OC27: The ‘pulling‐out sign’ for intestinal deep infiltrating endometriosis: prognostic role of findings at 3D transvaginal sonography

To determine the accuracy of 3D transvaginal sonography (3D-TVS) in the evaluation of the depth of wall infiltration of intestinal deep infiltrating endometriosis (DIE). Some 32 consecutive fertile women with intestinal DIE were prospectively enrolled. 3D-TVS was performed with a GE Voluson 730-pro unit, using a wide-band 3–9 -MHz transducer. Compound Resolution Imaging and Speckle Reduction Imaging technologies were used to optimize images before volume acquisition by enhancing contrast resolution and reducing artifacts and speckle. Volume contrast imaging (VCI) analysis by 2 mm slices of the stored 3D multiplanar examinations was considered for evaluation of the depth of wall infiltration of intestinal DIE. The rectum/sigmoid colon was considered involved when an irregular hypoechogenic mass was found penetrating into the intestinal wall, infiltrating the serosa (A), the muscularis propria (B) and the submucosa (C). In the latter case, we defined ‘pulling-out sign’ by the presence of an inhomogeneous lesion altering the mucosa profile. Sonographic imaging was compared to X-ray barium enema (BE) imaging on oblique projections: no minus image (A), regular minus image (B), irregular with tethering effect (C). Surgery and/or MRI were considered the gold standard. Median age was 34 (IR, 34–41) years; 75% of patients were symptomatic. BE was inconclusive in one case. All cases with the ‘pulling-out sign’ at 3D-TVS had an altered intestinal profile at BE. Only one patient had a significant sigmoid lumen reduction. The table shows the comparative diagnosis at 3D-TVS and BE. 3D-TVS adequately diagnoses the depth of wall infiltration of intestinal DIE. VCI analysis may allow improved operator confidence in patients with sigmoid endometriosis. Further investigation on intestinal DIE should be indicated only in patients with the ‘pulling-out sign’, comparable to the tethering effect at BE, thus confirming a severe intestinal DIE.