Dijagnostika i liječenje endometrioze crijeva

master's thesis

• Title (english): Diagnosis and treatment of bowel endometriosis
• Author: Ivona Novosel
• Mentor: Mario Ćorić (mentor)
• Committee member: Goran Vujić (predsjednik povjerenstva)
• Committee member: Dinka Pavičić Baldani (član povjerenstva)
• Committee member: Mario Ćorić (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Gynecology and Obstetrics); Zagreb
• Defense date and country: 2021-07-16, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Gynecology and Obstetrics

Abstract

Endometrioza je česta dobroćudna i proliferirajuća kronična bolest za koju je karakteristično postojanje endometrijskih žlijezda i strome izvan maternice, od koje boluje čak 10% - 15% žena reprodukcijske dobi. Ektopično endometrijsko tkivo pokazuje iste cikličke promjene pod utjecajem hormona kao i eutopično tkivo u maternici kroz različite faze menstruacijskog ciklusa. Duboka infiltrirajuća endometrioza (DIE) je definirana kao endometrijska lezija koja infiltrira peritoneum, penetrira u retroperitonejski prostor ili zid zdjeličnih organa sa dubinom infiltracije minimalno 5 mm. Više od 90% intestinalnih sijela endometrioze zahvaća rektum i distalni kolon. Kirurško liječenje je kurativna metoda liječenja DIE koja zahtjeva kompletno odstranjenje svih endometrijskih implantata i obnavljanje normalnih anatomskih odnosa. Patognomonični znakovi su dishezija, krv u stolici, proljev tijekom menstruacije, jaka menstruacijska miktalgija i širenje boli u perineum. Dijagnoza se postavlja na temelju kliničkog pregleda i transvaginalnog ultrazvuka, koja se nadopunjuje magnetskom rezonancom ako se sumnja na manjkav nalaz UZV-a ili se očekuje kompleksni kirurški zahvat zbog lokacije, striktura ili blizine delikatnih živčano-žilnih struktura. Laparoskopski se intraoperacijski radi sekundarna procjena proširenosti i odlučuje kirurški pristup tom specifičnom patoanatomskom nalazu. Hormonska terapija stvara hipoestrogeno stanje koje inducira atrofiju ektopičnog endometrija i omogućuje kontrolu bolnih simptoma reduciranjem intra- i peri-lezijske upale endometrijskih nodula. Progestini niske doze ili u kombinaciji sa oralnim kontraceptivima su generalno dobro tolerirani i terapija su prvog izbora. Kirurški pristup se svrstava u tri kategorije: shaving ekscizija, disk resekcija i segmentalna resekcija. Shaving ekscizija je naziv za odstranjenje lezija sloj po sloj sve dok se ne dođe do zdravog podležećeg tkiva i indicirana je ako DIE lezija ne zahvaća intestinalnu stijenku dublje od mišićnog sloja. Diskoidnom resekcijom se operiraju singularni noduli, manji od 3 cm, koji infiltriraju stijenku dublje od mišićnog sloja i zahvaća manje od 1/3 cirkumferencije stijenke. Segmentalna resekcija ima veliko mjesto u terapiji DIE crijeva jer jednostavno postoje lezije koje nisu primjerene za konzervativnije tehnike prema gore navedenim indikacijama. Indikacije za segmentalnu resekciju su lezije > 3 cm, lezije koje zahvaćaju > 2/3 cirkumferencije ili kod prisutnosti opstrukcije crijeva.

Abstract (english)

Endometriosis is a common benign and proliferating chronic disease characterized by the existence of endometrial glands and stroma outside the uterus, which affects as many as 10% - 15% of women of reproductive age. Ectopic endometrial tissue shows the same cyclic changes under the influence of hormones as eutopic tissue in the uterus through different phases of the menstrual cycle. Deep infiltrating endometriosis (DIE) is defined as an endometrial lesion that infiltrates the peritoneum, penetrates the retroperitoneal space or pelvic wall minimal with depth 5 mm. More than 90% of intestinal endometriosis affects the rectum and distal colon. Surgical treatment is a curative method of treating DIE that requires complete removal of all endometrial implants and restoration of normal anatomical relationships. Pathognomonic signs are dyshesia, blood in the stool, diarrhea during menstruation, severe menstrual myctalgia, and spread of pain to the perineum. The diagnosis is made on the basis of clinical examination and transvaginal ultrasound, which is supplemented by magnetic resonance imaging if a deficient ultrasound finding is suspected or complex surgery is expected due to the location, strictures or proximity of delicate neurovascular structures. Laparoscopically, a secondary assessment of enlargement is performed intraoperatively and a surgical approach to this specific pathoanatomical finding is decided. Hormone therapy creates a hypoestrogenic condition that induces ectopic endometrial atrophy and allows control of painful symptoms by reducing intra- and peri-lesion inflammation of endometrial nodules. Low-dose progestins or in combination with oral contraceptives are generally well tolerated and are the therapy of choice. The surgical approach falls into three categories: shaving excision, disc resection, and segmental resection. Shaving excision is the name for the removal of lesions layer by layer until healthy underlying tissue is reached and is indicated if the DIE lesion does not involve the intestinal wall deeper than the muscle layer. Discoid resection is operated on singular nodules, smaller than 3 cm, which infiltrate the wall deeper than the muscle layer and involve less than 1/3 of the circumference of the wall. Segmental resection has a large place in the therapy of DIE bowel because there are simply lesions that are not suitable for more conservative techniques according to the above indications. Indications for segmental resection are lesions> 3 cm, lesions involving> 2/3 of the circumference, or in the presence of bowel obstruction.

• Keywords: duboka infiltrirajuća endometrioza; hormonska terapija; laparoskopske operacije; shaving ekscizije; diskoidne i segmentalne resekcije
• Keywords (english): deep infiltrating endometriosis; hormone therapy; laparoscopic surgery; shaving excisions; discoid and segmental resections
• Language: croatian
• URN:NBN: urn:nbn:hr:105:446138
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2022-03-24 10:34:52