Bowel/GI endometriosis

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Gastrointestinal (GI) symptoms are common with endometriosis, anywhere from one third to up to 85% of endometriosis patients have GI symptoms, usually with a gradual onset (Aragon & Lessey, 2017; Ek et al., 2015). Of those with GI symptoms, the location of endometriosis lesions weren’t necessarily on the bowel itself (Ek et al., 2015).  Women with endometriosis are often diagnosed with irritable bowel syndrome (IBS); but one study noted that when those individuals have surgery for endometriosis, the individuals had endometriosis lesions on or near the rectum or in the pouch of Douglas (posterior cul-de-sac) and had generally minimal or mild disease (Aragon & Lessey, 2017). The symptoms are attributed to the inflammatory process from endometriosis (Aragon & Lessey, 2017)

The incidence of endometriosis on the bowel itself ranges from 5% to 12% of those with endometriosis, most often seen on the rectum and sigmoid colon  (Habib et al., 2020). Those with lesions on or close to the bowel did have more nausea and vomiting (Ek et al., 2015). Other reported symptoms include “a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea), dyschezia, dysmenorrhoea and dyspareunia in addition to infertility” (Habib et al., 2020, para. 1). Bowel endometriosis is associated with lesions on the uterosacral ligaments  and vaginal wall, which can cause painful penetration (Habib et al., 2020). Treatments for endometriosis that actually worsened GI symptoms included opioids and GnRH analogs (Ek et al., 2015). 

While hormonal medications have been shown to help relieve symptoms, it may not stop the progression of the disease which can lead, in severe cases, to bowel obstruction; therefore, it is recommended that close follow-up be utilized if you do not choose surgical treatment (Habib et al., 2020; Ferrero et al., 2011). If you think you might have bowel involvement, it is important to find the right care. The success of surgery depends on the skills and experience of the surgeon and a multidisciplinary team. It is recommended that “surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care” (Habib et al., 2020, para. 1). Before committing to surgery, you want to know how they remove endometriosis; how often do they perform this surgery; does the surgeon have the advanced knowledge/surgical skills to address all disease in all locations (bowel, bladder, near ureters, culs de sac, uterine ligaments, etc.). Learning what questions to ask and choosing the right surgeon can make all the difference. (see “Choosing Your Surgeon“)

When working up symptoms of the bowel, many doctors may suggest a colonoscopy, which can rule out other problems such as colitis, polyps, diverticulosis or diverticulitis. However, in one study, a colonoscopy did not diagnose intestinal endometriosis in 92% of the patients and the authors conclude that a colonoscopy “should not be routinely performed in the diagnostic work-up of bowel endometriosis” (Milone et al., 2015, para. 4). Bowel endometriosis is treatable, without full laparotomy and without colostomy (Tarjanne, Heikinheimo, Mentula, & Härkki, 2015). For more on surgical technique for bowel endometriosis look here.

*Dyschezia- excessive straining with stools, dysmenorrhoea- pain with menstruation, dyspareunia- painful intercourse

Gastrointestinal (GI) Disease: 

Links:

Studies:

  • Rectosigmoid Endometriosis Surgery: Moawad, N. S., Guido, R., Ramanathan, R., Mansuria, S., & Lee, T. (2011). Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 15(3), 331. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183552/

“…patients often present with severe symptoms, such as dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain, along with a spectrum of bowel symptoms like diarrhea, constipation, bloating, or cyclic rectal bleeding. The triad of dysmenorrhea, dyspareunia, and bowel symptoms was found to be 80% sensitive for diagnosing bowel endometriosis.1,6–8 Multifocal bowel involvement is common, affecting 25% to 34% of patients.2,9

“Although medical and hormonal therapy have been found to be effective for improving the pain symptoms associated with rectal endometriosis, the relief is usually transient and symptoms generally recur once medical therapy is discontinued.10 Due to persistent or recurrent pain, and the marked anatomic distortion caused by deep infiltrating rectovaginal endometriosis, surgery is considered the treatment of choice for symptomatic disease.11 Moreover, surgery is mandatory in severe cases of rectovaginal nodules that result in luminal stenosis and obstructive symptoms.12

“Multiple studies suggest that complete excision of endometriotic lesions, including bowel resection when necessary, results in significant improvement in pain, as well as improvement in bowel symptoms and quality of life.9,13–15.”

“Bowel endometriosis affects between 3.8% and 37% of women with endometriosis. The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis. Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease. Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis. Hormonal therapies (progestins, gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive. However, hormonal therapies may not prevent the progression of bowel endometriosis and, therefore, patients receiving long-term treatment should be periodically monitored. Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%. Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection. Both surgical procedures improve pain, intestinal symptoms and fertility. Nodulectomy may be associated with a lower rate of complications.”

  • Bowel Endometriosis Surgery Study: Afors, K., Centini, G., Fernandes, R., Murtada, R., Zupi, E., Akladios, C., & Wattiez, A. (2016). Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. Journal of Minimally Invasive Gynecology, 23(7), 1123-1129. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27544881/ 

“All 3 treatment modalities are effective in terms of immediate symptom relief with acceptable complication rates. However, significantly higher rates of symptom recurrence and reintervention were noted in the shaving group, whereas segmental resection is more likely to be indicated in cases of large nodules.”

  • Case Study of Endometriosis Causing A Small Bowel Obstruction: Slesser, A. A., Sultan, S., Kubba, F., & Sellu, D. P. (2010). Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: a case report. World Journal of Emergency Surgery, 5(1), 27. Retrieved from https://wjes.biomedcentral.com/articles/10.1186/1749-7922-5-27 

“We present the case of a 33 year old female of Asian origin who presented with symptoms and signs of an acute small bowel obstruction. A right hemicolectomy for suspected malignancy was performed with an ileocolic anastomosis. Histological examination demonstrated extensive endometriosis of the appendix and ileocaecal junction. Conclusion: Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction. A high index of suspicion is required to arrive at a diagnosis of this elusive condition.”

  • Extremely rare case of gastric endometriosis:

Ha, J. K., Choi, C. W., Kim, H. W., Kang, D. H., Park, S. B., Kim, S. J., & Hong, J. B. (2015). An extremely rare case of gastric subepithelial tumor: gastric endometriosis. Clinical endoscopy, 48(1), 74. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323438/ 

“Frequent locations for endometriosis outside of the pelvic cavity include a variety of tissues and organs, such as the intestines, kidneys, lungs, skin, and pleura, with the exception of the spleen.1 Endometriosis affects the gastrointestinal tract in 5% of cases, with the sigmoid colon being the most commonly affected location, followed by the rectum.2,3 However, to the best of our knowledge, the present case is among the very few reports of gastric endometriosis. Here, we report a very rare case of gastric endometriosis that presented as a subepithelial tumor.”

  • Hepatic (liver) endometriosis a rare case and literature review:

Liu, K., Zhang, W., Liu, S., Dong, B., & Liu, Y. (2015). Hepatic endometriosis: a rare case and review of the literature. European Journal of Medical Research, 20(1), 48. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389341/

“…endometriotic lesions have also been described in almost all other remote organs of the human body, including the omentum, gastrointestinal tract, peritoneum, operative scars, lymph nodes, umbilicus, skin, lungs, pleura, bladder, kidneys, pancreas, and even in males [3]. Hepatic endometriosis, one of the rarest forms of atypical endometriosis, was first described in 1986 [4]. To our knowledge, only 21 cases of hepatic endometriosis have been previously reported in the literature. We herein describe the 22nd case of hepatic endometriosis and evaluate the current literature addressing the diagnosis of hepatic endometriosis focusing on advances in the clinical manifestation, pathogenesis, and diagnostic workup.”

Bloating with endometriosis:

“Conclusions: The majority of endometriosis patients experience more severe gastrointestinal symptoms than controls. A poor association between symptoms and lesion localization was found, indicating existing comorbidity between endometriosis and irritable bowel syndrome (IBS). Treatment with opioids or GnRH analogs is associated with aggravated gastrointestinal symptoms….Gastrointestinal symptoms among patients with endometriosis described in the literature include abdominal pain, bloating, nausea, constipation, vomiting, painful bowel movements, and diarrhea [3–5]. However, reported symptoms differ between studies. Aggravated symptoms during menstruation have been reported [4, 6, 7] such as cyclic-related bloating and constipation [4]. Fauconnier et al. [7] concluded that symptoms including diarrhea, constipation, and colic rectal pain were more frequent among patients with endometriosis lesions within or close to the bowel. In contrast, Maroun et al. [3] reported gastrointestinal symptoms to be primarily independent of localization of endometriosis lesions in relation to the bowel. Different explanations concerning the occurrence of these symptoms include: endometriosis lesions cause inflammatory activity and local prostaglandin release, which can alter bowel function [8]; endometriosis lesions within the bowel cause symptoms due to mechanical obstruction or cyclic micro-hemorrhages [9]; or there is an existing comorbidity between endometriosis and irritable bowel syndrome (IBS) [8].”

  • Luscombe, G. M., Markham, R., Judio, M., Grigoriu, A., & Fraser, I. S. (2009). Abdominal bloating: an under-recognized endometriosis symptom. Journal of Obstetrics and Gynaecology Canada, 31(12), 1159-1171. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20085682 

“A significantly larger proportion of women with endometriosis than control subjects experienced abdominal bloating (96% vs. 64%). In women with abdominal bloating, the following were more common in those who had endometriosis: associated severe discomfort (30% vs. 0%), wearing loose clothes during bloating (87% vs. 38%), and simultaneous hand swelling (30% vs. 6%). The experiences of cyclically related diarrhea and constipation were more frequent with endometriosis. While there were significant changes in bloating and discomfort ratings across the menstrual cycle, there was a trend towards a difference between the control subjects and unmedicated endometriosis groups only in how the pattern of bloating severity fluctuated across the cycle. Lower abdominal girth measurements changed significantly across menstrual cycle phases. Control and unmedicated endometriosis groups differed significantly in girth changes across the menstrual cycle, controls experiencing much less variation. Compared with the unmedicated endometriosis group, women receiving hormonal treatment had higher bloating severity ratings and discomfort scores, but there was no objective difference in abdominal girth. Conclusion: Painful abdominal bloating appears to be common in women with endometriosis and causes considerable symptomatic distress.”

“Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.”

As pelvic floor dysfunction and other issues can contribute to bowel symptoms: (see “Pelvic Floor Dysfunction“)

References

Aragon, M., & Lessey, B. A. (2017). Irritable Bowel Syndrome and Endometriosis: Twins in Disguise. GHS Proc, 43-50. Retrieved from https://hsc.ghs.org/wp-content/uploads/2016/11/GHS-Proc-Ibs-And-Endometriosis.pdf

Ek, M., Roth, B., Ekström, P., Valentin, L., Bengtsson, M., & Ohlsson, B. (2015). Gastrointestinal symptoms among endometriosis patients—A case-cohort study. BMC women’s health, 15(1), 59. doi: 10.1186/s12905-015-0213-2

Ferrero, S., Camerini, G., Maggiore, U. L. R., Venturini, P. L., Biscaldi, E., & Remorgida, V. (2011). Bowel endometriosis: Recent insights and unsolved problems. World journal of gastrointestinal surgery, 3(3), 31. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069336/

Habib, N., Centini, G., Lazzeri, L., Amoruso, N., El Khoury, L., Zupi, E., & Afors, K. (2020). Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. International Journal of Women’s Health, 12, 35. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996110/

Milone, M., Mollo, A., Musella, M., Maietta, P., Fernandez, L. M. S., Shatalova, O., … & Milone, F. (2015). Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World Journal of Gastroenterology: WJG, 21(16), 4997. doi: 10.3748/wjg.v21.i16.4997

Tarjanne, S., Heikinheimo, O., Mentula, M., & Härkki, P. (2015). Complications and long‐term follow‐up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall. Acta Obstetricia et Gynecologica Scandinavica, 94(1), 72-79. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.12515

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