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Deeply Infiltrating Endometriosis(DIE)
Deeply infiltrating endometriosis (DIE) is a kind of functional endometrial growth that invades the deep peritoneum and pelvic organs and invades the tissue more than 5mm, which is called DIE.
There are two explanations for the occurrence of DIE: the theory of meridians and blood flow and the theory of metaplasia. At present, most scholars believe that the DIE is caused by endometrial glandular epithelial cells and stromal cells implanted in the pelvic peritoneum with the menstrual blood flow back.
The endometrial cells with different characteristics flow back to the pelvic cavity and adhere to the surface of the peritoneum. Under the joint action of abnormal hormone level, inflammatory factors, and immune mechanism, new blood vessels are formed, and the lesions move to the deep peritoneum Infiltrate and grow and stimulate the proliferation of deep fibrous connective tissue or smooth muscle tissue to form nodules together. The latter refers to the formation of DIE from the cells on the remnant of the peritoneum or Mullerian tube to the endometrial cells.
The clinical manifestation is closely related to the lesion site. Patients with endometriosis of vagina, rectum, diaphragm, and uterosacral ligament often complain of pain in the lower abdomen and lumbosacral part during menstruation, which is persistent and sometimes aggravated. The most severe pain is before and at the beginning of menstruation, and it will be relieved after menstruation is clean. Deep sexual intercourse pain is a common symptom of this kind of patient.
Some patients may have increased menstrual volume and prolonged menstrual period, which is characterized by bleeding before and after menstruation. Gynecological examination of the utero rectal fovea and uterosacral ligament can reach the tenderness nodule.
The ectopic endometrium invades the intestinal wall to form a mass, oppresses the rectum, and produces the feeling of urgency and heaviness. It can have pelvic pain, rectal pain, periodic rectal bleeding, diarrhea, constipation, and sexual intercourse pain, and it can cause intestinal obstruction when it is obvious.
The digital rectal examination can touch the mass outside the intestinal wall or mucous membrane, with obvious tenderness and smooth and complete mucous membranes. Urinary endometriosis can invade the whole layer of bladder and ureter, and also the kidney.
Most of the symptoms are urinary tract irritation related to menstrual cycles, such as frequency of urination, the urgency of urination, and dysuria.
The most insidious symptoms were lumbago and hematuria during menstruation; the most common symptoms were renal dysfunction, lumbago and abdominal pain and hematuria with the ureter, and upper urinary tract obstruction with hypertension; the most common symptoms were frequency of urination, pain in the bladder area, pain in urine and hematuria, which were obvious or aggravated during menstruation, but not only in vesicovaginal area Symptoms of malaise or menstrual discomfort.
It is very important to identify the site of DIE before surgery because the therapeutic effect is significantly related to the thoroughness of surgical resection. The corresponding information can be obtained by asking symptoms, gynecological examination, and preoperative auxiliary examination.
Pain and infertility are the main symptoms of DIE, and its clinical manifestations such as dysmenorrhea, deep sexual intercourse pain, aperiodic lower abdominal pain, intestinal and urinary tract symptoms are closely related to the location of the lesions.
The location of the corresponding lesions can be understood by asking the symptoms. We should know the relationship between pain symptoms and menstrual cycle, whether it is aggravated in the menstrual period, and whether the use of drugs to inhibit ovarian function can reduce pain symptoms.
More than 85% of the patients with DIE had no obvious pathological changes in the vaginal mucosa, and about 87% of the patients could touch the nodule during double diagnosis. Therefore, even if all gynecological examinations are normal, the existence of DIE cannot be excluded.
Transrectal ultrasonography
MRI examination
Determination of serum CA125
For patients with periuterine infiltration, double renal ultrasonography should be performed, except for hydronephrosis. If necessary, intravenous pyelography (IVP) should be performed to determine the location of the obstruction and renal rheogram to evaluate renal function impairment.
1. Drug treatment
At present, there is no special drug for deep invasive lesions. The principle of drug treatment and drug types are the same as other types of endometriosis. The purpose of drug therapy is to relieve the disease or as an assistant treatment before and after the operation. Drug treatment can reduce the focus and relieve the pain, but it often recurred after drug withdrawal.
At present, the commonly used drugs include high-efficiency progesterone, danazol, Nemestran, gonadotropin-releasing hormone analogue (GnRH - α), danazol vaginal ring and levonorgestrel intrauterine releasing system (Mirena), etc.
Drug treatment may be considered in the following cases:
1.1 The symptoms recurred after several previous operations;
1.2 The operation needs to be postponed for various reasons.
1.3 Because of the wide range of lesions, the difficulty of surgical resection and the high risk of operation, the preoperative medication can be considered to make the lesions atrophic, so as to reduce the surgical bleeding, and the operation is more safe and effective, but the preoperative medication itself can not improve the prognosis of the operation.
Postoperative medication can delay recurrence. Fuyan pill, a traditional Chinese medicine, can not only treat endometriosis but also help patients to regulate the internal, balance Qi and blood, improve immunity, so as to achieve the effect of removing diseases and consolidating the foundation.
2. Surgical treatment
Compared with other types of endometriosis, surgical treatment is more emphasized. The purpose of the operation is to remove the heterotopic nodule, separate the adhesion, relieve the pain, restore the normal anatomical relationship and physiological function of the pelvic organ so as to restore the fertility and delay the recurrence.
Laparoscopic or open surgery has always been controversial. The choice of surgical method depends not only on the patient's focus stage but also on the operator's experience and technology.
There is no clear evidence for the effect of different surgical methods on reproductive function. For pain control, laparoscopic and open focus resection showed a significant therapeutic effect. The recurrence time of endometriosis was the same in the two methods.
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