"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

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 surgery in March (performed by my general gyn) that the laparotomy I had was a total failure and Dr. X was able to confirm that after this surgery. Both of my ovaries were attached to my uterus and my right ovary and ureter was also attached to the uterus. My right ovary was very diseased and had to be removed along with the right tube. Endometriosis was found all over the small bowel and Dr. X was not able to remove that. He is recommending that I find a general surgeon somewhere who specializes in surgery of the bowel. He feels that a bowel resection will be necessary. Are you or any of the other physicians at Athena skilled in performing that 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 they eventually came back while still on the injections. 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.

BOWEL ANATOMY 101
The intestines (bowel) are made up of two basic parts, the small intestine and the large intestine. The small intestine is about 9 feet long and the large intestine is about 3.5 feet long. The small intestine connects the stomach to the large intestine. The small intestine fills the area from the from the bottom of the ribs to the top of the uterus. It has no set course and looks a bit like a bunch a spaghetti. The large intestine connects the small intestine to the anus. From the anus the large intestine follows a course behind the vagina, cervix and uterus, and makes an upside down "U", up the left side of the body, 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 bowel connect. The contents of the small bowel are primarily liquid while those of the large bowel are primarily solid. The bowel wall is made up of three basic layers; (1) the serosa, (2) the muscle wall and (3) the mucosa. The serosa is outside lining of the bowel wall. It is very thin, similar to saran wrap. Most of the bowel wall is made up of muscle. This is the middle layer. 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 will determine the type of symptoms that 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, then the patient will usually experience rectal bleeding with her period. While it is common for the 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 colonoscopsies in diagnosing bowel endometriosis. The location of the bowel will be the primary determining factor of the type of symptoms when the muscle wall of the bowel is involved with endometriosis.

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. Bowl movements can also 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 bowel 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 the appendix can result in right sided pain. Bowel endometriosis can also result in adhesions (scar tissue). These adhesions can involve other loops of bowel resulting in a partial obstruction (blockage), the ovary, fallopian tube or even the ureter. These adhesions can also result in pain. Endometriosis of the large bowel rarely results in obstruction of the bowel.

SMALL BOWEL
Endometriosis of the small bowel usually results in bloating and pain which 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 impossible to tell preoperatively if bowel endometriosis is present. The laser laparoscope is a wonderful surgical instrument for treating bowel endometriosis. This combination provides the magnification and precision necessary for me to remove the endometriosis from the bowel, without having to perform a bowel resection in the vast majority of cases. Situations in which the crude electrosurgery would result in the need for bowel resection are easily handled by laparoscopic laser surgery. This is true for both the large and small bowel. In the rare cases that the endometriosis has completely replaced a section of bowel, the diseased segment of bowel is removed by one of the bowel surgeons of my team and the normal ends of the bowel are reconnected.

THE TEAM APPROACH TO THE TREATMENT OF ENDOMETRIOSIS
Endometriosis is a dreaded disease which 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 or the bowel surgeon may help if the bowel is involved or 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 the individual with endometriosis.

NON SURGICAL TREATMENT OF BOWEL ENDOMETRIOSIS
At this point in time there is no non surgical treatment of bowel endometriosis. Lupron, birth control pills etc, may slow the growth of endometriosis, but they will not get rid of the endometriosis nor the associated fibrosis or adhesions. Invasive bowel endometriosis is a serious condition which 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. Yes, at Athena we are skilled in treating bowel endometriosis. I hope we have the opportunity to help you feel better!

Updatede October 29, 2005