Transcript Severe Endometriosis - Isfahan University of Medical Sciences

‫بسم هللا الرحمن الرحیم‬
Severe Endometriosis
Dr.Zarean
Dr.Naderi
CASE
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47 years old/ G2L2 (2×C/S)
C.C: Abdominal Pain
Admission Date: 26/12/1385
P.I : LLQ and Hypogastric Pain from 1 month ago that
increasing 2 days before.
AUB: Menometrorhagia from 85’s Mordad. LMP:15/12/1385.Irregular Mense
Nausea -)
Vomiting -)
Shoulder Pain -)
Rectal Pressure -)
PCB -)
Dysmenorrhea +)
Occasionally Dys paronia +)
PMH : Primary and Secondary Infertility Laparascopy . 3x IVF. 2xc/s.
Married Date:24 Y/O
DH :
HD  2 cycle
Ph.E :
BP: 90/60
PR: 80
RR: 20
T : 37
Abd : Guarding +)
LLQ and Hypogastric Tenderness +)
VE : Cervical motion tenderness
CX : NL
Adnexes : Fullness and Tenderness specially left side
Lab Data :
BG:A+
Hb :12.7  10.6  12.1
PLt :188000
Cr : 0.7
ßHCG : Negative
Sonography : 23/5/1385 : L.t.Ovary  2 Simple Cyst : 3cm , 2cm
FF -)
:30/10/1385 : L.t.Ovary  2 Simple Cyst : 45mm , 33mm and
R.t.Ovary  1 Simple Cyst : 35mm
:23/12/1385:Uteruse: NL
ET : 10mm
R.t.Ovary  1 Simple Cyst : 43mm
L.t.Ovary  1 Simple Cyst : 53mm
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Pre Operative Diagnosis : Acute Abdomen
Complicated Bilateral Ovarian Cyst Probably Torsion.
Plan : Laparatomy Under General Anesthesia.
Findings :300 cc Blood in peritoneal Cavity.
Abundant and severe adhesion band .
Left Ovary : 7cmx6cm fixed to posterior of uterus
,pelvic floor and bowels.
The size of Right Ovary wasn’t cleared because of
adhesion.
Enterolysis and disection of Ovaries ,uterus and
inflammatory Tubes was performed to some extent.
There was bilateral Endometrioma and masive and
severe Endometriosis that caused adhesion.
The uterus was fixed to pelvic floor in lateral and
posterior.
Bilateral Adnexectomy and endometrial biopsy was
performed.
Pathology
Left ovary
Endometriosis
Right ovary
7 cm
Endometriosis
Semitorsion
Hemorrhagic fibrin deposition
Inflamation
endometrium
Early secretory
Severe Endometriosis: multiple superficial and deep implants
including large ovarian endometrioma ,filmy and dense
adhesions are usually present.
 Symptoms: chronic pelvic pain (may be) but is often more
severe during mense or at ovulation.
 Dysmenorrhea
infertility
Deep Dysparomia
AUB
chronic fatigue
cyclical bowel or bladder symptom
 Endometriosis is the most common diagnosis made at the time
of Gynecological Laparascopy for evaluate of CPP(1/3). 40%
with CPP due to endometriosis have physical findings on pelvic
examination:
 Uterosacral ligament abnormalities (nodularity ,thickening focal
tenderness)
 lat. displacement of cervix
 Cervical stenosis
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Adnexal enlargement maybe palpable if an endometrioma is present.
Non Gynecological findings  red hair color
 scoliosis
 dysplastic nevi
Pelvic ulterasound is highly sensitive for identifying
pelvic masses , including ovarrian mass but is less
reliable for distinguish.
 sonography is useful for detecting small pelvicmasses
(<4cm) which often can’t be palpated on pelvic
examination
 Endometrioma usually present as a pelvic mass arising
from growth of ectopic endometrial tissue within the
ovary. They typically contain thick brown tarlike
fluid(chocolate cyst) and are often densely adherent
to surronding structures ,such as the peritoneum
,fallopian tubes and bowel.
 An endometricma may be associatedwith symtoms of
endometriosis or identified at the time of evaluation
for a pelvic mass or infertility .
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Pseudo cyst (progressive invagination of the
ovarian cortex over the implant. The cyst
content has high concentration of iron
 diagnosis: Histopathology is required to make
a definitive diagnosis of endometrioma.
However, a cilinical diagnosis can often be
made with a high degree of certainty in a
woman with histologically confirmed
endometriosis and on adnexal mass , since
50% of women with endometriosis develop
endometrioma, which are often bilateral.
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Ultrasound supports the diagnosis ,but of
limited value for determining extent of disease
since it lacks adequate resolution for visualizing
adhesions and superficial implants.
 However when there are sonographic signs
suggestive of endometrioma ,it is likely that
moderate to severe endometriosis is present.
 Therefore ,extensive surgery may be required
for relief of pain.
 CA125: stage III or IV . levels > 100 IU/mL
:adhesions or ruptured endometrioma.
 DDx : hemorrhagic cyst/neoplasm.
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medical
Management
indications
surgery: Cystectomy- oophorectomy
the prefered therapeutic approach
pain
asymptomatic
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