{"paper_id":"74146297-c592-4c59-a74c-b7ef97e47fd3","body_text":"Abstract\nEndometriosis is a common condition primarily impacting women of childbearing age. Despite increasing awareness that endometriosis can be diagnosed non-invasively with the correct imaging techniques, there exists a significant delay in diagnosis, to the tune of 5–10 years. This gap can be narrowed by understanding that this is a disease that lends itself to pattern recognition, and learning to recognize the characteristic patterns on any imaging study will allow earlier diagnosis and prevent long-term complications that can occur with progressive, untreated endometriosis. The disease is often multifocal and thus can present with a wide array of nonspecific symptoms. When clinical findings do not suggest endometriosis, patients often undergo non-targeted imaging, such as chest, abdominal, or pelvic computed tomography (CT); Magnetic Resonance imaging (MRI) studies optimized for neurologic or musculoskeletal indications; or ultrasound (US) exams performed for palpable masses or nonspecific abdominal pain. Familiarity with endometriosis’s characteristic patterns across organ systems and how it can masquerade as other diseases helps radiologists broaden their differential to include endometriosis, even on studies not originally aimed at its detection. This review article will describe those imaging findings of endometriosis affecting various organ systems that mimic other pathologies and will enable the reader to pause and question whether endometriosis should be included in the differential.\nGraphical abstract\nSimilar content being viewed by others\nData availability\nNo datasets were generated or analysed during the current study.\nReferences\nZondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244-1256. https://doi.org/10.1056/NEJMra1810764\nDe Corte P, Klinghardt M, von Stockum S, Heinemann K. Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics-A Systematic Literature Review. BJOG. 2025;132(2):118-130. https://doi.org/10.1111/1471-0528.17973\nTaylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. The Lancet. 2021;397(10276):839-852. https://doi.org/10.1016/S0140-6736(21)00389-5\nZondervan KT, Becker CM, Koga K, Missmer SA, Taylor RN, Viganò P. Endometriosis. Nat Rev Dis Primers. 2018;4(1):9. https://doi.org/10.1038/s41572-018-0008-5\nRuaux E, VanBuren WM, Nougaret S, et al. Endometriosis MR mimickers: T2-hypointense lesions. Insights Imaging. 2024;15(1):20. https://doi.org/10.1186/s13244-023-01588-2\nWon HR, Abbott J. Optimal managementof chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Int J Womens Health. 2010;2:263-277. https://doi.org/10.2147/IJWH.S7991\nSarma D, Iyengar P, Marotta TR, terBrugge KG, Gentili F, Halliday W. Cerebellar Endometriosis. American Journal of Roentgenology. 2004;182(6):1543-1546. https://doi.org/10.2214/ajr.182.6.1821543\nSiquara De Sousa AC, Capek S, Amrami KK, Spinner RJ. Neural involvement in endometriosis: Review of anatomic distribution and mechanisms. Clinical Anatomy. 2015;28(8):1029-1038. https://doi.org/10.1002/ca.22617\nOsório F, Alves J, Pereira J, et al. Obturator Internus Muscle Endometriosis with Nerve Involvement: a Rare Clinical Presentation. Journal of Minimally Invasive Gynecology. 2018;25(2):330-333. https://doi.org/10.1016/j.jmig.2017.07.013\nColak C, Chamie LP, Youngner J, et al. MRI Features of Pelvic Nerve Involvement in Endometriosis. RadioGraphics. 2024;44(1):e230106. https://doi.org/10.1148/rg.230106\nKale A, Baydili KN s, Keles E, Gundogdu Elif, Usta T, Oral E. Comparison of Isolated Sciatic Nerve and Sacral Nerve Root Endometriosis: A Review of the Literature. Journal of Minimally Invasive Gynecology. 2022;29(8):943-951. https://doi.org/10.1016/j.jmig.2022.05.017\nPossover M, Chiantera V. Isolated infiltrative endometriosis of the sciatic nerve: a report of three patients. Fertility and Sterility. 2007;87(2):417.e17-417.e19. https://doi.org/10.1016/j.fertnstert.2006.05.084\nHowe BM, Amrami KK, Nathan MA, Garcia JJ, Spinner RJ. Perineural spread of cervical cancer to the sciatic nerve. Skeletal Radiol. 2013;42(11):1627-1631. https://doi.org/10.1007/s00256-013-1653-0\nJoseph J, Sahn SA. Thoracic endometriosis syndrome: New observations from an analysis of 110 cases. The American Journal of Medicine. 1996;100(2):164-170. https://doi.org/10.1016/S0002-9343(97)89454-5\nXiao L, White D, Kruger LF, et al. Thoracic endometriosis syndrome: imaging findings and the value of a dedicated MRI protocol. Abdom Radiol. Published online February 18, 2025. https://doi.org/10.1007/s00261-025-04835-w\nHwang SM, Lee CW, Lee BS, Park JH. Clinical features of thoracic endometriosis: A single center analysis. Obstet Gynecol Sci. 2015;58(3):223. https://doi.org/10.5468/ogs.2015.58.3.223\nRousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, Revel MP. Thoracic endometriosis syndrome: CT and MRI features. Clinical Radiology. 2014;69(3):323-330. https://doi.org/10.1016/j.crad.2013.10.014\nBourgioti C, Preza O, Panourgias E, et al. MR imaging of endometriosis: Spectrum of disease. Diagnostic and Interventional Imaging. 2017;98(11):751-767. https://doi.org/10.1016/J.DIII.2017.05.009\nChamié LP, Ribeiro DMFR, Tiferes DA, Macedo Neto ACD, Serafini PC. Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings. RadioGraphics. 2018;38(1):309-328. https://doi.org/10.1148/rg.2018170093\nNair SS. Thoracic Endometriosis Syndrome: A Veritable Pandora’s Box. JCDR. Published online 2016. https://doi.org/10.7860/JCDR/2016/17668.7700\nPagano F, Schwander A, Vaineau C, et al. True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation. J Minim Invasive Gynecol. 2023;30(4):329-334. https://doi.org/10.1016/j.jmig.2023.01.006\nClement PB. Pathology of endometriosis. Pathol Annu. 1990;25 Pt 1:245-295.\nJha P, Sakala M, Chamie LP, et al. Endometriosis MRI lexicon: consensus statement from the society of abdominal radiology endometriosis disease-focused panel. Abdom Radiol. 2020;45(6):1552-1568. https://doi.org/10.1007/s00261-019-02291-x\nBiscaldi E, Barra F, Ferrero S. Magnetic Resonance Enema in Rectosigmoid Endometriosis. Magnetic Resonance Imaging Clinics of North America. 2020;28(1):89-104. https://doi.org/10.1016/j.mric.2019.08.006\nMeyers WC. Diagnosis and Surgical Treatment of Colonic Endometriosis. Arch Surg. 1979;114(2):169. https://doi.org/10.1001/archsurg.1979.01370260059009\nDarvishzadeh A, McEachern W, Lee TK, et al. Deep pelvic endometriosis: a radiologist’s guide to key imaging features with clinical and histopathologic review. Abdom Radiol. 2016;41(12):2380-2400. https://doi.org/10.1007/s00261-016-0956-8\nLevitt MD, Hodby KJ, Merwyk AJV, Glancy RJ. CYCLICAL RECTAL BLEEDING IN COLORECTAL ENDOMETRIOSIS. Australian and New Zealand Journal of Surgery. 1989;59(12):941-943. https://doi.org/10.1111/j.1445-2197.1989.tb07635.x\nRemorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel Endometriosis: Presentation, Diagnosis, and Treatment. Obstetrical & Gynecological Survey. 2007;62(7):461-470. https://doi.org/10.1097/01.ogx.0000268688.55653.5c\nGhosh S, Alhamshari A, Prajapati P, et al. Role of computed tomography in imaging of endometriosis. Abdom Radiol. Published online March 27, 2025. https://doi.org/10.1007/s00261-025-04907-x\nYoon JH, Choi D, Jang KT, et al. Deep rectosigmoid endometriosis: “mushroom cap” sign on T2-weighted MR imaging. Abdom Imaging. 2010;35(6):726-731. https://doi.org/10.1007/s00261-010-9643-3\nWorking group of ESGE, ESHRE, and WES, Keckstein J, Becker CM, et al. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis†‡¶. Human Reproduction Open. 2020; 2020(1):hoaa002. https://doi.org/10.1093/hropen/hoaa002\nBricou A, Batt RE, Chapron C. Peritoneal fluid flow influences anatomical distribution of endometriotic lesions: Why Sampson seems to be right. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2008;138(2):127-134. https://doi.org/10.1016/j.ejogrb.2008.01.014\nTong A, VanBuren WM, Chamié L, et al. Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel. Abdom Radiol. 2020;45(6):1569-1586. https://doi.org/10.1007/s00261-020-02483-w\nCollin M, Barat M, Oudjit A, et al. Comparison between CT-enterography and MR-enterography for the diagnosis of right-sided deep infiltrating endometriosis of the bowel. European Journal of Radiology. 2023;161:110730. https://doi.org/10.1016/j.ejrad.2023.110730\nBazot M, Kermarrec E, Bendifallah S, Daraï E. MRI of intestinal endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology. 2021;71:51-63.https://doi.org/10.1016/j.bpobgyn.2020.05.013\nJaramillo-Cardoso A, Shenoy-Bhangle AS, VanBuren WM, Schiappacasse G, Menias CO, Mortele KJ. Imaging of gastrointestinal endometriosis: what the radiologist should know. Abdom Radiol. 2020;45(6):1694-1710. https://doi.org/10.1007/s00261-020-02459-w\nVanBuren W, Feldman M, Shenoy-Bhangle AS, et al. Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting. Goh V, ed. Radiology. 2024; 312(3):e233482. https://doi.org/10.1148/radiol.233482\nKnabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertility and Sterility. 2015;103(1):147-152. https://doi.org/10.1016/j.fertnstert.2014.09.028\nGabriel B, Nassif J, Trompoukis P, Barata S, Wattiez A. Prevalence and Management of Urinary Tract Endometriosis: A Clinical Case Series. Urology. 2011;78(6):1269-1274. https://doi.org/10.1016/j.urology.2011.07.1403\nLeone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. European Urology. 2017; 71(5):790–807. https://doi.org/10.1016/j.eururo.2016.12.015\nSavelli L, Manuzzi L, Pollastri P, Mabrouk M, Seracchioli R, Venturoli S. Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis. Ultrasound in Obstet & Gyne. 2009;34(5):595-600. https://doi.org/10.1002/uog.7356\nShenoy-Bhangle AS, Pires Franco I, Ray LJ, et al. Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique. Acad Radiol. 2024;31(9):3659-3671. https://doi.org/10.1016/j.acra.2023.10.053\nSaccardi C, Vitagliano A, Litta P. Bladder endometriosis: a summary of current evidence. Minerva Obstet Gynecol. 2017; 69(5). https://doi.org/10.23736/S0026-4784.17.04059-X\nHorn LC, Do Minh M, Stolzenburg JU. Intrinsic Form of Ureteral Endometriosis Causing Ureteral Obstruction and Partial Loss of Kidney Function. Urol Int. 2004;73(2):181-184. https://doi.org/10.1159/000079702\nNezhat C, Paka C, Gomaa M, Schipper E. Silentloss of kidney seconary to ureteral endometriosis. JSLS. 2012;16(3):451-455. https://doi.org/10.4293/108680812X13462882736213\nBarra F, Scala C, Biscaldi E, et al. Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. Human Reproduction Update. 2018;24(6):710-730. https://doi.org/10.1093/humupd/dmy027\nShafrir AL, Farland LV, Shah DK, et al. Risk for and consequences of endometriosis: A critical epidemiologic review. Best Practice & Research Clinical Obstetrics & Gynaecology. 2018;51:1-15. https://doi.org/10.1016/j.bpobgyn.2018.06.001\nUimari O, Nazri H, Tapmeier T. Endometriosis and Uterine Fibroids (Leiomyomata): Comorbidity, Risks and Implications. Front Reprod Health. 2021;3:750018. https://doi.org/10.3389/frph.2021.750018\nMiao K, Lv Q, Zhang L, Zhao N, Dong X. Discriminative diagnosis of ovarian endometriosis cysts and benign mucinous cystadenomas based on the ConvNeXt algorithm. Eur J Obstet Gynecol Reprod Biol. 2024;298:135-139. https://doi.org/10.1016/j.ejogrb.2024.05.010\nHuang KJ, Li YX, Wu CJ, Chang WC, Wei LH, Sheu BC. Sonographic features differentiating early-stage ovarian clear cell carcinoma from endometrioma with atypical features. J Ovarian Res. 2022;15:84. https://doi.org/10.1186/s13048-022-01019-8\nWoodard TL, Awonuga AO, Puscheck E. Malignant Transformation of Endometrioma in a Woman with a History of Ovulation Induction and In Vitro Fertilization. Case Rep Med. 2012;2012:497362. https://doi.org/10.1155/2012/497362\nChapron C, Pietin-Vialle C, Borghese B, Davy C, Foulot H, Chopin N. Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril. 2009;92(2):453-457. https://doi.org/10.1016/j.fertnstert.2008.06.003\nYoung SW, Jha P, Chamié L, et al. Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis. Radiology. 2024;311(1):e232191. https://doi.org/10.1148/radiol.232191\nSakala MD, Jha P, Tong A, Taffel MT, Feldman MK. MR Imaging of Endometriosis of the Adnexa. Magn Reson Imaging Clin N Am. 2023;31(1):121-135. https://doi.org/10.1016/j.mric.2022.06.006\nSomigliana E, Benaglia L, Paffoni A, Busnelli A, Vigano P, Vercellini P. Risks of conservative management in women with ovarian endometriomas undergoing IVF. Hum Reprod Update. 2015;21(4):486-499. https://doi.org/10.1093/humupd/dmv012\nOrlov S, Sladkevicius P, Rivano Eckerdal I, Jokubkiene L. Morphological changes of endometriomas during pregnancy and after delivery detected using ultrasound. Fertility and Sterility. 2025;123(2):211-220. https://doi.org/10.1016/j.fertnstert.2024.08.355\nGuerriero S, Conway F, Pascual MA, et al. Ultrasonography and Atypical Sites of Endometriosis. Diagnostics (Basel). 2020;10(6):345. https://doi.org/10.3390/diagnostics10060345\nAndrade MT, De Freitas CVM, Câmara SFC, Vieira JJN. Umbilical Nodule with Cyclical Bleeding: A Case Report and Literature Review of Atypical Endometriosis. Case Reports in Obstetrics and Gynecology. 2016;2016:1-6. https://doi.org/10.1155/2016/7401409\nAllen SE, Rindos NB, Mansuria S. Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management. Current Opinion in Obstetrics & Gynecology. 2021;33(4):288-295. https://doi.org/10.1097/GCO.0000000000000714\nArkoudis NA, Moschovaki-Zeiger O, Prountzos S, Spiliopoulos S, Kelekis N. Caesarean-section scar endometriosis (CSSE): clinical and imaging fundamentals of an underestimated entity. Clinical Radiology. 2023;78(9):644-654. https://doi.org/10.1016/j.crad.2023.05.020\nAkdemir A, Akman L, Yavuzsen HT, Zekioglu O. Clinical features of patients with endometriosis on the cesarean scar. The Kaohsiung J of Med Scie. 2014;30(10):541-543. https://doi.org/10.1016/j.kjms.2013.12.001\nKido A, Himoto Y, Moribata Y, Kurata Y, Nakamoto Y. MRI in the Diagnosis of Endometriosis and Related Diseases. Korean J Radiol. 2022;23(4):426. https://doi.org/10.3348/kjr.2021.0405\nPapadoliopoulou M, Margaris I, Giannakis A, et al. Nuck Canal Endometriosis Following IVF Attempts in a Young Patient—Report of a Case. Clinics and Practice. 2024;14(4):1245-1250. https://doi.org/10.3390/clinpract14040100\nAuthor information\nAuthors and Affiliations\nContributions\nA.S.B. was responsible for conceptualizing the manuscript. A.S.B., C.C., A.T., L.P., M.T.T., K.S.B., S.G., L.P.C., S.W.Y., and M.K.F. wrote the manuscript and created Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. S.G. was responsible for creating videos 1, 2, 3, 4 as supplementary material. A.S.B., M.K.F., and M.T.T. reviewed and edited the manuscript.\nCorresponding author\nEthics declarations\nConflict of interest\nThe authors declare no competing interests.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary Information\nBelow is the link to the electronic supplementary material.\nSupplementary file2 (MP4 19565 kb)\nSupplementary file3 (MP4 3978 kb)\nSupplementary file4 (MP4 11019 kb)\nSupplementary file5 (MP4 4929 kb)\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nShenoy-Bhangle, A.S., Carnelli, C., Tong, A. et al. Head to toe: expand your diagnosis on routine imaging to include endometriosis. Abdom Radiol 51, 299–315 (2026). https://doi.org/10.1007/s00261-025-05051-2\nReceived:\nRevised:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s00261-025-05051-2","source_license":"CC0","license_restricted":false}