Use of anal endosonography in diagnosis of endometriosis of the external anal sphincter

PURPOSE: Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars. METHODS: We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography. CONCLUSION: We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.     

Rare Case of Hepatic Endometriosis as an Incidental Finding: Difficult Diagnosis of a Diagnostic Dilemma

Endometriosis is the abnormal existence of functional uterine mucosal tissue outside the uterus. It is a usual disorder of women in reproductive age which is mainly located in the female genital tract. Hepatic endometriosis is one of the rarest disorders characterised by the presence of ectopic endometrium in the liver. It is often described as cystic mass with or without solid component. Preoperative diagnosis is difficult via cross-sectional imaging and histopathologic evaluation remains the gold standard for diagnosis. We report an asymptomatic 40-year-old female with a large cystic mass involving the left hepatic lobe. She underwent laparoscopic removal of the cyst. The diagnosis of hepatic endometriosis was established by the histopathological analysis of the surgical specimen.     

Genetic or enzymatic disruption of aromatase inhibits the growth of ectopic uterine tissue

Aromatase P450 (P450arom) is the key enzyme for the biosynthesis of estrogen that is essential for the growth of human endometriosis, a pathology characterized by endometrium-like tissue on the peritoneal surfaces of abdominal organs manifest by pelvic pain and infertility. Surgically transplanted autologous uterine tissue to ectopic sites on the peritoneum in mice has been used as an animal model to study endometriosis. Using this mouse model, we evaluated the roles of the P450arom gene and aromatase enzyme activity in the growth of endometriosis represented by ectopic uterine tissues in mice. Endometriosis was induced surgically in the following groups of mice: 1) untreated transgenic mice with disrupted P450arom gene (ArKO); 2) ArKO mice treated with systemic estrogen; 3) untreated wild-type (WT) mice; 4) WT mice treated with estrogen; 5) WT mice treated with the aromatase inhibitor, letrozole; and 6) WT mice treated with letrozole and estrogen. Each group contained eight mice; +/+ littermates of ArKO mice were used as WT controls. Treatment with estrogen increased the size of ectopic uterine tissues in ArKO and WT mice significantly. The ectopic uterine lesions in untreated and estrogen-treated ArKO mice were strikingly smaller than those in untreated and estrogen-treated WT controls, respectively. Systemic treatment of WT mice with letrozole significantly decreased the lesion size in a dose-dependent manner. The addition of estrogen to letrozole treatment increased the ectopic lesion size, although these lesions were significantly smaller than those in mice treated with estrogen only. As tissue controls, the effects of these conditions on normally located (eutopic) uterine tissue were evaluated. The effects of disruption of the P450arom gene and treatments with letrozole and estrogen seemed to be more profound on ectopic tissues, suggesting that ectopic tissues might be more sensitive to estrogen for growth. We conclude that both an intact P450arom gene and the presence of aromatase enzyme activity are essential for the growth of ectopic uterine tissue in a mouse model of endometriosis.     

Abdominal Wall Endometriomas

Endometriosis is a condition in which uterine mucosal tissue is located outside the uterus. Endometriosis may be pelvic or extrapelvic. The term endometrioma is used when endometriosis appears as a circumscribed mass. Abdominal wall endometriomas are usually a secondary process in scars after surgical procedures. A retrospective study of abdominal wall endometrioma, from March 1992 through April 1999 at our institution was done. The mean age of the patients was 28.4 years. Twelve of these reported cases were secondary to previous surgery. One patient presented primarily with an abdominal wall mass without previous surgical history. The most common presentation was an abdominal wall mass associated with pain during the menstrual cycle. Endometrioma was considered as a differential diagnosis in seven patients. All patients underwent surgery. Along with the literature review on endometrioma, the importance of considering it in the differential diagnosis for patients of child-bearing age is discussed.     

Expression of scavenger receptor class B1 in endometrium and endometriosis

Endometriosis is characterized by the presence of endometrial glands and stroma within the peritoneum and other extrauterine sites. The presence of aromatase, a key enzyme in the biosynthesis of estradiol, has been demonstrated in eutopic endometrial samples of women with moderate to severe endometriosis, but not in those of disease-free women. Animal studies have shown that high density lipoprotein provides precursor cholesterol pool for steroidogenesis. Scavenger receptor class B1, a 82-kDa cell surface protein, is involved in the binding of high density lipoprotein to target cells and promotes cholesteryl ester uptake. In this study we detected the presence of scavenger receptor class B1 in eutopic and ectopic endometrium. There was more scavenger receptor class B1 protein associated with endometriosis compared with matched endometrium. Two bands (82 and 45 kDa) were detected in the endometrium and endometriosis samples. Glycanase treatment indicated that the 45-kDa protein might be a nonglycosylated form of scavenger receptor class B1. Immunostaining of fixed tissues detected scavenger receptor class B1 in glandular epithelium of both tissues. Scavenger receptor class B1 and aromatase mRNA were increased in endometriosis tissues. Scavenger receptor class B1 expression in the endometrium and endometriosis supports a role for this receptor in the uptake of high density lipoprotein cholesterol, possibly supporting in situ estrogen production, which is detrimental in the progression of endometriosis.     

Quelles nouveautés sur l’endométriose ?

Endometriosis concerns 6 to 10 % of the female population, and is responsible for severe pelvic pain and infertility. This estrogen dependant disease, is characterized by the presence of endometrial tissue outside of the uterus cavity. Although his physiopathology remains poorly understood, recent data have focused on angiogenesis, which could represent a key factor for the growing of lesions of endometriosis. New antiangiogenesis treatments represent a therapeutic hope, and have been tested in vitro or in vivo in mice. Those drugs have proven their efficacy on endometriotic lesions. Secondly, several hypothesis are discussed to explain infertility in endometriosis. In particular, a direct impact of peritoneal fluid from women with endometriosis on sperm DNA could be involved.     

Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.     

Anomalies in the inflammatory response in endometriosis and possible consequences: a review

Defined by the presence of endometrial-like cells outside the uterus, endometriosis is one of the most diagnosed gynecological disorders, affecting 5 to 10 % of reproductive age women, but the true incidence is unknown. Endometriosis is a major cause of pelvic pain, dysmenorrhea, dyspareunia, infertility and menstrual irregularities, but there is no clear correlation between the symptoms and the extent of the disease. Despite decades of intensive investigations, little is known about the pathogenesis of endometriosis. The disease is often associated with chronic pelvic inflammation. Abnormal levels of immune cells such macrophages, dendritic and natural killer cells were found in the peritoneal cavity of patients. However these cells seem to be unable to detect and eliminate ectopic endometrial cells. Several studies showed that peritoneal immune cells are dysfunctional and may rather contribute to endometriosis development. A review of relevant clinical and scientific studies was carried out. This review sheds light on cellular and immunological pro-inflammatory changes which were observed in patients with endometriosis, their impact on angiogenesis, apoptosis, extracellular matrix remodeling and hormonal production and consequences on fertility.     

Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-yearold woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.     

Une cause rare d’occlusion intestinale: endométriose intestinale. A propos d’un cas

Endometriosis is defined by the presence of endometrial tissue outside the uterus. It’s a rare cause of occlusion. Its diagnosis by pathologics features in the absence of pathognomonic signs to make diagnosis preoperatively. throuth a clinical case, we show the possibility of presentation of intestinal endometriosis with an aray of accute occlusion suggesting a diagnosis of neoplasia in surgical and radiological stage.     

Down-regulation of endometrial matrix metalloproteinase-3 and -7 expression in vitro and therapeutic regression of experimental endometriosis in vivo by a novel nonsteroidal progesterone receptor agonist, tanaproget

CONTEXT: Endometriosis, the growth of endometrial tissue outside the uterus, is principally an estrogen-dependent disease. In contrast, exposure to progesterone during pregnancy or therapeutically has been shown to provide benefit to some women with this disease. However, recent research suggests that the presence of endometriosis impairs the capacity of the eutopic endometrium to respond to endogenous progesterone. OBJECTIVE: Reduced progesterone responsiveness results in an elevated endometrial expression of matrix metalloproteinases (MMPs) during the secretory phase of the menstrual cycle in women with endometriosis. Although cyclic MMP expression is critical for endometrial growth and remodeling, the failure of progesterone to down-regulate MMPs may impair nidation and promote the invasive establishment of endometriosis. In the current study we examined the ability of a newly developed progesterone receptor (PR) agonist, tanaproget (TNPR), to down-regulate endometrial MMP expression in vitro and regress experimental endometriosis in vivo. SETTING: This study was performed at a university-based medical center. PARTICIPANTS: Asymptomatic volunteers and patients with endometriosis were studied. MAIN OUTCOME MEASURES: We examined the ability of TNPR to down-regulate endometrial MMP expression in vitro compared with that of natural progesterone and two currently marketed synthetic steroidal progestins. Using a human/mouse model of endometriosis, we also tested the in vivo ability of TNPR to regress ectopic lesions established by tissues with reduced progesterone sensitivity. RESULTS: TNPR effectively down-regulated MMP expression in vitro and induced significant reduction of lesions in mice with disease established by tissues from endometriosis patients. CONCLUSION: Given the positive preclinical pharmacological profile of TNPR that has recently been reported, additional development of this compound for the treatment of endometriosis is warranted.     

What is new about endometriosis?

Endometriosis concerns 6 to 10 % of the female population, and is responsible for severe pelvic pain and infertility. This estrogen dependant disease, is characterized by the presence of endometrial tissue outside of the uterus cavity. Although his physiopathology remains poorly understood, recent data have focused on angiogenesis, which could represent a key factor for the growing of lesions of endometriosis. New antiangiogenesis treatments represent a therapeutic hope, and have been tested in vitro or in vivo in mice. Those drugs have proven their efficacy on endometriotic lesions. Secondly, several hypothesis are discussed to explain infertility in endometriosis. In particular, a direct impact of peritoneal fluid from women with endometriosis on sperm DNA could be involved.     

Rectosigmoid endometriosis with lymph node involvement

Endometriosis mainly affects women of a fertile age and is usually located in the pelvis. Extrapelvic involvement is less frequent. We present the case of a female patient with endometriosis of the rectosigmoid and mesenteric lymph nodes, which is an extremely rare finding. Although the most widely accepted theory of the pathogenesis of this disease postulates retrograde menstruation through the Fallopian tubes with subsequent implantation in the peritoneum, these findings support lymphatic dissemination of endometrial cells as a theory of pathogenesis in cases of extrapelvic involvement.     

Hemorrhagic ascites: are we missing endometriosis?

Peritoneal tuberculosis, carcinomatosis and pancreatic ascites are often considered as differential diagnosis of hemorrhagic ascites. Endometriosis can rarely present as hemorrhagic ascites and closely mimic these conditions. When this occurs without common clinical features of endometriosis, it can create a diagnostic challenge to the treating physician. We present three patients with endometriosis who presented with hemorrhagic ascites; two of them did not have gynecological symptoms or significant pelvic disease. These patients were evaluated several times in many centers and even received multiple courses of anti-tuberculous treatment. The diagnosis was made by histologic examination of parietal peritoneum obtained by laparoscopy or laparotomy. The diagnosis was missed possibly because of the atypical presentation, lack of clinical suspicion and incomplete assessment. In conclusion, this potentially treatable condition should be considered as a differential diagnosis for hemorrhagic ascites in a premenopausal woman.     

Ultrasonographic evaluation of anal endometriosis: report of four cases

Background

The presence of endometriosis in the anal canal and perianal tissues is rare and difficult to suspect at clinical examination. We report our experience with preoperative ultrasound evaluation of four cases of anal endometriosis.

Methods

Four patients were evaluated by transperineal and high-resolution three-dimensional endoanal ultrasonography.

Results

In 3 of 4 women, the lesions involved old episiotomy scars. Anal endometriosis appeared as hypoechoic cystic lesions with areas of microcalcification, not well delimited and highly vascularized. The lesions either involved the anal sphincter (n = 2, one within the rectovaginal septum) or were localized superficially in the ischiorectal space (n = 2). Surgery and pathologic exam confirmed the ultrasonographic findings.

Conclusions

Ultrasonographic findings of anal endometriosis are characteristics and may allow accurate preoperative staging of the disease.     

Transcriptional characterizations of differences between eutopic and ectopic endometrium

Endometriosis, defined as the presence of endometrial glandular and stromal cells outside the uterine cavity, is a common gynecological disease with poorly understood pathogenesis. Using laser capture microdissection and a cDNA microarray with 9600 genes/expressed sequence tags (ESTs), we have conducted a comprehensive profiling of gene expression differences between the ectopic and eutopic endometrium taken from 12 women with endometriosis adjusted for menstrual phase and the location of the lesions. With dye-swapping and replicated arrays, we found 904 genes/ESTs that are differentially expressed. We validated the gene expression using real-time RT-PCR. We found that the expression patterns of these genes/ESTs correctly classified the 12 patients into ovarian and nonovarian endometriosis. We identified gene clusters that are location-specific. In addition, we identified several biological themes using Expression Analysis Systematic Explorer. Finally, we identified 79 pathways with over 100 genes with known functions, which include oxidative stress, focal adhesion, Wnt signaling, and MAPK signaling. The identification of these genes and their associated pathways provides new insight. Our findings will stimulate future investigations on molecular genetic mechanisms underlying the pathogenesis of endometriosis.     

Ileal perforation secondary to intestinal endometriosis

Endometriosis is defined as the presence of endometrial tissue outside the uterus. The bowel is not often affected. There are no specific clinical findings for intestinal endometriosis. It is typically asymptomatic, but sometimes can present with abdominal pain, diarrhoea, constipation or intestinal obstruction. Ileal perforation is a rare complication of intestinal endometriosis and only a few cases have been reported in the literature. Intestinal endometriosis can mimic many gastrointestinal diseases, such as irritable bowel syndrome, inflammatory bowel disease, infections and neoplasms. The diagnosis is made by laparoscopy or laparotomy. We present a case of a woman with intermittent abdominal pain and ileal perforation secondary to intestinal endometriosis.     

Vascular development in endometriosis

Endometriosis, defined as the presence of endometrial tissue outside the uterus, is an estrogen-dependent disease which causes pelvic pain and subfertility in women of reproductive age. The condition has a dramatic impact on the professional, social and marital life of sufferers. Direct and indirect evidence suggests that angiogenesis is required for the development and persistence of endometriosis. In this review the state-of-the-art with regard to our understanding of the role of angiogenesis in the ectopic implantation and survival of menstrual endometrial tissue will be discussed. Correspondence to: Patrick G. Groothuis, Research Institute GROW, Department of Obstetrics and Gynecology, Academisch Ziekenhuis Maastricht, Peter Debyelaan 25, 6229 HX Maastricht, The Netherlands. Tel:␣+31-43-3876625; Fax: +31-43-3876613; E-mail: patrick.groothuis@ path.unimaas.nl     

The expression of human chorionic gonadotropin/human luteinizing hormone receptors in ectopic human endometrial implants.

Our laboratory previously demonstrated that normal human endometrium contains hCG/human LH receptors. Since ectopic endometrial implants in endometriosis arise directly at least in part from uterine endometrium, we investigated whether the implants continue the expression of these receptors. The presence of hCG/LH receptor mRNA and/or immunoreactive receptor protein in ectopic endometrial implants on pelvic peritoneum, uterine endometrium, and unaffected or normal peritoneum from patients with (n = 12) and without (n = 14) clinically apparent endometriosis was examined by in situ hybridization and immunocytochemistry analyses. The results showed that the peritoneal biopsies with visible or microscopic endometrial implants contain receptor mRNA and receptor protein. The glands contain more receptor mRNA and receptor protein than stromal cells in implants similar to uterine endometrium from patients with or without endometriosis. However, there is no consistent difference in the expression of receptors in implants compared to uterine endometria from patients with or without endometriosis. Contrary to ectopic endometrial implants, unaffected or normal peritoneum contain neither receptor mRNA nor receptor protein. In summary, we conclude that ectopic endometrial implants contain hCG/LH receptor mRNA and receptor protein, which suggests new possibilities in the medical treatment of endometriosis.     

Endometriosis pulmonar torácica: presentación de 2 casos de una enfermedad muy poco frecuente

Endometriosis is characterized by the growth of endometrium outside the uterine cavity or myometrium. There is no specific radiologic finding that defines endometriosis. Parenchymal lesions, nodules or blebs are reported in the literature, although this clinical entity is rare. Definitive diagnosis and treatment are often possible with surgery. We report here two cases: a forty-two-year-old female patient with a 2-year history of intermittent hemoptysis associated with her menstrual cycle was diagnosed as having endometriosis and treated via thoracotomy; another 30-year-old female referred to our department due to recurrent pneumothorax caused by underlying endometriosis underwent surgical treatment which revealed endometrial foci on the diaphragm.