by Tamer Seckin, MD | Posted on October 20, 2019
Endometriosis is an inflammatory reaction to displaced menstrual tissue that lines the inner surface of the uterus, affecting all organs in the pelvic region, including the bowels. The most commonly affected portion of the bowel is in the cul-de-sac region and the anterior portion of the rectum, neighboring the upper part of the vagina. The severity of involvement is often limited to the serosal (outer) layer of the rectum and pararectal locations (the area around the rectum including the surface called the peritoneum). Peritoneal endometriosis is the most prevalent yet the most ignored manifestation of endometriosis, which leads to persistence and/or resumption of symptoms, despite the surgical approach. In peritoneal endo, the endometriosis tissue implants itself outside the bowel walls and continues to grow and menstruate, causing inflammation and symptoms such as stomach pain and painful bowel movements. The bowels can be involved at the serosal level (outer layer of a bowel) or muscular level (further embedded into the tissue), and are usually associated with approximately 18% of all endometriosis cases.
Endometriosis can spread to a variety of locations. It is common for patients to be unsatisfied with their endometriosis surgery when their bowel symptoms go ignored and their bowel lesions are not recognized during surgery. Patients are often misdiagnosed with Irritable Bowel Syndrome (IBS) or Crohn’s disease, as physicians mistakenly attribute the patient’s symptoms to a gastrointestinal cause. It is important to ask whether or not a patient’s bowel symptoms are in sync with their menstrual cycle. If these questions are not asked and the surgery team is not alerted beforehand, then the lesions will go unnoticed, unremoved, and untreated. For these reasons, we find it highly important for our patients to be aware of what bowel endometriosis is, why is it often misdiagnosed, and how it should be properly treated.
Area of Involvement
In bowel endometriosis, lesions implant onto a multitude of areas outside the uterus.
Overall, the lesions of the bowel can be multi-focal or multi-centered. Multi-focal means that lesions are found in the same area, but there are multiple locations within that area of tissue. For example, if there are multiple lesions solely in the rectum or upper vagina. Multi-centered lesions are localized to the bowels but are spread diffusely throughout the rectum, colon, appendix, etc. In our own clinical setting, we have found that about 10-15% of our endometriosis cases have nodules that are multi-centered, whereas 20% of the time the lesions are multi-focal. 
Symptoms experienced by patients with bowel endometriosis may be exactly the same as those associated with most bowel disorders, and patients are commonly misdiagnosed with IBS, appendicitis, or even Crohn’s disease. To avoid misdiagnosis, it is important to distinguish the subtle—yet critical—differences between bowel endometriosis and other gastrointestinal diseases. If bowel symptoms worsen at different phases of the menstrual cycle, it is likely that endometriosis is involved. For this reason, we encourage patients to record their symptoms as they correlate with their menstrual cycle. Oftentimes, bowel dysfunction caused by bowel endometriosis will be in-sync with a woman’s period, or at least alternate in varying levels of severity during different points in her ovulation cycle. Women may receive many “normal” colonoscopies by gastroenterologists without ever being asked these questions. They are almost always given a “dump diagnosis” or “diagnosis of exclusion” such as IBS. Symptoms of bowel endometriosis include:
Bowel symptoms are some of the most prominent of endometriosis symptoms, even in cases of adolescents. Endometriosis symptoms will often start with bowel symptoms (diarrhea, constipation, etc.), causing patients to seek a gastroenterologist, who will proceed to attribute the symptoms to irritable bowel syndrome (IBS), appendicitis, Crohn’s disease, or even colon cancer. These diagnoses are made without biopsy samples or a pathology report. Instead, patients go on to receive multiple colonoscopies and endoscopies and are often diagnosed with IBS, or other bowel disorders, without a full evaluation of what may really be the underlying cause of their bowel symptoms. For these reasons, we consider an IBS diagnosis without evaluation for endometriosis a “dump diagnosis” for a patient’s bowel dysfunction and pain, particularly if they have endometriosis symptoms that coincide with the patient’s period. Patients who receive such a misdiagnosis are improperly treated and experience persistent symptoms, only to find out, years later, that they had endometriosis all along. In these instances, patients can go 5 to 10 years without being treated, sometimes missing the prime reproductive years of their life.
Whereas inflammation of the bowel caused by IBS materializes exclusively within the intestines, inflammation caused by bowel endometriosis occurs when lesions attach to the outside of the bowels. Procedures such as colonoscopies and endoscopies can only examine the inside of the bowels and are therefore unable to identify inflammation caused by endometriosis. Laparoscopic surgery is the only way to formally and definitively diagnose endometriosis in the bowel region.
When a surgeon looks into the abdomen using laparoscopy, one of the first steps of the procedure should be to evaluate the appendix and ileum of the small intestine. The surgeon will then perform a procedure called, “running the bowels,” which is when they ‘run through’ all of the small intestine, like unwinding a fish hook, all the way to the stomach and check for any suspected lesions or deformity. They will then also check the diaphragm and colon (large intestine). In cases of redundant colon, which is an abnormally long large intestine that causes the widening of the intestine right before the rectum, this “running” procedure is particularly important as the sigmoid (S-shaped extra colon) must be mobilized completely. It is also important to note that this technique takes great skill, and is part of the reason why bowel endometriosis cases are so complicated and present more risk. In turn, this procedure should only be performed by those with vast experience. Once the intestines have been unwound and freed, a rectal probe is put in with a manipulator in order to perform a thorough examination of the rectum and associated rectal vaginal symptoms. The surgeon will then be able to check the bowels for suspected lesions and remove them accordingly, using their preferred technique. The treatments for bowel endometriosis are either the removal of the nodule(s), most of the time including the full thickness of the wall (90%). If the nodules are multiple and obstructive, the treatment is bowel resection surgery. This is particularly difficult and requires special skills in colorectal surgery.
Advanced cases of bowel endometriosis may benefit significantly from definitive surgery, which would consist of a hysterectomy and a deep cleaning of the bowel endometriosis. However, eighty-percent of cases do not require large-scale bowel resection surgeries, and instead lesions will be excised and the bowels repaired by sewing or suturing (this requires the special technique of suturing in “layers”).
No, not necessarily. A hysterectomy is only performed with end-stage endometriosis or if patients prefer to eliminate their fertility. Hysterectomies are often mistakenly viewed as curative surgical treatment for patients with endometriosis . Removal of the uterus eliminates menstruation but it does not treat the endometriosis that has already grown and infiltrated surrounding organs. These lesions, if left untreated, may grow, causing bowel symptoms to persist even after a hysterectomy is performed. When choosing a doctor, it is important to keep in mind that he or she should not only check for endometriosis in the bowels but must also be qualified to remove lesions, even when the treatment plan involves a hysterectomy. Nevertheless, a hysterectomy may be beneficial in certain cases of extensive bowel endometriosis.
In general, as long as the operation is performed laparoscopically, as is the case with all our surgeries, the recovery time is no different than any other standard laparoscopy procedure, and patients are discharged within the day of their surgery. However, for patients who undergo suturing of bowels (conservative surgery), it is advised to stay overnight in the hospital until they pass gas and have their first bowel movement. It is important to note, however, that bowel endometriosis surgery is some of the most difficult and specialized forms of surgery, and for these reasons, complications can often arise. In fact, even with the most precise, skillful surgery, 1 in 20 bowel endometriosis cases present some form of perioperative complication.
Following bowel endometriosis surgery, you can expect your bowels to be very sensitive and require a few days to rest before resuming normal function. Below are just a few of the common complications that will arise for a few days following bowel endometriosis surgery, along with suggestions to help relieve these symptoms:
Bowel endometriosis surgery is one of the most difficult procedures to perform. It requires great experience and meticulous attention to detail, as a surgeon must go through the entirety of the intestines, from the rectum to the small intestines. For these reasons, bowel surgery with endometriosis is the riskiest of any other endometriosis surgery. In our experience, nearly 1 out of 20 cases (5%) experienced complications following surgery, which can include bloatedness, gassiness, abdominal and rectal pain, etc. While this is a very promising recovery number for a procedure that only a select few can perform and can have a tremendous impact on a patient’s relief of symptoms, we feel it is very important for the patient to be aware of the potential risks.
Diet and lifestyle changes can be used as a complementary measure in the treatment of bowel endometriosis, particularly for pre-and post-surgery. Because endometriosis causes widespread inflammation causing symptoms such as constipation, diarrhea, and abnormal gas and bloating, patients may experience some symptom relief when following certain anti-inflammatory diets.
There are many diets that may help, but it is important to understand that every patient is unique and will respond differently. There is no one diet for endometriosis. Consulting with your doctor or nutritionist when making a dietary change and recording the effects of dietary changes on your symptoms may be useful in determining a diet that is appropriate for you.
One study found that a low FODMAP diet can be a highly beneficial measure for relieving symptoms of bowel dysfunction in endometriosis patients. FODMAP is an acronym for “Fermentable oligosaccharides, disaccharides and monosaccharides, and polyols.” Foods containing these molecules—mainly carbohydrates, with the exception of polyols (alcohol)—are poorly absorbed by some human GI tracts. Generally, a low FODMAP diet consists of a low intake of carbohydrates and gluten in order to reduce inflammation. Sugar and carbohydrates are harmful to many conditions including endometriosis, inflammatory diseases, auto-immune diseases, bacterial and yeast infections, and cancer. Sugar nourishes these conditions and worsens their associated symptoms, or in the case of bacteria or yeast, worsens the infection itself.
|Food Category||High FODMAP foods||Low FODMAP food alternatives|
|Vegetables||Asparagus, artichokes, onions(all), leek bulb, garlic, legumes/pulses, sugar snap peas, onion and garlic salts, beetroot, Savoy cabbage, celery, sweet corn||Alfalfa, bean sprouts, green beans, bok choy, capsicum (bell pepper), carrot, chives, fresh herbs, choy sum, cucumber, lettuce, tomato, zucchini|
|Fruits||Apples, pears, mango, nashi pears, watermelon, nectarines, peaches, plums||Banana, orange, mandarin, grapes, melon|
|Milk and dairy||Cow’s milk, yogurt, soft cheese, cream, custard, ice cream||Lactose-free milk, lactose-free yogurts, hard cheese|
|Protein sources||Legumes/pulses, red meat||Meats, fish, chicken, tofu, tempeh|
|Breads and cereal||Rye, wheat-containing bread, wheat-based cereals with dried fruit, wheat pasta||Gluten-free bread and sourdough bread, rice bubbles, oats, gluten-free pasta, rice, quinoa|
|Biscuits (cookies) and snacks||Rye crackers, wheat-based biscuits||Gluten-free biscuits, rice cakes, corn thins|
|Nuts and seeds||Cashews, pistachios||Almonds (<10 nuts), pumpkin seeds|
About 1 in 4 of our endometriosis cases involve the bowels, which is a bit higher than the normal amount of bowel endometriosis cases in the average endometriosis patient. For this reason, we take both great pride and care in surgically treating bowel endometriosis. Having practiced our endometriosis laparoscopic surgery technique for several decades now, our team has great skill in handling even the most complex cases of bowel endometriosis, while at the same time ensuring a minimally invasive surgery.
As discussed earlier, once we make incisions into the abdomen and insert a laparoscope, we first check the appendix and ileum of the small intestine, as these are common sites in which bowel endometriosis lesions often implant. We will then meticulously and thoroughly unwind the intestines, a technique termed “running the bowels,” and insert a rectal probe with a manipulator. This mobilizes the intestines, making them accessible to examine and operate on. Then, we identify and remove suspected endometriosis lesions.
In order to identify bowel endometriosis, a surgeon must not only be looking for these specific lesions, but also have a tremendous amount of experience in repairing the bowels, rectum, and sigmoid colon. This is arguably the most difficult part of bowel endometriosis surgery and is why so many endometriosis cases go improperly treated. In addition to advanced training in laparoscopic surgery and proper identification techniques of endometriosis, if a surgeon is to perform excision of endometriosis they must also have the skill to restore, reconstruct, and repair the infected organs. Many endometriosis lesions are difficult to remove without cutting into the mucosa, especially when the lesions are involved at the muscularis level. In other words, these nodules are transmural with full-thickness involvement (buried within the muscular tissue), and will thus require distortion of the normal bowel anatomy so that the lesions can be removed. This will then require anatomical repairing.
Over the years, we have mastered the technique of proper restoration of the bowels original function once endometriosis lesions are removed. Following excision of bowel endometriosis, we perform all necessary restoration, reconstruction, and repair of the organs that have been operated on. After bowel resection has been completed and the anatomy has been reconstructed, the function of the intestines must then be tested using what is called an “air leak” test (or flat tire test). During this technique, we submerge the bowels in water and methylene blue dye, then apply pressure to the area in order to push air into the intestine and ensure there is no leakage of the newly restored organs and the sutures are properly intact.
Sometimes, more extensive bowel surgery is needed. When an infected organ or area of tissue is diffusely involved, segmental resection and anastomosis may be required. This is a surgical procedure we use that cuts into the bowel in order to remove areas of diffuse endometriosis involvement, followed by subsequent reattachment of the bowels to their newly restored anatomy. Other versions of this include serosal/peritoneum excision, nodulectomy, and disk and segmental excision. At times we may even end up doing multi-centered surgery which involves rectal resection, sigmoid resection, ileocecal resection, and anastomosis. In other words, we can end up doing three different resection techniques with anastomosis in order to thoroughly treat the multiple organ involvement that bowel endometriosis can cause.
Endometriosis is a multiple-organ disease, meaning it can affect organs other than the reproductive organs, such as the bowels, bladder, diaphragm, and even the lungs and kidneys. For this reason, teamwork is a necessary component of our approach. Bowel endometriosis is particularly complex and requires a multidisciplinary surgical team in order to provide the best quality care. During these surgeries, Dr. Seckin and Dr. Goldstein work with a team of highly skilled laparoscopic surgeons; the colorectal and urology specialists on our team have worked with us for many years, and have extensive experience performing surgeries alongside Dr. Seckin. Our philosophy of endometriosis team practice ensures a high surgical volume of diversification and knowledge, which is crucial to minimize postoperative complications and increase the opportunity for a successful outcome.
We strongly believe in increasing the quality of endometriosis surgery by removing endometriosis from every anatomical location including the bowel, bladder, nerves, and ureters. While many surgeons strictly focus on the reproductive system in cases of endometriosis, we believe in conducting a thorough examination of the abdominal anatomy in its entirety, which includes the bowels. A margin-free, complete excision without leaving any disease behind is the gold standard that our team practices. It is also important to not leave behind any scar tissue to ensure a patient their highest chance of recovery and symptom relief. There are also several key components and ideals we uphold in all of our endometriosis surgeries, in order to give the patient the best quality of care that they deserve. These include:
Bowel endometriosis surgeries require a surgeon to complete meticulously-demanding tasks such as “running through” the entirety of the intestines to inspect for endometriosis lesions and reconstructing, repairing, and restoring the bowels after they have been operated on. We have learned that such surgery does not only require great experience but also calls for keen attention to detail. Only through meticulous surgical execution can a surgeon remove endometriosis in the bowels. By removing these lesions, which otherwise would go undetected, we provide our patients with their highest chance of recovery and symptom relief.
As noted above, while bowel endometriosis may be prevalent in less than 20% of endometriosis cases, in our practice nearly one in every four of our patients show signs of possible bowel endometriosis. For this reason, we have a number of bowel endometriosis stories from patients who underwent bowel excision and resection surgery. Meet Patrice M., who was rushed to the ER due to an ovarian cyst bursting in her right ovary, only to find that her endometriosis had spread to the bowels.
Read more stories of patients who had surgery for endometriosis after their disease spread to the bowels, including the rectum, appendix, and colon, in our testimony section.
There aren’t enough stars for Seckin Endometriosis. They deserve 100/ 5. I want to make sure every woman right now who is looking for help, who is looking for a doctor and is scared and confused knows this is where you need to be. It doesn’t matter if you have to come from the other side of the United States or from the other side of the world, I can guarantee it will be worth it. Every member of their…
I’ve seen many obgyns over the years explaining my monthly symptoms during my period...but eventually it became a daily struggle with these pain. It feels like a poke here and there near my right pelvic region. I was given birth control pills for the past ten years but honestly, it didn’t help at all. I was in bed whenever I had my period. I was previously sent to GI doctors for possible appendicitis but it was ruled out from imagings…
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin, I was experiencing almost daily terrible pain to the point where I had difficulty walking, inability to eat, inexplicable weight…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…