Is It Endometriosis?

Endometriosis is a common cause of abdominal pain in young adults

The overall incidence of endometriosis in adolescent females appears to be low based on diagnosis by pediatric surgeons

Pediatric surgeons 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

In adolescence, endometriosis lesions are more likely to be red and clear rather than the classic dark lesions

The anterior cul-de-sac (the area above the bladder and anterior to the uterus) should be examined first in systematic evaluation for endometriosis

Bilateral round ligaments should be evaluated as they insert into the inguinal canal

The appendix should be examined for endometriotic lesions, including careful examination of the tip

The bowel should be run with particular attention to the cecum and sigmoid colon, as they are often involved in endometriosis

The diaphragm should be evaluated after visualizing the liver, gallbladder, and stomach

Diaphragmatic endometriosis can become quite extensive with miliary distribution of lesions

The presacral space should be examined from the aortic bifurcation cranially, the sacral promontory caudally, and common iliac vessels bilaterally

All surfaces of the ovary should be examined with lateral retraction

Medial rotation of the rectosigmoid allows for evaluation of the right paracolic gutter

The posterior cul-de-sac may show a miliary pattern of fibrosis or isolated red and white lesions along the rectum

Gentle manipulation of the fallopian tube is necessary to visualize lesions in the ampullary portion

Endometriotic lesions can partially obstruct indigo carmine dye extravasation from the fallopian tube

Peritoneal defects should be evaluated as they may hide endometriotic lesions

The pelvic sidewall should be examined with gentle medial retraction of the ovary to visualize lesions over the ureter

Hemosiderin deposits can look similar to red endometriotic lesions, but wash away with suction and irrigation

Vaginal exam, rectal exam, and sigmoidoscopy are key adjuncts to evaluate depth of endometriotic lesions

Consideration of endometriosis should be included in all laparoscopies for abdominal pain in the adolescent female