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• W1997894927 abstract "In patients with endometriosis of the appendix, other sites are use to be affected by the disease, mainly bladder, rectosigmoid and retrocervical endometriosis. When these characteristics are present or if patients have more than three sites affected by endometriosis, the surgeon should evaluate the appendix carefully. In patients with endometriosis of the appendix, other sites are use to be affected by the disease, mainly bladder, rectosigmoid and retrocervical endometriosis. When these characteristics are present or if patients have more than three sites affected by endometriosis, the surgeon should evaluate the appendix carefully. The prevalence of bowel endometriosis varies from 5.4% to 25.4% (1Weed J.C. Ray J.E. Endometriosis of the bowel.Obstet Gynecol. 1987; 69: 727-730PubMed Google Scholar), and the most commonly affected site is the rectosigmoid, in around 65% of cases, followed by the ileum and the appendix (2Remorgida V. Ferrero S. Fulcheri E. Ragni N. Martin D.C. Bowel endometriosis: presentation, diagnosis, and treatment.Obstet Gynecol Surv. 2007; 62: 461-470Crossref PubMed Scopus (239) Google Scholar). The prevalence of endometriosis affecting the appendix ranges from 0.4% to 22%, depending on the population studied, and is higher in patients with endometriosis in other sites compared with those with no other site concomitantly affected by this disease (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). With respect to pathogenesis, cases of acute appendicitis have been found in which endometriosis was obstructing the lumen of the appendix. Clinically, patients have also reported symptoms of intestinal bleeding during menstruation (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar).It is possible to accurately diagnose deep lesions of the retrocervical region, rectosigmoid, bladder, and ureter preoperatively, and nuclear magnetic resonance, transvaginal ultrasound with bowel preparation, and transrectal ultrasound are imaging methods that have all been used for this purpose (4Brosens I. Puttemans P. Campo R. Gordts S. Brosens J. Non-invasive methods of diagnosis of endometriosis.Curr Opin Obstet Gynecol. 2003; 15: 519-522Crossref PubMed Scopus (57) Google Scholar, 5Abrão M.S. Gonçalves M.O. Dias Jr., J.A. Podgaec S. Chamie L.P. Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.Hum Reprod. 2007; 22: 3092-3097Crossref PubMed Scopus (367) Google Scholar).No studies have yet established the actual prevalence of endometriosis of the appendix or the relationship between the presence of this type of endometriosis and the presence of the disease at other sites and the clinical characteristics of these patients. Therefore, the objectives of the present study were to describe the symptoms and surgical findings of patients with endometriosis grossly affecting the appendix and to compare these findings with those of patients in whom this organ was not grossly affected by the disease.Between July 1999 and August 2007, 737 patients consecutively who were submitted to videolaparoscopy and in whom endometriosis was confirmed by histology were analyzed. Indication for surgery was based on the clinical symptoms reported by the patients, particularly with respect to the presence of pelvic pain and infertility. The study was approved by the institution's internal review board. The surgical procedures were performed by the same medical team in all cases, the findings were recorded, and the disease was staged in accordance with the 1996 American Society for Reproductive Medicine (ASRM) classification (6The American Society for Reproductive Medicine Revised American Society for Reproductive Medicine Endometriosis Classification.Fertil Steril. 1996; 1997: 817-821Google Scholar). The number of sites affected by endometriosis and the presence of superficial peritoneal, ovarian, or deep retrocervical endometriosis or of endometriotic lesions affecting the bladder, ureter, or rectosigmoid were evaluated. The appendix was resected during laparoscopy if any evidence of abnormalities such as the presence of nodules or adhesions suggestive of endometriosis was found or whenever transvaginal ultrasound indicated that this organ was affected by the disease, and this suspicion was confirmed during surgery. The appendix was resected in 26 cases, with histology confirming the diagnosis of endometriosis in all cases (study group). Patients with endometriosis in whom the appendix was not affected served as a control group.The χ2-square test was used to detect qualitative differences, while the Mann-Whitney test was used to evaluate quantitative variables. Statistically significant differences (P<.05) were evaluated as independent risk factors using multivariate analysis with stepwise multiple logistic regression.Endometriosis of the appendix was histologically confirmed in 26 (3.5%) of the 737 patients. Table 1 shows the presurgical clinical data of the patients evaluated in this study and their laparoscopic findings. There was a higher prevalence of cyclic bowel abnormalities in patients with endometriosis of the appendix (65.4%) compared with those in whom the appendix was not affected (27.7%; P<.001).Table 1Clinical and surgical characteristics of the patients operated.Endometriosis of the appendix (n = 26)Endometriosis not affecting the appendix (n = 711)P valueAge, y (mean ± SD)34.54 ± 5.9233.05 ± 7.31.304Severe/incapacitating dysmenorrhea18 (69.2%)384 (54.1%).126Acyclic pain10 (38.5)221 (31.1).426Deep dyspareunia16 (61.5)408 (56.8).674Cyclic urinary changes3 (11.5)76 (10.7).752Cyclic bowel changes17 (65.4)197 (27.7)<.001Primary or secondary infertility12 (46.2)285 (40.1).937Previous surgeries for endometriosis (mean ± SD)0.65 ± 0.890.76 ± 0.83.381Stage I or II11.5%33.6%.019Stage III or IV88.5%66.4%Number of sites affected by endometriosis (mean ± SD)3.62 ± 1.201.73 ± 0.98<.001Peritoneum15 (57.7)367 (51.6).543Ovary13 (50)407 (57.2).464Retrocervical region15 (57.7)173 (24.3)<.001Rectosigmoid16 (61.5)159 (22.3)<.001Bladder6 (23.1)26 (3.7)<.001Ureter1 (3.8)17 (2.4).48Vagina2 (7.7)28 (3.9).286Note: Data are mean ± SD or n (%). Open table in a new tab Advanced stages of the disease were found in 88.5% of the patients with endometriosis of the appendix, compared with in 66.4% of patients in whom the appendix was not affected (P=.019). Likewise, there were more sites affected by the disease in the women with endometriosis of the appendix (3.62 ± 1.20) compared with the control group (1.73 ± 0.98; P<.001). Statistically significant differences were also found between the groups of women with and without endometriosis of the appendix with respect to other surgical findings: coexistence of deep retrocervical endometriosis (57.7% vs. 24.3%) and endometriosis of the rectosigmoid (61.5% vs. 22.3%) and bladder (23.1% vs. 3.7%; P<.001).Analysis of the multiple logistic regression model showed an odds ratio of 3.0 (95% confidence interval [CI], 2.2–4.1) for patients in whom multiple sites were affected by endometriosis (three or more sites affected by the disease, excluding the appendix) to have lesions in the appendix. Evaluation of these data on a receiver operating characteristic curve showed a sensitivity of 69% and a specificity of 81% for the prediction of endometriosis of the appendix in a patient with multiple (three or more) lesions.To the best of our knowledge, no other studies have evaluated and associated the factors studied here in patients with endometriosis of the appendix. In 2006, Gustofson et al. (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar) analyzed the 8198 women previously reported as having endometriosis of the appendix in a universe of 87,343 patients and established a prevalence of 2.8% for patients with endometriosis and 0.4% for patients in whom the disease was not detected during surgery.Some investigators have suggested that endometriosis of the gastrointestinal tract involves nonspecific abdominal symptoms and may mimic other clinical, surgical, or gynecological pathologies (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). Cases of acute appendicitis etiopathogenically found to represent cases of endometriosis obstructing the lumen of the appendix have been described in the literature (7Thiel C.W. Endometriosis of the appendix and cecum associated with acute appendicitis.Minn Med. 1986; 69: 20-21PubMed Google Scholar). On the other hand, patients have also reported symptoms of intestinal bleeding (hematochezia) during menstruation (8Uohara J.K. Kovara T.Y. Endometriosis of the appendix. Report of twelve cases and review of the literature.Am J Obstet Gynecol. 1975; 121: 423-426PubMed Scopus (45) Google Scholar).In the present sample, the patients with endometriosis affecting the appendix were more likely to report changes in bowel habits or intestinal bleeding compared with the controls. On the other hand, the prevalence of severe or incapacitating dysmenorrhea, chronic pelvic pain, and deep dyspareunia were no higher in this group of patients than in the other patients with endometriosis. It should be emphasized that the present sample consists of patients receiving care at a specialized endometriosis outpatient clinic who were operated by our own team of investigators. Women operated under emergency conditions were not included in the study. The fact that patients submitted to emergency surgery were not included in the present study may, on the one hand, have resulted in a lower prevalence of endometriosis of the appendix; however, on the other hand, it ensures that the findings of endometriosis at other sites are more reliable. At laparoscopy, it is impossible to affirm that an appendix that appears normal at microscopy is indeed free of disease, and this fact constitutes a limitation of the present study; however, we believe this to be clinically irrelevant, since it would also imply that it would be unethical to perform an appendectomy on a laparoscopically normal appendix.The findings of the present study support the need for special attention to be paid to the appendix when certain intrasurgical findings are confirmed. Patients with endometriosis of the appendix are more likely to have more advanced stages of the disease, stages III or IV according to the ASRM 1996 criteria. Likewise, the prevalence of deep endometriosis, bladder involvement, concomitant retrocervical disease, and concomitant involvement of the rectosigmoid was higher in patients with endometriosis of the appendix. The presence of multiple sites (three or more sites) affected by endometriosis was more common in those women who had endometriosis of the appendix. Multivariate analysis of these cases revealed an odds ratio of 3.05 (95% CI, 2.22–4.15) compared with the presence of the disease at fewer than three sites, confirming that the extent of the disease is a positive predictive factor for involvement of the appendix.The effective treatment of endometriosis depends on the correct identification of the sites affected by the disease, principally when surgical treatment is the option. In our opinion, during laparoscopy, the appendix must always be inspected, and involvement of this organ should be suspected in patients with cyclic bowel symptoms, advanced stages of the disease, and multiple lesions. If there are deep retrocervical, rectosigmoid, and bladder lesions, there is a higher chance of endometriosis in the appendix. Moreover, it is well-known that ovarian and various deep endometriotic lesions can be diagnosed by imaging at a preoperative workup. Data are currently being collected in a prospective study that is being developed in this institute to determinate the accuracy of pelvic ultrasound in evaluating the appendix affected by endometriosis. The results of this prospective study should supply further useful information in addition to the data provided by the present study. The prevalence of bowel endometriosis varies from 5.4% to 25.4% (1Weed J.C. Ray J.E. Endometriosis of the bowel.Obstet Gynecol. 1987; 69: 727-730PubMed Google Scholar), and the most commonly affected site is the rectosigmoid, in around 65% of cases, followed by the ileum and the appendix (2Remorgida V. Ferrero S. Fulcheri E. Ragni N. Martin D.C. Bowel endometriosis: presentation, diagnosis, and treatment.Obstet Gynecol Surv. 2007; 62: 461-470Crossref PubMed Scopus (239) Google Scholar). The prevalence of endometriosis affecting the appendix ranges from 0.4% to 22%, depending on the population studied, and is higher in patients with endometriosis in other sites compared with those with no other site concomitantly affected by this disease (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). With respect to pathogenesis, cases of acute appendicitis have been found in which endometriosis was obstructing the lumen of the appendix. Clinically, patients have also reported symptoms of intestinal bleeding during menstruation (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). It is possible to accurately diagnose deep lesions of the retrocervical region, rectosigmoid, bladder, and ureter preoperatively, and nuclear magnetic resonance, transvaginal ultrasound with bowel preparation, and transrectal ultrasound are imaging methods that have all been used for this purpose (4Brosens I. Puttemans P. Campo R. Gordts S. Brosens J. Non-invasive methods of diagnosis of endometriosis.Curr Opin Obstet Gynecol. 2003; 15: 519-522Crossref PubMed Scopus (57) Google Scholar, 5Abrão M.S. Gonçalves M.O. Dias Jr., J.A. Podgaec S. Chamie L.P. Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.Hum Reprod. 2007; 22: 3092-3097Crossref PubMed Scopus (367) Google Scholar). No studies have yet established the actual prevalence of endometriosis of the appendix or the relationship between the presence of this type of endometriosis and the presence of the disease at other sites and the clinical characteristics of these patients. Therefore, the objectives of the present study were to describe the symptoms and surgical findings of patients with endometriosis grossly affecting the appendix and to compare these findings with those of patients in whom this organ was not grossly affected by the disease. Between July 1999 and August 2007, 737 patients consecutively who were submitted to videolaparoscopy and in whom endometriosis was confirmed by histology were analyzed. Indication for surgery was based on the clinical symptoms reported by the patients, particularly with respect to the presence of pelvic pain and infertility. The study was approved by the institution's internal review board. The surgical procedures were performed by the same medical team in all cases, the findings were recorded, and the disease was staged in accordance with the 1996 American Society for Reproductive Medicine (ASRM) classification (6The American Society for Reproductive Medicine Revised American Society for Reproductive Medicine Endometriosis Classification.Fertil Steril. 1996; 1997: 817-821Google Scholar). The number of sites affected by endometriosis and the presence of superficial peritoneal, ovarian, or deep retrocervical endometriosis or of endometriotic lesions affecting the bladder, ureter, or rectosigmoid were evaluated. The appendix was resected during laparoscopy if any evidence of abnormalities such as the presence of nodules or adhesions suggestive of endometriosis was found or whenever transvaginal ultrasound indicated that this organ was affected by the disease, and this suspicion was confirmed during surgery. The appendix was resected in 26 cases, with histology confirming the diagnosis of endometriosis in all cases (study group). Patients with endometriosis in whom the appendix was not affected served as a control group. The χ2-square test was used to detect qualitative differences, while the Mann-Whitney test was used to evaluate quantitative variables. Statistically significant differences (P<.05) were evaluated as independent risk factors using multivariate analysis with stepwise multiple logistic regression. Endometriosis of the appendix was histologically confirmed in 26 (3.5%) of the 737 patients. Table 1 shows the presurgical clinical data of the patients evaluated in this study and their laparoscopic findings. There was a higher prevalence of cyclic bowel abnormalities in patients with endometriosis of the appendix (65.4%) compared with those in whom the appendix was not affected (27.7%; P<.001). Note: Data are mean ± SD or n (%). Advanced stages of the disease were found in 88.5% of the patients with endometriosis of the appendix, compared with in 66.4% of patients in whom the appendix was not affected (P=.019). Likewise, there were more sites affected by the disease in the women with endometriosis of the appendix (3.62 ± 1.20) compared with the control group (1.73 ± 0.98; P<.001). Statistically significant differences were also found between the groups of women with and without endometriosis of the appendix with respect to other surgical findings: coexistence of deep retrocervical endometriosis (57.7% vs. 24.3%) and endometriosis of the rectosigmoid (61.5% vs. 22.3%) and bladder (23.1% vs. 3.7%; P<.001). Analysis of the multiple logistic regression model showed an odds ratio of 3.0 (95% confidence interval [CI], 2.2–4.1) for patients in whom multiple sites were affected by endometriosis (three or more sites affected by the disease, excluding the appendix) to have lesions in the appendix. Evaluation of these data on a receiver operating characteristic curve showed a sensitivity of 69% and a specificity of 81% for the prediction of endometriosis of the appendix in a patient with multiple (three or more) lesions. To the best of our knowledge, no other studies have evaluated and associated the factors studied here in patients with endometriosis of the appendix. In 2006, Gustofson et al. (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar) analyzed the 8198 women previously reported as having endometriosis of the appendix in a universe of 87,343 patients and established a prevalence of 2.8% for patients with endometriosis and 0.4% for patients in whom the disease was not detected during surgery. Some investigators have suggested that endometriosis of the gastrointestinal tract involves nonspecific abdominal symptoms and may mimic other clinical, surgical, or gynecological pathologies (3Gustofson R.L. Kim N. Liu S. Stratton P. Endometriosis and the appendix: a case series and comprehensive review of the literature.Fertil Steril. 2006; 86: 298-303Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar). Cases of acute appendicitis etiopathogenically found to represent cases of endometriosis obstructing the lumen of the appendix have been described in the literature (7Thiel C.W. Endometriosis of the appendix and cecum associated with acute appendicitis.Minn Med. 1986; 69: 20-21PubMed Google Scholar). On the other hand, patients have also reported symptoms of intestinal bleeding (hematochezia) during menstruation (8Uohara J.K. Kovara T.Y. Endometriosis of the appendix. Report of twelve cases and review of the literature.Am J Obstet Gynecol. 1975; 121: 423-426PubMed Scopus (45) Google Scholar). In the present sample, the patients with endometriosis affecting the appendix were more likely to report changes in bowel habits or intestinal bleeding compared with the controls. On the other hand, the prevalence of severe or incapacitating dysmenorrhea, chronic pelvic pain, and deep dyspareunia were no higher in this group of patients than in the other patients with endometriosis. It should be emphasized that the present sample consists of patients receiving care at a specialized endometriosis outpatient clinic who were operated by our own team of investigators. Women operated under emergency conditions were not included in the study. The fact that patients submitted to emergency surgery were not included in the present study may, on the one hand, have resulted in a lower prevalence of endometriosis of the appendix; however, on the other hand, it ensures that the findings of endometriosis at other sites are more reliable. At laparoscopy, it is impossible to affirm that an appendix that appears normal at microscopy is indeed free of disease, and this fact constitutes a limitation of the present study; however, we believe this to be clinically irrelevant, since it would also imply that it would be unethical to perform an appendectomy on a laparoscopically normal appendix. The findings of the present study support the need for special attention to be paid to the appendix when certain intrasurgical findings are confirmed. Patients with endometriosis of the appendix are more likely to have more advanced stages of the disease, stages III or IV according to the ASRM 1996 criteria. Likewise, the prevalence of deep endometriosis, bladder involvement, concomitant retrocervical disease, and concomitant involvement of the rectosigmoid was higher in patients with endometriosis of the appendix. The presence of multiple sites (three or more sites) affected by endometriosis was more common in those women who had endometriosis of the appendix. Multivariate analysis of these cases revealed an odds ratio of 3.05 (95% CI, 2.22–4.15) compared with the presence of the disease at fewer than three sites, confirming that the extent of the disease is a positive predictive factor for involvement of the appendix. The effective treatment of endometriosis depends on the correct identification of the sites affected by the disease, principally when surgical treatment is the option. In our opinion, during laparoscopy, the appendix must always be inspected, and involvement of this organ should be suspected in patients with cyclic bowel symptoms, advanced stages of the disease, and multiple lesions. If there are deep retrocervical, rectosigmoid, and bladder lesions, there is a higher chance of endometriosis in the appendix. Moreover, it is well-known that ovarian and various deep endometriotic lesions can be diagnosed by imaging at a preoperative workup. Data are currently being collected in a prospective study that is being developed in this institute to determinate the accuracy of pelvic ultrasound in evaluating the appendix affected by endometriosis. The results of this prospective study should supply further useful information in addition to the data provided by the present study." @default.
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• W1997894927 title "Endometriosis at several sites, cyclic bowel symptoms, and the likelihood of the appendix being affected" @default.
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