Endometriosis and Bowel Symptoms
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:
Painful bowel movements
Constipation
Diarrhoea
Alternating constipation and diarrhoea
Intestinal cramping
Nausea and/or vomiting
Abdominal pain
Rectal pain
Rectal bleeding
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 Endo 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
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.
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 Crohns 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 Crohns 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.
