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Endometriosis and bowel symptoms
by
Ken Sinervo, MD of the Center for
Endometriosis Care Many
of the women seen at the Center for Endometriosis Care have been told they have
Irritable Bowel Syndrome or a spastic colon. A few of them do. But many of them
have endometriosis somewhere in their intestinal tracts.
Endometriosis
patients who present with bowel symptoms may experience a long delay in getting
a diagnosis or have other medical conditions related to the bowel considered
before their physicians consider the possibility of endometriosis. Bowel
symptoms are extremely common in patients with endometriosis. While the exact
percentage of endometriosis patients affected with bowel symptoms is difficult
to pin down, information from the database Dr. Albee and I have compiled
suggests that as many as 60% or more may have at least one symptom referable to
their gastrointestinal tracts. Because of the nature of our practice we tend to
have more patients with stage III and IV (moderate to severe) disease than may
occur in the general population. Such patients may have more symptoms related to
their bowels. Even so, the incidence is still very high. Based
on the pre-operative questionnaires that all of our patients complete,
intestinal cramping and painful bowel movements occur in approximately 25% of
patients; constipation occurs in 35% of patients and diarrhoea occurs in more
than 60% of patients. These numbers reflect the patients with severe or
crippling symptoms only. When patients with mild or moderate symptoms are
included, these symptoms become even more common. There is a constellation of bowel symptoms that can occur in endometriosis patients. These include:
Some
patients will only have one of these symptoms, while others may have all of
them. Often, these symptoms are more problematic during their periods or
pre-menstrually. These women may seek medical help and undergo a series of GI
tests, and when no clear answer is found, their frustration grows. However, a
negative colonoscopy can actually be somewhat reassuring, because it indicates
that endometriosis has not penetrated through the wall of the bowel. What
causes bowel symptoms in endometriosis patients? In
the great majority of patients, endometriosis is not found directly on the
bowel. In general, fewer than 10-15% of patients actually have endometriosis
directly on their bowel. When endo is found on the bowel, approximately 90% have
superficial or localized disease. This disease can usually be effectively
removed with simple laparoscopic excision, much as it would be removed from any
other surface affected with endometriosis. The serosal or outer layer of the
bowel can often be “peeled off” leaving the muscularis or muscular portion
of the bowel undamaged. Occasionally,
a portion of the muscularis must also be excised to ensure complete treatment of
the endo. In these cases, the muscularis is oversewn laparoscopically. This just
means one or more reinforcing sutures are placed to maintain the integrity of
the bowel wall. One
to two percent of our patients require more significant surgery for their bowel
endometriosis. These patients may have large segments of bowel involved with
deeper or multi-focal implants (several areas are affected along a portion of
the bowel). A segmental bowel resection may be required to completely treat
their disease. This means the diseased portion of the bowel is removed entirely,
and the healthy ends are reconnected. These procedures are usually performed
with the assistance of a general surgeon or colorectal surgeon, and virtually
always laparoscopically. Even
when endometriosis does not occur directly on the bowel, it can cause bowel
symptoms. Inflammatory mediators can affect the bowel and contribute to them. Inflammatory
mediators are released by tissues in response to inflammation or injury, and
include prostaglandins, tumour necrosis factor (TNF), interleukins and
cytokines. They create changes within the tissues and can cause new blood vessel
growth, attract other things to the area such as white blood cells or contribute
to scarring.
Prostaglandins, which are released from the endometriosis implants and uterus
during menses, can cause smooth muscle contractility. This not only affects the
uterus, but can also cause increased contractility of the bowel. In these cases,
diarrhoea and intestinal cramping can result. There are likely other mediators
that are released that can also contribute to bowel symptoms. Occasionally,
deep implants in adjacent structures such as the uterosacral ligaments or
rectovaginal septum can also cause bowel symptoms. Painful bowel movements and
occasionally rectal bleeding can result from endometriosis in these locations. The dreaded bowel prep In
order to have these procedures at the time of surgery, most of our patients
undergo a bowel prep. While this is not the most enjoyable way to spend the
afternoon before surgery, it is worth enduring to get to the desired result of
completely removing all the endometriosis. The prep is usually clear liquids and
an agent to thoroughly clean out the bowel. If a prep were not performed, bowel
surgery becomes extremely risky, because faecal matter could spill and put the
patient at high risk for serious infection. If a prep is not done, and bowel
surgery is needed, a second surgical procedure would be required at a later
date. Editor’s
Note: Please see the Coping Zone’s article about How
to survive a bowel prep Other causes for bowel symptoms While
endometriosis can cause or contribute to bowel symptoms, there are other
important causes of bowel symptoms. Inflammatory Bowel Disease (IBD), or
Crohn’s Disease and Ulcerative Colitis can be seen. As many as 8% of
endometriosis patients with bowel symptoms may eventually be diagnosed with
inflammatory bowel disease. IBD is usually characterized by abdominal pain,
constipation, diarrhoea, or alternating bouts of constipation and diarrhoea as
well as intestinal cramping. Patients with Crohn’s Disease may also have mouth
ulcers, fatigue, anaemia and haemorrhoids. Rarely, patients can have abscesses
or bowel obstruction. A colonoscopy is usually required to confirm the
diagnosis. IBD is usually treated with medical therapy that aims to keep the
disease in remission or to treat flare ups. Occasionally, surgery is required
for complications such as bowel obstruction or abscesses. Women
with symptoms similar to those of IBD but without any abnormalities on
colonoscopy are often diagnosed with Irritable Bowel Syndrome (IBS). IBS is
usually treated with dietary changes to avoid food triggers, and increasing
dietary fibre. In some patients, stress can be a trigger. Avoiding stress or
learning to deal more effectively with stress may help reduce the number of
episodes. Exercise is beneficial for many patients. Medications are necessary
for some patients. These may include anti-depressants, anti-spasmodics and other
medications. In addition, medications that work better for patients with
predominantly diarrhoea or constipation are also available and have been shown
to be beneficial for some, but not all patients. Adhesions
can also cause or contribute to bowel symptoms (as well as other symptoms
associated with endometriosis). Often the bowel is stuck to other structures
such as the ovaries, uterus or pelvic sidewall. This scarring can lead to pain
during bowel movements or constipation or diarrhoea. Abdominal bloating is also
associated with adhesive disease, and carefully treating the adhesions may help
reduce many of these symptoms. What about the appendix? The
appendix is another gastrointestinal organ that may contribute to bowel
symptoms, or abdominal or pelvic pain. Some studies have demonstrated
endometriosis in up to 20% of appendices. Although endometriosis may not be
present, other conditions such as scarring or fibrosis may be found, as well as
acute or chronic appendicitis, and even carcinoid tumours (a form of cancer)
have been found in appendices that have been removed. We are more likely to
recommend removal of the appendix if the patient has a history of right lower
quadrant pain. However, if the appendix appears to have pathology at the time of
surgery, it can usually be removed with minimal additional risk of complication
and usually only adds a few minutes to the surgery. When required, appendectomy
can almost always be performed laparoscopically. Will my symptoms improve? The
incidence of bowel symptoms does improve significantly after excision surgery
for endometriosis. Based on the post-operative follow-up questionnaires that our
patients complete yearly, there is an 80% reduction in most bowel symptoms. Of
the more than 1000 patients in our database, only 3 to 7% continue to have more
severe episodes of painful bowel movements, constipation or intestinal cramping.
Diarrhoea, which was present in 63% of our endometriosis patients, is only
significant in 13% following surgery. While
most patients have improvement in their bowel symptoms following excision
surgery for their endometriosis, some will have a persistence of these symptoms.
This may be due to another underlying medical condition (IBD or IBS). In those
patients in whom a work-up has not been performed, it may be indicated at this
time. Blood tests that detect antibodies associated with IBD may be helpful.
Often a colonoscopy or other studies are required. Many
gynaecologists have little or no experience treating bowel endometriosis. They
choose not to treat it. Sometimes they refer these patients to a general surgeon
for later treatment. At the CEC, these procedures can almost always be performed
laparoscopically. It is worthwhile to ask your doctor how he or she would deal
with endometriosis if it were found on your bowel. If you are not satisfied with
the answers, keep searching until you find the right person to work with. _________
©
2004 Center for
Endometriosis Care. Used with author’s permission. This
article may be copied, republished, translated, or redistributed only with prior
specific permission. Please submit your request to webmaster@endometriosiszone.org.
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