{"paper_id":"aac7b490-942c-4d19-a3ee-1d9b2d4b4188","body_text":"Correlation of Endoscopic Findings with\nSuspected Intestinal Endometriosis in the Distal\nSigmoid and Rectum as Observed on Transrectal\nUltrasonography\nVinicius Pfuetzenreiter 1 Jarbas Faraco M. Loureiro 1 Carolina Viana Teixeira 1\nLucio Giovanni Battista Rossini 1\n1 Department of Endoscopy, Hospital Sirio-Libanes, São Paulo, SP,\nBrazil\nJ Coloproctol 2023;43(1):36 –42.\nAddress for correspondence Vinicius Pfuetzenreiter, Master Degree,\nHospital Sirio-Libanes, São Paulo, SP, Brazil\n(e-mail: vinipfu@gmail.com).\nIntroduction\nThe differential diagnoses of abdominal or chronic pelvic\npain include diseases such as irritable bowel syndrome,\ninflammatory bowel disease, abdominal tumors, and intes-\ntinal endometriosis.\n1–3 Currently, there is no endoscopic\ndefinition regarding intestinal involvement in endometriosis\n(EDT), which may lead to failure or delay in diagnosis.\nEndometriosis is a benign gynecological disease, de fined\nby the presence of tissue similar to that of the endometrium,\nglands, and/or stroma that is located outside the uterine\ncavity and responsive to hormonal stimuli.\n4–7 When EDT\ninfiltrates the wall of the rectum or colon, colonoscopy may\nexhibit deviations from normal findings. However, few stud-\nies to date have described these changes or an actual\nKeywords\n► endometriosis\n► sigmoidoscopy\n► colonoscopy\n► sigmoid colon\n► rectal diseases\nAbstract Introduction Colonoscopy enables detailed endoscopic evaluation of the interior of\nthe colon. Changes observed via colonoscopy may be subtle or pronounced and can\nsometimes mimic those of other diseases, s uch as deep intestinal endometriosis. The\ndiagnosis of endometriosis in the distal sigmoid and rectum by colonoscopy has been\ndescribed in previous case reports.\nObjective We aimed to correlate the endoscopic changes found in the distal sigmoid\nand rectum with the presence of endometrial deposits con firmed by transrectal\nultrasound (TRUS).\nMethods We included 50 female patients referred to the endoscopy department at\nour institution for colonoscopy, rectosig moidoscopy, or TRUS, who exhibited one or\nmore symptoms associated with endometriosis.\nResults The colonoscopic findings were normal in 36 patients but showed alterations\nin 14 patients. Among the latter, TRUS revealed involvement of the sigmoid and/or\nrectal wall in 11 patients.\nConclusions The endoscopic changes in the distal sigmoid or rectum described in this\nstudy were strongly associated with endometrial deposits con firmed using TRUS.\nreceived\nNovember 18, 2022\naccepted after revision\nJanuary 23, 2023\nDOI https://doi.org/\n10.1055/s-0043-1764194.\nISSN 2237-9363.\n© 2023. Sociedade Brasileira de Coloproctologia. All rights\nreserved.\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution-NonDeri vative-NonCommercial-License,\npermitting copying and reproduction so long as the original work is given\nappropriate credit. Contents may not be used for commercial purposes, or\nadapted, remixed, transformed or built upon. (https://creativecommons.org/\nlicenses/by-nc-nd/4.0/)\nThieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de\nJaneiro, RJ, CEP 20270-135, Brazil\nOriginal Article\nTHIEME\n36\nArticle published online: 2023-03-22\n\nassociation with endometrial deposits located near or in fil-\ntrating the wall of the colon and rectum. 3,4\nThe appearance and maintenance of endometrial deposits\nare dependent on hormonal stimulation. Therefore, the\nincidence of the disease is higher in reproductive-age wom-\nen and does not commonly occur before menarche, or in\npostmenopausal women who are not exposed to estrogen\nreplacement therapy. It is estimated that the incidence of\nEDT among reproductive-age women is between 5 and\n15%.\n5,8,9 The most common sites of deep intestinal EDT\nimplantation are the ovaries, fundus of the Douglas ’ pouch,\nround ligament, uterosacral ligament, uterus, uterine tubes,\nsigmoid colon, and appendix 4,6,10–12)). In cases of EDT that\naffects the intestinal segments, the sites with the highest\nincidence rates are the rectum and the distal sigmoid,\naccounting for up to 95% of intestinal implants.\n3,13–15\nTransrectal ultrasound (TRUS) examination is one of the\nmost specific methods used for the diagnosis and evaluation\nof intestinal involvement of endometrial deposits. The use of\nrigid transducers similar to those used in transvaginal ultra-\nsound or endoscopes with ultrasound transducers on their\nend enable examination of the entire rectum and sigmoid\nwhen studying the disease using the echo-logic classi fica-\ntion, which allows the detailing of the degree of invasion of\nthe rectal or colonic wall (T1 when there is no invasion, T2 for\ninvolvement of the serosa, T3 when the muscularis propria is\ninvolved, T4 for involvement of the submucosa, and T5 when\nthe mucosa is involved).\n16 Histological con firmation is pos-\nsible via laparoscopy or echo-guided puncture (solely for\nendometrial deposits); therefore, the diagnosis can be made\nbased on clinical and radiological examinations alone. These\nimaging studies are important for diagnosis, classi fication,\nand surgical planning, when necessary, and include the\nfollowing: abdominal ultrasonography, transvaginal ultraso-\nnography (TRUS), three-dimensional transvaginal ultraso-\nnography, magnetic resonance imaging (MRI), double\ncontrast barium enema, water enema computed tomogra-\nphy, colonoscopy, and virtual colonoscopy, although these all\nhave specific indications and limitations.\n6,16–28 Laparoscopy\ndisplays low detection accuracy in the case of endometrial\ndeposits in the rectum or distal sigmoid. Transvaginal ultra-\nsonography, transrectal endoscopy, and MRI are the most\nappropriate options, with similar results.\n13\nIt is important to emphasize that TRUS is a minimally\ninvasive and highly accurate modality; it is considered one of\nthe best preoperative examinations to determine the degree\nof invasion of lesions in the intestinal wall, especially in the\nrectum and distal sigmoid, thereby providing important\ninformation for surgical planning.\n18,22,29,30 Therefore, this\nstudy aimed to correlate the endoscopic changes found in the\ndistal sigmoid and rectum with the presence of endometrial\ndeposits con firmed via TRUS.\nMethods\nThis was a prospective cross-sectional study approved by the\nResearch Ethics Committee CAAE: 32790414.3.0000.5461.\nThe study population included female patients between 18\nand 55 years of age who were referred to the endoscopy\ndepartment of our institution for colonoscopy, rectosigmoi-\ndoscopy, or TRUS, who presented with one or more of the\nfollowing symptoms associated with EDT: abdominal pain,\npain during defecation, rectal bleeding, dyspareunia, and\ninfertility. All participants provided written informed\nconsent.\nThis is a pioneering study comparing endoscopic and\nsonographic findings in patients with EDT that affects the\nrectosigmoid. No consistent data for sample size calculation\nwere found in the literature and, therefore, a pilot study with\n50 individuals was conducted to determine the required\nnumber of patients.\nThe exclusion criteria were as follows: patients with\nactive, or a history of, cancer; inadequate preparation of\nthe rectum and/or distal sigmoid (Boston scale equal to 0 or 1\nin the rectum or distal sigmoid); refusal to participate;\nrelative or absolute contraindications to colonoscopy or\nTRUS; and relative or absolute contraindications to sedation\nor anesthesia. Participants agreed to undergo laparoscopy or\nlaparotomy with surgical intervention in the rectum and/or\ndistal sigmoid and/or gynecological interventions (except for\ncesarean section and/or resection of ovarian cysts).\nThe following variables were evaluated in this study:\nClinical variables: 1) Pain upon direct pressure on the\nvaginal fornix during sexual intercourse (deep dyspareunia)\nand/or vaginal examination; 2) chronic pelvic pain (constant\ninfraumbilical pain for more than 30 days and/or pain\nassociated with menstruation for more than 3 cycles); and\n3) intestinal bleeding with red blood and without hemody-\nnamic repercussion in the previous 7 years.\nEndoscopic variables: 1). Fold thickening (with preserved\ncircular anatomy of the organ and one or more haustrations\nwith visually altered thickness) (\n►Fig. 1 ); 2) bulging without\nnodules (with visually altered circular anatomy of the organ\nand semicircular bulging without notches or other bulges\nabove it ( ►Figs. 2A B ); 3) bulging with lobulation (visually\naltered circular anatomy of the organ, noting bulging shaped\nlike an irregular semicircle, with notches or other bulges)\n(►F i g .3 A ,B ,C ); 4). alteration of the mucosa (enanthema,\nFig. 1 Fold thickening.\nJ Coloproctol Vol. 43 No. 1/2023 © 2023. Sociedade Brasileira de Coloproctologia. All rights reserved.\nAssociation between Altered Endoscopic Findings and Endometriosis Pfuetzenreiter et al. 37\n\n\nedema, unusual coloration, and/or increased vasculariza-\ntion) ( ►Fig. 4 ); and 5) obstruction of the rectum and/or\ndistal sigmoid (probe unable to pass through the rectum or\ndistal sigmoid) ( ►Fig. 5 ).\nThe patients referred to the department for TRUS or\nrectosigmoidoscopy underwent distal sigmoid colon and\nrectum preparation with two applications of 130 mL of a\nsolution containing sodium phosphate monobasic (160\nmg/mL) þ sodium phosphate dibasic (60 mg/mL) via the rec -\ntum; the first application was performed the night preceding\nthe exam, and the second application was performed 1 hour\nbefore the exam. For patients referred for colonoscopy, the\npreparation of the entire colon and rectum included a low-\nresidue liquid diet and two bisacodyl tablets (5 mg) the day\nbefore the examination. On the day of the procedure, the\npreparation was completed with the ingestion of a mannitol\nsolution (500 mL of 20% mannitol with 500 mL of water,\norange juice, isotonic, or similar beverage) and, if necessary,\nrectal lavage with 500 to 1,000 mL of 0.9% saline solution,\nrepeating the procedure until two clear liquid rectal dis-\ncharges occurred. The patients who ful filled the inclusion\ncriteria were provided with a questionnaire and invited to\nFig. 2 (A) Bulging without nodules. ( B) Bulging without nodules.\nFig. 3 (A) Bulging with nodules. ( B) Bulging with nodules. ( C) Bulging with nodules.\nFig. 4 Changes in the mucosa.\n Fig. 5 Obstruction.\nJ Coloproctol Vol. 43 No. 1/2023 © 2023. Sociedade Brasileira de Coloproctologia. All rights reserved.\nAssociation between Altered Endoscopic Findings and Endometriosis Pfuetzenreiter et al.38\n\n\nparticipate in the study. Those who agreed to participate\nsigned the consent form and had their concerns, if any,\naddressed.\nThe endoscopic examinations of the distal sigmoid and\nrectum were all performed by the same endoscopist, who\nhad performed over 2,000 colonoscopies. After the endo-\nscopic examination, ultrasound examination was conducted\nby the hospital ’s physician, who had performed over 3,000\nTRUS procedures and who was blinded to the endoscopic\nfindings of the already-sedated patients.\nThe procedures were performed using Olympus, Fujinon\nand/or Hitachi-Aloka devices (Olympus Corporation, Tokyo,\nJapan; Fuji film, Tokyo, Japan; Hitachi Aloka Medical Ltd,\nTokyo, Japan).\nAfter data collection, the clinical and endoscopic variables\nwere stratified, and sensitivity and speci ficity were calculat-\ned. The positive predictive value (PPV), negative predictive\nvalue (NPV), and accuracy were also calculated with a\nconfidence interval (CI) of 95%.\nResults\nThe present study targeted 53 patients enrolled between\nAugust 4, 2014, and September 4, 2015. Of the 53 patients, 3\nwere excluded: 2 did not consent to participate and 1 had\nincomplete colon preparation. Therefore, 50 patients (age:\n21–51 [mean: 35.8 /C6 7.2] years) were included in the\nanalysis.\nThe most frequently reported symptoms were chronic\npelvic pain ( n ¼ 29; 58.0%) and abdominal pain ( n ¼ 27;\n54.0%).\nThirty-six patients (72.0%) exhibited normal colonoscopic\nfindings; the other 14 (28%) were strati fied based on our\nendoscopic variables as follows: 5 patients (10%) with fold\nthickening, 5 (10%) with bulging without nodules, 3 (6%)\nwith bulging with nodules, and 1 (2%) with changes in the\nmucosa.\nAccording to the TRUS findings, 33 (66.0%) patients had\nsuspected endometriosis, but only 14 (28%) had endometri-\notic lesions in contact with the rectum or sigmoid, in the\nfollowing proportion: rectum (6 patients, 12%) and sigmoid\n(8 patients, 16%) (\n►Table 1 ).\n►Table 2 shows the demographic and clinical character-\nistics of the 14 patients with intestinal endometriosis: age,\nsymptoms, endoscopic findings, history of pelvic surgery,\npresence of free fluid in the cavity, location of the foci of\nintestinal endometriosis, and the degree of in filtration in the\nwall of the sigmoid colon or rectum.\nIn 9 of the 14 patients, it was possible to evaluate the\ncircumferential involvement of the colon or rectum, distrib-\nuted as follows: 1/8 of the circumference (1 patient), 1/4 (2\npatients), 1/3 (4 patients), and 1/2 (2 patients).\nThe correlation of the endoscopic findings with the pres-\nence of endometriosis, regardless of location, provided the\nfollowing results ( ►Table 3 ): prevalence of 66.0% (95%CI:\n51.0–78.8%), sensitivity of 36.4% (95%CI: 20.4 –54.9%), speci-\nficity of 88.2% (95%CI: 63.6 –98.5%), PPV of 85.7% (95%CI:\n57.2–98.2%), NPV of 41.7% (95%CI: 25.5 –59.2%), accuracy of\n54.0% (95%CI: 39.3 –68.2%), positive likelihood ratio of 3.1\n(95%CI: 0.8 –12.3), negative likelihood ratio of 0.7 (95%CI:\n0.5–1.0), and area under the receiver operating characteristic\n(ROC) curve of 0.623 (95%CI: 0.508 –0.738).\nThe results shown in ►Table 4 were obtained by crossing\nthe endoscopy data with the presence of endometriosis in\nthe rectum or distal sigmoid and were as follows: prevalence\nof 28.0% (95%CI: 16.2 –42.5%), sensitivity of 78.6% (95%CI:\n49.2–95.3%), speci ficity of 91.7% (95%CI: 77.5 –98.3%), PPV of\n78.6% (95%CI: 49.2 –95.3%), NPV of 91.7% (95%CI: 77.5 –\n98.3%), accuracy of 88.0% (95%CI: 75.7 –95.5%), positive like-\nlihood ratio of 9.43 (95%CI: 3.0 –28.8), negative likelihood\nratio of 0.2 (95%CI: 0.1 –0.6), and area under the ROC curve of\n0.851 (95%CI: 0.733 –0.942).\nThe presence of an endometriosis lesion and the degree of\ninfiltration in the sigmoid or rectum in patients who dis-\nplayed alterations during the endoscopic evaluation are\ndescribed in\n►Table 5 . It is important to note that the\nendoscopic changes and the ultrasound findings were locat-\ned at the same distance from the anal verge. In addition, the\nendoscopic images ( ►Figs. 1 , 2, 3 and 4) that yielded 91.7%\n(95%CI: 77.5 –98.2%) speci ficity for intestinal endometriosis\nin the rectum or sigmoid.\nThe endoscopic and ultrasonographic alterations were\nmarked using the distance between the anal verge and the\nendometrial deposit, con firming that the endoscopic alter-\nations found were the same as those present in the\nultrasound.\nDiscussion\nEfforts regarding early diagnosis of EDT are valuable because\nof its importance in reproductive-aged women, the dif ficulty\nof its diagnosis, the cost associated with the diagnosis and/or\ntreatment, and particularly the decline in the quality of life of\naffected patients. Therefore, this study demonstrates the\nimportance of thorough evaluation of the distal sigmoid\nand rectum in women of childbearing age who present\nwith symptoms associated with deep EDT and are referred\nTable 1 Location and in filtration of endometriosis foci\ndiagnosed by transrectal ultrasound: Correlation between the\nendoscopic findings\nn%\nMain focus of endometriosis\nRectum 6 18.2\nSigmoid 8 24.2\nOther location 19 57.5\nInfiltration\nSerosa 1 3.0\nMuscularis propria 6 18.2\nSubmucosa 7 21.2\nWithout in filtration 19 57.6\nJ Coloproctol Vol. 43 No. 1/2023 © 2023. Sociedade Brasileira de Coloproctologia. All rights reserved.\nAssociation between Altered Endoscopic Findings and Endometriosis Pfuetzenreiter et al. 39\n\n\nfor colonoscopy, with emphasis on speci fic endoscopic alter-\nations that may be associated with endometrial deposits, to\nenable an early diagnosis.\nThe characteristics of the population in this study were\nsimilar to those described in previous literature. The patients\nwere aged 21 to 51 (mean 35.8 /C6 7.2) years, which is in line\nwith the age associated with a higher incidence of EDT. 5–7\nThe most common symptoms observed in the study were\nsimilar to those of other studies, 4,7,8 with chronic pelvic\n(58%) and abdominal (54%) pains being the most frequent.\nTable 2 Demographic and clinical characteristics of the 14 patients with intestinal endometriosis included in the study:\nCorrelation between the endoscopic findings and intestinal endometriosis in the distal sigmoid and rectum, as con firmed via\ntransrectal ultrasound in São Paulo in 2014 to 2015 ( n ¼ 50)\nNr. of\npatient\nAge Symptoms Pelvic\nsurgery\nColonoscopy Free\nfluid\nLocation of\nendometriosis\nInfiltration\n54 7 A b d o m i n a l þ pelvic pain Bulging with\nnodules\nNo Sigmoid Submucosa\n11 46 Abdominal þ pelvic pain Fold thickening Yes Sigmoid Muscularis\npropria\n13 34 Infertility and abdominal þ\npelvic þ fundus of\nthe pouch pain\nBulging Yes Sigmoid Muscularis\npropria\n14 36 Infertility and pelvic pain Bulging with\nnodules\nNo Sigmoid Submucosa\n18 26 Pelvic pain Normal No Rectum Serosa\n19 29 Pelvic þ fundus of the\npouch pain\nCesarean\nsection\nBulging No Rectum Muscularis\npropria\n26 34 Abdominal pain Bulging with\nnodules\nYes Sigmoid Mucosa\n28 44 fertility and abdominal þ\nfundus of the pouch pain\nBulging with\nnodules\nYes Rectum Muscularis\npropria\n30 40 Pelvic þ abdominal pain Changes in the\nmucosa\nNo Rectum Submucosa\n34 38 Pelvic þ abdominal þ\nfundus of the pouch\npain and intestinal bleeding\nCesarean\nsection\nBulging Yes Sigmoide Submucosa\n35 37 Pelvic pain Bulging Yes Sigmoid Muscularis\npropria\n42 33 Infertility and\nabdominal pain\nNormal No Sigmoid Submucosa\n47 32 Abdominal pain Thickening No Rectum Submucosa\n50 40 Pelvic þ abdominal pain Cesarean section Normal No rectum Muscularis\npropria\nTable 3 Results of endoscopy and transrectal ultrasound:\nCorrelation between the endoscopic findings and intestinal\nendometriosis in the distal sigmoid and rectum, as con firmed\nvia transrectal ultrasound in São Paulo in 2014 to 2015 ( n ¼ 50)\nEndoscopy Transrectal ultrasound\n–\nendometriosis\nTotal\nNo Yes\nn( % ) n( % ) n( % )\nNormal 15 (30) 21 (42) 36 (72)\nAltered 2 (4) 12 (24) 14 (28)\nTotal 17 (34) 33 (66) 50 (100)\nTable 4 Results of endoscopy and transrectal ultrasound of the\npatients with intestinal endometriosis: Correlation between\nthe endoscopic findings and intestinal endometriosis in the\ndistal sigmoid and rectum, as con firmed via transrectal\nultrasound in São Paulo in 2014 to 2015 ( n ¼ 50)\nEndoscopy Transrectal ultrasound\n–\nintestinal endome-\ntriosis\nTotal\nNo Yes\nn( % ) n( % ) n( % )\nNormal 33 (66) 3 (6) 36 (72)\nAltered 3 (6) 11 (22) 14 (28)\nTotal 36 (72) 14 (28) 50 (100)\nJ Coloproctol Vol. 43 No. 1/2023 © 2023. Sociedade Brasileira de Coloproctologia. All rights reserved.\nAssociation between Altered Endoscopic Findings and Endometriosis Pfuetzenreiter et al.40\n\n\nThe endoscopy results revealed that 36 (72.0%) patients\nhad normal findings, and the other 14 (28%) were strati fied\naccording to the endoscopic variables. It was, therefore,\nobserved that mucosal involvement in endometriosis was\na rare event, as described in the literature.\nThe results of TRUS showed a prevalence of endometriosis\nof 66% (33 patients) in the study population, likely due to the\nfact that the sample comprised those with a previous diag-\nnosis of or symptoms strongly suggestive of EDT.\nThe patients were strati fied into two groups. One group\ncomprised patients with EDT but with the focus distant from\nthe rectum or sigmoid: the other group comprised patients\nwith EDT adhered to or in contact with the rectum or distal\nsigmoid. We diagnosed 14 patients with EDT adhered to or in\ncontact with the rectum or sigmoid, resulting in an incidence\nrate of intestinal EDT of 28% (\n►Table 4 ), a fact, again,\nexplained by the characteristics of the study population.\n►Table 5 describes the characteristics of the patients with\nendometriotic lesions in the rectum or sigmoid and shows\nthat all presented with chronic abdominal and/or pelvic pain\nas symptoms, suggesting that intestinal foci are, in fact,\nassociated with a higher incidence of pain in these patients.\nThe observed endoscopic changes were fold thickening,\nbulging, bulging with nodules, and mucosal changes. No\npatient presented with obstruction of the sigmoid or rectum.\nInfiltration of the serosa, muscularis propria, submucosa,\nand mucosa was observed, but it was not possible to estab-\nlish a relationship between the degree of in filtration and\nendoscopic findings due to the low sample size representing\neach variable.\nThe analysis of the data regarding the presence of EDT and\nits location showed a low sensitivity of endoscopy for the\ndiagnosis of EDT in the pelvic cavity (only 36.4%), which\nsuggests that endoscopic examination is not indicated for the\ndiagnosis of pelvic EDT. However, the data on speci ficity\n(88.2%) and PPV (85.7%) demonstrate that endoscopy does\npresent some association with EDT in this location.\nThe analysis of the relation between the presence of\nintestinal EDT and the changes evaluated in this study\n(endoscopic variables) yielded better results: a sensitivity\nof 78.6%, speci ficity of 91.7%, PPV of 78.6%, and NPV of 91.7%.\nThese confirm that in the present study, the changes detected\nin the endoscopic assessment were strongly associated with\nintestinal EDT in the rectum and distal sigmoid.\nAmong patients with endoscopic alterations, three exhib-\nited false positive results for deep EDT and all three displayed\nfold thickening on endoscopy. When this variable was ana-\nlyzed individually, five cases were detected, two with endo-\nmetriosis in the rectum or sigmoid and three false positives.\nThis suggests that if the variable fold thickening is excluded\nfrom the analysis, a table with more speci fic endoscopic\nvariables is obtained, albeit with a lower sensitivity for EDT\nin those segments. The small sample size associated with\neach variable means that the CIs associated with the sensi-\ntivity, specificity, and accuracy values speci fic to each endo-\nscopic variable were too wide-ranging.\nThe study possessed some limitations, the most impor-\ntant being the small number of existing studies on the\nsubject, which prevented us from performing a statistical\ncalculation to determine the minimum number of patients,\nthereby prompting us to conduct an initial study with 50\npatients. The fact that data collection was performed at an\nendoscopy department that specializes in colonoscopy and\nTRUS, with a signi ficant number of patients referred to the\ndepartment already having a diagnosis of deep EDT, was\ncritical for the results obtained. It is important to note that all\nof the tests were performed by the same two endoscopists\nwith experience in cases of deep EDT, a fact that possibly\naffected the final result.\nConclusion\nEndoscopic changes detected in the distal sigmoid colon and\nrectum were correlated with the presence of EDT in these\nsegments, as con firmed using TRUS.\nConsidering the results and limitations of the study, it can\nbe suggested that colonoscopies performed in patients,\nwith pelvic and/or chronic abdominal pain should include\nTable 5 Patients with endoscopic changes and correlation\nwith transrectal ultrasound : Correlation between endoscopic\nfindings and intestinal endometriosis in the distal sigmoid and\nrectum, as con firmed via transrectal ultrasound in São Paulo in\n2014 to 2015 ( n ¼ 50)\nNr.\nof\npatient\nAge Endoscopic\nchange\nResult TRUS/\ninfiltration\n5 47 Bulging with\nnodules\nSubmucosa\n11 46 Fold thickening Muscularis propria\n13 34 Bulging without\nnodules\nMuscularis propria\n14 36 Bulging with\nnodules\nSubmuocsa\n19 29 Bulging without\nnodules\nMuscularis propria\n25 39 Fold thickening Without in filtration/\nwithout endometriosis\n26 34 Bulging with\nnodules\nMucosa\n28 44 Bulging without\nnodules\nMuscularis propria\n30 40 Changes in the\nmucosa\nSubmucosa\n33 51 Fold thickening Without in filtration/\nwith endometriosis\n34 38 Bulging without\nnodules\nSubmucosa\n35 37 Bulging without\nnodules\nMuscularis propria\n43 29 Fold thickening Without in filtration/\nwithout endometriosis\n47 32 Fold thickening Submucosa\nJ Coloproctol Vol. 43 No. 1/2023 © 2023. Sociedade Brasileira de Coloproctologia. All rights reserved.\nAssociation between Altered Endoscopic Findings and Endometriosis Pfuetzenreiter et al. 41\n\n\na thorough examination of the rectum and distal sigmoid,\nfocusing on the alterations described in the present study. If\nsome of these changes are detected, an examination for the\nconfirmation of intestinal EDT should be requested.\nFuture studies focusing on these endoscopic changes in\ndifferent populations and involving larger sample sizes are\nrequired to con firm these results. However, the information\nreported herein is relevant and should be disseminated\namong colonoscopists both in training and in practice.\nConflict of Interests\nThe authors have no con flict of interests to declare.\nReferences\n1 Triolo O, Laganà AS, Sturlese E. Chronic pelvic pain in endometri-\nosis: an overview. J Clin Med Res 2013;5(03):153 –163\n2 Habib N, Centini G, Lazzeri L, et al. 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