Advances in Clinical Medicine
Vol.
11
No.
01
(
2021
), Article ID:
39841
,
5
pages
10.12677/ACM.2021.111022
直肠子宫内膜异位症1例诊治分析并文献复习
罗磊*,王烨,李娟,吕丽娜,周洁,万晓梅,刘小雷#
青岛大学附属医院平度院区普外一科,山东 青岛
![](http://html.hanspub.org/file/22-1571847x2_hanspub.png)
收稿日期:2020年12月16日;录用日期:2021年1月5日;发布日期:2021年1月20日
摘要
背景:子宫内膜异位症(endometriosis, EMS)是指子宫内膜组织(腺体和间质)异位至子宫体腔外生长。最常见于25~45岁育龄期女性,属于一种良性疾病,却有类似恶性肿瘤的远处转移和种植能力。按组织发生和临床表现不同可分为腹膜型、卵巢型、深部浸润型及其他部位的内异症4种。其中深部浸润型又可分为4型,第4型浸润至肠道,称为肠型子宫内膜异位症,直肠和乙状结肠是最易受累的部位,发生率约3.8%~37%,其次是小肠和盲肠。直肠、乙状结肠EMS患者轻则无明显临床症状,重者可引发腹痛、排便习惯改变或周期性便血等非特异性消化道症状,临床鉴别较困难,易误诊为肠道肿瘤。病例介绍:本文中一例病人即出现明显的便血症状后来我院就诊。两次内镜检查均考虑直肠肿瘤,行手术治疗后明确为直肠子宫内膜异位症。结论:结直肠子宫内膜异位症是一种极易与直肠肿瘤混淆的一种疾病,诊疗过程中,要详细询问病史及既往史,便血与月经周期的关系。术前行完善全腹CT及肠镜检查,必要时于超声内镜活检,仍不能明确诊断时,建议腹腔镜检查。
关键词
直肠,子宫内膜异位症,诊断,外科治疗
![](http://html.hanspub.org/file/22-1571847x4_hanspub.png)
Analysis of the Diagnosis and Treatment of Rectal Endometriosis: A Case Report and Literature Review
Lei Luo*, Ye Wang, Juan Li, Lina Lv, Jie Zhou, Xiaomei Wan, Xiaolei Liu#
The First Department of General Surgery, Pingdu District, The Affiliated Hospital Qingdao University, Qingdao Shandong
Received: Dec. 16th, 2020; accepted: Jan. 5th, 2021; published: Jan. 20th, 2021
ABSTRACT
Endometriosis is defined as a disease of endometrial-like tissue outside the uterus. It is a benign disease for women of reproductive age 25~45 years, but has the capacity for distant metastasis and implantation similar to malignant tumors. There are four types of endometriosis: peritoneal type, ovarian type, deep infiltrative type, and endometriosis of other sites, depending on tissue occurrence and clinical manifestations. The fourth type infiltrates into the intestine and is called intestinal endometriosis. The rectum and sigmoid colon are the most susceptible sites, with an incidence of 3.8% to 37%, followed by the small intestine and cecum. Patients with EMS of the rectum and sigmoid colon may have no obvious clinical symptoms, while those with severe symptoms may have non-specific gastrointestinal symptoms such as abdominal pain, changes in bowel habits, or periodic blood in the stool, which are difficult to distinguish clinically and can be misdiagnosed as intestinal tumors. Case presentation: In this paper, a patient presented with obvious symptoms of blood in the stool and later visited our hospital. Both endoscopies considered rectal tumors, and after surgical treatment it was clearly rectal endometriosis. Conclusion: Colorectal endometriosis is a disease that can be easily confused with rectal tumors, and a detailed history of the disease and its past, as well as the relationship between blood in the stool and the menstrual cycle, should be asked in the course of treatment. Full abdominal CT and colonoscopy were performed preoperatively, and endoscopic ultrasound biopsy was present if necessary, but still no definite diagnosis was made, laparoscopic examination was recommended.
Keywords:Intestinal, Endometriosis, Diagnose, Resection
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
1. 介绍
直肠子宫内膜异位症在临床中属于一种罕见疾病,可引起便秘、腹泻、肛门坠胀、大便习惯改变及周期性便血等临床症状,临床表现不特异,极易与结直肠肿瘤相混淆,肠镜阳性率较低,误诊率较高。本文通过回顾直肠子宫内膜异位症一例,并进行文献复习,总结该疾病的诊断要点、治疗方法及误诊因素,以提高对该疾病的认识,降低误诊率。
2. 案例介绍
病人戈某某,女,45岁,因“右下腹疼痛1年,间歇性血便3月。”入院。病人于1年前无明显诱因出现右下腹间歇性疼痛不适,呈隐痛,无恶心、呕吐,3月前出现暗红色果冻样大便,不伴粘液,有里急后重感及大便变细,无寒战、高热等不适。1周前于当地医院行肠镜检查,提示:直肠肿物。当地医院病理提示:送检组织慢性炎,部分腺体呈轻度非典型增生。请我院青岛大学附属医院崂山院区院病理科会诊:管状腺瘤。既往史、个人史均无特殊情况。查体:腹部平坦,肚脐下3~5 cm处压痛,有反跳痛,未及明显肿物。直肠指检:于胸膝卧位进指约6 cm,未及明显肿物。入院后于我院内镜中心行结肠镜检查示:直肠肿物,详见图1。病理仍未发现肿瘤细胞。追问病史,病人月经史与便血情况几乎同步。结合CT (详见图2)表现不排除有直肠子宫内膜异位症。病人腹痛逐渐加重,同病人及家属沟通病情,要求手术,随即我科联合妇科进行手术治疗,术中发现:肝、胆、胰腺、脾脏等未见明显异常,直肠与子宫关系密切,但未及明显癌性肿物,左、右卵巢分别可见一2 × 3 cm、7 × 4 cm大小囊性肿物,其中右侧已出现囊肿破裂。行直肠部分切除术 + 右侧附件切除。术中冰冻病理:直肠壁全层及肠周脂肪组织内见异位子宫内膜腺体及间质。右侧卵巢子宫内膜异位囊肿并黄体囊肿。术后病理如图3。
距肛门18 cm处,见一局部粘膜隆起型病灶,表面充血糜烂,占据肠1/3周,边界清,局部官腔狭窄
Figure 1. Patient’s preoperative endoscopy results
图1. 患者术前内镜检查结果
(a) (b)(a)图中箭头所指处为直肠壁增厚处,同时可见右侧附件囊肿,(b)图中箭头可见直肠增厚处与子宫关系密切
Figure 2. Preoperative abdominal CT results of the patient
图2. 患者术前腹部CT结果
(直肠)肠壁全层及肠周脂肪组织内见异位的子宫内膜腺体及间质,上下切缘未见病变累及;肠周淋巴结(5枚)均呈反应性增生。免疫组化:CD10内膜间质(+),Pax-8内腺体(+),CK20(−),CD117(−)
Figure 3. Endothelial glands inside the rectum under 100× magnification
图3. 直肠里面内膜腺体放大100倍镜下表现
3. 讨论
3.1. 形成机制及临床特点
子宫内膜异位症的发生原因,目前各种学说比较多,本文采用目前最主流的学硕:Sampson教授提出“种植学说”,此学说认为月经血中所含内膜碎片可以随月经血发生逆流,然后经输卵管管腔进入腹腔,从而种植于盆腔,并在种植部位继续生长、侵袭、蔓延,形成盆腔子宫内膜异位症 [1]。此外猕猴试验证实逆流入盆腔的经血,可形成子宫内膜异位病灶。人为因素包括宫颈及阴道部位的损伤、剖腹产、分娩、引产、流产、手术、腹腔镜等情况将子宫内膜带到身体其他部位异位种植的内膜。我国著名的妇科教授朗景和经过系列对照研究对此学说做了补充,即异位的内膜碎片形成病灶,需经过粘附、侵袭、血管生成等三个步骤 [2]。当结直肠受累时,可能出现排便习惯改变:如腹泻、便秘、里急后重及周期性便血等不适,因此对于直肠子宫内膜异位症患者,必须与肠易激综合征、孤立性直肠溃疡综合征和直肠肿瘤进行鉴别诊断 [3]。
3.2. 诊断方法及鉴别诊断
CT平扫或者增强CT检查常用于诊断子宫内膜异位囊肿及子宫腺肌病,但特异性较差,其中子宫内膜异位囊肿可在CT检查上表现出特异性征象:囊内局灶性高密度灶,高度提示凝血块,液性部分不强化;另外CT引导下的穿刺性病理学诊断有利于确定肿物性质,术前对怀疑子宫内膜异位症的患者进行常规增强CT等影像学检查也具有一定的临床意义 [4]。此外,有学者通过对43例子宫内膜异位症患者其中28例行MRI,研究结果显示,MRI诊断准确率为92.9%,有较高的诊断价值。但在用MRI诊断盆腔子宫内膜异位症时,因经期出血及月经周期等因素,容易混合新旧病灶有一定的误差率 [5]。
除影像学检查外,术前检测血清CA125值和抗子宫内膜抗体是临床诊断及检测内异症和卵巢癌的重要生化指标。但观察发现只有50%的早期卵巢癌患者存在血清CA125升高情况,内异症也会发生血清 CA125升高情况。血清CA125不能作为诊断内异症恶变的特异性指标,其风险评估临界值为43~165 KU/L,但最终确诊还需术后病理 [6]。
4. 总结
对于结直肠子宫内膜异位症的病人来讲,笔者认为应当从几方面引起重视:1) 仔细询问病史,尤其是月经和便血是否具有相关性,病人如果存在间歇性便血应详细完善检查,排除是否存在妇科疾病;2) 不能过度依赖内镜检查,本文中所讨论的这位病人,多家医院内镜中心的医师均认为肿物非常疑似恶性肿瘤,但病理均提示未发现肿瘤细胞,此时不能简单的以为没有取到恶性肿瘤细胞,需进一步完善标志物及影像学检查;3) 影像学检查尚不能确定结直肠肿物时不可急于手术,请妇科会诊,目前对于子宫内膜异位症的治疗手段并不仅有手术这一种方式,还包括药物治疗、介入等治疗方式;4) 术前做好知情同意,像本例病人,出现明显的便血,且出现腹痛逐渐加重,出现腹膜炎表现,高度怀疑存在附件囊肿的破裂,应及时手术;术后告知病人需及时到相关科室复诊。
同意书
本病例报告资料搜集及发表已获得病人及授权人的知情同意。
文章引用
罗 磊,王 烨,李 娟,吕丽娜,周 洁,万晓梅,刘小雷. 直肠子宫内膜异位症1例诊治分析并文献复习
Analysis of the Diagnosis and Treatment of Rectal Endometriosis: A Case Report and Literature Review[J]. 临床医学进展, 2021, 11(01): 150-154. https://doi.org/10.12677/ACM.2021.111022
参考文献
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