A Case Report on Deep Infiltrating Endometriosis- Endometrioma

Dr Arunima Rathore * ¹, Dr Ayushman Gupta ²

1. MBBS DGO DNB FICOG FMAS, Sri Mata Vaishno Devi Multispecialty Narayana Hospital, Kakryal, Jammu (J&K), India.

2. MBBS, Sri Mata Vaishno Devi Multispecialty Narayana Hospital, Kakryal, Jammu (J&K), India.

Corresponding Author: Dr Arunima Rathore, Consultant Gynaecologist in Smt Mata Vaishno Devi Narayana Multispeciality Hospital Kakryal, Jammu State J and K, India.

Copy Right: © 2023 Dr Arunima Rathore, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 24, 2023

Published Date: April 01, 2023

DOI: https://doi.org/10.5281/zenodo.10820274

Abstract

Endometriosis a progressive debilitating and estrogen dependent disease is the presence of endometrial tissue (glands and stroma) outside the uterus affecting general mental and social well-being of women¹. In recent times, changing lifestyles, increased awareness and better diagnostic modalities have led to an increase in the incidence of endometriosis. In reproductive age group, endometriosis affects 7 -10% of women and 8-10% of women who are infertile or present with pain abdomen. Also last three decades have seen a significant increase in research related to endometriosis.

Endometriotic tissue most commonly implants in pelvic viscera and peritoneum, less commonly involves cervix, hernial sac, umbilicus, laparotomy or episiotomy scars². No mutations are known to cause endometriosis so far. No mendelian pattern of inheritance seen but a multi factorial inheritance is suggested. Daniel Shroen in 17^th century first described the disease but definitive cause not known so far with poorly understood pathogenesis and limited therapeutic options which are effective. Various theories ranging from transplantation, metaplasia theory to various genetic  and immunologic factors have been proposed. To explain occurrence of endometriosis in cul-de-sac, mainly the Mullerian remnant theory, suggesting that atypical migration or differentiation of these remnants could imitate endometriotic tissue in posterior pelvic floor³.

Endometriotic lesions have a variable appearance?, typically ranging from superficial red lesions to white to black, dark brown or bluish puckered lesions to atypical yellowish discolorations in peritoneum, can present as subovarian adhesions or endometriomas in ovaries. Women with endometriosis can present with severe dysmennorhoea, dyspareunia, chronic pelvic pain, infertility, painful defecation, premenstrual pain or bleed, ovulation pain etc. and pelvic tenderness, a fixed retroverted uterus, tender utero-sacral ligaments, enlarged ovaries, visible lesions on vagina or cervix on examination (detection improved during menstruation)?.

The modalities to diagnose endometriosis can very from physical examination, MRI, with TVS playing a very little role and the gold standard is laparoscopy followed by histological examination. Doppler improves the diagnostic accuracy (pericystic flow with resistive index more than 0.45 indicating low resistance waveform).CA 125 has a low sensitivity so not used for screening.

Keywords: Estrogen dependent disease; Dysmmenorrhoea; Infertility; Endometriosis; Endometrioma/Chocolate cyst.

Abbreviations

TAH-  Total Abdominal Hysterectomy

BSO-  Bilateral Salpingoophorectomy

CECT-Contrast Enhanced Computed Tomography

PLND-Pelvic Lymph Node Dissection

CA-125-Cancer Antigen 125

DIE-   Deep Infiltrating Endometriosis

HCG- Human Chorionic Gonadotropin

VAS- Visual Analogue Scale

Case Report

In December of 2022, a 36 years old female patient Para 3 Live 3 presented to hospital with complaints of fever with pain abdomen. Patient was admitted to hospital. Patient was hemodynamically stable. All routine investigations were  normal,CA-125:135.90,Beta-HCG:1.20.Pap smear was reactive for inflammatory cells.

CECT of whole abdomen revealed bilateral adnexal cystic lesion, bilateral ovaries not visualized separately and imaging suggestive of left tubo-ovarian abscess. A Radical TAH performed with BSO with omentectomy with PLND with adhesiolysis, samples of which were sent for histopathological examination. Operative findings showed a bilateral complex ovarian mass (Right>left) measuring 6cm in size, severe adhesions seen engulfing posterior surface of uterus with left tuboovarian mass, sigmoid colon with momentum adherent to uterosacral ligament (DIE).

Histopathological examination of left ovary showed endometriotic cyst and hemorrhagic corpus luteal cyst in right ovary. Additional findings showed endometrial polyp, adenomyosis uteri, endocervical polyp with focal squamous metaplastic changes, reactive pelvic lymph nodes, showed red endometriotic lesions. The patient was diagnosed with DIE Stage 4 Endometriosis with Adenomyotic uterus with severe adhesions with Omental Endometriosis. Postoperatively patient was shifted to intensive care unit and managed with intravenous antibiotics and fluids, proton pump inhibitor, anti-emetics and other supportive measures. Intra operative and post operative period was uneventful. Patient was stable and discharged from hospital with follow up in gynaecology outpatient department within a week.

Discussion

STAGE 1(MINIMAL) 1-5

STAGE 2(MILD) 6-15

STAGE 3(MODERATE) 16-40

STAGE 4(SEVERE) >40

According to American Society of Reproductive Medicine, doctor assign points according to spread of endometrial tissue, depth and areas affected?.

• Stage 1/Minimal-few implants or lesions found on tissue lining pelvis without scars.
• Stage 2/Mild-More implants than stage 1.They are also deeper in tissue with some scar tissue.
• Stage 3/Moderate- There are many deep implants, small cysts on both ovaries along with adhesions.
• Stage 4/Severe-This is most widespread with many deep implants or thick adhesions. Bilateral large ovarian cyst seen.

Endometriosis has four main types

1. Superficial peritoneal endometriosis
2. Endometriomas
3. Deeply infiltrating endometriosis
4. Abdominal wall endometriosis

In DIE, the endometrial tissue has invaded organs either within or outside pelvic cavity. It’s rare, happens in 1-5% of people with endometriosis. This condition is called frozen Pelvis?.

Conclusion

Treatment should be individualized. Due to heterogeneity of patient population, surgical approches, preferences and techniques vary for treatment of pain associated with deep endometriosis. The VAS score for pain decreased significantly after surgical castration thereby improving quality of life. Henceforth, DIE patients are operated in center of expertise.

Acknowledgements

Authors are thankful to Oncology department, Dr Abhinav Choudhary, DNB Surgical Oncology, Clinical Director Dr JP Singh, Sri Mata Vaishno Devi Multispecialty Narayana Hospital, Kakryal, Jammu (J&K) for continued support and motivation.

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