Endometriosis of the Intestine (Bowel)
Question:
My doctor did a laparoscopy and found endometriosis and adhesions throughout my abdominal region. I had known from the first day after my laparotomy (performed by my general GYN) that the surgery I had was a failure. Six months later, Dr. X was able to confirm that after the laparoscopy. Both of my ovaries and my ureter were attached to my uterus. My right ovary was very diseased and had to be removed, along with the right fallopian tube. Endometriosis was found all over the small bowel, but Dr. X was not able to remove it. He is recommending that I find a general surgeon somewhere who specializes in surgery of the bowel, as he feels that a bowel resection will be necessary. Are you or any of the other physicians at Vital Health Institute skilled in performing this type of operation? This is a very scary thing for me to comprehend right now, and I will probably seek whatever alternatives are available to me before choosing surgery again. However, I have been through many of the treatments, such as continuous birth control and Lupron. The only thing that Lupron helped me with was temporary relief of my bowel symptoms last year. But while I was still on the injections, my symptoms eventually came back. Is there anything that you can recommend for me at this point?
Answer:
First, I am glad that you persisted and listened to your body, and kept going until you found someone who could help you. I am sorry, though, that at the end of your most recent surgery you have still not gotten your problem fixed, and you are now faced with yet another surgery. Let’s take a look at your situation.
Bowel Anatomy 101
The intestines (bowel) are made up of two basic parts, the small intestine and the large intestine. They derive their names from their diameter, not their length. The small intestine is about 23 feet long, and the large intestine is about 5 feet long. The contents of the small bowel are primarily liquid, while those of the large bowel are primarily solid.
The small intestine connects the stomach to the large intestine. The small intestine fills the area from the bottom of the ribs to the top of the uterus. It has no set course, and looks a bit like a bunch of spaghetti.
The large intestine connects the small intestine to the anus and makes an upside down "U" in the abdominal cavity. Following the large intestines backwards, starting at the outside anus, the large intestine follows a course behind the vagina, cervix and uterus, and jogs over to the left going up the left side of the body to the level of the ribs, across the upper abdomen just below the ribs and down the right side of the abdomen, ending near the hip-bone on the right. The appendix is a small, worm-like structure projecting off of the large intestine, close to where the large and small bowels connect.
The bowel wall is made up of three basic layers: (1) the serosa, (2) the muscle wall, and (3) the mucosa. The serosa is the outside lining of the bowel wall. It is very thin, similar to Saran Wrap. The middle layer, which is mostly muscle, makes up most of the bowel. The inside lining of the bowel is called the mucosa, and is also quite thin.
Endometriosis of the Bowel
Endometriosis has been reported to grow in almost every organ in the body outside of the reproductive organs. The bowel is the most common, non-reproductive organ involved with endometriosis.
Invasion
The degree of invasion of the bowel wall by endometriosis is one factor that determines the type of symptoms the patient will experience. If the bowel endometriosis is superficial, involving only the outside serosal surface, the most common symptoms are bloating, nausea and loose stools with menses. At the other extreme, if the endometriosis has invaded all the way through the bowel wall, including the inside mucosa, the patient will often experience rectal bleeding with her period. While it is common for endometriosis to invade through the outside serosa and the middle muscle wall, it is unusual to invade through the inner mucosal layer. This probably accounts for the high failure rate of barium enemas and colonoscopies in diagnosing bowel endometriosis. When the muscle wall of the bowel is involved with endometriosis, the location of the bowel will be the primary determining factor of the type of symptoms a woman experiences.
Large Bowel
The pelvic portion of the large bowel (the rectum and the sigmoid colon) is the most commonly involved part of the intestine. The close proximity of this portion of the bowel to the vagina and cervix often results in painful intercourse. Also, bowel movements can be very painful, since the bowel contents are solid in this portion of the bowel. The portion of the intestine where the large and small bowels connect is located in the area between the belly button and the right hip-bone. This is in the same area as the appendix. Involvement of the bowel in this area, or of the appendix, can result in right-sided pain. Bowel endometriosis can also result in adhesions (scar tissue). These adhesions can involve the ovary, fallopian tube, ureter, or other loops of bowel that can result in a partial obstruction (blockage) of the bowel. Adhesions can also cause pain.
Small Bowel
Endometriosis of the small bowel usually results in bloating and pain that is associated with eating. Often, patients with small-bowel endometriosis have restricted the amount and type of foods that they eat. The symptoms are slowly progressive over time, and the patient may not even realize the extent to which she has altered her diet. Small-bowel endometriosis often results in a partial bowel obstruction. As the bowel swells following a meal, the bowel kinks, and like a kinked garden hose, the contents do not get through until enough pressure builds up to push by the narrowed portion.
Treatment of Bowel Endometriosis
All of my patients undergoing surgery have a preoperative bowel preparation. It is usually impossible to tell preoperatively if bowel endometriosis is present. But once surgery commences, the laser laparoscope is a wonderful surgical instrument for treating bowel endometriosis. In the vast majority of cases, this instrument provides the magnification and precision necessary for me to remove the endometriosis from the bowel, without having to perform a bowel resection. In the rare cases that the endometriosis has completely replaced a section of bowel, the diseased segment of bowel will be removed by one of the bowel surgeons on my team, and the normal ends of the bowel will be reconnected.
The Team Approach to the Treatment of Endometriosis
Endometriosis is a dreaded disease that has no respect for the boundaries of the various medical subspecialties. This is why it is so important to use a team approach in the treatment of individuals with endometriosis. For example: The urologist may help if the endometriosis involves the bladder, the bowel surgeon may help if the bowel is involved, and the thoracic surgeon may help if a thoracoscopy is needed to diagnose and treat endometriosis of the lung. Proper preoperative evaluation and preparation, in conjunction with the team approach, should result in the complete treatment of an individual with endometriosis.
Non-Surgical Treatment of Bowel Endometriosis
At this point in time, there is no non-surgical treatment for bowel endometriosis. Lupron, birth control pills, etc., may slow the growth of endometriosis, but they will not get rid of it completely, nor its associated fibrosis or adhesions. Invasive bowel endometriosis is a serious condition that can lead to an acute surgical emergency (bowel obstruction).
Conclusion
In summary, you probably are looking at another surgery to treat the endometriosis of your intestine. Using laser treatment, the vast majority of bowel endometriosis can be treated without having to perform a bowel resection. At Vital Health Institute we are very skilled in treating bowel endometriosis. I hope we have the opportunity to help you feel better!
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