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Imaging of gastrointestinal endometriosis: what the radiologist should know


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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  1. 1.

    Burney RO, Giudice LC (2012) Pathogenesis and pathophysiology of endometriosis. Fertility and Sterility 98(3):511–9.

    CAS  PubMed  Google Scholar 

  2. 2.

    Vercerllini P, Somigliana-Edgardo L, Fedele L (2014) Endometriosis: Pathogenesis and treatment. Endometriosis: Pathogenesis and Treatment 10(5):1–477.

  3. 3.

    Nnoaham KE, Hummelshoj L, Webster P, et al. (2011) Impact of endometriosis on quality of life and work productivity: A multicenter study across ten countries. Fertility and Sterility 96(2):366-373.e8.

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Agarwal SK, Chapron C, Giudice LC, et al. (2019) Clinical diagnosis of endometriosis: a call to action. American Journal of Obstetrics and Gynecology 220(4):354.e1-354.e12.

    Google Scholar 

  5. 5.

    Morassutto C, Monasta L, Ricci G, et al. (2016) Incidence and estimated prevalence of endometriosis and adenomyosis in Northeast Italy: A data linkage study. PLoS ONE 11(4):1–11.

    Google Scholar 

  6. 6.

    Woodward PJ, Sohaey R, Mezzetti TP (2001) From the Archives of the AFIP Endometriosis: Radiologic-Pathologic Correlation. RadioGraphics 21(1):193–216.

    CAS  PubMed  Google Scholar 

  7. 7.

    Bong JW, Yu CS, Lee JL, et al. (2019) Intestinal endometriosis: Diagnostic ambiguities and surgical outcomes. World Journal of Clinical Cases 7(4):441–51.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Abrão MS, Petraglia F, Falcone T, et al. (2015) Deep endometriosis infiltrating the recto-sigmoid: Critical factors to consider before management. Human Reproduction Update 21(3):329–39.

    PubMed  Google Scholar 

  9. 9.

    Chapron C, Chopin N, Borghese B, et al. (2006) Deeply infiltrating endometriosis: Pathogenetic implications of the anatomical distribution. Human Reproduction 21(7):1839–45.

    PubMed  Google Scholar 

  10. 10.

    Coutinho A, Bittencourt LK, Pires CE, et al. (2011) MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay. RadioGraphics 31(2):549–67.

    PubMed  Google Scholar 

  11. 11.

    Charatsi D, Koukoura O, Ntavela IG, et al. (2018) Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis. Advances in Medicine 2018:1–11.

    Google Scholar 

  12. 12.

    Nyangoh Timoh K, Stewart Z, Benjoar M, et al. (2018) Magnetic Resonance Enterography to Assess Multifocal and Multicentric Bowel Endometriosis. Journal of Minimally Invasive Gynecology 25(4):697–705.

    PubMed  Google Scholar 

  13. 13.

    Bazot M, Daraï E (2017) Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertility and Sterility 108(6):886–94.

    PubMed  Google Scholar 

  14. 14.

    Abrão MS, Dias JA, Rodini GP, et al. (2010) Endometriosis at several sites, cyclic bowel symptoms, and the likelihood of the appendix being affected. Fertility and Sterility 94(3):1099–101.

    PubMed  Google Scholar 

  15. 15.

    Nisenblat V, Prentice L, Pmm B, et al. (2016) Combination of the non-invasive tests for the diagnosis of endometriosis (Review). (7).

  16. 16.

    Gupta S (2013) Endometriosis: A Comprehensive Update. Vol. 155 Spec N, Springer Briefs in Reproductive Biology. 78–81; quiz 82 p.

  17. 17.

    Giudice LC, Kao LC (2004) Endometriosis. Lancet 364(9447):1789–99.

    PubMed  Google Scholar 

  18. 18.

    Vercellini P, Chapron C, Fedele L, et al. (2004) Evidence for asymmetric distribution of lower intestinal tract endometriosis. BJOG: An International Journal of Obstetrics and Gynaecology 111(11):1213–7.

  19. 19.

    Chapron C, Fauconnier A, Vieira M, et al. (2003) Anatomical distribution of deeply infiltrating endometriosis: Surgical implications and proposition for a classification. Human Reproduction 18(1):157–61.

    PubMed  Google Scholar 

  20. 20.

    Chamié LP, Ribeiro DMFR, Tiferes DA, et al. (2018) Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings. RadioGraphics 38(1):309–28.

    PubMed  Google Scholar 

  21. 21.

    Rawson JM (1991) Prevalence of endometriosis in asymptomatic women. The Journal of reproductive medicine 36(7):513–5.

    CAS  PubMed  Google Scholar 

  22. 22.

    Vercellini P, Fedele L, Aimi G, et al. (2007) Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: A multivariate analysis of over 1000 patients. Human Reproduction 22(1):266–71.

    CAS  PubMed  Google Scholar 

  23. 23.

    Mohamed AAA, Selim Y, Arif MA, et al. (2016) Gastric wall endometriosis in a postmenopausal woman. Egyptian Journal of Radiology and Nuclear Medicine.

  24. 24.

    Ha JK, Choi CW, Kim HW, et al. (2015) An extremely rare case of gastric subepithelial tumor: Gastric endometriosis. Clinical Endoscopy.

  25. 25.

    Kashyap P, Medeiros F, Levy M, et al. (2011) Unusual submucosal tumor in the stomach. Gastroenterology.

  26. 26.

    Anaf V, Buggenhout A, Franchimont D, et al. (2014) Gastric endometriosis associated with transverse colon endometriosis: a case report of a very rare event. Archives of Gynecology and Obstetrics.

  27. 27.

    Roman H, Ness J, Suciu N, et al. (2012) Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study. Human Reproduction 27(12):3440–9.

    PubMed  Google Scholar 

  28. 28.

    Piketty M, Chopin N, Dousset B, et al. (2009) Preoperative work-up for patients with deeply infiltrating endometriosis: Transvaginal ultrasonography must definitely be the first-line imaging examination. Human Reproduction 24(3):602–7.

    PubMed  Google Scholar 

  29. 29.

    Gimonet H, Laigle-Quérat V, Ploteau S, et al. (2016) Is pelvic MRI in women presenting with pelvic endometriosis suggestive of associated ileal, appendicular, or cecal involvement? Abdominal Radiology 41(12):2404–10.

    PubMed  Google Scholar 

  30. 30.

    Yantiss R, Clement R, Young R (2001) Endometriosis of the intestinal tract: A study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. American Journal of Surgical Pathology 25(4):445–54.

    CAS  PubMed  Google Scholar 

  31. 31.

    Scarmato VJ, Levine MS, Herlinger H, et al. (2000) Ileal endometriosis: radiographic findings in five cases. Radiology 214(2):509–12.

    CAS  PubMed  Google Scholar 

  32. 32.

    López Carrasco A, Hernández Gutiérrez A, Hidalgo Gutiérrez PA, et al. (2017) Ileocecal endometriosis: diagnosis and management. Taiwanese Journal of Obstetrics and Gynecology 56(2):243–6.

    PubMed  Google Scholar 

  33. 33.

    Bianchi A, Pulido L, Espín F, et al. (2007) Endometriosis intestinal. Estado actual. Cirugia Espanola 81(4):170–6.

    PubMed  Google Scholar 

  34. 34.

    Bacalbasa N, Balescu I, Filipescu A (2017) Ileocecal obstruction due to endometriosis - A case report and literature review. In Vivo 31(5):999–1002.

    Google Scholar 

  35. 35.

    Rousset P, Peyron N, Charlot M, et al. (2014) Bowel Endometriosis: Preoperative Diagnostic Accuracy of 3.0-T MR Enterography—Initial Results. Radiology 273(1):117–24.

  36. 36.

    Busard MPH, Van Der Houwen LEE, Bleeker MCG, et al. (2012) Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion. Abdominal Imaging 37(4):549–57.

    PubMed  Google Scholar 

  37. 37.

    Bennett GL, Slywotzky CM, Cantera M, et al. (2010) Unusual Manifestations and Complications of Endometriosis—Spectrum of Imaging Findings: Pictorial Review. American Journal of Roentgenology 194(6_supplement):WS34–46.

  38. 38.

    Langlois NEI, Park KGM, Keenan RA (1994) Mucosal changes in the large bowel with endometriosis: A possible cause of misdiagnosis of colitis? Human Pathology 25(10):1030–4.

    CAS  PubMed  Google Scholar 

  39. 39.

    Dimoulios P, Koutroubakis IE, Tzardi M, et al. (2003) A case of sigmoid endometriosis difficult to differentiate from colon cancer. BMC Gastroenterology 3:1–5.

    Google Scholar 

  40. 40.

    Berker B, LaShay N, Davarpanah R, et al. (2005) Laparoscopic appendectomy in patients with endometriosis. Journal of Minimally Invasive Gynecology 12(3):206–9.

    PubMed  Google Scholar 

  41. 41.

    Gustofson RL, Kim N, Liu S, et al. (2006) Endometriosis and the appendix: a case series and comprehensive review of the literature. Fertility and Sterility 86(2):298–303.

    PubMed  Google Scholar 

  42. 42.

    Mabrouk M, Raimondo D, Mastronardi M, et al. (2019) Endometriosis of the Appendix: When To Predict and How To Manage? Multivariate Analysis of 1,935 Endometriosis Cases. Journal of Minimally Invasive Gynecology.

  43. 43.

    Chapron C, Fauconnier A, Dubuisson JB, et al. (2003) Deep infiltrating endometriosis: Relation between severity of dysmenorrhoea and extent of disease. Human Reproduction 18(4):760–6.

    PubMed  Google Scholar 

  44. 44.

    Emre A, Akbulut S, Yilmaz M, et al. (2013) An unusual cause of acute appendicitis: Appendiceal endometriosis. International Journal of Surgery Case Reports 4(1):54–7.

    PubMed  Google Scholar 

  45. 45.

    Collins D. (1951) Endometriosis of the Vermiform Appendix. AMA Archives of Surgery 63(5):617.

    CAS  PubMed  Google Scholar 

  46. 46.

    Kimura H, Konishi K, Yabushita K, et al. (1999) Intussusception of a mucocele of the appendix secondary to an obstruction by endometriosis: Report of a case. Surgery Today 29(7):629–32.

    CAS  PubMed  Google Scholar 

  47. 47.

    Old JL, Dusing RW, Yap W, et al. (2005) Imagingforsuspectedappendicitis. 71(1):71–8.

  48. 48.

    Tsuda M, Yamashita Y, Azuma S, et al. (2013) Mucocele of the appendix due to endometriosis: A rare case report. World Journal of Gastroenterology 19(30):5021–4.

    PubMed  PubMed Central  Google Scholar 

  49. 49.

    Driman DK, Melega DE, Vilos GA, et al. (2003) Mucocele of the Appendix Secondary to Endometriosis. American Journal of Clinical Pathology 113(6):860–4.

    Google Scholar 

  50. 50.

    Hapke, M, Bigelow B (1977) Mucocele of the Appendix Secondary to Obstruction by Endometriosis. Human pathology 8(5):585–9.

    CAS  PubMed  Google Scholar 

  51. 51.

    Lainas P, Dammaro C, Rodda GA, et al. (2019) Appendiceal endometriosis invading the sigmoid colon: a rare entity. International Journal of Colorectal Disease :3–6.

  52. 52.

    Hines JJ, Paek GK, Lee P, et al. (2016) Beyond appendicitis; radiologic review of unusual and rare pathology of the appendix. Abdominal Radiology 41(3):568–81.

    PubMed  Google Scholar 

  53. 53.

    Chattot C, Huchon C, Paternostre A, et al. (2019) ENDORECT: a preoperative score to accurately predict rectosigmoid involvement in patients with endometriosis. Human Reproduction Open 2019(2):1–9.

  54. 54.

    Shi X, Fan C (2018) Endometriosis in the rectum accompanied by hemorrhoids leading to diagnostic pitfalls: A rare case report. BMC Women’s Health 18(1):1–5.

    Google Scholar 

  55. 55.

    Fauconnier A, Staraci S, Huchon C, et al. (2013) Comparison of patient- and physician-based descriptions of symptoms of endometriosis: a qualitative study. Human Reproduction 28(10):2686–94.

    PubMed  Google Scholar 

  56. 56.

    Guerriero S, Saba L, Pascual MA, et al. (2018) Transvaginal ultrasound vs magnetic resonance imaging for diagnosing deep infiltrating endometriosis: systematic review and meta-analysis. Ultrasound in Obstetrics and Gynecology 51(5):586–95.

    CAS  PubMed  Google Scholar 

  57. 57.

    Ferrero S, Scala C, Stabilini C, et al. (2019) Transvaginal sonography with vs without bowel preparation in diagnosis of rectosigmoid endometriosis: prospective study. Ultrasound in Obstetrics and Gynecology 53(3):402–9.

    CAS  PubMed  Google Scholar 

  58. 58.

    Atkinson NSS, Bryant R V., Dong Y, et al. (2017) How to perform gastrointestinal ultrasound: Anatomy and normal findings. World Journal of Gastroenterology 23(38):6931–41.

    PubMed  PubMed Central  Google Scholar 

  59. 59.

    Hudelist G, Oberwinkler KH, Singer CF, et al. (2009) Combination of transvaginal sonography and clinical examination for preoperative diagnosis of pelvic endometriosis. Human Reproduction 24(5):1018–24.

    CAS  PubMed  Google Scholar 

  60. 60.

    Benacerraf BR, Groszmann Y, Hornstein MD, et al. (2015) Deep infiltrating endometriosis of the bowel wall: The comet sign. Journal of Ultrasound in Medicine 34(3):537–42.

    PubMed  Google Scholar 

  61. 61.

    Guerriero S, Ajossa S, Gerada M, et al. (2008) Diagnostic value of transvaginal “tenderness-guided” ultrasonography for the prediction of location of deep endometriosis. Human Reproduction 23(11):2452–7.

    PubMed  Google Scholar 

  62. 62.

    Reid S, Condous G (2017) Update on the ultrasound diagnosis of deep pelvic endometriosis. European Journal of Obstetrics and Gynecology and Reproductive Biology 209:50–4.

    PubMed  Google Scholar 

  63. 63.

    Chiu LC, Leonardi M, Lu C, et al. (2019) Predicting Pouch of Douglas Obliteration Using Ultrasound and Laparoscopic Video Sets: An Interobserver and Diagnostic Accuracy Study. Journal of Ultrasound in Medicine :1–7.

  64. 64.

    Reid S, Lu C, Casikar I, et al. (2013) Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: The sliding sign. Ultrasound in Obstetrics and Gynecology 41(6):685–91.

    CAS  PubMed  Google Scholar 

  65. 65.

    Tammaa A, Fritzer N, Strunk G, et al. (2014) Learning curve for the detection of pouch of Douglas obliteration and deep infiltrating endometriosis of the rectum. Human Reproduction 29(6):1199–204.

    PubMed  Google Scholar 

  66. 66.

    Darvishzadeh A, McEachern W, Lee TK, et al. (2016) Deep pelvic endometriosis: a radiologist’s guide to key imaging features with clinical and histopathologic review. Abdominal Radiology 41(12):2380–400.

    PubMed  Google Scholar 

  67. 67.

    Rossini LGB, Ribeiro PAAG, Rodrigues FCM, et al. (2012) Transrectal ultrasound-Techniques and outcomes in the management of intestinal endometriosis. Endoscopic Ultrasound 1(1):23–35.

    PubMed  PubMed Central  Google Scholar 

  68. 68.

    Ito TE, Abi Khalil ED, Taffel M, et al. (2017) Magnetic resonance imaging correlation to intraoperative findings of deeply infiltrative endometriosis. Fertility and Sterility 107(2):e11–2.

    PubMed  Google Scholar 

  69. 69.

    Siegelman ES, Oliver ER (2012) MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 32(6):1675–91.

    PubMed  Google Scholar 

  70. 70.

    Paula A, Moura C, Salom H, et al. (2019) Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis : Systematic review and meta-analysis. :87–92.

  71. 71.

    Yoon JH, Choi D, Jang KT, et al. (2010) Deep rectosigmoid endometriosis: “Mushroom cap” sign on T2-weighted MR imaging. Abdominal Imaging 35(6):726–31.

    PubMed  Google Scholar 

  72. 72.

    Koga K, Osuga Y, Yano T, et al. (2003) Characteristic images of deeply infiltrating rectosigmoid endometriosis on transvaginal and transrectal ultrasonography. Human Reproduction 18(6):1328–33.

    PubMed  Google Scholar 

  73. 73.

    Arévalo N, Méndez R (2018) “Mushroom cap” sign in deep rectosigmoid endometriosis. Abdominal Radiology 43(11):3201–3.

    PubMed  Google Scholar 

  74. 74.

    Leone Roberti Maggiore U, Biscaldi E, Vellone VG, et al. (2017) Magnetic resonance enema vs rectal water-contrast transvaginal sonography in diagnosis of rectosigmoid endometriosis. Ultrasound in Obstetrics and Gynecology 49(4):524–32.

    CAS  PubMed  Google Scholar 

  75. 75.

    Jeong2013 The Usefulness of Computed Tomographic Colonography for Evaluation of Deep Infiltrating Endometriosis Journal of Computer Assisted Tomography,.pdf.

  76. 76.

    Iosca S, Lumia D, Bracchi E, et al. (2013) Multislice computed tomography with colon water distension (MSCT-c) in the study of intestinal and ureteral endometriosis. Clinical Imaging 37(6):1061–8.

    PubMed  Google Scholar 

  77. 77.

    Burnett TL, Feldman MK, Huang JQ (2020) The role of imaging as a guide to the surgical treatment of endometriosis. Abdominal Radiology (0123456789).

  78. 78.

    Millochau JC, Stochino-Loi E, Darwish B, et al. (2018) Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis. Journal of Minimally Invasive Gynecology 25(1):139–46.

    PubMed  Google Scholar 

  79. 79.

    Donnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertility and Sterility 108(6):931–42.

    PubMed  Google Scholar 

  80. 80.

    Meuleman C, Tomassetti C, D’Hoore A, et al. (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Human Reproduction Update 17(3):311–26.

    PubMed  Google Scholar 

  81. 81.

    Afors K, Centini G, Fernandes R, et al. (2016) Segmental and Discoid Resection are Preferential to Bowel Shaving for Medium-Term Symptomatic Relief in Patients With Bowel Endometriosis. Journal of Minimally Invasive Gynecology 23(7):1123–9.

    PubMed  Google Scholar 

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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).

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