Endometrial obstruction

Introduction Under normal circumstances, the endometrium covers the surface of the uterine cavity. If the endometrium grows in other parts of the body due to certain factors, it can become endometriosis. This ectopic endometrium has histological not only glandular glands, but also endometrial stroma; functionally with estrogen levels, which vary with the menstrual cycle, but only partially Affected by progesterone, it can produce a small amount of "menstruation" and cause various clinical phenomena. If the patient is pregnant, the ectopic endometrium may have a decidual change. Although this ectopic endometrium grows in other tissues or organs, it is different from the invasion of malignant tumors. The peak of the disease is 30 to 40 years old. The actual incidence of endometriosis is much higher than that seen in clinical practice. For example, in the laparotomy of other gynecological diseases and careful examination of the excised uterine attachment specimens, it can be found that about 20 to 25% of patients have ectopic endometrium.

Cause

First, the implant theory: the earliest (1921) Some people believe that the occurrence of pelvic endometriosis, endometrial debris with the menstrual blood flow, through the fallopian tube into the pelvic cavity and planted in the ovary or other parts of the pelvic cavity. Clinically, menstrual blood can be found in the pelvic cavity during laparotomy during menstruation, and the endometrium can be found in the blood. Abdominal wall scar endometriosis formed after cesarean section is a good example of implant theory.

Second, the serosal theory: also known as the theory of metaplasia, that ovarian and pelvic endometriosis is caused by the mesenchymal cell layer of the peritoneum. The secondary renal tube is developed from the original peritoneal invagination, with the ovarian hair growth epithelium, pelvic peritoneum, and atresia of the peritoneal depression, such as the peritoneal sheath (nucleus) of the inguinal region, rectal vaginal septum, umbilicus, etc. It is differentiated from the body cavity epithelium. Any tissue that occurs from the body cavity epithelium has the potential to generate tissue that is almost indistinguishable from the endometrium. Therefore, the peritoneal mesothelial cells may be mechanical (including tubal ventilation, posterior uterus, cervical obstruction), inflammatory, and different. Under the stimulation of factors such as pregnancy, it is prone to metaplasia of the endometrium. The germinal epithelium on the surface of the ovary is the original body cavity epithelium and has the potential to differentiate. Under the influence of hormones and inflammation, various tissues that can be formed into embryos, including the endometrium, can be formed. The ovary is the most easily involved part of external endometriosis, and it is easy to explain with the theory of metaplasia. Implantation theory cannot explain the causes of endometriosis beyond the pelvic cavity.

3. Immunology: In 1980, Weed et al reported that lymphocytes and plasma cells infiltrated around the ectopic endometrium. The macrophages contained hemosiderin and various degrees of fibrosis. They believe that the ectopic endometrial lesions act as foreign bodies, which activate the body's immune system. Since then, many scholars have explored the etiology and pathogenesis of endometriosis from the aspects of cellular immunity and humoral immunity.

(1) Defects in cellular immune function: 1. Deficiency of T lymphocyte function; 2. Functional defect of natural killer cell (NK): NK cells are a group of heterogeneous multifunctional immune cells whose functional characteristics are not required. The presence of antibodies can kill certain tumor cells or virus-infected cells without antigen sensitization, and plays an important role in immune monitoring in vivo.

(2) Defects in humoral immune function:

Theories about the occurrence of endometriosis are also:

1 Lymphatic dissemination theory. It is believed that the endometrium can be spread through the lymphatics, and it has been found that the parauterine lymph nodes and the intraorbital lymph nodes contain endometrial tissue. However, the weakness of this theory is that the endometrial tissue is rarely seen in the central lymph node, and the normal site does not conform to normal lymphatic drainage;

2 blood flow dissemination theory. According to reports in the literature, ectopic endometrium has been found in veins, pleura, liver parenchyma, kidney, upper arm, and lower extremities.

Some scholars believe that the most likely endometria is caused by blood flow to the above tissues and organs, and has caused experimental endometriosis in the rabbit lung. However, some people think that these conditions may be caused by blood circulation, but the local metaplasia can not be ruled out because the pleura is also differentiated from the body cavity epithelium. When the embryo and the middle kidney tube are produced in the embryonic stage, it is possible that the body cavity epithelium is located therein, and the tissue can be metaplasticized in the future to form endometriosis in each part.

Regardless of the source of ectopic endometrium, its growth is related to ovarian endocrine. Clinical data may indicate that most of the symptoms occur in women of reproductive age (more than 80% of 30 to 50 years old), and often have ovarian dysfunction. After ovariectomy, the ectopic endometrium is atrophied. The growth of ectopic endometrium mainly depends on estrogen. Progesterone secretion is more during pregnancy, and ectopic endometrium is inhibited. Long-term oral synthesis of progestogens such as alkyne-norbornone, causing pseudopregnancy, can also cause ectopic endometrial atrophy.

Pathological changes:

1. Intrinsic Endometriosis: The endometrium grows from the basal to the muscular layer and is confined to the uterus, hence the name adenomyosis. The ectopic endometrium is often dispersed throughout the uterine muscle wall. Due to the intimal invasion of the intima, the reactive hyperplasia of fibrous tissue and muscle fibers causes the uterus to expand, but rarely exceeds the full-term fetus. Uneven or focal distribution is common in the posterior wall. Because of its limitation in the uterus, it often makes the uterus irregularly enlarged, which is similar to uterine fibroids. The hyperplastic muscle tissue on the cut surface also looks like a vortex-like structure of the fibroid, but no fibroid has a capsule-like tissue separate from the surrounding normal muscle fibers.

There is a softening zone in the middle of the lesion, and even a small cavity with a small amount of stale blood is scattered. The endometrial glands seen by microscopic examination are the same as the endometrial glands, surrounded by the endometrial stroma (Photo 2). The ectopic endometrium changes with the menstrual cycle, but the secretory phase changes are not obvious, indicating that the ectopic endometrial glands are less affected by progesterone. When conceived, the stromal cells of the ectopic endometrium can be significantly decidual.

Second, interstitial endometriosis: a special type of endometriosis, less common, that is, ectopic endometrium only endometrial interstitial tissue, or endometrial invasion The extent and extent of posterior interstitial tissue development in the myometrium far exceeds the glandular composition (photo 3). Generally, the uterus is increased in consistency. The ectopic cells are scattered in the muscle layer or concentrated in a certain area. The color is yellow, and often has the elasticity of the elastic rubber sample. It is softer than the fibroids, and the cord-like larvae are often seen on the cut surface. The diagnosis can be established accordingly. Ectopic tissue can also develop into a polypoid mass in the uterine cavity, multiple, smooth surface, pedicle width and a large area of the uterine muscle wall, and can be from the uterine wall to the uterine cavity or along the uterus to the broad ligament protruding. To the uterine cavity prominence caused by menorrhagia or even after menopause bleeding; to the broad ligament prominent can be diagnosed by gynecological double diagnosis. Interstitial endometriosis can be spread by the lungs, even after several years of uterine resection. Because of this feature, it is believed that interstitial endometriosis is a low-grade malignant sarcoma.

Third, extrinsic endometriosis: the intimal invasion of tissues other than the uterus (including the ectopic endometrium of the uterine serosa layer by the pelvic cavity) or organs, often involving multiple organs or tissues.

The ovary is the most common site of extrinsic endometriosis, accounting for 80%, followed by the peritoneum of the uterus rectal fossa, including the uterine iliac ligament. The anterior wall of the uterus rectal fossa is equivalent to the posterior vaginal fornix and the posterior wall of the cervix. Equivalent to the inner cervix. Sometimes the ectopic endometrium invades the anterior wall of the rectum, causing the intestinal wall to form a dense adhesion to the posterior wall of the uterus and the ovary, which is difficult to separate during surgery. External endometriosis can also invade the rectal vaginal septum and form scattered dark purple spots on the posterior vaginal mucosa. It can even form cauliflower-like protrusions, which resemble cancerous tumors. It can be confirmed as endometrial by biopsy. A disease. In addition, as mentioned above, the fallopian tube, the cervix, the vulva, the appendix, the umbilicus, the abdominal wall incision, the hernia sac, the bladder, the lymph nodes, and even the pleura and pericardium, the upper limbs, the thighs, and the skin may have ectopic endometrial growth.

The ectopic endometrium at the rectal fossa can also form a purple-black hemorrhage or a small blood sac on the peritoneum, which is embedded in the fibrous tissue with severe adhesion. The typical endometrium can be seen by microscopy. The ectopic endometrial tissue can still form a tender and solid nodule to the rectal vaginal septum and the uterine ligament. Or penetrate the vaginal mucosa of the vagina, forming a blue-violet papillary mass, many small bleeding spots can occur during menstruation. If the anterior rectal wall is involved, menstrual pain can occur. Sometimes the endometrial lesions expand around the rectum to form a narrow ring, which is very similar to cancer. The intestinal invasion accounts for about 10% of endometriosis. The lesion is often located in the serosa and muscle layers, and few mucosa are invaded to cause ulceration. Occasionally, intestinal obstruction occurs due to the formation of a mass in the intestinal wall or fibrotic stenosis or adhesion, resulting in intestinal obstruction, and may cause irritation, such as intermittent diarrhea, and the menstrual period is heavier.

an examination

Related inspection

Vaginal palpation endometrial biopsy vaginal secretions check immunosuppressive acidic protein

Clinical manifestations:

Symptoms and signs of endometriosis vary with the location of the ectopic endometrium and are closely related to the menstrual cycle.

First, the symptoms:

(A) dysmenorrhea: a common and prominent symptom, mostly secondary, that is, from the occurrence of endometriosis, the patient complained that there was no pain in the past menstrual cramps, and dysmenorrhea began from a certain period. Can occur before menstruation, menstruation and after menstruation. Some dysmenorrhea is more difficult, and you need to rest in bed or use drugs to relieve pain. Pain often worsens with the menstrual cycle. As the level of estrogen continues to rise, the ectopic endometrial hyperplasia and swelling, such as the effects of progesterone, bleed, stimulating local tissue, resulting in pain. If it is endometriosis, it can cause uterine muscle contracture, and dysmenorrhea is bound to be more significant. In cases of ectopic tissue without bleeding, dysmenorrhea may be caused by vascular congestion. After menstruation, the ectopic endometrium gradually shrinks and the dysmenorrhea disappears. In addition, in pelvic endometriosis, many inflammatory processes can be detected, and it is likely that local inflammatory processes are accompanied by active peritoneal lesions, resulting in pain or tenderness caused by prostaglandins, kinins and other peptides.

However, the degree of pain often does not reflect the extent of the disease detected by laparoscopy. Clinically, endometriosis is significant, but no pain, accounting for about 25%.

The psychological state of women can also affect pain.

(2) Menorrhagia: Intrinsic endometriosis, menstrual flow is often increased, and menstrual period is prolonged. May be due to increased endometrium, but more accompanied by ovarian dysfunction.

(3) Infertility: Patients with endometriosis are 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%. The causal relationship between infertility and endometriosis is still controversial. Pelvic endometriosis can often cause adhesions around the fallopian tubes to affect the oocyte pick-up or cause blockage of the lumen. Or infertility caused by ovarian lesions affecting the normal progression of ovulation. However, some people think that long-term infertility, menstruation without a closed period, can cause endometriosis opportunities; and once pregnant, the ectopic endometrium is inhibited and shrunk.

(4) Sexual intercourse pain: Endometriosis occurs in the rectal fossa and vaginal rectum, which causes the surrounding tissue to swell and affect sexual life. The premenstrual period is not sensitive.

(5) Swelling of the stool: generally occurs in the premenstrual period or after menstruation, the patient feels the pain when the feces pass through the rectum, but does not have this feeling at other times. It is a typical symptom of endometriosis near the rectal fossa and the rectum. . Occasionally, the ectopic endometrium is deep into the rectal mucosa, and there is menstrual rectal bleeding. Endometriosis lesions around the rectum to form a stenosis in the urgency of the weight and obstruction symptoms, it is similar to cancer.

(6) Bladder symptoms: more common in the endometriosis to the bladder, with periodic urinary frequency, urinary pain symptoms; when invading the bladder mucosa, periodic hematuria can occur.

Endometriosis of the abdominal wall and uterine endometriosis have periodic localized masses and pain.

Second, the signs:

Patients with intrinsic endometriosis tend to swell, but rarely exceed 3 months of pregnancy. Mostly, the swell is uniform, and it may also feel that a certain part is more prominent than a uterine fibroid. If it is the posterior uterus, it is often fixed. In the uterus rectal fossa, the uterine ligament or the posterior wall of the cervix can often touch one or two hard small nodules, such as mung bean or soybean, the size is more obvious, and the anus is more obvious. This is very important. Occasionally, a dark purple bleeding point or nodule can be seen in the posterior vagina. If the rectum has more lesions, it can touch a hard block or even be misdiagnosed as rectal cancer.

Ovarian hematoma often adheres to and adheres to the surrounding area. When the gynecological double diagnosis is made, the mass with a large tension can be touched and there is tenderness. The history of infertility is misdiagnosed as an attached inflammation block. Internal bleeding occurred after rupture, manifested as acute abdominal pain.

Third, the diagnosis:

The disease occurs mostly in women aged 30 to 40 years. The main complaint is secondary progressive severe dysmenorrhea, which should be highly suspected as endometriosis. Patients are often accompanied by infertility, menorrhagia and sexy discomfort. During gynecological examination, the uterus is slightly enlarged, and the uterine ligament or the posterior wall of the cervix has a nodule and can be diagnosed as endometriosis. In the presence of ovarian endometrial cysts, double-diagnosis can touch one or both cystic or cystic solid masses, usually within 10 cm diameter, and have a sticky feeling with the surrounding.

Differential diagnosis

Identification:

First, uterine fibroids: uterine fibroids often show similar symptoms. Generally, endometriosis is severe in dysmenorrhea, which is secondary and progressive. The uterus is inflated, but not very large. If accompanied by ectopic endometrium in other parts, it will help to identify. Those who are really difficult can try medical treatment. If the symptoms are rapid (1 to 2 months), the diagnosis is prone to endometriosis. It should be noted that adenomyosis can coexist with uterine fibroids (about 10%). Generally, it is difficult to identify before surgery, and it is necessary to be surgically removed for pathological examination of the uterus.

Second, the attachment inflammation: endometriosis of the ovary, often misdiagnosed as attachment inflammation. Both can form a tender mass in the pelvic cavity. However, patients with endometriosis have no history of acute infection, and patients with various anti-inflammatory treatments have no effect. The level of dysmenorrhea and the degree of pain should be asked in detail. This type of case often has ectopic endometrial nodules at the rectal fossa, which can be diagnosed if it is checked. If necessary, drug treatment can be used to see if there is any effect to identify. Generally in the ovarian endometriosis, the fallopian tubes are often unobstructed. Therefore, you can try the tubal water test, such as patency, you can rule out tubal inflammation.

Third, ovarian malignant tumor: ovarian cancer misdiagnosed as ovarian endometriosis, delay treatment, it must be careful. Ovarian cancer does not necessarily have symptoms of abdominal pain, and if it is often persistent, unlike periodic abdominal pain of endometriosis. Ovarian cancer is a substantial sense during examination, and the surface is uneven and the volume is also large. Ovarian endometriosis may also be associated with endometriosis in other areas, with signs of lesions in each part. For patients who cannot be identified, laparotomy should be performed for older patients, and endometriosis should be treated for a short period of time to observe the effect.

Fourth, rectal cancer: When endometriosis invades the rectum and sigmoid colon and has a wide range, it often forms a hard block there, causing partial obstruction. In some cases, ectopic endometrial invasion and intestinal mucosa cause bleeding, it is more like Rectal cancer. However, the incidence of rectal cancer is much higher than that of intestinal endometriosis. Generally, patients with rectal cancer have significant weight loss, frequent intestinal bleeding, no relationship with menstruation, and no dysmenorrhea. At the time of anal examination, the tumor is fixed on the intestinal wall, and the circumference of the intestinal wall is narrow. Intestinal mucosa is uneven in the barium enema, and the range of poor filling is small. Sigmoidoscopy can see ulcers, bleeding, and biopsy can confirm the diagnosis. Intestinal endometriosis does not reduce weight, intestinal bleeding is rare, individual bleeding also occurs in the menstrual period, dysmenorrhea is heavier. During the anus examination, the mucosa does not adhere to the bottom mass, and only the front wall is hard. The barium enema shows that the intestinal mucosa is smooth and the sputum filling is poor.

diagnosis:

The disease occurs mostly in women aged 30 to 40 years. The main complaint is secondary progressive severe dysmenorrhea, which should be highly suspected as endometriosis. Patients are often accompanied by infertility, menorrhagia and sexy discomfort. During gynecological examination, the uterus is slightly enlarged, and the uterine ligament or the posterior wall of the cervix has a nodule and can be diagnosed as endometriosis. In the presence of ovarian endometrial cysts, double-diagnosis can touch one or both cystic or cystic solid masses, usually within 10 cm diameter, and have a sticky feeling with the surrounding.

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