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Imaging of gastrointestinal endometriosis: what the radiologist should know

Abstract

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

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Acknowledgements

We would like to acknowledge Dr. Luciana Pardini Chamié, MD, PhD From the Department of Diagnostic Imaging, Chamié Imagem da Mulher, and the Department of Diagnostic Imaging, Fleury Medicina e Saúde, in São Paulo, Brazil, and credit her for providing Fig. 10a., as well as video 1 and 2 in the supplementary material referenced in this manuscript.

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Correspondence to Adrian Jaramillo-Cardoso.

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Supplementary material 1 (AVI 3881 kb) Video 1. Transvaginal Ultrasound shows a negative sliding sign, hereby the cervix and uterus do not slide over the rectum by the pressure applied with the transducer. A negative sliding sign is suggestive of fibrosis and obliteration of the rectovaginal space due to endometriotic implants (Not shown in this video)

Supplementary material 2 (AVI 5578 kb) Video 2. Transvaginal Ultrasound in another patient showing the “kissing ovary” sign in the posterior cul-de-sac. Please note the left sided endometrioma

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Jaramillo-Cardoso, A., Shenoy-Bhangle, A.S., VanBuren, W.M. et al. Imaging of gastrointestinal endometriosis: what the radiologist should know. Abdom Radiol 45, 1694–1710 (2020). https://doi.org/10.1007/s00261-020-02459-w

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Keywords

  • Gastrointestinal
  • Endometriosis
  • Bowel
  • MRI
  • MRE
  • Ultrasound
  • Gynecologic surgery