Rectal endometriosis

Introduction to rectal endometriosis Endometriosis (rectalendometriosis) refers to the abnormal growth of endometrial tissue with growth viability outside the uterine cavity. Any part of the body may occur, but most of the lesions are confined to the pelvic cavity, endometrial tissue. Leaving the uterus, invading the pathological state caused by the rectum, is the rectal endometriosis, which grows slowly and spreads easily. basic knowledge The proportion of illness: 0.004%-0.007% Susceptible people: no specific population Mode of infection: non-infectious Complications: infertility

Causes of rectal endometriosis

Genetic factors (35%)

Genetic studies have found that sisters (5.9%) and mothers (8.1%) of patients with endometriosis currently have endometriosis, and the incidence rate is only 1 in female first-degree relatives of patients. %. Therefore, some scholars believe that EM is a hereditary disease with disordered immune surveillance.

Physiological factors (25%)

Reproductive tract obstruction exacerbates menstrual blood flow, which is easy to progress in endometriosis. Therefore, endometriosis is more likely to occur in patients with residual uterus, hymen atresia, and vaginal diaphragmatic hernia. Therefore, while performing laparoscopic diagnosis and treatment, we recommend correcting these anatomical abnormalities at the same time. Reduce the risk of endometriosis by repairing anatomical abnormalities.

Environmental factors (10%)

A large number of studies have shown that exposure to environmental toxins may play a role in the development of endometriosis. 2,3,7,8-tetrachlorobenzene dioxins (TCDD) are the most common environmental toxins. TCDD stimulates the formation of endometriosis by binding to estrogen and appears to block progesterone-mediated changes in endometriosis regression. In the environment, TCCD and other dioxins are by-products of industrial production, and contaminated food or accidental exposure is the most common form of exposure.

Pathogenesis

1. Distribution: endometriosis has a wide range of distribution, common parts are pelvic peritoneal and pelvic organs, such as ovary, uterine serosa, fallopian tube, uterine fibular ligament, round ligament, uterine rectum, rectum, bladder Surface, can also occur in the umbilicus, appendix, groin, laparotomy incision scar, sigmoid colon, small intestine, liver, pancreas, pelvic lymph nodes, kidney, ureter, cervix, vagina, vulva, bronchus, lung, chest, mediastinum, breast, central Nervous system, peripheral nerves, limbs, bones, etc. Currently, only endometriosis has not been found in the spleen, which may be related to the immunological function advantage of the spleen compared with other abdominal organs.

Uterine rectal depression is the lowest position of the pelvic cavity, and is also a good site for endometriosis. Therefore, colorectal endometriosis is not uncommon. 50% of severe endometriosis has different degrees of intestinal tract. Invasion, Mayo Medical Center data showed that in 2686 cases of endometriosis, there were 497 cases (18.5%) of intestinal endometriosis, of which 360 cases were in the sigmoid colon, rectum and junction. There were 67 cases in the rectal vaginal septum, accounting for 72.4% and 13.5% of the intestinal lesions respectively. The University of Texas Medical Center data also showed that intestinal endometriosis accounted for 5.4% of the total endometriosis, rectum Endometriosis of the uterus rectal cavity accounted for 70% of the intestinal tract. In another group of 163 cases of intestinal endometriosis distribution, 65 cases (40%) of the sigmoid colon, sigmoid colon junction 33 There were 32 cases (20%) in the appendix, 20 cases (12%) in the ileocecal area, 17 cases (10%) in the rectum, and 1 case (O.61%) in the transverse colon.

2. Pathology

(1) Gross morphology: Endometriosis lesions often appear as purple-blue superficial spots, which are "gunpowder burns". The diameter of a single lesion is no more than 0.5cm. There are often fibrous tissue hyperplasia around, such as hyperplasia. With endometrial hemorrhage can form endometrial tumors. With the development of lesions, the ectopic endometrium in the menstrual cycle decreases with the level of ovarian hormones. After repeated hemorrhage, the blood in the lesions increases, the fibrous tissue thickens, and finally the induration is formed. Or in the early stage of colorectal endometriosis, in the uterine rectum concave surface, the uterine tibia ligament can be seen in purple blue superficial spots or gray-red shrinking scars, after the rectum and the uterus adhesion, the uterus rectum becomes shallow and even Disappeared, there may be multiple induration at the humeral ligament of the uterus. The development of the lesion to the vaginal rectum can compress the rectum. The lesion on the colorectal is mainly located on the surface of the serosa and the muscle layer. The mucosa is rarely affected, but when the lesion is severe, the tumor is caused by inflammation. Fibroplasia and scar contracture can lead to intestinal obstruction. In addition, ectopic endometrium can invade the intestinal wall to form masses, causing intestinal bleeding or stalks. .

In the lesion, the ovary can be a "chocolate cyst" or a "tar-like cyst" that closely adheres to the surrounding tissue. A severe patient can form a "frozen pelvis" of endometriosis like chronic pelvic inflammatory disease.

After menopause, unless there is endogenous or exogenous persistent estrogen source, the lesions gradually degenerate. During pregnancy or hormone therapy, the ectopic endometrium can be decidual, the lesion becomes edematous and slightly jelly-like. Similar to malignant lesions, a biopsy should be made to confirm the diagnosis.

Sometimes the lesions show atypical changes, appearing:

1 peritoneal white opaque area, may not thicken;

2 peritoneal red flame-like lesions, often protruding from the peritoneal surface;

3 peritoneal surface gland neoplasms;

4 round peritoneal defects;

5 adhesion under the ovary, there is no pigmentation lesion between the ovary and the ovarian fossa peritoneum, these conditions are common in laparoscopic examination, their biopsy confirmed the diagnosis rate of endometriosis 45% ~ 81%.

(2) histological morphology: microscopic examination of tissue sections of endometriosis can be seen:

1 endometrial gland, interstitial;

2 evidence of bleeding, that is, see red blood cells, phagocytose a large number of hemosiderin-containing macrophages and hemosiderin, there are often a large number of inflammatory cells around the lesion, disease edema changes and fibrous connective tissue.

Microscopic examination often shows the location of the lesion, the onset time, is affected by ovarian hormones, and the ectopic endometrium is also affected by ovarian hormones, but there is no periodic change.

3. Malignant transformation: The structure and function of the ectopic endometrium and the normal endometrium are basically the same, and the possibility of malignant transformation should be the same, but the ectopic endometrium rarely undergoes malignant transformation.

4. Staging: Endometriosis is similar to some gynecological tumors, and there are diffuse planting behaviors in the pelvic cavity and intra-abdominal cavity. In order to determine the extent of the lesion, it is necessary to carry out a unified staging method in order to formulate a reasonable treatment plan according to this. The effect is compared.

The American Fertility Association (AFS) developed a scoring method based on laparotomy or laparoscopic findings. It was revised in 1985. The revised staging, RAFS staging, has been widely adopted internationally.

In 1989, Markham et al. proposed a classification staging criteria for extrapelvic endometriosis that did not include the uterus, fallopian tubes, ovaries, and surrounding peritoneum.

(1) Classification of extrapelvic endometriosis:

Class I endometriosis violates the intestine

U-type endometriosis invades the urethra

L-type endometriosis invades the lungs, chest

O-type endometriosis invades other parts of the abdomen

(2) Staging of extrapelvic endometriosis:

Stage I has no organ defects.

1 Exogenous: organ surface (serosal membrane, pleura)

a lesion <1cm

b lesion 1 ~ 4cm

c lesion> 4cm

2 endogenous: mucosa, muscle layer, substance

a lesion <1cm

b lesion 1 ~ 4cm

c lesion> 4cm

Stage II organ defect

1 Exogenous: organ surface (serosal membrane, pleura)

a lesion <1am

b lesion 1 ~ 4cm

c lesion> 4cm

2 endogenous: mucosa, muscle layer, substance

a lesion

b lesion 1 ~ 4cm

c lesion> 4cm

Organ defects are based on organ invasion, including but not limited to: intestinal tract, urethral obstruction and partial obstruction, hemothorax caused by lung invasion, hemoptysis, pneumothorax.

There are still some shortcomings in the current stage, mainly in:

1 staging according to clinical data rather than statistical results;

2 to score according to the disease site rather than the relevant risk;

3 degree staging is more arbitrary;

4 focus on the prognosis of fertility, ignoring other symptoms.

Rectal endometriosis prevention

Because the etiology of endometriosis is complicated and may even be related to genetic factors, it is not completely preventable at this stage. However, if medical personnel pay attention to the following aspects and take some effective measures, It is possible to reduce the incidence of this disease.

1. Take appropriate measures to correct various gynecological conditions that may lead to menstrual reflux, such as severe uterine posterior tilt, lower genital atresia or stenosis.

2. Prevent the occurrence of iatrogenic endometriosis as much as possible, avoid tubal ventilation before the onset of menstruation, and do a freehand surgery on the posterior uterus to prevent endometrial debris from being passed through the fallopian tube. Pushed to the pelvic cavity, as far as possible, without the use of cesarean section as a method to terminate the second trimester of pregnancy, and instead of drug induction, try not to use artificial abortion as a birth control measure, but use the method of placing an intrauterine device or taking birth control pills. When performing cesarean section, gauze should be used to protect the abdominal wall incision to prevent endometrial debris from being implanted into the abdominal wall tissue. After suturing the peritoneum, the abdominal wall wound is washed with physiological saline, and then layered and sutured.

Rectal endometriosis complications Complications infertility

First, infertility: endometriosis patients often accompanied by infertility. According to reports from Tianjin and Shanghai, primary infertility accounted for 41.5 to 43.3%, and secondary infertility accounted for 46.6 to 47.3%. Pelvic endometriosis can often cause adhesions around the fallopian tubes to affect the oocyte pick-up or cause blockage of the lumen. Or caused by factors such as poor follicular development or ovulation disorders.

Second, periodic bladder irritation symptoms: When endometriosis affects the bladder peritoneal pleats or invades the bladder muscle layer, there will be symptoms such as urinary urgency and frequent urination. If the lesion invades the bladder mucosa (bladder endometriosis), there is periodic hematuria and pain.

Third, the symptoms of periodic rectal irritation: rectum, anus, genital bulge, falling pain, feelings of urgency and increased stool frequency. As the lesions worsen, the symptoms become more pronounced and the symptoms disappear after the passage.

Symptoms of rectal endometriosis Common symptoms Dysmenorrhea menstrual bleeding Abdominal discomfort Secondary infertility Intestinal bleeding Congestive diarrhea Abdominal pain Blood in the stool

Symptom

Colorectal endometriosis has common symptoms and intestinal symptoms of endometriosis.

(1) abnormal menstruation: about 80% of patients have menstrual abnormalities, mainly manifested as dysmenorrhea, excessive menstruation or irregular menstruation.

1 dysmenorrhea: secondary, that is, dysmenorrhea after several years of menarche, increased year by year, can be radiated to the vagina, perineum, anus or leg, the most severe one day before the menstrual period, the pain is completely disappeared, the pain is mainly due to ectopic Endometrial edema before menstruation, menstrual bleeding, stimulation or pulling around the tissue.

2 excessive volume or irregular menstruation and ovarian interstitial invasion of the endometrium, severe adhesions around the ovary can not ovulate, ovarian hormone secretion disorders and so on.

(2) Sexual pain: more obvious before menstruation, mostly located in the deep part of the vagina, the patient refuses sex life, cold sex, and reduced chances of conception. This may be related to the pelvic peritoneum that touches the cervix during sexual intercourse and stimulates congestion.

(3) Infertility: 30% to 50% of patients have primary or secondary infertility, 30% to 50% of infertile patients see ectopic lesions by laparoscopic examination, infertility and fallopian tube obstruction, ovulation disorders, Gamete or fertilized egg delivery disorders, ovarian tissue extrusion, luteal function, unruptured follicular luteinization syndrome, follicular maturation and egg fertilization disorders, implantation disorders, the presence of fungal tubers and intra-abdominal microenvironment.

(4) Intestinal symptoms: In the early stage of colorectal involvement, there may be bowel pain, abdominal discomfort, diarrhea and other intestinal symptoms. Constipation, bloody stools and other symptoms may occur when the lesion is large or invade the intestinal mucosa. Or menstrual aggravation, sometimes blood in the stool without cycle, advanced patients can develop complete intestinal obstruction, according to Coronado et al, 77 patients with common symptoms of rectal pain (74%), sexual pain (46%), constipation (49%), Diarrhea (36%), rectal bleeding (31%), Bailey et al found that 130 patients had symptoms of pelvic pain (85%), rectal pain (50%), periodic rectal bleeding (18%), and diarrhea (40%). , constipation (41%), sexual pain (64%), etc., obvious symptoms of intestinal obstruction are less common.

2. Signs: typical signs of pelvic endometriosis are single or several indurations of the uterine ligament or uterus rectum. The fixation is fixed, tender, and the nodules increase during menstruation. The tenderness is more obvious. The uterus generally does not increase, the position may be normal, but most of them are posteriorly inclined and fixed. When the lesion involves the bladder, the uterus-bladder recess can touch the induration. When the lesion involves the ovary, the wall thickness of one or both sides of the uterus can be touched. The cystic mass is fixed to the uterus and has tenderness.

When the lesion involves the rectum, the rectal vaginal septum thickens and adheres to the posterior wall of the uterus, which can form a mass. Coronado et al found that 84% of patients had a uterus rectal depression, 57% of which were fixed with the rectum. Bailey et al also found that The most common signs before are the uterus rectal depression and the uterine fibular ligament mass, and the rectal wall and the uterus rectal recession, which can be detected by double diagnosis. When the rectal stenosis, the rectal examination can find the stenosis, there is also a surrounding The circle structure is obviously thicker.

Examination of rectal endometriosis

At the time of serological examination.

1. Serum CA125 test: serum CA125 is elevated in patients with endometriosis, and the positive rate of patients with moderate to severe disease is nearly 100%. The change of serum CA125 during treatment can be:

1 to guide the dosage of the therapeutic drug and the length of the treatment;

2 evaluate the therapeutic effect;

3 early detection of recurrence, serum CA125 can also be used to identify endometriosis and ovarian cancer, ovarian cancer serum CAl25 elevation is more obvious than endometriosis.

2. Serum placental protein 14: Placental protein 14 is an antibody of endometrial tissue secreted by the endometrium. The serum concentration has a menstrual cycle-like change, and the concentration of placental protein 14 in patients with endometriosis is increased. The diseased tissue secretes placental protein 14 and CAl25 into the abdominal cavity, and deep invasive lesions secrete these substances into the blood.

Although the patient's serum CA125 and placental protein 14 increased, the degree of increase was not related to the severity of the lesion.

3. Rectal vaginal double diagnosis: It can touch the uterus and rectum recess and the uterine fibular ligament mass and the rectal wall and the uterus rectum.

4. Digital rectal examination: It can be found that the tissue around the intestinal wall is obviously thicker and the rectum is narrow.

5. Rectal sigmoidoscopy: Patients with colorectal endometriosis may have varying degrees of stenosis, smooth and intact mucosa but with shrinkage and congestion, and tissue should be taken for pathological examination when the tumor is difficult to identify.

6. Barium enema examination: In the mid-menstrual period and the second day of menstruation, the bowel enema examination is used to observe the changes of the lesions in the intestinal stenosis, which is helpful for diagnosis. When the barium enema is found, it can be found:

1 The rectum and/or colon have a long filling defect, narrow, narrow edges and intact mucosa;

2 The intestine has only mild inflammation, the stenosis is fixed, tender, slightly irregular, but not as stiff or ruptured as a tumor.

7. B-ultrasound: In the diagnosis of endometriosis, B-ultrasound is limited to detecting elevated adenomas of the ovary, and the sensitivity to implant lesions is very low (about 11%).

8. Laparoscopy: The advent of laparoscopic surgery has made a leap in the early diagnosis and correct diagnosis of endometriosis. There is no history of typical endometriosis in the clinic, early symptoms of symptoms and signs, mainly through the abdominal cavity. Mirror examination to make diagnosis and staging, the correct rate of diagnosis under the microscope is related to the operator's understanding of the disease, generally around 95%, about 5% of endometriosis is missed, and 50% of patients have lesions underestimate.

Endometriosis lesions are various in laparoscopic shape, color is different, can be blue, yellow, white, red, colorless and transparent, etc., should be confirmed by biopsy, ovarian endometriosis The cyst can be seen under the microscope. The wall thickness is blue-white or faint brown, which adheres to the surrounding tissue. The surface shows blue spots or coffee-like plaques. The puncture can obtain brown thick liquid.

9. MRI examination: MRI detection of endometriosis attachment mass is higher, its sensitivity, specificity, predictability are 90%, 98%, 96%, respectively, the diagnosis of pelvic scattered lesions is more accurate than B-ultrasound, but the sensitivity is still very low, the check is:

1 observe the degree of pelvic adhesion before surgery;

2 Once the diagnosis is successful, it can be used to monitor the treatment effect later.

10. Fine needle aspiration cytology examination: For the uterus rectal recession or rectal vaginal septum mass can be sucked through the vagina for fine needle aspiration, aspirate for cytological examination, such as seeing a cluster of endometrial cells, stale Red blood cells, hemosiderin, etc. are helpful for diagnosis.

Diagnosis and diagnosis of rectal endometriosis

Diagnostic criteria

Endometriosis is a common disease, frequently-occurring disease, all patients who encounter infertility, dysmenorrhea should think of the disease, the following symptoms and signs should be highly suspected colorectal endometriosis:

1 intestinal symptoms associated with dysmenorrhea, dyspareunia, such as progressive constipation, lower abdominal pain;

2 periodic blood in the stool, incomplete intestinal obstruction;

3 The intestinal mass is located outside the mucosa or the mass is reduced after the menstrual period;

4 accidentally found intestinal lumps adjacent to the pelvis;

5 gynecological examination of the diagnosis of pelvic endometriosis in the presence of intestinal symptoms.

Rectal sigmoidoscopy and biopsy should be performed for diagnosis.

Differential diagnosis

Colorectal endometriosis has some in common with colorectal tumors and inflammatory lesions, and it is often necessary to identify them clinically.

1. Colorectal tumors: The following characteristics of colorectal tumors help to identify:

1 good age is too large;

2 very few infertility and abnormal menstruation history;

3 shorter course;

4 often accompanied by weight loss, cachexia, ascites and other advanced cancer symptoms;

5 The degree of symptoms is not closely related to menstruation;

6 barium enema found that the filling defect range is small, the edge is irregular but clear, and the mucosa is broken.

It should be emphasized that the invaded mass should be pathologically examined to determine the nature of the lesion. The rectal mass found during surgery should also be examined by frozen section. It should not be diagnosed as rectal cancer and combined with abdominal perineal resection. Rectal endometriosis is mistaken for rectal cancer and is reported as a combination of abdominal and vaginal resection.

2. Colorectal inflammatory lesions: The following characteristics of colorectal inflammatory lesions help to identify:

1 often have a history of fever and weight loss;

2 white blood cell count increased;

3 abnormal stool examination and bacterial culture examination;

4 barium enema examination showed a longer filling defect, the edge was not neat, the mucosa was deformed, and the boundary with the normal part was not clear.

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