直肠子宫内膜异位症10例临床分析

目的分析直肠子宫内膜异位症的临床特点及诊治方法。 方法回顾性分析2020年1月至2022年1月江苏省苏北人民医院经手术病理确诊的10例直肠子宫内膜异位患者的临床资料及超声内镜检查结果。 结果10例患者肠镜下表现为直肠前壁或侧壁黏膜下隆起性病变。病灶距肛门口5~15 cm,大小为1.5~2.8 cm。其中4例误诊为直肠良性肿瘤或者直肠癌,误诊率达40.0%（4/10）。10例患者均经超声内镜检查诊断为直肠子宫内膜异位症,超声内镜检查见病灶位于直肠黏膜下及固有肌层,呈低回声影,内部回声不匀,部分突破外膜累及子宫。 结论直肠子宫内膜异位症虽然误诊率较高,但超声内镜检查有助于辅助诊断,提高诊断准确率。     

子宫内膜异位症患者盆腔疼痛与病灶特点的相关性分析

目的 探讨子宫内膜异位症患者盆腔疼痛与病变特点的关系.方法 选择子宫内膜异位症患者200例,回顾性分析其盆腔疼痛与病灶特点的关系.结果 患者病变位于子宫骶韧带与子宫直肠凹的患者盆腔疼痛(痛经、肛门坠胀或排便痛、性交痛与慢性盆腔痛)的发生率高于其它部位(P ＜0.05);200例患者中有148例合并不同程度的盆腔粘连,中、重度粘连患者痛经、肛门坠胀或排便痛、性交痛的发生率高于轻度粘连患者(P＜0.05);浸润深度≥5 mm患者的痛经、肛门坠胀或排便痛、性交痛的发生率高于浸润深度＜5mm的患者(P＜0.05).结论 子宫内膜异位症盆腔疼痛与病灶特点关系密切,其中盆腔粘连、子宫直肠凹及骶韧带的深部病灶是盆腔疼痛的重要因素.     

子宫内膜异位症患者盆腔疼痛与病变特点的关系

目的探讨子宫内膜异位症（内异症）患者盆腔疼痛与病变特点的关系。方法经腹腔镜、病理检查确诊的内异症患者330例,回顾性分析其病灶特点与盆腔疼痛的关系。结果内异症腹膜病灶尤其是位于宫骶韧带及子宫直肠陷窝的病灶、深部病灶及粘连程度均与患者盆腔疼痛有关。结论盆腔疼痛与内异症病灶的部位、类型、浸润程度、盆腔粘连有关。术中应尽量切除所有病灶,特别是宫骶韧带、子宫直肠陷窝的病灶及深部病灶,尽量松解粘连组织。     

结直肠子宫内膜异位症术前活检病理误诊分析6例

目的:探讨有效提高结直肠子宫内膜异位症术前活检诊断准确率的方法及思路.方法:回顾性分析我院2002年至今收治的6例结直肠子宫内膜异位症患者的临床表现、肠镜结果,对比术前活检和术后手术标本的组织病理学表现,分析误诊的原因,同时行ER、PR、CK7、CK20和CD10的免疫组织化学检测.结果:结直肠子宫内膜异位和结直肠癌临床表现、肠镜结果、B超和CT检查结果在一定程度上相似;本组6例结直肠子宫内膜异位症肠镜活检诊断中,3例误诊为慢性炎症,其中1例认为伴有中度异型增生;1例误诊为溃疡误诊率达67%(4/6).异位子宫内膜的免疫组织化学表型为腺体Ck7阳性,腺体及内膜间质ER、PR阳性以及间质细胞CD10阳性,而正常结直肠黏膜免疫组织化学表型为:腺上皮Ck7阴性,上皮及黏膜固有层间质ER、PR及CD10阴性.CK20在异位子宫内膜腺体及肠黏黏膜腺上皮内表达均为阴性.本组6例手术后大标本免疫组织化学检测结果与术前肠镜活检标本免疫表型均显示一致.结论:本研究表明仅根据临床症状,影像学和内镜检查结果,临床医生很难将其与恶性肿瘤区分;而通过形态学观察,并且综合特征性的临床病史、结合免疫组织化学检测ER、PR及CK7可以有效提高结直肠子宫内膜异位症术前活检诊断的准确率.     

内镜黏膜下挖除术治疗直肠子宫内膜异位症1例

肠道子宫内膜异位症主要累及直肠和乙状结肠, 针对有明显症状的肠道子宫内膜异位症患者, 需综合考虑病灶位置、浸润深度、大小等病变特点以及患者个人意愿制定个体化治疗方案, 手术治疗的目的是尽可能完整地切除病灶同时保留器官的功能。本例患者采用内镜黏膜下挖除术治疗直肠子宫内膜异位症, 疗效确切, 为直肠子宫内膜异位症的治疗提供了新思路。     

内镜超声诊断肠道子宫内膜异位症二例

子宫内膜异位症是指具有生长活力的子宫内膜组织在子宫腔以外部位的异常生长。肠壁异位内膜组织受卵巢激素周期性刺激而发生增生、出血、脱落,临床可有不同程度的肠道刺激症状。本文报道了2例因腹部非特异性症状就诊,肠镜下不典型,后经内镜超声、病灶活检确诊的肠道子宫内膜异位症的患者诊治情况。     

米非司酮治疗子宫内膜异位症120例疗效分析

2003年1月～2007年5月,我院门诊使用米非司酮治疗子宫内膜异位症患者120例,取得较满意的效果.现报告如下. 临床资料:120例患者,年龄25～40岁.病理诊断为子宫内膜异位症,不伴有其他子宫及附件疾病,患者曾行卵巢子宫内膜异位囊肿剥除或切除术及盆腔子宫内膜异位病灶电凝或切除术(保留子宫).     

超声诊断子宫内膜异位症的价值研究

目的探讨超声在子宫内膜异位症临床诊断中的运用价值,为子宫内膜异位症的影像诊断选择提供依据。方法对我科2011年1月—2012年6月24例手术、病理及超声影像资料较完整的子宫内膜异位症患者进行回顾性分析。结果 24例子宫内膜异位症患者中,内在性子宫腺肌症21例,卵巢异位2例,腹壁切口异位1例。经超声明确诊断20例,占83.3%;提出可疑性诊断2例,占12.5%;误诊1例,占4.2%。结论超声分辨率较高,能全方位较多显示子宫内膜异位症的病理形态变化,诊断准确率高,是本病较理想的首选辅助检查手段。     

临床非创伤性检测指标诊断子宫内膜异位症的价值

目的探讨子宫内膜异位症非创伤性诊断方法。方法回顾性分析我院接受开腹或腹腔镜手术治疗的子宫内膜异位症75例与非子宫内膜异位症51例患者的临床资料,观察盆腔痛、体征、CA125及超声阳性结果诊断子宫内膜异位症的敏感性与特异性。结果盆腔痛、体征、CA125及超声阳性4项指标中任意2项联合诊断子宫内膜异位症的敏感性为83.89%,特异性91.11%,阳性预测值92.16%,阴性预测值82.0%。结论盆腔痛、阳性体征、CA125及超声阳性对于子宫内膜异位症的诊断有较高价值。     

子宫内膜异位症24例诊治体会

１９８６～１９９９年,我院共收治子宫内膜异位症２４例,采用手术及药物保守治疗,效果满意,现报告如下。一般资料：本组患者年龄１６～５０岁,平均３４岁;未婚４例,已婚２０例;有子女者１５例;不孕５例。异位的子宫内膜位于卵巢者１８例,子宫直肠窝、盆腔腹膜者３例,腹壁切口子宫内膜异位症１例,乙状结肠及升结肠者各１例。治疗方法：手术治疗２０例,药物治疗４例。其中术前诊断为子宫内膜异位症者６例,１１例在妇科手术中诊断,３例在外科手术中发现。治疗结果：２０例手术者中术后妊娠２例,复发５例,再手术２例;４例药物…     

Comparison of endoscopic ultrasound and magnetic resonance imaging in severe pelvic endometriosis

Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Digestive infiltration is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown with incomplete resection and sometimes repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectosigmoid infiltration but their usefulness in the preoperative staging is still to be evaluated. The aim of this work was to evaluate and compare both techniques in the preoperative detection of deep pelvic endometriosis, particularly digestive infiltration. PATIENTS AND METHODS: From 1996 to 1998, 48 women with painful deep pelvic endometriosis had preoperative imaging exploration with endoscopic ultrasonography and MRI, and were operated on in order to attempt complete endometriosis resection. Patients were proposed for laparoscopic resection if endoscopic ultrasonography and/or MRI did not reveal digestive infiltration or for open resection if endoscopic ultrasonography and/or MRI were positive for digestive infiltration. RESULTS: Endoscopic ultrasonography and/or MRI led to suspicion of digestive endometriosis in 16 patients. Surgical resection was performed in 12 and digestive wall invasion was histologically demonstrated. At final follow-up, all patients had a dramatic decrease of their symptoms. The remaining 4 patients refused digestive resection and had only laparoscopic gynecologic resection. Infiltration although not histologically proven was very likely both on operative findings and clinical evolution. Digestive infiltration was preoperatively excluded in the 32 other patients. All had a laparoscopic treatment without digestive resection and pain diminished in all patients. In the 12 patients group who had digestive resection, digestive infiltration was correctly diagnosed by endoscopic ultrasonography in all cases (no false negative) whereas MRI, even with the use of endocoil antenna, led to correct diagnosis in 8 out of 12 cases. When endoscopic ultrasonography was negative for digestive infiltration, laparoscopic resection of lesions at surgery appeared complete in all cases. For the 16 patients with presumed digestive infiltration, sensitivity of endoscopic ultrasonography and MRI was 100 and 75% respectively, with a 100% specificity in both cases. MRI appeared very accurate for the detection of ovarian endometriotic locations. MRI was more sensitive but less specific than endoscopic ultrasonography for the diagnosis of isolated endometriotic recto-vaginal septum and utero-sacral ligaments lesions. CONCLUSION: Endoscopic ultrasonography was the best technique for the diagnosis of digestive endometriotic infiltration, which complicates the therapeutic strategy. MRI, however, allows more complete staging of other pelvic endometriotic lesions.     

Endorectal Ultrasonography in Predicting Rectal Wall Infiltration in Patients With Deep Pelvic Endometriosis: A Modern Tool for an Ancient Disease

Purpose This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis. Methods Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography wasperformed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360° view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the “gold standard” to evaluate the validity of endorectal ultrasonography. Results This study was based on 37 patients (mean age, 35.8 (range, 26–46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis. Conclusions Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.     

Role of EUS and EUS-guided FNA in the diagnosis of symptomatic rectosigmoid endometriosis

BACKGROUND: Rectosigmoid endometriosis is an underrecognized cause of GI symptoms in women. Pelvic magnetic resonance imaging and CT have a low sensitivity in making this diagnosis. The role of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of rectosigmoid endometriosis in symptomatic patients is not well studied. METHODS: A review of medical records identified 5 women who were diagnosed with rectosigmoid endometriosis by EUS and EUS-FNA over a period of 1 year. OBSERVATIONS: Five women with nonspecific GI complaints underwent EUS examination of a rectosigmoid subepithelial mass found on colonoscopy. EUS revealed a hypoechoic lesion infiltrating the muscularis propria and the serosa of the rectal wall, and extending outside the rectal wall, findings consistent with rectosigmoid endometriosis. This diagnosis was confirmed by EUS-FNA, surgical exploration, and/or the patient's clinical course. CONCLUSIONS: EUS and EUS-FNA are noninvasive, sensitive techniques for the diagnosis of rectosigmoid endometriosis in symptomatic patients.     

Rectal endometrial stromal sarcoma arising in endometriosis

PURPOSE: Endometriosis of the rectovaginal septum can harbor different types of secondary tumors that may involve the rectal wall and protrude into its lumen, thus making diagnosis difficult. Extrauterine low-grade endometrial stromal sarcoma may rarely arise in endometriosis. The purpose of this article was to present the third case of this association. METHOD: This was a clinicopathologic study. RESULTS: A 42-year-old female presented with abdominal pain and fever. Laparotomy revealed a large pelvic mass involving the rectovaginal septum and the colonic wall and which protruded into the lumen forming endoluminal polypoid masses. Concomitant peritoneal nodules and a metastatic paracolic lymph node were also found. Histopathologically, primary endometriotic foci were found in close relationship with an endometrial stromal sarcoma which invaded the rectal wall. The female genital tract had no endometriotic lesions. The patient was treated by surgery and subsequent chemotherapy and was alive and well 20 months later. CONCLUSIONS: Endometriosis and its possible malignant changes should be taken into account in the differential endoscopic diagnosis of rectal masses in females.     

Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management

Purpose In patients with histopathologically proven or suspected endometriosis with possible involvement of the rectum, endorectal ultrasound was performed to determine the sensitivity and specificity of this method with regard to rectal wall involvement and the impact on the following operation. METHODS: In an historical cohort analysis, 85 females with histopathologically proven or suspected endometriosis with possible involvement of the rectum were treated between 1992 and 2001. Endorectal ultrasound was performed with a 7.5 MHz real-time unit, and results of endorectal ultrasound were compared with intraoperative findings and histopathologic diagnosis of 65 patients undergoing operation. A questionnaire was used to evaluate postoperative signs and symptoms. RESULTS: Of 65 patients undergoing surgery, 37 underwent laparotomy with 25 resections of the bowel and 28 laparoscopy. In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P< 0.05) reduction of preoperative symptoms by approximately 60 percent. CONCLUSIONS: Endorectal ultrasound is a useful, noninvasive technique for preoperative evaluation of possible rectal wall involvement in endometriosis. Based on the high sensitivity and specificity, recommendation for laparotomy and bowel resection in cases with suspected rectal involvement can be facilitated. Supported by the Department for General and Thoracic Surgery. University of Kiel.     

Macrophage migration inhibitory factor is markedly expressed in active and early-stage endometriotic lesions

The establishment of a new vascular supply is essential for the survival of endometrial tissue and its development in ectopic locations. We have previously shown that ectopic endometrial cells release an important mitogenic activity for human endothelial cells and identified macrophage migration inhibitory factor (MIF) as one of the principal bioactive molecules involved in endothelial cell proliferation. In the present study, immunohistochemical and dual immunofluorescence analyses showed that MIF is effectively expressed by endometriotic tissue, particularly in the glands, and identified endothelial cells, macrophages, and T lymphocytes as cells markedly expressing MIF in the stroma. Western blot analysis showed a single 12.5-kDa band corresponding to the known mol wt of the molecule. The highest concentrations of MIF protein in endometriotic tissue, as measured by ELISA, were found in flame-like red endometriotic lesions, compared with typical black-bluish (P < 0.01) or with white lesions (P < 0.01). Interestingly, MIF displayed a marked expression in lesions from the initial stage of endometriosis (stage I). Semiquantitative RT-PCR analysis of MIF mRNA levels in the same endometriotic tissues showed a pattern of expression comparable with that of the protein. In view of its potent proinflammatory and angiogenic properties, local production of MIF within endometrial implants, particularly in those that are highly vascularized and representing the earliest and most active forms of the disease, make plausible the involvement of this factor in the local immunoinflammatory process observed in endometriosis and the initial steps of endometriotic tissue growth and development.     

Diagnostic accuracy of endoscopic ultrasonography for rectal neuroendocrine neoplasms

AIM:To investigate the diagnostic accuracy of endoscopic ultrasonography(EUS)for rectal neuroendocrine neoplasms(NENs)and the differential diagnosis of rectal NENs from other subepithelial lesions(SELs).METHODS:The study group consisted of 36 consecutive patients with rectal NENs histopathologically diagnosed using biopsy and/or resected specimens.The control group consisted of 31 patients with homochronous rectal non-NEN SELs confirmed by pathology.Epithelial lesions such as cancer and adenoma were excluded from this study.One EUS expert blinded to the histological results reviewed the ultrasonic images.The size,original layer,echoic intensity and homogeneity of the lesions and the perifocal structures were investigated.The single EUS diagnosis recorded by the EUS expert was compared with the histological results.RESULTS:All NENs were located at the rectum 2-10 cm from the anus and appeared as nodular(n=12),round(n=19)or egg-shaped(n=5)lesions with a hypoechoic(n=7)or intermediate(n=29)echo pattern and a distinct border.Tumors ranged in size from 2.3 to 13.7 mm,with an average size of 6.8 mm.Homogeneous echogenicity was seen in all tumors except three.Apart from three patients(stage T2 in two and stage T3 in one),the tumors were located in the second and/or third wall layer without involvement of the fourth and fifth layers.In the patients with stage T1 disease,the tumors were located in the second wall layer only in seven cases,the third wall layer only in two cases,and both the second and third wall layers in27 cases.Approximately 94.4%(34/36)of rectal NENs were diagnosed correctly by EUS,and 74.2%(23/31)of other rectal SELs were classified correctly as nonNENs.Eight cases of other SELs were misdiagnosed as NENs,including two cases of inflammatory lesions and one case each of gastrointestinal tumor,endometriosis,metastatic tumor,lymphoma,neurilemmoma,and hemangioma.The positive predictive value of EUS for rectal NENs was 80.9%(34/42),the negative predictive value was 92.0%(23/25),and the diagnostic accuracy was85.1%.CONCLUSION:EUS has satisfactory diagnostic accuracy for rectal NENs with good sensitivity,but unfavorable specificity,making the differential diagnosis of NENs from other SELs challenging.     

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM:To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis.METHODS:This prospective observational study was performed between September 2011 and July 2014.Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included.The study was approved by the local ethics committee and written informed consent was obtained in all cases.Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques.Laparoscopy was performed within4 wk of colonoscopic examination.All hypothetical colonoscopy findings(eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis)were compared with laparoscopic and histological findings.We calculated the sensitivity,specificity,positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis.RESULTS:A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy andsurgical intervention were included in our analysis.In 76 of the women(43.6%),intestinal endometrial implants were found at surgery and histopathological examination.Specifically,38 of the 76 lesions(50%)were characterized by the presence of serosal bowel nodules;28 of the 76 lesions(36.8%)reached the muscularis layer;8 of the 76 lesions(10.5%)reached the submucosa;and 2 of the 76 lesions(2.6%)reached the mucosa.Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the174(4%)examinations.Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women(92.1%).A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement,in 3of 8 cases(37.5%)of submucosal involvement,in no cases of muscularis layer involvement and in 1 of 38cases(2.6%)of serosa involvement.The sensitivity,specificity,positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%,98%,85%and 58%,respectively.CONCLUSION:Being an invasive procedure,colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.     

直肠类癌的内镜超声诊断和内镜黏膜下切除

目的 研究内镜超声对直肠类癌的诊断价值，探讨内镜下黏膜切除术治疗直肠类癌的应用价值。方法 应用微超声探头对结肠镜发现的黏膜正常的大肠隆起性病灶进行超声检查，对诊断直肠类癌病例应用套扎器对准病灶负压吸引进行圈套结扎，再在皮圈根部连皮圈电切病灶。比较内镜超声诊断和病理检查结果，观察切除标本基底有无肿瘤累及。结果 126例黏膜正常的大肠隆起性病灶经内镜超声诊断，25例直肠类癌全部得到病理证实。直肠类癌表现为黏膜下层的边界清晰、回声欠均匀的低回声肿块。全部类癌病例无固有肌层和血管浸润，行内镜黏膜下切除无一例出现出血和穿孔，切除标本边缘和基底无肿瘤累及。结论 内镜超声可以明确直肠类癌的肠壁来源、大小、内部回声性质、边界、有无肌层和周围血管浸润，内镜下黏膜切除术治疗直肠类癌疗效确切。     

Endometriosis recti — Wertigkeit der Endosonographie in der präoperativen Diagnostik

36 women with suspected rectal endometriosis were examined by endorectal sonography to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management. In 13 patients rectal wall involvement was detected by endorectal sonography. Those 13 women were operated by laparotomy and anterior rectal resection (n=9), particular excision of the involved wall (n=4) in the surgical department. In two cases the endometrial tumor was localized directly beyond the M. propria without infiltration. In 21 women rectal involvement could be excluded. All 23 patients without rectal involvement were treated laparoscopically in the gynecological department. Preoperative diagnosis was confirmed in all patients during operation. Endorectal sonography is able to visualize perirectal endometriomas and to access rectal wall involvement. Based on these preoperative findings operative management can be changed to laparotomy and resection of rectal wall or laparoscopic coagulation of endometriomas without rectal involvement.