Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Abstract

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis. Graphical Abstract

Diagnostic Clues for Women with Acute Surgical Abdomen Associated with Ruptured Endometrioma

“…Abdominal CT scans are typically employed as the primary imaging modality when women present to the emergency room with acute abdominal pain, aiming to facilitate the initial evaluation. However, diagnosing ruptured endometrioma can be challenging due to the nonspecific nature of CT findings [ 42 ]. In a prior study, it was reported that ruptured endometriomas exhibited an average diameter of 7 cm and displayed a multilocular structure with thicker walls in comparison to functional cysts [ 43 ].…”

Gynaecological Causes of Acute Pelvic Pain: Common and Not-So-Common Imaging Findings

“…The most common acute complications of endometriosis have an intestinal aetiology, such as obstruction, perforation, and acute appendicitis caused by endometriosis fibrotic implants. Other acute endometriosis manifestations include endometrioma ruptures, endometrioma superinfection, PID with tubo-ovarian abscess, and urinary tract obstruction [57][58][59][60]. MRI is considered the reference standard imaging modality for the diagnosis of endometriosis [61,62].…”

“…In the case of gastrointestinal or urinary tract complications in an emergency setting, endometriosis is rarely identified as an aetiologic factor on imaging, even if it should be suspected in the context of known endometriosis with intestinal or urinary tract involvement. The presence of stellar, mildly enhanced, infiltrative, and fibrotic lesions in suggestive areas in female patients of reproductive age may help doctors reach the correct diagnosis [57,58]. During MRI, the presence of a hyperintense area on T1-weighted fat-saturated sequences within the lesion can suggest the diagnosis of endometriosis [44].…”

“…In the case of endometrioma superinfection, CT usually shows a nonspecific hypodense cystic adnexal with adjacent fat stranding. During the MRI, the superinfection of an endometrioma is suggested by the presence of thickened and enhancing walls of the lesion, an increase in size of an already known endometrioma, the loss of the characteristic high signal in T1 and the shading sign in T2, and a marked restriction of diffusion in DWI [58].…”