Bowel Endometriosis

When the endometriosis invades the layers of bowel wall (serosa, muscular layer, submucosa, mucosa), bowel endometriosis results. Depending upon the depth of invasion, size of lesion, and location of invasion, the type of surgery is decided. The most common sites where the intestines affected are rectum, sigmoid, appendix, cecum, and distal ileum in descending order. If you face symptoms of IBS, and/or endo belly specifically associated with painful menstruation, it may suggest bowel endometriosis existence and flare-ups.

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    Prevalence1 out of 5 endometriosis cases infiltrate deeper into the large and small intestine.

    Area of Involvement:

    90% of bowel endometriosis cases involve the rectum and sigmoid colon, while 10% involve the appendix and ileum. Patients with bowel disease also have a higher chance of developing diaphragmatic endometriosis. Advanced bowel disease–requiring nodule excision or bowel resection procedures–involves the urinary system also, including the ureters and bladder. Approximately 15-20% of bowel endometriosis are multi-focal (diffuse within a certain area), while the rest are multi-centered.

    Symptoms of bowel endometriosis

    • painful bowel movements, rectal pain, and bowel spasms specifically  increasing during periods
    • blood stained stools during periods
    • constipation, especially during periods
    • alternating diarrhea and constipation (some patients have diarrhea first then constipation, while others have the reverse) during menses
    • abnormal gas, especially during periods
    • abdominal bloating
    • Painful sex (dyspareunia), due to infiltration of endometriosis to the rectum and pouch of Douglas
    • Irritable bowel syndrome worsening around the time of menses

    As most of the symptoms of bowel endometriosis include digestive or gastrointestinal pain, it is commonly misunderstood as irritable bowel syndrome (IBS). The only difference is in the frequency and severity of pain in endometriosis related IBS. A woman with pure IBS without endometriosis may experience pain several times per week and any day of the month, while bowel endometriosis causes intense pain specifically around timing of the menstrual cycle.

     

    Endometriosis will often present with bowel symptoms (diarrhea, constipation, etc.), causing women to seek aadvice from gastroenterologists, who will likely attribute the symptoms to IBS, appendicitis, Crohn’s disease, or even colon cancer.

    These diagnoses are made without taking biopsy or performing histopathology report. Unfortunately, women go on to receive multiple colonoscopies and are often diagnosed without a full evaluation of what may really be the underlying cause of their symptoms. For these reasons, IBS diagnosis is given to women without evaluation for endometriosis -a “wrong diagnosis” for a patient’s bowel dysfunction and pain, specifically if they have symptoms which coincide with their period. Not only the misdiagnosis, such women receive the wrong treatment and continue to bear the persistent symptoms for many years (approximately 5-10 years), and realize that they had endometriosis all these years.

    In IBS, inflammation of the bowel is exclusively seen within the intestines whereas Inflammation caused due to bowel endometriosis occurs to the outside of the bowels (commonly involving the outer layers of wall). Colonoscopies and endoscopies can only examine the mucosa (innermost layer) of the bowels. So, colonoscopies are unable to identify inflammation caused by endometriosis. Laparoscopic surgery is the only way for definitive diagnosis of bowel endometriosis.

    If, during your periods, you experience pain and/or IBS with your bowel movements, then speak with Endometriosis specialist in Ahmedabad, Dr Sandip Sonara.

    Diagnosis:

    • overall physical exam, including a manual check for any tender area or endometriotic nodule/spot in the vagina or rectum.
    • imaging tests such as ultrasound, MRI, barium enema
    • endoscopic procedures such as colonoscopy, Laparoscopy

     

    Surgery to excise the endometrial tissue from the bowels is the most common treatment option for bowel endometriosis. Procedures vary, depending on the location, size, and depth of invasion of the endometrial tissue in bowel layers, and may include:

    • Rectal shaving: which involves shaving off the endometriosis from the superficial layers extending up to muscularis layer of the bowel wall, without removing any part or length of the intestines. Harmonic scalpels or cold scissors are best to perform this.
    • Discoid dissection: In this surgery the endometriosis specialist cuts the small part of bowel of the endometriosis like a disc which is spread more in width rather than depth and then closes the remaining bowel same time without opening it into tummy. In cases where the endometriotic nodule is unifocal, deep and smaller than 3 cm, discoid resection is considered the first option.
    • Segmental bowel resection or resection and anastomosis (RA) of bowel: Segmental resection of bowel is performed in cases of unifocal lesions more than 3 cm in diameter, two or more infiltrative lesions (nodules), and/or a unifocal lesion involving more than 50% of the intestinal wall. When the full thickness of bowel wall is invaded by endometriosis or stricture is formed due to long term endometriosis disease, the small length of the bowel with endometriotic nodule is removed and is reconnected with the healthy part of the bowel at the same time.

    These types of surgeries usually require bowel preparation, as well as antibiotic prophylaxis.

    • Recovery: It varies depending on the severity of the condition, type of surgery, duration of surgery, long anesthesia time, way of handling of bowels and of course the skill and knowledge of the surgeon in treating such cases.

    If you suffer from bowel endometriosis, be sure to communicate closely with your endometriosis specialist for comprehensive care to manage your pain and determine the best outcome for your long-term wellbeing.

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