GASTROINTESTINAL MANIFESTATIONS OF COMPLICATED ENDOMETRIOSIS

Abstract

Introduction: Endometriosis is a chronic, estrogen-dependent inflammatory disease affecting 6% to 10% of women of reproductive age. Deep and complicated forms of the disease, particularly those involving the gastrointestinal tract, are associated with severe pelvic pain, infertility, and significant impairment of quality of life. Intestinal endometriosis accounts for approximately 5% to 12% of cases and mainly affects the rectum and sigmoid colon, potentially causing symptoms similar to functional gastrointestinal disorders, which contributes to an average diagnostic delay of seven to ten years. Objective: The objective of this study was to review the main gastrointestinal manifestations of complicated endometriosis, discuss the pathophysiological mechanisms, diagnostic methods, and most recent therapeutic strategies. Methodology: This is an integrative narrative review conducted between 2015 and 2024, using the PubMed, Scielo, and Web of Science databases with the DeCS/MeSH descriptors: Endometriosis, Gastrointestinal Diseases, Colorectal Surgery, Pelvic Pain, and Diagnostic Imaging. Original studies, reviews, and meta-analyses addressing deep intestinal endometriosis and its clinical implications were included. Results: The findings showed that gastrointestinal manifestations are varied and include cyclic abdominal pain, dyschezia, constipation, alternating diarrhea, bloating, and, in more severe cases, rectal bleeding during menstruation. Rectosigmoid involvement occurs in up to 80% of cases and, when transmural, can cause partial obstruction of the intestinal lumen and, rarely, perforation. Pain during defecation, especially in the luteal phase, is considered the most specific symptom of deep intestinal infiltration. Transvaginal ultrasound with bowel preparation and pelvic magnetic resonance imaging are currently the most accurate imaging methods, with sensitivity greater than 85%. Results: Treatment should be individualized and depends on the depth of infiltration, intensity of symptoms, and the patient's reproductive desires. Hormone therapies, such as GnRH analogs and progestogens, can control pain and reduce the volume of lesions, but in complicated forms with obstruction or gastrointestinal bleeding, surgery is the treatment of choice. Techniques such as discoid resection and laparoscopic rectosigmoidectomy provide symptomatic control in more than 90% of cases, with a low recurrence rate when combined with postoperative hormonal suppression. Laparoscopy and robotic surgery offer rapid recovery and lower morbidity when performed by multidisciplinary teams composed of gynecologists and colorectal surgeons. Conclusion: It is concluded that the gastrointestinal manifestations of complicated endometriosis constitute a relevant clinical and diagnostic challenge. Early diagnosis, based on clinical suspicion and appropriate imaging tests, is crucial to prevent complications and preserve fertility. The integrated approach between gynecology, internal medicine, and digestive surgery represents the cornerstone of modern management of this condition, which requires individualized therapy and continuous follow-up to prevent recurrences and improve the quality of life of patients.