xiomi- Intestinal Endometriosis

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St. Medical Center

Endometriosis Newsletter

Spring 1998

Intestinal Endometriosis

By B. Redwine, MD

Most patients with endometriosis do not have intestinal (GI) involvement.

Among the difficult cases of endometriosis I see from around the world, only

27% have GI involvement. Since over 1900 patients with endometriosis have

undergone surgery at St. , that means I’ve operated on over 500

patients with GI involvement.

The symptoms of GI involvement depend on the severity and location of the

disease. The severity of disease depends on the depth of invasion into the

bowel wall.

When endometriosis invades the bowel wall deeply, it causes a lot of

scarring and retraction and can form a tumor which partially obstructs the

bowel wall. When disease is very superficial, it usually causes no symptoms

at all. There is a long continuum of disease severity from very superficial

to very bulky and invasive, and some patients can have both superficial

disease in one area of the bowel, and bulky invasive disease in another.

The location of GI endometriosis follows well-defined patterns. The lower

rectosigmoid colon is most commonly involved, followed by the last part of

the ileum (the small intestine), the cecum (the first part of the large

bowel), and the appendix (which hangs off of the cecum). Thirty percent of

patients have more than one GI area involved. Superficial disease in any of

these areas usually causes no symptoms, but bulky, deeply invasive disease

can cause real problems.

When the rectum is involved by endometriosis, it frequently scars forward to

the back of the uterus, causing what is known as obliteration of the cul de

sac. This indicates the presence of deeply invasive disease in the

uterosacral ligaments, the cul de sac, and usually the front wall of the

rectum itself with what is called a rectal nodule. The disease can

occasionally invade the rear wall of the vagina as well.

Interestingly, although you might think vaginal endometriosis would be

obvious on speculum exam in the office, it is usually missed because most

physicians don’t think to look just behind the cervix; they are more intent

on seeing the cervix so they can do a PAP smear. Frequently the doctor may

be able to feel nodularity behind the cervix on exam, and this area can be

very painful.

When endometriosis invades the

bowel wall deeply, it causes a

lot of scarring and retraction and

can form a tumor which partially

obstructs the bowel wall. When

disease is very superficial, it

usually causes no symptoms at all.

A rectal nodule with obliteration of the cul de sac can cause painful bowel

movements all month long, rectal pain during intercourse or while sitting,

and rectal pain with passing gas. It can also cause constipation, although

diarrhea can be present during the menstrual flow. When the sigmoid colon is

involved by bulky disease, patients can have constipation alternating with

diarrhea and intestinal bloating and cramping. Bulky endometriosis invading

the ileum can result in right lower quadrant pain, bloating, and intestinal

cramping. Disease of the cecum and appendix usually causes no specific

symptoms at all. Most patients with GI endometriosis do not have rectal

bleeding, although when rectal bleeding and painful symptoms occur during

the menstrual flow, this raises suspicion for GI involvement.

GI x-rays and colonoscopy are rarely useful in diagnosing GI endometriosis

because the disease usually doesn’t penetrate all the way through the bowel,

but remains in the muscular wall of the bowel. Most

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patients will have negative GI workups, and GI endometriosis requires

surgery for its diagnosis. Laparoscopy is adequate for diagnosing GI disease

provided that the surgeon takes the effort to look at the areas which can be

involved and also knows what GI disease can look like (it’s most commonly

white because of scarring surrounding the disease). Most gynecologists do

not look at the intestines very closely, so many laparoscopies are useless

for ruling out GI disease.

…it is rarely necessary to consider

removal of the

uterus, tubes and ovaries

to treat pelvic or GI

endometriosis since

removing those organs

doesn’t eradicate

the disease.

Looking at GI endometriosis will not make it go away, and now the question

about treatment comes up. Fortunately, this is a simple topic. Medical

therapy has never been studied with respect to intestinal endometriosis.

Medical therapy does not eradicate endometriosis of any stage or location

anyway and is not FDA-approved for treating infertility associated with

endometriosis. The only indication for medical therapy in treating

endometriosis of the pelvis or GI tract is to attempt to achieve temporary

pain relief if the patient must wait a long time for surgery. Surgery is the

only way to eradicate GI endometriosis. Many patients who have had GI

disease diagnosed have hysterectomy and removal of the ovaries recommended

to them, even though these organs may be uninvolved by disease.

While it is true that depriving the patient of estrogen stimulation of

endometriosis by such surgery will often reduce or eliminate pain, it makes

much more sense in many patients to remove the disease first and see what

that does for pain. If the uterus is causing problems because of fibroid

tumors or adenomyosis, and if the patient has completed her childbearing

career and simply is tired of putting up with pain and repeated surgeries,

then removal of the pelvic organs may add to the relief of removing all

endometriosis. However, it is rarely necessary to consider removal of the

uterus, tubes and ovaries to treat pelvic or GI endometriosis since removing

those organs doesn’t eradicate the disease.

While many surgeons like to use laser vaporization or electrocoagulation to

treat pelvic endometriosis, it is unsafe to burn at the bowel (although some

surgeons occasionally do this) because a hole could be created which is not

obvious and which can cause serious complications. Excision of the

endometriosis with suture or staple repair of the bowel wall is necessary to

safely and completely remove GI disease.

At St. , we have pioneered

surgical treatment

of GI endometriosis, and

it is now possible to treat

most cases of GI involvement

with the laparoscope.

At St. , we have pioneered surgical treatment of GI endometriosis,

and it is now possible to treat most cases of GI involvement with the

laparoscope. Most patients do not require a segmental bowel resection where

the diseased segment is removed and the 2 ends of the bowel are put back

together. Even if this is necessary, laparotomy is not always required.

In a new twist for those who do require laparotomy, I have found that if the

laparoscope is used to treat all pelvic disease and then to isolate the

segment of bowel to be removed, that the incision can be kept quite small.

One patient recently had full thickness resection and repair of a rectal

nodule, but I also saw nodular disease of her sigmoid and ileum. By

isolating the sigmoid nodule laparoscopically, I was able to make a small 3

inch incision and we were able to do segmental bowel resections on both the

ileum and sigmoid through this tiny incision. The patient was dreading

seeing her incision, but when I took the dressing off two days later, she

looked at it and said " That’s not so bad. I can still wear my bikini. "

Colostomy is not necessary in any patient to treat GI endometriosis. We have

had only one serious complication in over 500 patients. A patient developed

a leak from her suture line a few days after surgery and required a

temporary colostomy for healing. This has since been reversed and she is

having normal bowel movements once again. Another patient developed a

stricture requiring dilation of the bowel.

To our knowledge, the endometriosis

treatment team at St. has more

experience than any center in the world

in treating GI involvement.

To our knowledge, the endometriosis treatment team at St. has more

experience than any center in the world in treating GI involvement. I

personally do most of the bowel surgery and enlist the aid of Dr. Dean

Sharpe or Dr. Marinus Koning when the occasional segmental bowel resection

is necessary. GI endometriosis doesn’t need to be frightening or mysterious.

Like pelvic endometriosis, it is actually straightforward when the disease

is understood. Doctors sometimes tend to make things sound more complicated

than they really are because they may not have much experience treating

endometriosis.