{"paper_id":"6f2571b9-b396-49a0-9761-37d0c8290873","body_text":"Abstract\nWhile 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.\nSimilar content being viewed by others\nReferences\nBenagiano G, Brosens I (2006) History of adenomyosis. Best Pract Res Clin Obstet Gynaecol 20:449–463. doi:10.1016/j.bpobgyn.2006.01.007\nKratzer GL, Salvati EP (1955) Collective review of endometriosis of the colon. Am J Surg 90:866–869\nMissmer SA, Hankinson SE, Spiegelman D, et al. (2004) Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am J Epidemiol 160:784–796. doi:10.1093/aje/kwh275\nSangi-Haghpeykar H, Poindexter AN 3rd (1995) Epidemiology of endometriosis among parous women. Obstet Gynecol 85:983–992. doi:10.1016/0029-7844(95)00074-2\nGiudice LC, Kao LC (2004) Endometriosis. Lancet 364:1789–1799. doi:10.1016/S0140-6736(04)17403-5\nCramer DW, Wilson E, Stillman RJ, et al. (1986) The relation of endometriosis to menstrual characteristics, smoking, and exercise. JAMA 255:1904–1908\nBallard K, Lane H, Hudelist G, Banerjee S, Wright J (2010) Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain. Fertil Steril 94:20–27. doi:10.1016/j.fertnstert.2009.01.164\nSakamoto K, Maeda T, Yamamoto T, et al. (2006) Simultaneous laparoscopic treatment for rectosigmoid and ileal endometriosis. J Laparoendosc Adv Surg Tech A 16:251–255. doi:10.1089/lap.2006.16.251\nPetta CA, Peloggia A (2015) Imaging techniques for the diagnosis of deep endometriosis. Austin J Reprod Med Infertil 2:1020\nMoawad NS, Caplin A (2013) Diagnosis, management, and long-term outcomes of rectovaginal endometriosis. Int J Womens Health 5:753–763. doi:10.2147/IJWH.S37846\nSlesser AA, Sultan S, Kubba F, Sellu DP (2010) Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: a case report. World J Emerg Surg 5:27. doi:10.1186/1749-7922-5-27\nDmowski WP, Lesniewicz R, Rana N, Pepping P, Noursalehi M (1997) Changing trends in the diagnosis of endometriosis: a comparative study of women with pelvic endometriosis presenting with chronic pelvic pain or infertility. Fertil Steril 67:238–243. doi:10.1016/S0015-0282(97)81904-8\nSeaman HE, Ballard KD, Wright JT, de Vries CS (2008) Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study—Part 2. BJOG 115:1392–1396. doi:10.1111/j.1471-0528.2008.01879.x\nChapron C, Dubuisson JB, Pansini V, et al. (2002) Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis. J Am Assoc Gynecol Laparosc 9:115–119\nHudelist G, Ballard K, English J, et al. (2011) Transvaginal sonography versus clinical examination in the preoperative diagnosis of deep infiltrating endometriosis. Ultrasound Obstet Gynecol 37:480–487. doi:10.1002/uog.8935\nDenny E (2004) Women’s experience of endometriosis. J Adv Nurs 46:641–648. doi:10.1111/j.1365-2648.2004.03055.x\nRogers PA, D’Hooghe TM, Fazleabas A, et al. (2013) Defining future directions for endometriosis research: workshop report from the 2011 World Congress of Endometriosis in Montpellier, France. Reprod Sci 20:483–499. doi:10.1177/1933719113477495\nKim JS, Hur H, Min BS, et al. (2009) Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases. Yonsei Med J 50:732–735. doi:10.3349/ymj.2009.50.5.732\nYantiss RK, Clement PB, Young RH (2001) Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol 25:445–454\nRemorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC (2007) Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 62:461–470. doi:10.1097/01.ogx.0000268688.55653.5c\nMeyers WC, Kelvin FM, Jones RS (1979) Diagnosis and surgical treatment of colonic endometriosis. Arch Surg 114:169–175\nWeed JC, Ray JE (1987) Endometriosis of the bowel. Obstet Gynecol 69:727–730\nCollier HA, Gonzales LL, Bossert LJ (1962) Cyclic ascites as a manifestation of endometriosis. Report of a case. Obstet Gynecol 19:681–683\nMacafee CH, Greer HL (1960) Intestinal endometriosis. A report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Emp 67:539–555\nLevitt MD, Hodby KJ, van Merwyk AJ, Glancy RJ (1989) Cyclical rectal bleeding in colorectal endometriosis. Aust N Z J Surg 59:941–943\nAnaf V, El Nakadi I, Simon P, et al. (2004) Preferential infiltration of large bowel endometriosis along the nerves of the colon. Hum Reprod 19:996–1002. doi:10.1093/humrep/deh150\nRemorgida V, Ragni N, Ferrero S, et al. (2005) The involvement of the interstitial Cajal cells and the enteric nervous system in bowel endometriosis. Hum Reprod 20:264–271. doi:10.1093/humrep/deh568\nCollins DC (1955) A study of 50,000 specimens of the human vermiform appendix. Surg Gynecol Obstet 101:437–445\nKhoo JJ, Ismail MS, Tiu CC (2004) Endometriosis of the appendix presenting as acute appendicitis. Singap Med J 45:435–436\nDriman DK, Melega DE, Vilos GA, Plewes EA (2000) Mucocele of the appendix secondary to endometriosis. Report of two cases, one with localized pseudomyxoma peritonei. Am J Clin Pathol 113:860–864. doi:10.1309/EUTL-BC88-TLAX-1UJ4\nCurbelo-Pena Y, Guedes-De la Puente X, Saladich-Cubero M, et al. (2015) Endometriosis causing acute appendicitis complicated with hemoperitoneum. J Surg Case Rep. doi:10.1093/jscr/rjv097\nCollins DC (1951) Endometriosis of the vermiform appendix; review of literature, with addition of nine new instances, one of which caused severe melena. AMA Arch Surg 63:617–622\nMuthyala T, Sikka P, Aggarwal N, et al. (2015) Endometriosis presenting as carcinoma colon in a perimenopausal woman. J Midlife Health 6:122–124. doi:10.4103/0976-7800.165592\nDonnez J, Spada F, Squifflet J, Nisolle M (2000) Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 74:1175–1181\nGabriel B, Nassif J, Trompoukis P, Barata S, Wattiez A (2011) Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 78:1269–1274. doi:10.1016/j.urology.2011.07.1403\nTarumi Y, Mori T, Kusuki I, Ito F, Kitawaki J (2015) Endometrioid adenocarcinoma arising from deep infiltrating endometriosis involving the bladder: a case report and review of the literature. Gynecol Oncol Rep 13:68–70. doi:10.1016/j.gore.2015.07.003\nChamie LP, Blasbalg R, Pereira RM, Warmbrand G, Serafini PC (2011) Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 31:E77–100. doi:10.1148/rg.314105193\nSchonman R, Dotan Z, Weintraub AY, et al. (2013) Deep endometriosis inflicting the bladder: long-term outcomes of surgical management. Arch Gynecol Obstet 288:1323–1328. doi:10.1007/s00404-013-2917-6\nLeone Roberti Maggiore U, Ferrero S, Salvatore S (2015) Urinary incontinence and bladder endometriosis: conservative management. Int Urogynecol J 26:159–162. doi:10.1007/s00192-014-2487-6\nBogart LM, Berry SH, Clemens JQ (2007) Symptoms of interstitial cystitis, painful bladder syndrome and similar diseases in women: a systematic review. J Urol 177:450–456. doi:10.1016/j.juro.2006.09.032\nSeracchioli R, Mabrouk M, Manuzzi L, et al. (2008) Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 15:435–439. doi:10.1016/j.jmig.2008.03.005\nGoncalves MO, Podgaec S, Dias JA Jr, Gonzalez M, Abrao MS (2010) Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy. Hum Reprod 25:665–671. doi:10.1093/humrep/dep433\nBazot M, Darai E, Hourani R, et al. (2004) Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology 232:379–389. doi:10.1148/radiol.2322030762\nVimercati A, Achilarre MT, Scardapane A, et al. (2012) Accuracy of transvaginal sonography and contrast-enhanced magnetic resonance-colonography for the presurgical staging of deep infiltrating endometriosis. Ultrasound Obstet Gynecol 40:592–603. doi:10.1002/uog.11179\nHirai M, Shibata K, Sagai H, Sekiya S, Goldberg BB (1995) Transvaginal pulsed and color Doppler sonography for the evaluation of adenomyosis. J Ultrasound Med 14:529–532\nSakhel K, Abuhamad A (2012) Sonography of adenomyosis. J Ultrasound Med 31:805–808\nFerrero S, Biscaldi E, Vellone VG, Venturini PL, Leone Roberti Maggiore U (2016) Computed tomographic colonography versus rectal-water contrast transvaginal ultrasonography in the diagnosis of rectosigmoid endometriosis: a pilot study. Ultrasound Obstet Gynecol. doi:10.1002/uog.15905\nTrippia CH, Zomer MT, Terazaki CR, et al. (2016) Relevance of imaging examinations in the surgical planning of patients with bowel endometriosis. Clin Med Insights Reprod Health 10:1–8. doi:10.4137/CMRH.S29472\nBenacerraf BR, Groszmann Y, Hornstein MD, Bromley B (2015) Deep infiltrating endometriosis of the bowel wall: the comet sign. J Ultrasound Med 34:537–542. doi:10.7863/ultra.34.3.537\nGuerriero S, Ajossa S, Gerada M, et al. (2008) Diagnostic value of transvaginal ‘tenderness-guided’ ultrasonography for the prediction of location of deep endometriosis. Hum Reprod 23:2452–2457. doi:10.1093/humrep/den293\nFratelli N, Scioscia M, Bassi E, et al. (2013) Transvaginal sonography for preoperative assessment of deep endometriosis. J Clin Ultrasound 41:69–75. doi:10.1002/jcu.22018\nFedele L, Bianchi S, Portuese A, Borruto F, Dorta M (1998) Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol 91:444–448\nRossini LG, Ribeiro PA, Rodrigues FC, et al. (2012) Transrectal ultrasound—techniques and outcomes in the management of intestinal endometriosis. Endosc Ultrasound 1:23–35. doi:10.7178/eus.01.005\nGriffiths A, Koutsouridou R, Vaughan S, et al. (2008) Transrectal ultrasound and the diagnosis of rectovaginal endometriosis: a prospective observational study. Acta Obstet Gynecol Scand 87:445–448. doi:10.1080/00016340801948318\nFedele L, Bianchi S, Raffaelli R, Portuese A (1997) Pre-operative assessment of bladder endometriosis. Hum Reprod 12:2519–2522\nPateman K, Holland TK, Knez J, et al. (2015) Should a detailed ultrasound examination of the complete urinary tract be routinely performed in women with suspected pelvic endometriosis? Hum Reprod 30:2802–2807. doi:10.1093/humrep/dev246\nSavelli L, Manuzzi L, Pollastri P, et al. (2009) Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis. Ultrasound Obstet Gynecol 34:595–600. doi:10.1002/uog.7356\nPateman K, Mavrelos D, Hoo WL, et al. (2013) Visualization of ureters on standard gynecological transvaginal scan: a feasibility study. Ultrasound Obstet Gynecol 41:696–701. doi:10.1002/uog.12468\nFaccioli N, Foti G, Manfredi R, et al. (2010) Evaluation of colonic involvement in endometriosis: double-contrast barium enema versus magnetic resonance imaging. Abdom Imaging 35:414–421. doi:10.1007/s00261-009-9544-5\nRoman H, Carilho J, Da Costa C, et al. (2016) Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: the surgeon’s point of view. Gynecol Obstet Fertil 44:3–10. doi:10.1016/j.gyobfe.2015.11.008\nIosca S, Lumia D, Bracchi E, et al. (2013) Multislice computed tomography with colon water distension (MSCT-c) in the study of intestinal and ureteral endometriosis. Clin Imaging 37:1061–1068. doi:10.1016/j.clinimag.2013.07.003\nLandi S, Barbieri F, Fiaccavento A, et al. (2004) Preoperative double-contrast barium enema in patients with suspected intestinal endometriosis. J Am Assoc Gynecol Laparosc 11:223–228\nFaccioli N, Manfredi R, Mainardi P, et al. (2008) Barium enema evaluation of colonic involvement in endometriosis. AJR Am J Roentgenol 190:1050–1054. doi:10.2214/ajr.07.3062\nYoon JH, Choi D, Jang KT, et al. (2010) Deep rectosigmoid endometriosis: “mushroom cap” sign on T2-weighted MR imaging. Abdom Imaging 35:726–731. doi:10.1007/s00261-010-9643-3\nHottat N, Larrousse C, Anaf V, et al. (2009) Endometriosis: contribution of 3.0-T pelvic MR imaging in preoperative assessment—initial results. Radiology 253:126–134. doi:10.1148/radiol.2531082113\nMenni K, Facchetti L, Cabassa P (2016) Extragenital endometriosis: assessment with MR imaging. A pictorial review. Br J Radiol 89:20150672. doi:10.1259/bjr.20150672\nCoutinho A Jr, Bittencourt LK, Pires CE, et al. (2011) MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics 31:549–567. doi:10.1148/rg.312105144\nLoubeyre P, Petignat P, Jacob S, et al. (2009) Anatomic distribution of posterior deeply infiltrating endometriosis on MRI after vaginal and rectal gel opacification. AJR Am J Roentgenol 192:1625–1631. doi:10.2214/AJR.08.1856\nKruger K, Behrendt K, Niedobitek-Kreuter G, Koltermann K, Ebert AD (2013) Location-dependent value of pelvic MRI in the preoperative diagnosis of endometriosis. Eur J Obstet Gynecol Reprod Biol 169:93–98. doi:10.1016/j.ejogrb.2013.02.007\nBalleyguier C, Roupret M, Nguyen T, et al. (2004) Ureteral endometriosis: the role of magnetic resonance imaging. J Am Assoc Gynecol Laparosc 11:530–536\nCorwin MT, Gerscovich EO, Lamba R, Wilson M, McGahan JP (2014) Differentiation of ovarian endometriomas from hemorrhagic cysts at MR imaging: utility of the T2 dark spot sign. Radiology 271:126–132. doi:10.1148/radiol.13131394\nSiegelman ES, Oliver ER (2012) MR imaging of endometriosis: ten imaging pearls. Radiographics 32:1675–1691. doi:10.1148/rg.326125518\nKataoka ML, Togashi K, Yamaoka T, et al. (2005) Posterior cul-de-sac obliteration associated with endometriosis: MR imaging evaluation. Radiology 234:815–823. doi:10.1148/radiol.2343031366\nMussa FF, Younes Z, Tihan T, Lacy BE (2001) Anasarca and small bowel obstruction secondary to endometriosis. J Clin Gastroenterol 32:167–171\nAcknowledgements\nThe authors acknowledge the assistance of Eric J. Gray and Sonia Watson, Ph.D., for editing the manuscript and Christopher M. Brown for illustration design.\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nFunding\nNo funding was received for this study.\nConflicts of interest\nThe authors declare that they have no conflict of interest.\nEthical approval\nAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\nInformed consent\nStatement of informed consent was not applicable since the manuscript does not contain any patient data.\nRights and permissions\nAbout this article\nCite this article\nDarvishzadeh, A., McEachern, W., Lee, T.K. et al. Deep pelvic endometriosis: a radiologist’s guide to key imaging features with clinical and histopathologic review. Abdom Radiol 41, 2380–2400 (2016). https://doi.org/10.1007/s00261-016-0956-8\nPublished:\nIssue date:\nDOI: https://doi.org/10.1007/s00261-016-0956-8","source_license":"CC0","license_restricted":false}