Endo of the bowel

Hi there once again.
Well, I had a request to do a little review of endometriosis of the bowel. Bowel endo is actually more common than one might think, with over 25% of our patients here in Bend having intestinal endometriosis. That number is most likely higher than the general population, as our patients typically have more severe disease than what the average gynecologist sees. Most doctors aren't familiar with the treatment for bowel endo, so these patients tend to float around from doctor to doctor looking for someone who can help them. Unfortunately, usually nobody has until they get to us.
The most common site of intestinal endometriosis is the sigmoid colon, the portion just above the rectum that lies on the left side just beneath the left hip bone. Following that, the rectum (behind the vagina and cervix) is next, then the last part of the small bowel, appendix, and cecum (beginning of the large intestine). Some patients have bowel disease in more than one location, and it is often associated with ovarian endometriomas (also called "chocolate cysts"). (as we said in Med school, "there goes another food group....")
If the lesion is of sufficient depth, endo of the sigmoid and rectum will cause pain with bowel movements (sigmoid - left lower quadrant pain, rectum - midline pain right where the lesion is). Most of the time these will hurt all month but can get worse during the menses, and rarely (if the lining or mucosa is involved) they can cause rectal bleeding during menses. Some women have diarrhea, constipation, or both in an alternating fashion, but these symptoms alone do not necessarily indicate bowel involvement as they can be seen in those with pelvic (non-bowel) endo as well. Endometriosis of the appendix, cecum, and ileum tend not to cause pain, but in rare cases if the lesion is large enough obstructive symptoms (nausea, vomiting, intermittent crampy pain) can occur.
Why can't some cases of bowel endo get diagnosed? Doctors of old had very few "tests" to do (x-rays, lab studies), so they had to rely on their ability to ask the right questions, listen to what the patient was telling them, and gather the data they needed by their 5 senses. Nowadays, since the advent of CT scans, MRIs, Nuclear medicine scans and the like, plus the atmosphere of "defensive medicine", most docs have lost at least some of the old-fashioned ability to make a diagnosis with their brain, eyes, ears, and their own 2 hands. Imaging studies are notoriously poor at finding endometriosis (with the exception of endometriomas), so in order to diagnose it, one must have a strong suspicion from the history and the physical exam. Rectal nodules can usually be felt on exam and are exquisitely tender, reproducing the defecatory pain, but nodules of the sigmoid colon or higher oftentimes cannot be palpated. Disease is then confirmed by surgery where the surgeon sees the lesions, then by biopsy where the pathologist verifies the lesion to actually be endo and not an imposter. If the surgeon doesn't routinely look at or think about the bowel as many GYNs do (or don't), even at surgery lesions on the bowel can be missed. For those docs who don't trust their own suspicions as much as they trust a CT scan, bowel endo will be missed because it usually doesn't show up on ultrasound, CT, MRI, or most other imaging study. Once in a while if the lesion is large and the radiologist knows what to look for these lesions can be seen, but not commonly. Colonoscopy and flexible sigmoidoscopy (a "mini-colonoscopy" where only the rectum and sigmoid are inspected) typically do not reveal endometriosis either, so unless one is both familiar with and suspicious of bowel endo, it likely will go undiagnosed.
What can be done for bowel endo? The good news is that most patients who undergo surgery to remove the lesion have excellent, long-lasting pain relief. The bad news is that these lesions (even when they are diagnosed) are typically not removed by gynecologists because most don't operate on the bowel. Some patients are referred to general surgeons for treatment, but most are placed on Lupron for suppression, even though it has never been proven to work for this type of lesion. When Dr. Redwine and I remove bowel lesions, most of the time the lesion can be removed by either a partial thickness or full thickness resection of a disc-shaped area, then the hole is sutured closed in layers. This is almost always done laparoscopically, and most patients go home within 24 hours of surgery. Sometimes if the lesion is very large or more circumferential, a segmental resection must be done. This involves removing a whole segment of bowel, sometimes up to a foot in length, then reattaching it using a stapling device. Because of the larger dissection involved and the longer operating time, these types of procedures will usually require a 3-4 day stay in the hospital to allow for normal bowel function to return, marked by the passage of gas (flatus is the $10 medical term). The irony is that these patients very often have immediate pain relief, and when they wake up from anesthesia they can tell that that deep, burning, agonizing pain they've been living with for years is gone. Their postop pain is usually nothing compared to what they've been dealing with preop, and it has been my experience that these ladies are the happiest patients of all. In fact, for both Dr. Redwine and myself, seeing these women pain free for the first time in years is our reward for the physical challenge of a long, demanding surgery. Long-term results of these surgeries are excellent with about 80% cured at 5 years, and fertility rates above 40% (not perfect, but much better than preop).
Our experience thus far has been to operate on almost 800 cases of bowel endometriosis, and to be honest, it is my favorite type of patient to take care of. The surgery is challenging, fun, and satisfying because these women do so well, both in terms of their immediate postop course and their long-term pain relief.
I hope this helps those of you who see a little of yourselves in the above descriptions, and I wish you the best in dealing with your disease. Remember, I'm doing free record reviews through the end of March, so if you think this might be you but you're not sure, don't hesitate to contact us. I'm really not typically into self-promotion, but in this case, I have to because not very many other docs in this country do this well, and I have to say, David's the best. And I'm getting there. Let me know what other topics you're interested in.
Take care, and have a great week.
Dr. Mos