Symptomatic intestinal endometriosis requiring surgical resection: Clinical presentation and preoperative diagnosis

Objectives: Intestinal endometriosis (IE) can present with varied symptoms, making the diagnosis difficult. Modalities have been described to evaluate IE, but few can provide a confirmatory diagnosis. A preoperative diagnosis of IE may help guide management. We sought to describe the presentation, diagnostic evaluation, histology and operative management of 89 patients with tissue-confirmed symptomatic IE. Methods: The records of 89 patients from a single institution with histologically confirmed, symptomatic IE from 1 January 1994 to 30 September 2009 were reviewed. Results: Abdominal pain was the most common symptom in patients with IE; however, rectal bleeding was significantly associated with IE of the distal colon (P<0.02), while dysfunctional uterine bleeding was seen more in patients with proximal IE (P<0.01). Preoperative confirmation of IE was uncommon; colonoscopy with biopsy confirmed the diagnosis in 29.6% of patients tested and only 15% of patients with IE had histologic lesions involving mucosa. In the five patients who underwent endoscopic ultrasound (EUS), the diagnosis of IE was established in all cases (n4) where histology or cytology was obtained. Malignancy was considered nearly as frequently as IE preoperatively, and 90.4% of patients underwent laparotomy as the initial surgical approach. Conclusions: IE can present with a variety of manifestations, which may provide clues to location of bowel affected. Patients with known pelvic endometriosis and rectal bleeding are more likely to have distal bowel affected; EUS with tissue sampling may play a role if routine endoscopy fails to reveal the diagnosis. Making a diagnosis of IE preoperatively may allow for less invasive surgical approaches and better patient outcomes.