What the Bowel Does - the rest of the Story
The bowel, both the large and small intestines, are not mere tubes for passage of waste products. Besides their ability to do just that, these are fully functioning organs that have their own immune, vitamin manufacturing, and digestive abilities. The large bowel also contains your microbiome (the “good” bacteria that aid in digestion and break down bilirubin from the liver).
The bowel vigorously defends the entire abdomen from inflammation and infection, migrating to affected areas to stick to them, effectively walling them off from the rest of the abdominal cavity.
How does bowel or bowel function relate to endometriosis?
There are 2 ways that bowel and endometriosis can interact:
- Obstruction
- Bowel dysfunction resulting in bowel disease.
What is Obstruction?
The fat that hangs down like a curtain from the length of the bowel is not the fat we want to “diet away.” Far from being like other fat that accumulates from too much fast food or beer, it—like the intestines—is also a fully functioning organ that plays a crucial role in the defenses launched by the bowel. This fat is called the “omentum,” and among surgeons it is referred to as the “policeman of the abdomen,” because it is that part of the bowel structure that first migrates to wall off inflammatory areas.
Endometriosis causes many problems for women such as pain and infertility. For surgeons, however, one particularly troublesome result, from omentum sticking to areas where endometriosis is raging, is interfering with the free-floating nature of the bowel. Imagine putting your arm through a long sleeve—it passes easily. Now imagine the elbow is sewn to the collar—not occluding the path for your arm but making you navigate around this kink. This will result in some interesting gyrations and perhaps even some tears. Now imagine a piece of bowel stuck to a site of endometriosis on the uterus, fallopian tube, or even another piece of bowel. On the bowel, if the kink does not totally obstruct, feces gets through, but it’s the gyrations necessary to do this that cause the problems. Sometimes feces must pile up a bit to muster the pressure to get through the kinks. This causes distention.
Bowel is funny stuff when it comes to pain. Theoretically, you can cut it with a scissors—it doesn’t hurt; you can take a blowtorch to it—it doesn’t hurt. But if you distend it, it hurts badly. It’s why babies get colic. When feces have to turn difficult corners, colicky pain happens—quickly, severely, and sharply. Worse, the area before such partial obstructions can become chronically dilated, trapping gas and the fermentations of bacteria, which worsens the clinical picture.
What is Bowel Dysfunction?
Endometriosis which has spread to the bowel affects the intrinsic function of it. The stats fall out like this: it’s usually most frequently on the rectum (13-53%), then colon (18-47%), small bowel (2-5%), and appendix (3-18%). (An appendectomy may be a good idea in any woman undergoing surgery for bowel endometriosis.)
Endometriosis involvement with bowel will cause:
- Abdominal pain, bloating.
- Diarrhea
- Painful bowel movements, often requiring straining.
- Rectal bleeding (which will be noted with menstruation).
- Confusing blend of painful symptoms between pelvic pain from pelvic endometriosis and bowel inflammatory pain, sometimes delaying the correct diagnosis in favor of inflammatory bowel disease.
- Painful sex, as the rectum runs under the floor of the vagina. (Endometriosis can fill the space between the back of the vagina and the rectum.)
How is endometriosis of the bowel diagnosed?
Certainly, bowel symptoms that occur with each menses are a strong indicator for bowel endometriosis, but the timing is often not that exact. There can be confusion between the pelvic pain of endometriosis and bowel dysfunction. Endometriosis is a surgical diagnosis: it cannot be definitively diagnosed without actually seeing it, usually via minimally invasive laparoscopic and robotic procedures. So, in any procedure required to diagnose endometriosis, bowel involvement—if present—can be identified at the same time.
How does treatment for endometriosis of the bowel differ from the treatment for pelvic endometriosis only on pelvic organs?
It doesn’t. Medically, the same drugs (birth control pills, hormonal suppressants, and others) that are used to treat endometriosis in your pelvis are used to treat it anywhere it can occur.
Surgery, however, is still considered the best way to eliminate endometriosis, and with the same-day robotic surgeries such as those performed by Dr. Bozdogan of Advanced Endometriosis Center, surgical treatment has changed over the years from a major traumatic event with prolonged convalescence to a routine out-patient recovery.
Even with these advances, however, things become a little precarious when the bowel is involved. Any removal of endometriosis must respect the integrity of the bowel wall—that is, must ensure that it remains intact. The abdomen is a sterile environment and spillage of bowel contents can cause serious infections. The best way to prevent this while also getting the best result in eliminating endometriosis is by meticulous, exacting, and gentle surgery on and around the bowel.
What special precautions are used to ensure the bowel is not damaged?
This is what sets surgery apart among surgeons. At Advanced Endometriosis Center, the very meticulousness, exacting, and gentle bowel surgery needed to remove endometriosis is best done via the cosmetic-sensitive and minimally invasive robotic techniques already used as the first step in diagnosing endometriosis. In this way, unexpected surprises such as bowel involvement can be done at the same time the diagnostic procedure is being done, often saving a patient another surgery. Less surgeries—and the very concept of less surgery—is a benefit to the patient and the most compassionate strategy for women suffering from endometriosis, including bowel involvement.
