings and pathologic correlation.Radiographics 2006;26:407-417[PMID:16549606 DOI:10.1148/rg.262055041]
2 Ferrero S,Camerini G,Maggiore ULR,Venturini PL,Biscaldi E,Remorgida V.Bowel endometriosis:Recent insights and unsolved problems.World J Gastrointest Surg 2011;3:31-38[DOI:10.4240/wjgs.v3.i3.31]
3 Remorgida V,Ferrero S,Fulcheri E,Ragni N,Martin DC.Bowel endometriosis:presentation,diagnosis,and treatment.Obstet Gynecol Surv 2007;62:461-470[PMID:17572918 DOI:10.1097/01.ogx.0000268688.55653.5c]
4 Campagnacci R,Perretta S,Guerrieri M,Paganini AM,De Sanctis A,Ciavattini A,Lezoche E.Laparoscopic colorectal resection for endometriosis.Surg Endosc 2005;19:662-664[PMID:15759190DOI:10.1007/s00464-004-8710-7]
5 Meuleman C,Tomassetti C,D'Hoore A,Van Cleynenbreugel B,Penninckx F,Vergote I,D'Hooghe T.Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.Hum Reprod Update2011;17:311-326[PMID:21233128 DOI:10.1093/humupd/dmq057]
6 Seaman HE,Ballard KD,Wright JT,de Vries CS.Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease:findings from a national case-control study--Part 2.BJOG2008;115:1392-1396[PMID:18715239 DOI:10.1111/j.1471-0528.2008.01879.x]
7 Yantiss RK,Clement PB,Young RH.Endometriosis of the intestinal tract:a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation.Am J Surg Pathol 2001;25:445-454[PMID:11257618 DOI:10.1097/00000478-200104000-00003]
8 Goncalves MO,Podgaec S,Dias JA,Gonzalez M,Abrao MS.Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis,defining surgical strategy.Hum Reprod 2010;25:665-671[PMID:20023291 DOI:10.1093/humrep/dep433]
9 Rousset P,Peyron N,Charlot M,Chateau F,Golfier F,Raudrant D,Cotte E,Isaac S,Réty F,Valette PJ.Bowel endometriosis:preoperative diagnostic accuracy of 3.0-T MR enterography--initial results.Radiology 2014;273:117-124[PMID:24828001 DOI:10.1148/radiol.14132803]
10 Demirel F,Koca G,Demirel K,Aydogmus H,Korkmaz M,Gokmen B.Labeled red blood cell scintigraphy in the non-invasive diagnostics of endometriosis.Fertil Steril 2010;94:S202[DOI:10.1016/j.fertnstert.2010.07.784]
11 Kim KJ,Jung SS,Yang SK,Yoon SM,Yang DH,Ye BD,Byeon JS,Myung SJ,Kim JH.Colonoscopic findings and histologic diagnostic yield of colorectal endometriosis.J Clin Gastroenterol 2011;45:536-541[PMID:21030871 DOI:10.1097/MCG.0b013e3181fd297b]
12 Bergqvist A.Different types of extragenital endometriosis:a review.Gynecol Endocrinol 1993;7:207-221[PMID:8291459 DOI:10.3109/09513599309152504]
13 Peterson CM,Johnstone EB,Hammoud AO,Stanford JB,Varner MW,Kennedy A,Chen Z,Sun L,Fujimoto VY,Hediger ML,Buck Louis GM;ENDO Study Working Group.Risk factors associated with endometriosis:importance of study population for characterizing disease in the ENDO Study.Am J Obstet Gynecol 2013;208:451.e1-451.11[PMID:23454253 DOI:10.1016/j.ajog.2013.02.040]
14 Rizk B,Fischer AS,Lotfy HA,Turki R,Zahed HA,Malik R,Holliday CP,Glass A,Fishel H,Soliman MY,Herrera D.Recurrence of endometriosis after hysterectomy.Facts Views Vis Obgyn 2014;6:219-227[PMID:25593697]
15 Sel?uk?,Bozda?G.Recurrence of endometriosis;risk factors,mechanisms and biomarkers;review of the literature.J Turk Ger Gynecol Assoc 2013;14:98-103[PMID:24592083 DOI:10.5152/jtgga.2013.52385]
16 Guo SW.Recurrence of endometriosis and its control.Hum Reprod Update 2009;15:441-461[PMID:19279046 DOI:10.1093/humupd/dmp007]
17 Randall GW,Gantt PA,Poe-Zeigler RL,Bergmann CA,Noel ME,Strawbridge WR,Richardson-Cox B,Hereford JR,Reiff RH.Serum antiendometrial antibodies and diagnosis of endometriosis.Am J Reprod Immunol 2007;58:374-382[PMID:17845208 DOI:10.1111/j.1600-0897.2007.00523.x]
18 Landi S,Ceccaroni M,Perutelli A,Allodi C,Barbieri F,Fiaccavento A,Ruffo G,McVeigh E,Zanolla L,Minelli L.Laparoscopic nerve-sparing complete excision of deep endometriosis:is it feasible?Hum Reprod 2006;21:774-781[PMID:16449312 DOI:10.1093/humrep/dei324]
19 Chopin N,Vieira M,Borghese B,Foulot H,Dousset B,Coste J,Mignon A,Fauconnier A,Chapron C.Operative management of deeply infiltrating endometriosis:results on pelvic pain symptoms according to a surgical classification.J Minim Invasive Gynecol 2005;12:106-112[PMID:15904612 DOI:10.1016/j.jmig.2005.01.015]
20 Fedele L,Bianchi S,Zanconato G,Bettoni G,Gotsch F.Long-term follow-up after conservative surgery for rectovaginal endometriosis.Am J Obstet Gynecol 2004;190:1020-1024[PMID:15118634 DOI:10.1016/j.ajog.2003.10.698]
21 Seong SJ,Kim D,Lee KH,Kim TJ,Chung HH,Chang SJ,Lee EJ.Role of Hormone Therapy After Primary Surgery for Endometrioma:A Multicenter Retrospective Cohort Study.Reprod Sci 2016;23:1011-1018[PMID:26763524 DOI:10.1177/1933719115625841]
22 Heaps JM,Nieberg RK,Berek JS.Malignant neoplasms arising in endometriosis.Obstet Gynecol 1990;75:1023-1028[PMID:2188180]
23 Takeuchi M,Matsuzaki K,Uehara H,Nishitani H.Malignant transformation of pelvic endometriosis:MRimaging findings and pathologic correlation.Radiographics 2006;26:407-417[PMID:16549606 DOI:10.1148/rg.262055041]