Endometriosis and Deep endometriosis

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1 Endometriosis and Deep endometriosis 16/01/2018 Dott Matteo Generali AUSL Modena Carpi U.O. Ostetricia e Ginecologia

Definizione L endometriosi è una patologia ginecologica, benigna, cronica, ormonodipendente caratterizzata dalla presenza di tessuto endometriale componente stromale e ghiandolare, al di fuori della

2 Definizione L endometriosi è una patologia ginecologica, benigna, cronica, ormonodipendente caratterizzata dalla presenza di tessuto endometriale componente stromale e ghiandolare, al di fuori della cavità uterina Von Rokitansky C. Ueber uterusdrusen-neubildung in uterus and ovarilsarcomen. Z Ges Aerzte Wein 1860; 37: Sampson J. Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. 1927;

3 Incidenza Giudice LC, Endometriosis 2004

4 Localizzazioni pelviche ESHRE guideline for the diagnosis and treatment of endometriosis 2005

5 Sintomatologia 90% 60% 50% 45% 10% 20% Chapron C Endometriosis and infertility: pathophysiology and management 2010

6 Time to diagnosis Hadfield R Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. 1996;

7 Etiopatogenesi ESHRE guideline for the diagnosis and treatment of endometriosis 2005

8 Le cellule endometriosiche Migrano Aderiscono Invadono la matrice extracellulare Neovascolarizzano Starzinsky.The putative role of cell adhesion molecules in endometriosis: can we learn from tumor metastasis? 1999;

11 3 forme di endometriosi ovarica Peritoneale-aderenze Deep endometriosis Lesione infiltrante il peritoneo o retro peritoneale di almeno 5 mm; 4-37% donne

12 Compartimenti pelvici Anteriore Centrale Posteriore Vescica ureteri Utero ed annessi Douglas Rettosigma

13 Compartimenti pelvici Anteriore Centrale Posteriore Vescica ureteri Utero ed annessi Retto Centrale Utero ed annessi

14 La mia conoscenza della pelvi Lezione di anatomia del dottor Tulp 1632 Rembrandt

16 La mia conoscenza della patologia

17 Compartimento centrale utero ed annessi Descrivere dimensioni, morfologia, ecostruttura Valutazione della mobilità e dei rapporti anatomici con visceri adiacenti Cercare la collaborazione della paziente nell evocare i sintomi

18 Utero

19 Ovaio

locules) ground glass echogenicity and little to moderate

20 Hard Marker endometrioma Typical ultrasound appearance of an ovarian endometrioma: a unilocular cyst with (less than 5 locules) ground glass echogenicity and little to moderate peripheral vascularisation. Note the normal ovarian tissue around the cyst.

This is not a true papillations but hyperechoic tissue consisting of blood clots or fibrin lying adjacent to the

21 Endometrioma atipico Atypical ultrasound appearance of an ovarian endometrioma: Unilocular cyst Ground glass echogenicity, Internal papillation No vascularisation in the papillary projection. This is not a true papillations but hyperechoic tissue consisting of blood clots or fibrin lying adjacent to the cyst wall Almost 50% of the endometriomas had other ultrasound characteristics than the typical unilocular cyst with ground glass echogenicity of the cyst fluid.

22 Guerriero S, Ajossa S, Mais V, et al. The diagnosis of endometriomas using colour Doppler energy imaging. Hum Reprod 1998;6:

24 Endometriod borderline tumor Ultrasound characteristics of endometriomas differ in pre- and postmenopausal women. Masses in postmenopausal women, whose cystic contents have a ground glass appearance, have a high risk of malignancy. Endometriomas could serve as precursors of endometrioid borderline ovarian tumours. Endometrioid borderline ovarian tumours have the potential to progress to low-grade invasive carcinoma. Borderline tumours and carcinomas arising from endometrioid cysts show a vascularised solid component at ultrasound examination

the ovaries and tubes are identified and recognised, but the

25 Endometriosi e tube Endometriosis that affects the ovary and Fallopian tubes can create a tubo ovarian complex, in which the ovaries and tubes are identified and recognised, but the ovaries cannot be separated by pushing the tube with the vaginal probe

Endometriosi e aderenze Ovarian endometriomas are

such as adhesions and DIE, which are not easy to

Underestimation of extensive adhesions in women with

26 Endometriosi e aderenze Ovarian endometriomas are frequently associated with other endometriotic lesions, such as adhesions and DIE, which are not easy to diagnose. Underestimation of extensive adhesions in women with endometriomas before surgery is one of the main reasons why surgery is often incomplete leading to repeat operations

28 Compartimento posteriore D.I.E.

29 Morphological features - Hypoechoic nodules - Irregular margins «indian hairdresser sign» - No vascularization or minal peripheral spots

31 Compartimento posteriore Introduzione della sonda

32 Compartimento posteriore

33 Specificita 97% VPN 92.6% Donne con POD obliteration 63% interessamento intestinale Vs 1.4% senza obliterazione

34 Legamenti uterosacrali

35 Legamenti uterosacrali

36 Intestino 10-15cm 30 cm

38 M Muscolare ipoecogeno (rivestito da linea iperecogena che delinea la parte esterna ed interna del muscolo) M SM Strato sottomucoso iperecogeno SM Mu Mu Mucosa ipoecogena

39 Schematic and ultrasound image of a nodule of deep infiltrating endometriosis in the upper rectum (arrow). Nodules located above the level of a virtual line (red line) passing through the insertion of the uterosacral ligaments on the cervix are considered to be located in the upper rectum or recto-sigmoid junction.

Water-contrast in the rectum during transvaginal sonography is performed by injecting saline solution into the rectal lumen during transvaginal ultrasound examination.

40 Water-contrast in the rectum during transvaginal sonography is performed by injecting saline solution into the rectal lumen during transvaginal ultrasound examination. Note the presence of the deep infiltrating endometriosis nodule bulging into the bowel lumen. The lesion clearly reduces the rectal lumen. It infiltrates only the muscle layer of the bowel. The lesion is covered by the hyperechogenic submucosa and hypoechogenic mucosa.

42 Compartimento anteriore

43 E gli ureteri???

47 Vescica ureteri

48 e Reni

Accuracy of transvaginal ultrasound and magnetic resonance imaging in diagnosis and extension of pelvic endometriosis

Accuracy of transvaginal ultrasound and magnetic resonance imaging in diagnosis and extension of pelvic endometriosis A.Salem, Kh. Fakhfakh, S. Mehiri, Y. Ben Brahim, F. Ben Amara, H. Rajhi, R. Hamza,