Just a little info I found, very interesting! Long but worth reading ; )
Intestinal Endometriosis
By David 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. Charles, 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.
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 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.
