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  1. 1. Diagnosis Of Endometriosis Dr. Shashwat Jani. M.S. ( Gynec) Diploma In Advance Endoscopy. Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College, Sheth V. S. General Hospital, Ahmedabad. Mobile : +91 99099 44160. E-mail : drshashwatjani@gmail.com
  2. 2. Introduction  Endometriosis initially described by Von Rokitansky in 1860.  Endometriosis is a clinical and pathological entity.  It is characterized by the presence of tissue resembling functional endometrial glands and stroma outside the uterine cavity. 3-Sep-15 2Dr Shashwat Jani 9909944160
  3. 3. 3-Sep-15 Dr Shashwat Jani 9909944160 3
  4. 4. It is not a neoplastic condition, but malignant transformation is possible. 3-Sep-15 Dr Shashwat Jani 9909944160 4
  5. 5. Incidence  3 – 10 % of women of reproductive age  20-40% in infertile women  5-20% with chronic pelvic pain  20-50% asymptomatic, found during laparoscopy and sterilization.  50% dysmenorrhea 3-Sep-15 5Dr Shashwat Jani 9909944160
  6. 6. Etiology Estrogen dependent disease  Sampson’s theory Ectopic transplantation of endometrial tissue.  Meyer’s theory Coelomic metaplasia.  Halban's theory: Induction theory Genetic factors Immunologic factors Unknown factor Autoimmune Combination of the Above Environmental factors - dioxin No Single Theory Explains All Cases of Endometriosis 3-Sep-15 6Dr Shashwat Jani 9909944160
  7. 7. Risk Factors Family history of endometriosis. Early age of menarche Short menstrual cycles (<27 d)  Long duration of menstrual flow (>7 d) Heavy bleeding during menses  Inverse relationship to parity  Delayed childbearing  Defects in the uterus or fallopian tubes  less use of OCs 3-Sep-15 7Dr Shashwat Jani 9909944160
  8. 8. Diagnosis  Clinical Presentations  Clinical Examinations  Imaging Modalities  Histological Diagnosis  Biochemical Markers  Surgical Diagnosis 3-Sep-15 8Dr Shashwat Jani 9909944160
  9. 9. Clinical Presentation 3-Sep-15 9Dr Shashwat Jani 9909944160
  10. 10. Symptoms  PELVIC - Dymenorrhoea (50%), Abnormal menstruation (60%) Dyspareunia, Chronic Pelvic Pain, Premenstrual spotting  GASTROINTESTINAL- Constipation, Diarrhea, Hematochezia, Tenesmus  URINARY COMPLAINTS- Flank pain, Back pain, Abdominal pain, Urgency, Frequency,Hematuria  PULMONARY- Haemoptysis , Pneumothorax  INFERTILTY 3-Sep-15 10Dr Shashwat Jani 9909944160
  11. 11. Dysmenorrhea  Most common symptom  Pain starts a few days prior to menstruation, gets worse during menstruation( secondary dysmenorrhoea)  Pain due to Increased secretion of PGF2α, Thromboxane β2 from endometriotic tissue. 3-Sep-15 11Dr Shashwat Jani 9909944160
  12. 12. Abnormal Menstruation - Menorrhagia is a predominant abnormality. - Polymennorhoea, premenstrual spotting also occur. Dyspareunia It is usually deep, due to stretching of the structures of the Pouch of Douglas or direct contact tenderness found in endometriosis of rectovaginal septum or Pouch of Douglas and with fixed retroverted uterus. 3-Sep-15 12Dr Shashwat Jani 9909944160
  13. 13. Lower Abdominal Pain Abdominal pain lower abdominal pain or backache May be due to inflammation in peritoneal implants due to cystic bleeding Irritation or invasion of nerve Action of inflammatory cytokines released by the macrophages. 3-Sep-15 13Dr Shashwat Jani 9909944160
  14. 14. Infertility • Mechanical interference--- • Pelvic adhesions • Chronic salpingitis • Impaired oocyte pickup • Altered tubal motility • Distortion of tubo-ovarian relations • Alteration in peritoneal fluid • Increased concentration of prostaglandins • Increased number of macrophages • Increased production of cytokines • Phagocytosis of sperms 3-Sep-15 14Dr Shashwat Jani 9909944160
  15. 15. • Abnormal Systemic Immune system • Increased cell-mediated gametes injury • Increased prevalence of autoantibodies • Hormonal or ovulatory dysfuntion • Defective folliculogenesis • Luteinized unruptured follicle syndrome • Hyperprolactinemia • Luteal phase deficiency • Implantation failure 3-Sep-15 15Dr Shashwat Jani 9909944160
  16. 16. Clinical Examination General conditions- Pallor + due to Menorrhagia P/A - Mass may be felt in lower abdomen arising from the pelvis Enlarged chocolate cyst or tuboovarian mass, due to endometriotic adhesions. The mass is tender with restricted mobility. L/E- See Vulva and other structures P/S- See cervix, vagina for any deposits, discharge or growth. 3-Sep-15 16Dr Shashwat Jani 9909944160
  17. 17. Bimanual Pelvic Examination o Tender uterosacral ligament o Cul-de-sac nodularity found o Induration of the rectovaginal septum o Fixed retroversion of the uterus o Adnexal masses and generalized or localized pelvic tenderness present o Uterosacral nodules may be found 3-Sep-15 17Dr Shashwat Jani 9909944160
  18. 18. ASRM Classification 3-Sep-15 18Dr Shashwat Jani 9909944160
  19. 19. drshashwatjani@gmail.com 19
  20. 20. ASRM staging has poor correlation with pregnancy rate. In 2009 new staging system was proposed called “ Endometriosis Fertility Index. “ EFI is numerical measure of functional anatomy based on assessment of tubes, fimbriae and ovaries. EFI score 0 to 10 (0 – poorest and 10 – the best prognosis). 3-Sep-15 20Dr Shashwat Jani 9909944160
  21. 21. Imaging Modalities  TVS & TRS  CT SCAN  MRI 3-Sep-15 21Dr Shashwat Jani 9909944160
  22. 22. USG First line tool for suspected endometriosis Detects ovarian cysts ( Endometrioma ) and rule out other causes  May have role in detection of involvement of Bladder & Rectum. Detection of Endometrioma using USG is excellent with 83 % Sensitivity and 98 % Specificity. 3-Sep-15 22Dr Shashwat Jani 9909944160
  23. 23. Classical Appearance :  Homogenous , Hypoechoic mass with in the ovary with diffuse low level internal echoes with hyperechoic foci within the wall.  Wall nodularity should be differentiated from hyperechoic foci within the wall.  95% of endometriomas display low level of internal echoes. D/D : Dermoid , Hemorrhagic , Cystic neoplasm 3-Sep-15 Dr Shashwat Jani 9909944160 23
  24. 24. TRS : - To look at Sigmoid for endometriotic infiltrates. - Rounded or triangular hypoechoic deposits. - Infiltration of bowel wall is seen as thickening of Muscularis Propria. Doppler : • Better studied in late follicular & early luteal phase. • Blood flow in Endometrioma is usually Pericystic with RI > 0.45. 3-Sep-15 Dr Shashwat Jani 9909944160 24
  25. 25. CT Scan / MRI  MRI may detect even smallest of lesions and distinguish hemorrhagic signal of endometriotic implants; superior to CT scan in detecting limits between muscles and abdominal subcutaneous tissues  MRI demonstrated to accurately detect rectovaginal disease and obliteration in more than 90% of cases when ultrasonographic gel was inserted in the vagina and rectum 3-Sep-15 25Dr Shashwat Jani 9909944160
  26. 26. Sensitivity 90 % Specificity 98 %  Major role is to help visualize laparoscopic blind spots such as retroperitoneal space and lesions obscured by dense adhesions or typical lesions. DPE is best diagnosed and located by TRS & MRI. 3-Sep-15 Dr Shashwat Jani 9909944160 26
  27. 27. I.V. Urography : - Serosal deposits are seen at dome of bladder. - Involvement of Ureter is also seen. Barium Enema : Serosal deposits are causing thickening and fibrosis of Muscularis propria which is demonstrated as asymmetric narrowing or eccentric intramural filling defect. 3-Sep-15 Dr Shashwat Jani 9909944160 27
  28. 28. Histological Diagnosis • Positive confirms But Negative doesn’t exclude. • Visual is usually adequate but histology of any one lesion is ideal • In > 4 cm endometrioma & Deep infiltrating disease – histology should be done to identify endometriosis and exclude malignancy. 3-Sep-15 Dr Shashwat Jani 9909944160 28
  29. 29. • Microscopically : Implants consist of endometrial glands and stroma with or without hemosiderin laden macrophages. 3-Sep-15 Dr Shashwat Jani 9909944160 29
  30. 30. Biochemical Marker CA - 125  Cancer Antigen-125, a high molecular weight glycoprotein expressed on the cell surface of some derivatives of embryonic coelomic epithelium.  It is elevated towards the end of the luteal phase and during menstruation.  In many other conditions elevated CA-125 concentration like PID, adenomyosis, uterine leiomyoma, menstruation, pregnancy, epithelial ovarian cancer, pancreatitis, chronic liver disease. 3-Sep-15 30Dr Shashwat Jani 9909944160
  31. 31.  The result of most studies suggest that CA- 125 is not sufficiently sensitive to identify lesser stages of endometriosis. CA-125 is NOT reliable as a screening test. 3-Sep-15 31Dr Shashwat Jani 9909944160
  32. 32. Surgical Diagnosis “ Diagnostic Laparoscopy is the Gold Standard investigation for Endometriosis…” 3-Sep-15 32Dr Shashwat Jani 9909944160
  33. 33. For a definitive diagnosis of endometriosis, visual inspection of the pelvis at laparoscopy is the gold standard investigation, unless disease is visible in the posterior vaginal fornix or elsewhere… 3-Sep-15 Dr Shashwat Jani 9909944160 33
  34. 34.  Can classify the extent and severity of disease.  A double puncture technique is essential.  The grasper placed through the lower abdomen sheath permits mobilization of the tube and ovaries. 3-Sep-15 34Dr Shashwat Jani 9909944160
  35. 35.  Inspect the lateral side wall, all ovarian surface, both sides of the broad ligament, the bladder, bowel serosa, inferior aspect of cul-de-sac, evaluation of the uterosacral ligaments and rectal serosa.  To avoid under diagnosis it should not be performed during or within 3 months of hormonal therapy. 3-Sep-15 Dr Shashwat Jani 9909944160 35
  36. 36. Findings are…  Typical “powder-burn or “gunshot” lesions on the serosal surface of the peritoneum. These lesions are black, blue or dark brown, nodules or small cysts containing old hemorrhage surrounded by variable degree of fibrosis.  White lesions are predominantly fibromuscular scarring with scattered glandular and stromal elements.  Brown lesions are mainly haemosiderin deposits. Peritoneal defect and subovarian adhesions contain endometriosis in 40% -70%. 3-Sep-15 36Dr Shashwat Jani 9909944160
  37. 37. drshashwatjani@gmail.com 37
  38. 38.  For ovarian endometriosis- Large ovarian endometriotic cysts are usually located on the anterior surface of the ovary and associated with retraction, pigmentation and adhesions to the posterior peritoneum.  Ovarian endometriotic cyst contain a thick, viscous dark brown fluid. (Chocolate fluid) 3-Sep-15 38Dr Shashwat Jani 9909944160
  39. 39. 3-Sep-15 39Dr Shashwat Jani 9909944160 Chocolate cyst– sometimes it is confused with hemorrhagic corpus luteum cysts and neoplastic cysts. Biopsy must be done.
  40. 40. Thank you