Is It Endometriosis?

Is it endometriosis? Endometriosis is a common cause of abdominal pain in young adults, but the overall incidence in adolescent females appears to be low based on diagnosis by pediatric surgeons. As pediatric surgeons, we are often the surgical gynecologists for many patients and frequently perform diagnostic laparoscopies for abdominal pain. Young patients who present to gynecology with chronic abdominal pain often saw 3 physicians prior to laparoscopy for confirmation of endometriosis, leading to a 23 month delay in treatment. Is the incidence in pediatric population higher than we think and a source of pain we should be considering during a diagnostic laparoscopy? The first step in this evaluation requires knowing what endometriosis looks like. Its appearance is varied, but in adolescence, we are more likely to see red and clear lesions. If it is a diagnosis we are missing, how should we evaluate? We begin in the anterior cul-de-sac, the area above the bladder and anterior to the uterus. Here you see red lesions with adhesions, dark lesions and red lesions. And white lesions along the bladder flap. Then we evaluate the bilateral round ligaments as they insert into the inguinal canal with red and dark lesions demonstrated here. Next, examine the appendix and bowel. Here's an appendix with multiple red lesions. The appendix here appears normal, but with careful examination, there is a single red lesion at the tip. Then, run the bowel with particular attention to the cecum and sigmoid colon, as they are often involved. Next, proceed to the upper abdomen and diaphragm. After visualizing the liver, gallbladder, and stomach, evaluate the diaphragm. Here you can see multiple white and dark lesions along the right hemi diaphragm. Diaphragmatic endometriosis can become quite extensive with miliary distribution of lesions. This diaphragmatic endometriosis is accompanied by a liver lesion. Turning our attention south, we subsequently examined the presacral space, looking from the aortic bifurcation cranially, the sacral promontory caudally, and common iliac vessels bilaterally. Then move anteriorly to the ovaries and fallopian tubes. With lateral retraction of the ovary, multiple dark lesions are demonstrated, with care taken to examine all surfaces of the ovary. Gentle manipulation of the fallopian tube shows a single dark lesion in the amppillary portion. Evaluation of the contralateral ovary and fallopian tube shows a similar lesion that appears to partially obstruct indigo carmine dye extravasation. Next, we examine the pelvic side wall. With gentle medial retraction of the ovary, a red lesion is seen over the right ureter. As the ureter travels distally, darker lesions are seen. Along the left pelvic wall, white lesions are seen with white, red and clear lesions seen along the right pelvic wall. Medal rotation of the rectosigmoid allows for evaluation of the right paracolic gutter, revealing a white lesion. We finish the examination with the posterior cul-de-sac wherein you see a miliary pattern of fibrosis. Or isolated red and white lesions along the rectum. Tips be sure to evaluate peritoneal defects as they may hide endometriotic lesions. Remember, hemosiderin deposits can look similar to red lesions, but wash away with suction and irrigation. To evaluate depth of lesions, vaginal exam, rectal exam, and sigmoidoscopy are key adjuncts. Consideration of endometriosis should be included in all laparoscopies for abdominal pain in the adolescent female. Evaluation should be routine and systematic. For additional information, please contact education at najaat.com.