Figure 1 - available from: Abdominal Radiology
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Axial T2-weighted image shows a thickened hypointense and irregular left uterosacral ligament (arrow), indicating deep infiltrating endometriosis
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Purpose:
To evaluate whether deep pelvic endometriosis or endometriomas diagnosed at pelvic MRI are associated with extrapelvic bowel endometriosis (EPBE) (ileal, appendicular, or cecal involvement) in order to suggest criteria for performing an additional imaging examination dedicated to the assessment of EPBE.
Methods:
Ninety-six patients oper...
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Citations
... Among extragenital sites of disease, the bowel is the most common with a prevalence range of 3.8-37%, mainly affecting the rectum and the sigmoid colon [5,6]. ...
Objective
To assess the prevalence of endometriosis of the appendix and the association with other pelvic localizations of the disease and to provide pathogenesis hypotheses.
Methods
Monocentric, observational, retrospective, cohort study. Patients undergoing laparoscopic endometriosis surgery in our tertiary referral center were consecutively enrolled. The prevalence of the different localizations of pelvic endometriosis including appendix involvement detected during surgery was collected. Included patients were divided into two groups based on the presence of appendiceal endometriosis. Women with a history of appendectomy were excluded.
Measurements and main results.
Four hundred-sixty patients were included for data analysis. The prevalence of appendiceal endometriosis was 2.8%. In patients affected by endometriosis of the appendix, concomitant ovarian and/or bladder endometriosis were more frequently encountered, with prevalence of 53.9% (vs 21.0% in non-appendiceal endometriosis group, p = 0.005) and 38.4% (vs 11.4%, p = 0.003), respectively. Isolated ovarian endometriosis was significantly associated to appendiceal disease compared to isolated uterosacral ligament (USL) endometriosis or USL and ovarian endometriosis combined (46.2% vs 15.4% vs 7.7%, p < 0.001). Poisson regression analysis revealed a 4.1-fold and 4.4-fold higher risk of ovarian and bladder endometriosis, respectively, and a 0.1-fold risk of concomitant USL endometriosis in patients with appendiceal involvement.
Conclusion
Involvement of the appendix is not uncommon among patients undergoing endometriosis surgery. Significant association was detected between appendiceal, ovarian, and bladder endometriosis that may be explained by disease dissemination coming from endometrioma fluid shedding. Given the prevalence of appendiceal involvement, counseling regarding the potential need for appendectomy during endometriosis surgery should be considered.
... However, if performed, T2-weighted sequences depict a hypointense retractile mass or nodular thickening of the appendix. Involvement of the appendix can also be contiguous to fibrotic implants of the ovarian fossa [70,71] (Fig. 7). ...
... In clinical practice, when appendiceal endometriosis is isolated without pelvic implants, the diagnosis is not performed by imaging [7,71]. Conversely, the diagnosis may be evoked when features of deep endometriosis coexist with appendiceal findings on imaging. ...
Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.
Graphical Abstract
... (DIE) is one phenotype of endometriosis, which is defined by an extension of endometrial tissue-like under the peritoneal surface, usually >5 mm and/or nodular and able to invade adjacent structures, associated with fibrosis [2]. DIE can affect all pelvic compartments and can be associated with bowel involvement [3,4]. The distribution of the involvement of the different bowel segments is uneven. ...
... Although rare, extrapelvic involvement by DIE is a serious concern as it may require more extensive bowel resection that was not anticipated preoperatively [3,4,15,16]. In addition, endometriosis nodules that involve the appendix, cecum, or distal ileum are hard to detect with pelvic MRI because they are located above the upper slices of the MRI scan [4]. ...
... Although rare, extrapelvic involvement by DIE is a serious concern as it may require more extensive bowel resection that was not anticipated preoperatively [3,4,15,16]. In addition, endometriosis nodules that involve the appendix, cecum, or distal ileum are hard to detect with pelvic MRI because they are located above the upper slices of the MRI scan [4]. Gimonet et al. suggested that further specific imaging evaluation should be performed to identify ileal, appendicular or cecal endometriosis in women with sigmoid or rectosigmoid DIE [4]. ...
Objective:
To compare computed tomography-enterography (CTE) and magnetic resonance-enterography (MRE) in the detection of right-sided bowel deep infiltrating endometriosis (DIE).
Materials and methods:
Fifty women with DIE who underwent preoperatively CTE and MRE were included. CTE and MRE were first analyzed separately by two independent readers who analyzed five bowel segments (cecum, appendix, ileocecal junction, distal ileum and proximal small bowel [i.e., proximal ileum and jejunum]) for the presence of DIE and then interpreted in consensus. CTE, MRE and CTE with MRE were compared in terms of sensitivity, specificity and accuracy. Interobserver agreement was assessed with kappa (κ) test.
Results:
Using the reference standard 25 out 250 bowel segments were involved by DIE in 18 women and 225 were free of DIE. Sensitivity, specificity, and accuracy of CTE were 60% (95% confidence interval [CI]: 39-79), 93% (95% CI: 89-96) and 90% (95% CI: 85-93) for Reader 1, respectively, and 52% (95% CI: 31-72), 99% (95% CI: 97-100) and 94% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.564) and specificity (P = 0.181) between readers and fair interobserver agreement (κ = 0.37). For MRE these figures were 52% (95% CI: 31-72), 92% (95% CI: 88-95) and 88% (95% CI: 84-92) for Reader 1 and 60% (95% CI: 39-79), 99% (95% CI: 96-100) and 95% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.157) and specificity (P = 0.061) between readers and fair interobserver agreement (κ = 0.31). Significant differences in sensitivity (20%; 95% CI: 7-41) were found between CTE + MRE vs. CTE alone for Reader 1 and vs. MRE alone for Reader 2 (P = 0.041 for both) CONCLUSION: CTE and MRE have not different sensitivities and convey only fair interobserver agreement but are highly specific for the diagnosis of right-sided bowel DIE. CTE and MRE are complementary because they improve the detection of DIE implants when used in combination.
... Specifically, of the 37 women who underwent computerised tomography (CT), an ileal lesion was suspected in only 3 (8%) of them. Rousset et al. (2014) diagnosed all 6 cases of ileocaecal endometriotic lesions using 3.0-Tesla (T) MRI enterography; conversely, in Gimonet et al. (2016) no ileal lesion were found using MRI in 6 patients. A preoperative diagnosis of ileal endometriosis was suspected in one (3%) of 33 women who had double contrast barium enema (BDCE) and in one of the 9 women (11%) who underwent colonoscopy. ...
Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It is a common finding in premenopausal women and commonly affects the gastrointestinal tract, especially the rectosigmoid tract. Small bowel involvement is rare and usually asymptomatic making diagnosis difficult. Here we report an uncommon case of exophytic ileal endometriosis surgically treated. Detailed pre-operative counselling on the risk of ileal surgery should always be considered in all cases with endometriosis requiring surgery. We also present a review of the literature regarding the clinical presentation, diagnosis, and treatment of this challenging condition.
... Ileal involvement is described in 4.1-16.9% of the patients with multi-segmental small bowel involvement, and in up to 55% of patients that have rectal implants [9,28]. Detection of small bowel endometriosis can be particularly difficult on routine pelvic MRI exams intended to stage pelvic organ involvement due to the small field of view [27,29]. Therefore, in addition to a high degree of suspicion and focused attention to the right lower quadrant on a pelvic MRI, including additional sequences such as large field of view coronal T1 and T2-weighted sequences would help screen for small bowel involvement. ...
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.
... Some specialty centers and societies outside the United States (US), including those in South America and Europe, advocate for the utilization of bowel preparation prior to pelvic MRI in an effort to increase accuracy of implant detection ( Fig. 1) [20,[32][33][34][35]. Of the institutions participating in the survey, only one denoted routine bowel preparation utilization. ...
Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.
... As mentioned above, intestinal endometriosis refers to the rectum and sigmoid endometriosis. However, there are a special intestinal endometriosis, appendiceal endometriosis, which is considered as an uncommon finding, in the literature its prevalence varies widely [26]. In our study, there are 4 patients with appendiceal endometriosis , are responsible for approximately 4% of all intestinal lesions. ...
Background:
To investigate the characteristics of deep infiltrating endometriosis (DIE) lesion distribution when associated with ovarian endometrioma (OEM).
Methods:
The present study analyzed retrospective data obtained by the First Affiliated Hospital of Sun Yat-sen University, between June 2008 to June 2016. A total of 304 patients underwent laparoscopic surgery for complete removal of endometriosis by one experienced surgeon, and histological confirmation of OEM associated with DIE was conducted for each patient. Clinical data were recorded for each patient from medical, operative and pathological reports. Patients were then divided into two groups according to unilateral or bilateral OEM. Patients with unilateral OEM were subsequently divided into two subgroups according to OEM location (left- or right-hand side) and the diameter of the OEM (≤50 and > 50 mm). The distribution characteristics of DIE lesions were then compared between the groups.
Results:
DIE lesions were widely distributed, 30 anatomical sites were involved. Patients with associated unilateral OEM (n = 184 patients) had a significantly increased number of DIE lesions when compared with patients with bilateral OEM (n = 120 patients; 2.76 ± 1.52 vs. 2.33 ± 1.34; P = 0.006). Compared with bilateral OEM with DIE, there was a higher rate of intestinal (39.1% vs. 18.3%; P < 0.01) and vaginal (17.4% vs. 6.7%; P < 0.01) infiltration by DIE lesions in unilateral OEM with DIE. The mean number of DIE lesions was not significantly correlated with the location or size of the OEM (2.83 ± 1.56 vs. 2.74 ± 1.53; P = 0.678; and 2.65 ± 1.42 vs. 2.80 ± 1.43; P = 0.518, respectively). There was no significant difference between the groups with OEM ≤50 mm and > 50 mm.
Conclusion:
Lesion distribution characteristics in women diagnosed with histologically proven OEM associated with DIE were frequently multifocal and severe.
... However, there are a special intestinal endometriosis, appendiceal endometriosis, which is considered as an uncommon finding, in the literature its prevalence varies widely [26]. In our study, there are 4 patients with appendiceal endometriosis are responsible for approximately 4% of all intestinal lesions. ...
Background: To investigate the characteristics of deep infiltrating endometriosis (DIE) lesion distribution when associated with ovarian endometrioma (OEM). Methods: The present study analyzed retrospective data obtained by the First Affiliated Hospital of Sun Yat-sen University, between June 2008 to June 2016. A total of 304 patients underwent laparoscopic surgery for complete removal of endometriosis by one experienced surgeon, and histological confirmation of OEM associated with DIE was conducted for each patient. Clinical data were recorded for each patient from medical, operative and pathological reports. Patients were then divided into two groups according to unilateral or bilateral OEM. Patients with unilateral OEM were subsequently divided into two subgroups according to OEM location (left- or right-hand side) and the diameter of the OEM (≤50 and >50 mm). The distribution characteristics of DIE lesions were then compared between the groups. Results: DIE lesions were widely distributed, 30 anatomical sites were involved. Patients with associated unilateral OEM (n=184 patients) had a significantly increased number of DIE lesions when compared with patients with bilateral OEM (n=120 patients; 2.76±1.52 vs. 2.33±1.34; P=0.006). Compared with bilateral OEM with DIE, there was a higher rate of intestinal (39.1% vs. 18.3%; P<0.01) and vaginal (17.4% vs. 6.7%; P<0.01) infiltration by DIE lesions in unilateral OEM with DIE. The mean number of DIE lesions was not significantly correlated with the location or size of the OEM (2.83±1.56 vs. 2.74±1.53; P=0.678; and 2.65±1.42 vs. 2.80±1.43; P=0.518, respectively). There was no significant difference between the groups with OEM ≤50 mm and >50 mm. Conclusion: Lesion distribution characteristics in women diagnosed with histologically proven OEM associated with DIE were frequently multifocal and severe. Key Words: ovarian endometrioma, deep infiltrating endometriosis, lesion distribution characteristics
... They showed that women with AE had more widespread deep lesions and more frequent cyclic bowel symptoms. Another study conducted by Gimonet et al [4] described an association between sigmoid, rectosigmoid, and right ureteral involvement and extrapelvic bowel endometriosis, defined as the presence of an endometriotic lesion at the level of the ileum, appendix, or cecum. ...
... In contrast to Gimonet et al [4], we did not observe a significant association between AE lesions and the right ureter, but we did find as association with the left ureter and parametrium. This can be simply a statistical finding. ...
Study objective:
To evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery.
Design:
A retrospective cohort study.
Setting:
A tertiary level referral center, university hospital.
Patients:
One thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis.
Interventions:
Electronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants.
Measurements and main results:
AE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32-4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08-15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63-29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05-3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82-11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10-4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07-75.75).
Conclusion:
Among patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.
... Interestingly, in approximately 30% of cases with rectal and sigmoid involvement, right-sided bowel endometriosis is also present [37]. Furthermore, recent reports addressed a possible association between ileocecal/appendix endometriosis and right ureteral involvement [39]. Therefore, in women with deep invasive endometriosis the bowel proximal to the rectosigmoid junction should also be carefully examined. ...
... Preoperative work-up for the localization of bowel endometriosis is necessary for optimal therapeutic management. Surgical treatment of deep invasive endometriosis, especially when the rectosigmoid is involved, may be associated with complications such as rectovaginal fistula, pelvic abscess formation or anastomotic leak in cases of segmental bowel resection [39]; it is, therefore, suggested that the ''least radical option should be selected'' [41]. MRI may help surgeons plan more conservative surgical approaches in case of rectal and/or sigmoid involvement like rectal shaving, mucosal skinning or full-thickness anterior rectal wall excision (also known as disc resection); lack of multifocal disease, small size lesions (maximal diameter < 25-30 mm), absence of submocosa/mucosa infiltration, low (less than one third) percentage of intestinal circumference affected by the disease and sufficient distance (> 10 cm) between the rectal endometriotic implant and the annal verge are considered important for the selection of candidates for less radical bowel surgery [40]. ...
Endometriosis is a common gynecological disorder defined by the presence of endometrial tissue outside the uterus. It is the most common cause of chronic pelvic pain and typically affects the ovaries, uterine ligaments, peritoneum, tubes, rectovaginal septum and bladder. It may, however, be found at various extrapelvic sites, including the perineum, liver, pancreas, lung or even the central nervous system, and in such cases, diagnosis may be quite challenging. Even though definitive diagnosis requires laparoscopy, preoperative identification of endometriosis is important not only to differentiate it from other diseases with similar clinical presentations but also, for accurate presurgical mapping, since complete removal of all endometriotic foci is critical for the effective treatment of the patient's symptoms. Ultrasound is performed initially, but magnetic resonance imaging (MRI) is increasingly being used, particularly when sonographic findings are unclear, when deep pelvic endometriosis is suspected or when surgery is planned, as it provides better contrast resolution and a larger field of view compared to ultrasound. In this article, we will discuss distinctive MRI appearances of endometriotic foci and we will review common and uncommon locations of endometriosis within the body, in an attempt to familiarize radiologists with its wide spectrum of manifestations.
