Interactive Transcript
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So this case I put in here
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because it's a nice example of deep infiltrating endometriosis.
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So again, I start with the T2 non fat sat images.
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I scroll through on the sagittal.
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I don't see much going on in the anterior compartment.
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In the middle compartment,
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there are a couple of things going on in the myometrium that we can talk about.
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The uterus is anteverted and not terribly flexed one way or another.
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And then in the posterior compartment, there's something going on right here
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in the sigmoid colon that we're going to need to account for later.
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Looking at the axials to take a peek at the adnexa.
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We have one adnexa over here, another over here.
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Nothing super crazy there.
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Then I'll pull my T2 fat sat.
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Oh, sorry. My T1...
1:01
My T1 pres alongside.
1:04
I'm going to look at those together and make sure that I'm not seeing any
1:07
T1 brightness in the ovary that would suggest an endometrioma.
1:11
I'm not seeing any superficial endometriotic implants.
1:17
This protocol happened to have been done without fat saturation.
1:21
And then here with fat saturation.
1:28
So there are a couple of little punctate
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areas of T1 hyperintensity that we see better with the fat saturation.
1:34
That's why our protocol calls for that
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fat saturation on the T1s.
1:40
And then on the sagittal,
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that area of concern involving the sigmoid colon
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we can see is T1 dark as well as T2 dark.
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All right, so now let's kind of talk about what each of these things are.
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And before we do, can we get the next question, please?
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So which portion of the bowel is most commonly involved with endometriosis?
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The terminal ileum, cecum, sigmoid colon, or rectum?
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All right, so people have answered the sigmoid colon.
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The answer is actually the rectum.
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So the rectosigmoid colon, together, account for like 90% of cases
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of bowel involvement.
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But the rectum out edges the sigmoid colon a little bit.
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This case, there is involvement
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of the upper portion of the rectum and then into the sigmoid.
2:40
So I fooled you with this case.
2:41
I'm sorry.
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Bowel involvement in general seen in about 37% of cases of endometriosis.
2:49
So, here we have tethering of the uterus to the rectosigmoid colon here.
2:59
We have obliteration of the rectocervical space
3:04
and the lower part of the rectouterine space
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by this deep infiltrating endometriotic implant.
3:10
There are two morphologies of deep infiltrating endometriosis, which,
3:15
by definition, invades the peritoneal surface by greater than 5mm.
3:19
So there's the chronic stromal fibrotic
3:21
morphology and an active glandular morphology.
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This is a beautiful example of the chronic stromal fibrotic morphology.
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So that morphology is T2 dark and T1 dark.
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It can be nodular or stellate in appearance.
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It causes scarring and obliteration of spaces, meaning that,
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you know, the normal...
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the normal fat plane between the structures and the peritoneal cavity
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is obliterated by scarring that crosses it.
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This is the type of endometriosis that MRI is really great at detecting
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and that the surgeons really want us to tell them about before they go
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into the operating room, because when there is scarring
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and obliteration of spaces, they can't get to those areas
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laparoscopically, and it very significantly impacts
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the surgery that they need to do to help debulk the patient.
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This particular case is a nice example of what's called the mushroom cap sign.
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So that is a descriptor that we use to
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describe bowel involvement with endometriosis.
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You can almost imagine that this is
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a mushroom cap here if we had a little mushroom stalk coming down the bottom.
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And what that is, is it's basically deep endometrio...
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Deep infiltrating endometriosis that invades the muscularis propria
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and results in muscular hypertrophy of the wall of the bowel.
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And that's what is responsible for that mushroom cap appearance.
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When we are describing bowel involvement with endometriosis, it's really important
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that we describe the location of the bowel that's involved.
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Here we can see that area of involvement
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in the axial plane and appreciate just how long it is and how much bowel is involved.
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So we need to describe the location,
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the relationship to the peritoneal reflection.
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This one crosses the peritoneal reflection,
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the distance from the anal verge and the length and number of segments involved.
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And then finally, whether it is greater than 50%
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circumferential involvement or less than.
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And this would be an example of less than.
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And the reason the circumference involvement is important is because it,
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it dictates what type of surgery needs to be done to resect this lesion.
5:34
So if it's less than 50% circumferential involvement,
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the surgeons can just remove that part as it discoid resection.
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If, however, it's greater than 50% of the circumference of the bowel,
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or if there is narrowing, they have to do a segmental resection
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and anastomose the two disconnected segments back together.
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So if there's a lot of bowel involvement,
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the gynecologist may opt to have colorectal surgery involved.
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So it's important to describe all of these features when you see them in the report.
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This patient also, if we focus on the uterus,
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the junctional zone of the uterus here,
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so the T2 kind of gray portion
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of the myometrium that's just below the endometrium is thickened.
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If I were to measure it for you here, it's 13, almost 14 mm.
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So there's junctional zone thickening, which is consistent with adenomyosis,
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which is basically the presence of endometrial tissue in the myometrium
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and is also commonly seen in conjunction with endometriosis outside the uterus,
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since it essentially is endometriosis of the uterus itself.
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