Endometriosis presenting as carcinoma colon in a perimenopausal woman

Diet associations in endometriosis: a critical narrative assessment with special reference to gluten

Endometriosis is characterized by the presence of endometrium-like tissue outside the uterus. The etiology remains largely unknown. Despite adequate treatment, patients can still experience symptoms or side effects resulting in therapy incompliance and in self-management strategies such as dietary measures is increasing. A gluten free diet is thought to be contributory in reducing endometriosis-related pain, thereby optimizing quality of life. However, data is conflicting and currently provides no evidence for causality. This narrative review aims to put the effect of dietary self-management strategies on endometriosis in a balanced perspective, especially the effect of gluten and a gluten free diet. Several studies have found a strong overlap in symptoms, metabolic and immune responses associated with endometriosis and those associated with celiac disease, ulcerative colitis, Crohn's disease, irritable bowel syndrome and non-celiac wheat sensitivity. However, it remains unclear whether these diseases and/or disorders are causal to an increased risk of endometriosis. Some studies have found a positive effect on the risk of endometriosis, endometriosis-related symptoms and quality of life (QoL) when women either avoided certain nutrients or foods, or applied a specific nutrient supplementation. This includes the avoidance of red meat and omega-3, an increasing intake of foods rich in anti-oxidants, micronutrients and dietary fibers (e.g., fruit, vegetables) and the appliance of a gluten free diet. However, data from the available studies were generally graded of low quality and it was noted that placebo and/or nocebo effects influenced the reported positive effects. In addition, such effects were no longer seen when adjusting for confounders such as overweight, when a translation was made from in vitro to in vivo, or when the nutrients were not supplemented as isolated sources but as part of a mixed daily diet. Finally, some studies showed that long-term adherence to a gluten free diet is often associated with an impaired diet quality and nutrient intake, leading to negative health outcomes and reduced QoL. Concluding, scientific evidence on the efficacy of dietary interventions on well-defined clinical endpoints of endometriosis is lacking and recommending a gluten free diet to women solely diagnosed with endometriosis should therefore not be advised.

Caecal endometriosis presenting with an acute abdomen in pregnancy

Endometriosis is defined as the presence of endometrial tissue outside the uterus, which induces a chronic inflammatory response. Its prevalence remains unknown, but it has been estimated to affect up to 10% of women of reproductive age. Although it is a benign oestrogen-dependent gynaecological condition, women may describe painful symptoms such as cyclical pelvic pain, dysmenorrhoea and dyschezia. Intestinal endometriosis may affect the ileum, appendix, sigmoid colon and rectum. It may present with a myriad of symptoms such as abdominal pain, vomiting, diarrhoea, constipation and haematochezia. Caecal endometriosis can present as an acute appendicitis, making the diagnosis challenging to establish in pregnancy. Transmural involvement and acute occlusion are very rare events. The gold standard for diagnosis remains laparoscopy with tissue sampling for histological confirmation. Although endometriosis improves during pregnancy under the effect of progesterone, the ectopic endometrium becomes decidualised with a progressive reduction in size. The authors present the case of a multiparous woman in her mid-30s with acute onset of right-sided abdominal pain at 35 weeks gestation. Physical examination was suggestive of an acute appendicitis and MRI showed an inflamed caecum. She became acutely unwell requiring an emergency caesarean section. A mass in the caecum was observed with impending perforation at the caecal pole. A right hemicolectomy was performed. Histopathological examination confirmed the diagnosis of endometriosis with decidualisation. Although endometriosis improves during pregnancy, this case shows the unexpected complications of the disease and demonstrates the importance of considering endometriosis in the differential diagnosis of an acute abdomen in women of childbearing age to prevent maternal morbidity and fetal loss.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Deep pelvic endometriosis: a radiologist's guide to key imaging features with clinical and histopathologic review

While endometriosis typically affects the ovaries, deep infiltrating endometriosis can affect the gastrointestinal tract, urinary tract, and deep pelvis, awareness of which is important for radiologists. Symptoms are nonspecific and can range from chronic abdominal and deep pelvic pain to nausea, vomiting, diarrhea, constipation, hematuria, and rectal bleeding. Ultrasound and computed tomography may show nonspecific soft-tissue density masses causing bowel obstruction and hydronephrosis. This constellation of presenting symptoms and imaging evidence is easily mistaken for other pathologies including infectious gastroenteritis, diverticulitis, appendicitis, and malignancy, which may lead to unnecessary surgery or mismanagement. With this, deep pelvic endometriosis should be considered in the differential diagnosis in a female patient of reproductive age who presents with such atypical symptoms, and further work up with magnetic resonance imaging is imperative for accurate diagnosis, treatment selection, and preoperative planning.