What is endometriosis

Endometriosis is a serious condition in which tissue similar to the inner lining of the uterus grows outside the uterus. Invariably this erratic growth spreads into the pelvis, onto the reproductive organs, and very frequently invades the adjacent organs such as bladder, ureter, and bowels. Endometriosis can cause excruciating abdominal cramps and pelvic pain, painful sexual intercourse, frequently accompanied by gastrointestinal symptoms such as nausea, vomiting, bloating, constipation, and diarrhea. These symptoms often intensify before and during the menstrual cycle.  

Although similar to the uterine lining (endometrium), endometriosis tissue is unlike the endometrium in that it will not shed and flow out of the body with menstruation. Instead with each hormonal cycle, the endometriosis tissue along with the blood, glands, and connective tissue accumulate inside the body, causing massive inflammation. Furthermore, endometriosis form scar tissue (adhesions), which act like glue, causing organs, such as the bowel and other reproductive organs to “stick” to each other and form nodules. This causes considerable pain which in severe cases can result in a “frozen pelvis” and ruin the woman’s fertility.

What is bowel endometriosis?

Endometriosis is when tissue similar to the lining of the uterus (called “endometrial tissue”) is found outside of the uterus. Endometriosis is typically found in the pelvis, on the reproductive organs, and the tissue lining of the pelvis, called the peritoneum. However, endometriosis can sometimes spread to other parts of the body and reach into the gastrointestinal tract, or the bowels. Bowel endometriosis involves the abnormal growth of this endometrial-like tissue along the gastrointestinal tract and can cause extreme symptoms of pain, nausea, vomiting, bloating, constipation, and diarrhea which often times will worsen with the menstrual cycle. The treatment for bowel endometriosis is excision surgery involving removing any lesions on the bowel surface or in the bowel walls. Bowel endometriosis lesions that are limited to a very small area can some times be shaved off the bowel surface or by removing a small circle of bowel wall.lesions that involve larger areas commonly require removing a short length of the intestines.

Outside the reproductive organs, the most common region for endometriosis is the bowel where it can implant and develop lesions on the surface or inside the wall of the intestines, the rectum, sigmoid colon or in other bowel parts. Specifically it is in the pelvic portion or final section of the large intestine (the sigmoid colon and rectum) where lesions are most prevalent, accounting for about 90% of bowel endometriosis cases, with approximately 10% found in the final segment of the small intestine or in the appendix. ^(source) Bowel endometriosis occurs in 5–12% of those women who suffer from endometriosis, and it is generally not diagnosed until these women are  in their 30’s. Patients may exhibit abdominal cramps and pain, constipation and/or diarrhea, bloody stool. 

Additional symptoms include bloating, abdominal cramps, pain, nausea, and vomiting, which often become much more exaggerated before and during menstruation. Moreover, severe bowel endometriosis can completely obliterate the bowel lumen, causing signs and symptoms of complete bowel obstruction, The treatment for bowel endometriosis is surgery to excise all visible endometriosis on the bowel and, in rare occasions, to remove portions of the bowel (segmental bowel resection).Superficial endometriosis affects the surface of the bowel, whereas deep endometriosis penetrates into the bowel wall.  With deep endometriosis, the lesions themselves as well as inflammatory scar tissue can form ‘nodules,’ which eventually can cause bowel obstruction. 

Is bowel endometriosis the same as irritable bowel syndrome (IBS)?

Bowel endometriosis and irritable bowel syndrome (IBS), although sharing common symptoms such as constipation, diarrhea, bloating, and abdominal pain, and chronic inflammation, are totally different conditions.  As a consequence of shared symptoms and the ability to coexist, bowel endometriosis and irritable bowel syndrome (IBS) are commonly misdiagnosed and mismanaged. However, irritable bowel syndrome (IBS) is a diagnosis of exclusion, which means it should be diagnosed only after all other conditions, including bowel endometriosis, are ruled out.Healthcare providers tend to not recognize bowel endometriosis and instead give the misdiagnosis of irritable bowel syndrome (IBS).  Such misdiagnosis contributes to unnecessary testing, mismanagement of the disease, and, most troubling, an average of 7 – 9 year delay of the correct diagnostic.^Source  The key distinction between these two conditions is that irritable bowel syndrome (IBS) symptoms surfaces numerous times throughout the course of a month whereas symptoms of bowel endometriosis intensifies before or during the menstrual cycle.   

Bowel endometriosis symptoms 

Bowel endometriosis symptoms tend to overlap with symptoms of pelvic endometriosis and usually range from mild to severe depending on the menstrual cycle and characteristics of the lesion(s) including location, size, and depth in the bowel wall in the case of deep endometriosis.  Although bowel endometriosis may be asymptomatic  – and some women only become aware they had the condition after undergoing a procedure for a totally different condition, others may experience a combination of symptoms simultaneously, often just immediately prior to and during menstruation. Symptoms may include the following:

• Painful bowel movements
• Constipation
• Diarrhea
• Alternating constipation and diarrhea
• Intestinal cramping
• Nausea and/or vomiting
• Abdominal pain
• Painful cramps from menstruation that worsen over time
• Rectal pain
• Rectal bleeding
• Deep pelvic pain 
• Pelvic pain during or after sex
• Difficulty getting pregnant (infertility)
• Difficulty urinating and urinary tract symptoms
• Depression & anxiety
• More frequent urgency to pass bowel movements  
• Inability to completely empty the bowel   

In a recent study of women coping with endometriosis, while 85% reported bowel symptoms, only a  5% – 12% reported having endometriosis growing on the bowels.^{Source Source}.   The reason is that the inflammatory nature of the endometriosis lesions  create irritation to the pelvic nerves which then causes bowel symptoms. 

Diagnosing bowel endometriosis

The gold standard for diagnosis of bowel endometriosis is laparoscopy, a safe, effective laparoscopic visual assessment in combination with histological examination of excised lesions.  During this minimally invasive procedure a small incision is made in the patient’s navel, into which is inserted a tiny tube with a video camera or laparoscope.  This camera enables the visual identification of endometriosis lesions which can then be biopsied or removed during the surgery. 

Treating bowel endometriosis with surgery

Preoperative work-ups assess the patient’s health status and uncover any hidden conditions that could present problems during and after surgery.  Bowel endometriosis surgery preoperative work-ups involve a careful and thorough history of symptoms, as well as imaging, generally MRI and/or high resolution transvaginal ultrasound, to identify the extent of the endometriosis, including number of lesions, location, size, circumference, and depth which guide surgical decision-making. Depending on severity of symptoms and imaging findings, colonoscopy may be advised to evaluate for full-thickness (or complete penetration) bowel endometriosis. Management and treatment are individualized to the patient and tailored according to her medical history and needs, mindful of symptoms, age, pregnancy desire, and previous surgical or medical treatment.  

Laparoscopic surgery is the most commonly used approach to remove bowel endometriosis tissue (and the scar tissue it creates). The goal, of course, is the excision of the lesions while preserving the patient’s organs which will contribute to her overall health as well as provide relief from the painful symptoms.   Most cases involve removing endometriosis located in the pelvic portion of the large intestine (sigmoid colon and rectum).  Bowel endometriosis surgery can be a complex and nuanced procedure, depending on the size and location of the endometrium tissue, but generally involve one of three surgical approaches.

1. Segmental bowel resection:  This is for larger endometriosis lesions that cause narrowing of the bowel, kinking of the colon, or other complications.  In such instances it may be necessary to remove the section of the bowel containing the endometriosis and rejoin or reconnect the two healthy end portions (re-anastomosis).  While bowel endometriosis surgery usually involves addressing lesions on the surface of the bowel, severe cases can involve much of the circumference or full thickness of the bowel, protruding into the wall and inside the bowel. The final decision on performing a bowel resection is usually only made during the actual surgery, when the surgeon is in a better position to assess. However, in the comprehensive preoperative staging process, the surgeon and the patient discuss her situation, the surgery, the risk of complications, and the outcomes, enabling her to make a more intelligent, informed decision.

2.  Disc resection:  For smaller endometriotic lesions of thickness or depth within the bowel wall, a disc excision is made, where a circular portion around the affected bowel wall is removed, with closure and repair of the hole with sutures and staples.   

3.  Rectal Shaving: In many cases an endometriosis nodule can be ‘shaved’ or cut off the surface of affected areas using scissors without needing to open the inside of the bowel.   

Endometriosis can be a serious condition affecting all aspects of a woman’s life, often causing suffering and debilitation. Accurate diagnosis, management, and treatment are necessary to bring relief and to help her “get her life back” once again.The above information only provides a brief overview of endometriosis; however, each individual’s symptoms and treatment plan are unique. If you have concerns about possible endometriosis, feel free  to contact Dr. Liu for a complimentary, 15-minute phone consultation regarding your particular condition. Dr. Lora Liu is passionate about helping women suffering from endometriosis  and chronic pelvic pain to achieve an improved quality of life.

If surgery is indicated, her goal is complete resection of all visible lesions, while preserving organ function. Because of the multi-organ involvement of endometriosis, she routinely brings into her operating room a multi-disciplinary team, depending on the organs involved – a urologist, colo-rectal surgeon, thoracic surgeon, or other sub-specialist, enabling them to actually see and understand the endometriosis involvement of the organs of their specialties. This then allows those organs to be corrected during the endometriosis surgery, thereby eliminating the need for the patient to return for additional surgery/surgeries, thus greatly benefiting the patient. Because the patient’s journey does not end with surgery, Dr. Liu maintains working relationships with physiatrists, pain management specialists, and pelvic floor physical therapists as an extension of postoperative care.