A Targeted Biopsy during Menstruation for the Definitive Diagnosis of Rectovaginal Endometriosis: A Report of Two Cases

We herein report the definitive diagnosis of rectovaginal endometriosis in two cases. Case 1 involved a 46-year-old woman with abdominal pain and hematochezia. The diagnosis after the first and second examinations using lower gastrointestinal (GI) endoscopy was unclear. Differential diagnoses included mucosa-associated lymphoid tissue and colorectal cancer. The third lower GI endoscopy with a targeted biopsy, performed during menstruation, confirmed rectovaginal endometriosis. Case 2 involved a 38-year-old woman with hematochezia. Lower GI endoscopy during menstruation revealed rectovaginal endometriosis. When rectovaginal or bowel endometriosis is suspected, lower GI endoscopy and a targeted biopsy during menstruation can prevent unnecessary surgery.     

基于网络药理学探讨活血化瘀药治疗子宫内膜异位症的作用机制

目的 利用网络药理学探究活血化瘀药治疗子宫内膜异位症（endometriosis,EM）的可能作用机制。方法 以桃仁、红花、泽兰、丹参、益母草、川牛膝、王不留行等七味临床常用活血化瘀中药为研究主体。利用中药化学成分数据库TCMSP平台,检索获取七味活血化瘀药有效活性成分,通过Targets information软件获得有效成分对应靶点。使用GeneCards数据库收集EM相关靶基因,利用韦恩图工具得到活血化瘀药有效成分治疗EM的靶基因。应用Cytoscape 3.6.0软件构建活性成分－作用靶点－疾病网络。应用KEGG数据库分析获得靶点基因富集的信号通路。结果 七味活血化瘀药共筛选出94种活性成分,119个作用靶标。其中槲皮素、木犀草素、山柰酚等为关键活性成分,PTGS2、PTGS1、NCOA2、NCOA1等为关键靶点。七味中药共有20条EM相关KGEE通路,涉及性激素、炎症、细胞调亡以及血管生成等各个方面,其中PI3K-Akt、IL-17、TNF-α等炎症相关通路为主要通路。结论 活血化瘀药治疗EM具有多成分、多靶点、多通路的特点,针对EM的疼痛、炎症以及月经紊乱状态均有治疗作用。     

A rare case of sigmoid colon obstruction in patient with ulcerative colitis: role of transabdominal ultrasound-guided biopsy

Introduction

Endometriosis is a common chronic gynaecological disease affecting 10 % of women of reproductive age. Of these 5–12 % may present bowel endometriosis that may be asymptomatic or associated with aspecific symptoms even bowel obstruction.

Case presentation

The case of a 41-year-old woman with history of ulcerative colitis, previous diagnosis of ovarian endometriosis, recurrent abdominal pain not related to the menstrual cycle, with abdominal pain and obstinate constipation for 2 weeks was referred. The patient underwent colonoscopy, transabdominal ultrasound and ultrasound-guided fine-needle biopsy to have a diagnosis.

Discussion

Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with gastrointestinal or abdominal symptoms. As demonstrated in our case and by the burgeoning literature in this field, we believe that the role of transabdominal ultrasound should be reconsidered in the management of abdominal diseases because this examination associated with ultrasound-guided fine-needle biopsy allows, in expert hands, to obtain adequate histological samples avoiding patients to undergo more invasive tests to get a diagnosis.     

Endometriosis

Endometriosis, a condition defined by the presence of ectopic endometrium, is a disorder of increasing incidence and a significant cause of gastroenterologic distress in young women. Although clinical manifestations vary considerably depending upon the anatomic extent of disease, characteristic abdominal complaints and typical physical findings continue to be associated with misdiagnosis and delayed recognition of gastrointestinal involvement. The authors of this paper review the medical literature concerning endometriosis of the digestive tract-emphasizing modes of presentation, risk factors, diagnostic testing, complications, and therapy. Greater familiarity with the disease and heightened awareness of its sequellae are needed and prerequisite to improved medical management.     

Endometriosis in Adolescents

Background and Objectives:

Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes.

Methods:

We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery.

Results:

The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain.

Conclusions:

Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.     

不同卵巢储备功能的EMS患者行IVF-ET方案的选择

目的：了解不同卵巢储备功能的子宫内膜异位症( EMS)患者行不同方案的体外受精-胚胎移植( IVF-ET)治疗的结局差异。方法回顾性分析行IVF-ET治疗的337例EMS患者资料。据卵巢储备功能及治疗方案差异分为 A1组(卵巢储备功能正常,超长方案)、A2组(卵巢储备功能正常,长方案)和B1组(卵巢储备功能低下,超长方案)、B2组(卵巢储备功能低下,短方案),比较各组妊娠结局。结果A1组较A2组、B1组较B2组的获卵数、成熟卵母细胞数、受精数、卵裂数、可移植胚胎数及优质胚胎数均低(P<0．05),但卵裂率、可移植胚胎率及优胚率的差异均无统计学意义;A1组新鲜周期及解冻周期胚胎着床率、生化妊娠率、临床妊娠率及活产率均较A2组低( P<0．05),但B1组与B2组新鲜周期及解冻移植( F-ET)周期胚胎着床率、生化妊娠率、临床妊娠率及活产率的差异均无统计学意义。结论采取长方案取卵后行胚胎冷冻、治疗EMS后行F-ET是卵巢储备功能正常的EMS不孕患者IVF-ET最佳方案。     

Decidualization of intranodal endometriosis in a postmenopausal woman

Here we describe an unusual case of decidualized endometriosis detected in pelvic lymph nodes. The presence of intranodal ectopic decidua in pregnant women has been described. A few cases of decidualization of endometriotic foci in the pelvic or para-aortic lymph nodes have also been associated with pregnancy. However, decidualized intranodal endometriosis occurring in a postmenopausal woman has not been described. A 52-year-old woman presented with a very large adnexal mass. Menopause occurred at the age of 47, and she had been treated with hormone replacement therapy. She received a total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and para-aortic lymphadenectomy for clear cell carcinoma of the right ovary. Histological examination revealed the presence of ectopic decidua in several pelvic lymph nodes. The deciduas consisted of sheets of loosely cohesive, large, uniform, round cells with abundant eosinophilic cytoplasm. Typical of decidualization of intranodal endometriosis, a few irregularly shaped, inactive endometrial glands lined by single layers of columnar to cuboidal epithelium were present within the decidua. An immunohistochemical study revealed that the decidual cells were positive for CD10, vimentin, estrogen receptor and progesterone receptor, which indicated that progestin-induced decidualization had occurred in the intranodal endometriotic stroma. To the best of our knowledge, this case represents the first report of decidualized intranodal endometriosis occurring in association with hormone replacement therapy in a postmenopausal woman. Misdiagnosis of this condition as a metastatic tumor can be avoided by an awareness of these benign inclusions, supported by immunohistochemical staining results.     

MiR-191 inhibits TNF-α induced apoptosis of ovarian endometriosis and endometrioid carcinoma cells by targeting DAPK1

Emerging evidence showed that miRNA dysregulation is involved in the development of endometriosis and may contribute to pathological process of endometriosis associated ovarian cancer (EAOC). miR-191 is one of the most differentially expressed miRNAs in pairwise comparisons among healthy controls, endometriosis, and EAOC patients. However, its regulative network in endometriosis and EAOC are still not clear. This study explored the role of miR-191 in TNF-α induced cell death in ovarian endometriosis and endometrioid carcinoma cells. Based on tissues samples collected from healthy controls, endometriosis, and EAOC patients, this study verified significantly higher expression of miR-191 in endometriosis and endometrioid cancer. Interestingly, we also observed inverse expression trend between miR-191 and DAPK1, a positive mediator of programmed cell death. By conducting luciferase assay, we confirmed miR-191 can directly target DAPK1 and regulate its expression. Functionally, we also found DAPK1 can promote TNF-α induced cell death. DAPK1 knockdown in endometriosis CRL-7566 cells can weaken its response to TNF-α induced cell death, while its overexpression in endometrioid cancer cells CRL-11731 enhanced the response. These functions of DAPK1 can be directly modulated by miR-191. Therefore, the miR-191-DAPK1 axis may play an important role modulating the response of ovarian endometriosis and endometrioid carcinoma cells to death-inducers and might contribute malignant transformation of endometriosis.     

Tumor Necrosis Factor and Interleukin‐6 Gene Polymorphisms and Endometriosis Risk in Asians: A Systematic Review and Meta‐Analysis

A relationship between endometriosis and tumor necrosis factor (TNF‐α) and interleukin‐6 (IL‐6) gene polymorphisms has been raised for Asians. However, this topic is controversial. This study was a meta‐analysis to explore whether TNF‐α/IL‐6 gene polymorphisms were associated with a risk of endometriosis in Asians. By searching PubMed, HuGENet, and China National Knowledge Infrastructure (CNKI) databases, 17 studies were identified and included (3372 cases and 4008 controls). The odds ratio (OR) with 95% confidence interval (CI) was used to assess the association between TNF‐α/IL‐6 gene polymorphisms and endometriosis risk. An association of TNF‐α gene ‐1031T/C polymorphism with endometriosis was found (TT + TC vs. CC: OR 0.50, 95% CI 0.30–0.82, I² = 37.1%, P = 0.20; TT vs. CC: OR 0.50, 95% CI 0.30–0.82, I² = 43.0%, P = 0.173; TC vs. CC: OR 0.49, 95% CI 0.29–0.83, I² = 10.6%, P = 0.327). In addition, TNF‐α‐238A/G and IL‐6 ‐174C/G gene polymorphisms were also likely to be associated with endometriosis in Asians. For the TNF‐α‐238A/G gene polymorphism, the OR was 1.577 (95% CI: 1.01–2.48). For the IL‐6 ‐174C/G gene polymorphism, the OR was 1.554 (95% CI: 1.04–2.31). No associations were detected between the TNF‐α‐308A/G and IL‐6 ‐634C/G polymorphisms and susceptibility to endometriosis. Our results indicate that the TNF‐α gene ‐1031T/C polymorphism can reduce the risk of endometriosis, but for Asians, TNF‐α‐238A/G and IL‐6 ‐174C/G gene polymorphisms may be a risk factor for endometriosis. No association was found for the TNF‐α‐308A/G and IL‐6 ‐634C/G gene polymorphisms.