Endometriosis (endometrioid heterotopy) — a disease which is characterized by development outside the cavity of the uterus of the fabric having a structure, similar to an endometria, and also physiologically reacting to sex hormones. Endometriosis origins are finally not clear. For a long time development of endometriosis in pipes, ovaries, on a peritoneal cover of abdominal organs and a small pelvis was explained with implantation of the elements of an endometria which are thrown out in pipes and from pipes in an abdominal cavity during monthly (Sampson). Now most the hormonal theory according to which endometriosis results from disturbance of contents and a ratio of steroid hormones in the woman's organism that is connected with inferiority gipotalamo - pituitary and ovarian system (Baskakov V.P., 1990 was widely adopted; Ishchenko A.I., Kudrina E.A., 2002). Existence of the extra peritoneal endometrioid centers, according to a number of authors, is result of drift of particles of an endometria in bodies in the hematogenous way (Halban).
According to V.P. Baskakov (1990), endometriosis occurs at 1-2% of women of childbearing age, from them at 18-33% of patients involvement of a large intestine in pathological process is noted (Spjut H.J., Perkins D.E., 1959; Bozdech J.M., 1992). Most often endometriosis affects a direct and sigmoid gut, is more rare — terminal department of an ileal gut and a worm-shaped shoot. Symptoms of endometriosis are various, and in most cases are defined by its form and a stage of development of pathological process (Vorobyov G. And., 2001). The clinical picture of a disease along with oligodismenorey, amplifying before periods, is defined also by the level and nature of defeat of an intestinal wall. Considering recurrence of changes in the endometrioid centers, endometriosis is considered chronic high-quality proliferative process which result is the expressed fibrosis of a wall of a gut and formation of perifocal commissures that, on the one hand, leads to fixing of body, and with another — to deformation and narrowing of its gleam. These changes, generally define a clinical picture of endometrioid damage of a large intestine (Adamyan L.P. et al., 2004). In most cases patients are disturbed by the periodic pains in the bottom of a stomach amplifying before periods. Abdominal distention, tenesmus, frustration of the act of defecation — more rare symptoms. They are usually observed at the expressed changes in a gut wall which are followed by disturbance of a passage of intestinal contents. Long, constants, the exhausting dorsodynias and lower parts of a stomach are caused by cicatricial and commissural process in a cavity of a small pelvis with involvement in hems of nerve terminations and textures. According to some authors, the release of blood from a rectum connected with periods — a symptom rare and non-constant (Mandelstam A.E., 1976; Weed J.C. et al., 1987; Saidova R. A., 1999). Topical classification of endometrioses is presented on the scheme 1. According to this classification, endometriosis of a large intestine can be primary and secondary. Primary endometriosis of a large intestine (without damage of genitals) meets extremely seldom. The disease is observed at hematogenous drift of elements of an endometria in a wall of body. At primary endometriosis of a large intestine the pathological center has an appearance of submucosal formation of a nodal or polipovidny form, the sizes from several millimeters to 1,5 cm, a plotnovaty consistence. It is badly displaced, at a palpation is painful. The mucous membrane over endometriomy either is not changed, or is moderately hyperemic.
Scheme 1. Topical classification of endometrioses
In certain cases before periods and during her tumor increases in sizes. The mucous membrane over it gets a reddish or cyanochroic shade, becomes friable, kontaktno bleeds. Usually defeat has the isolated single character. Existence of several grouped educations which at a kolonoskopiya are visualized as excentricly located submucosal tumor with a krupnobugristy or knotty surface is seldom noted. Considering a gross appearance, primary endometriosis of a large intestine needs to be differentiated with adenomas, not epithelial tumors and a focal form of malignant lymphoma. Secondary endometriosis of a large intestine - the most common form of this disease which is observed at one of outside genital forms of endometriosis. The wall of a gut is involved in pathological process kontaktno. Pozadisheechny (retrocervical) endometriosis has the most expressed invasive growth. Allocate the following stages of development of secondary endometriosis (according to A.I. Ishchenko, 1993): The 1st stage — peritoneal implantation;
I am a stage - the 1st stage + damage of genitals;
I am a stage - process progressing, development of commissures around bodies of a small pelvis;
I am a stage — defeat of a serous cover of a bladder, a direct, sigmoid, ileal gut, etc.:
4a — growing of the endometrioid centers into thickness of an intestinal wall; 4b — germination by the endometrioid centers of an intestinal wall.
The endoscopic picture of secondary endometriosis is diverse. Lack of systematization of macroscopic displays of this disease is connected with insufficiency of clinical material and duration, multistaging of development of process (Fedorov V.D. et al., 1984; G. I. Sparrows et al., 2001; Olive D.L. et al., 1993). As a rule, at the 1st and 2nd stage of endometriosis a large intestine of an intaktn. Seldom when performing a kolonoskopiya the moderate increase of a tone of a sigmoid gut which is especially expressed in its lower third is diagnosed. The minimum endoscopic manifestations which have nonspecific character are typical for the 3rd stage of a disease. The colonopexy in rectosigmoid department and the lower third of a sigmoid gut is in most cases noted, the tone in a zone of commissures is raised: folds are high, thick, macroscopically remind physiological sphincters. Usually carrying out the endoscope through this site causes pain. Fibrous changes of a serous cover and the expressed commissural process, developments of pathological process, characteristic of the 4th stage, lead to forming of the fixed, difficult surmountable, sharp excesses of a gut. Most often they are observed in rectosigmoid department and the lower third of a sigmoid gut. Kolonoskopichesky research at this category of patients is followed by an intensive pain syndrome that in some cases does not allow to execute total full audit of a large intestine. Survey stops because of risk of traumatic damage of commissures and a serous cover of body (Sivak M.V., 2000; Church J., 2003). At 1/3 patients along with fixing deformation of a gleam of various degree of manifestation is noted. A gut wall in this area dense, at a palpation sharply painful (regardless of a phase of a menstrual cycle). A mucous membrane in a zone of narrowing of usual color, mobile. In certain cases in a phase of secretion and during periods it can change: bulks up, takes a friable edematous form, focal bluish spottiness (or intra mucous hemorrhages are formed) [Fedorov V.D. et al., 1984 kontaktno bleeds; Zwas F.R. et al., 1990]. When growing endometrioid fabric into thickness of an intestinal wall (4a a stage) fibrous changes of a serous cover of body lead to moderate circular narrowing of a gleam of a gut on a small extent (length about 5 cm). On this background on one of walls one or several submucosal educations in the form of a node or "a polyp on the wide basis" are defined. They have rounded shape, bright red or crimson and cyanochroic color, a dense consistence, motionless. The tool palpation is followed by morbidity. Germination of a gut of an endometriomama, as a rule, causes sharp consolidation of a wall of body and the expressed narrowing of a gleam of a gut. In an invasion zone the relief of a mucous membrane is changed, it is fixed, moderately kontaktno bleeds. At capture of a biopsy of fabric dense, rigid, sharply painful at contact.
It should be noted that irrespective of a process development stage, defeat of an intestinal wall endometrioid fabric extremely seldom is followed by formation of erosion or ulcers on a surface of the injured mucous membrane. Because of a depth of the pathological centers in fabric material not changed mucous membrane of a large intestine often is found. Morphological verification of the diagnosis is possible only at capture of a biopsy from deep layers of an intestinal wall. In fabrics the typical centers of the endometrial glands lying among a characteristic cellular stroma and the macrophages loaded with hemosiderin are found (Aruin L.I. et al., 1998). The wall in a zone of defeat is thickened due to growth of whitish layered fabric with a set of the small centers of brownish-brown color ("old" hemorrhages). Considering polymorphism of endoscopic signs, their not specificity, and also results of histologic research, diagnostic informational content of a kolonoskopiya as primary method of inspection, at patients with an intestinal form of endometriosis rather low. In these cases endoscopic survey of a large intestine should be used as a method of the specifying diagnosis, at a stage of completion of inspection of patients. Besides, "endometriosis of a large intestine" are of great importance for establishment of the final diagnosis:
anamnestic data, recurrence of emergence of symptoms;
age of the patient and duration of a course of a disease;
identification at inspection of one of genital forms of endometriosis;
favourite localization of pathological process — distal departments of a large intestine (a straight line, rectosigmoid department of a large intestine);
change of the sizes, forms and colors of education depending on a phase of a menstrual cycle;
lack of ulcerations on a mucosal surface of the cover located in a zone of growing or germination of an intestinal wall the endometrioid centers;
morbidity at a tool palpation of education;
lack of cancer cells in bioptata that excludes the malignant epithelial nature of education.
terms of carrying out kolonoskopiya: at suspicion on an intestinal form of endometriosis it is better to carry out survey in a secretion phase.
In most cases endometriosis of a large intestine demands surgical treatment which volume depends on prevalence of process. Only at primary form of intestinal endometriosis conservative hormonal therapy can be used.
Partial or full endoscopic removal of small single polipovidny educations at limited forms of a disease practices only in need of verification of the diagnosis by means of an expanded loopy biopsy.