Targeted ultrasound for deep intestinal endometriosis

Intestinal endometriosis is a complex gynecological condition that requires focused investigation and multidisciplinary care by an experienced team1. Here, we demonstrate the value of preoperative transvaginal ultrasound in the evaluation of deep endometriosis involving the intestine. We present a resected rectal segment containing the deep intestinal nodule previously identified on the dedicated transvaginal ultrasound. A preoperative pelvic ultrasound can characterize the extent of the disease to help plan a multidisciplinary surgical approach for the patient.

A 43-year-old patient presented with severe endometriosis confirmed by a previous laparoscopy. Her symptoms included a history of dysmenorrhea and catamenial dyschesia. She denied any history of hematochezia or dyspareunia. Sigmoidoscopy did not reveal any mucosal involvement, however external compression was noted at the rectosigmoid junction. Expert guided transvaginal ultrasound2 revealed a hypoechoic, avascular, and deep lesion along the rectal muscle layer measuring 3.7 cm x 1.2 cm x 2.4 cm (Figure 1). The nodule also showed signs of intestinal retraction and attachment to the back of the uterus3.

Figure 1Transvaginal ultrasound showing hypoechoic deep endometriotic intestinal nodule measuring 3.7 cm x 1.2 cm x 2.4 cm in the cul-de-sac, with no demonstrable blood flow.

A multidisciplinary surgical approach with a team dedicated to endometriosis (including gynecological and colorectal surgeons) has been planned. The patient underwent laparoscopic excision of endometriosis, total hysterectomy, bilateral salpingo-oophorectomy, ureterolysis and low anterior resection and primary anastomosis. Figure 2 shows the sectioned rectosigmoid specimen containing the deep nodule involving the muscularis of the intestine, as shown in the preoperative ultrasound. The patient recovered well from her intervention. This case illustrates the utility of an in-depth pelvic ultrasound to aid in planning a multidisciplinary surgical approach and provides a graphical correlation of imaging and gross pathology.
Figure 2

Figure 2Sectioned rectal intestine specimen showing the deep endometriotic nodule involving the muscularis of the intestinal wall. The firm and fibrous palpated nodule.

The references

  • 1

    Chou D, Perera S, Condous G, Cario G, Rosen D, Choi S, Al-Shamari M, Bukhari M. Shaving for intestinal endometriosis. J Minim Invasive Gynecol. Feb 1, 2020; 27 (2): 268-9.

  • 2

    Guerriero S, Condous G, Van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, Exacoustos C, Installé AJ, Martins WP, Abrao MS, Hudelist G. Systematic approach to ultrasound evaluation of the pelvis in women suspected of endometriosis, including terms, definitions and measures: a consensus opinion of the International Deep Endometriosis Analysis (IDEA) group. Ultrasound in obstetrics and gynecology. September 2016; 48 (3): 318-32.

  • 3

    Della Zazzera V, Benning H, Lortie K, Singh SS. Moose antler sign, sign of deep endometriosis infiltrating the intestine. Journal of Minimally Invasive Gynecology. 2017 Jul 1; 24 (5): 706.

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