Endometriosis of the ‘Accessory Organs of Digestion’
The presence of endometriosis among the ‘accessory organs of digestion’ (Liver and Gallbladder) have only been presented in case studies. As a result, no true prevalence of disease in these organs has been established to date. It is important to realize the complexity of the human body and the numerous differential diagnoses for a cluster of symptoms. If the slight possibility that differential diagnosis has led to suspicion of endometriosis, it should be investigated with attention to any catamenial patterns (symptoms regularly appear or increase around the menses). The ability to identify which organ/tissue most specific is involved, when it pertains to right upper quadrant abdominal pain and symptom referral to the right shoulder, neck and chest area, can require a plethora of testing.
Pathologies of the Diaphragm, Gallbladder and Liver can all create pain and discomfort in the Right Upper Quadrant of the abdomen (and up-under-the rib cage). The Large Intestine can also create symptoms. The large intestine changes direction from vertical to horizontal at the hepatic flexure, located behind the liver and just below the diaphragm. The hepatic flexure is an area of discomfort. Last, the Appendix should be added to the list despite its more common association with right lower quadrant pain, particularly at ‘McBurney’s Point’ (halfway between the belly button and point on the hip bone) but occassional anatomical anomalies occur that cause different symptom locations. All these areas can also cause nausea, vomiting and pain that comes in waves like cramps (colicky). These are symptoms associated with intestinal and gallbladder dysfunctions. Meals and diet often provoke symptoms.
If you experience pain that is felt (referred) into the shoulder, neck and upper arm area – the diaphragm, gallbladder and liver are among the areas your healthcare provider may want to investigate further. It is also important to remember there are many other causes for pain into this area that were not discussed here (ie heart, lung, neuromusculoskeletal etc).
Endometriosis of organs outside of the female reproductive system behave the same. The cyclical, repetitive presence that occur during the catamenial time frame (around menses), is highly suspicious that endometriosis may play a role in the concern.
To clarify: When symptoms come and go every month at the time of menstruation (catamenial), but they occur with other body systems and/or locations away from the ‘area below the belly button’, these concerns should be brought to the attention of your healthcare provider.
Endometriosis of the liver: Hepatic endometriosis is not one of the more frequently reported organs involved. This 2015 article (Hepatic endometriosis: a rare case and review of the literature. European Journal of Medical Research. 2015;20:48
Kai Liu, Weio Zhang, Songyang Liu, Bingfei Dong and Yahui Liu
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389341/) reports the 22nd published case study of the liver parenchyma (tissue within the liver-no inclusion of lesions located on the surface). Due to limitations of prevalence studies and universal methods to collect data of endometriosis encountered surgically throughout the body, we do not know the true prevalence. I will comment that I have encountered more than a few dozen women within the thoracic endometriosis online communities which have had lesions in the parenchyma or liver surface have not had their cases published.
The case here (Kai Liu et al.) involved a solitary lesion of the liver with NO other endometriosis found by the surgeon within the abdominopelvic cavity. We do not know the ability of the surgeon to identify all presentations or locations of disease however, the case reported no signs or symptoms suggestive of symptomatic endometriosis in her history.
Case Report: 36 year old female, complained of severe right upper quadrant pain, that recurred after a prior episode 6 months prior. Note: Pain occurred JUST PRIOR TO THE ONSET OF MENSTRUATION (lasting 3 hrs.) – CATAMENIAL.
At initial episode, ultrasound revealed a 6 cm cystic mass in the liver. Intervention was deferred by patient at the time.
Assessment: No History exposure to liver toxic chemicals/drugs or use of estrogens/progestin or oral contraceptive use. Negative tenderness with palpation; no lymph node enlargement; Blood Values and Liver Function Tests normal; Negative Hepatitis Screen.
Pre-operative Differential Diagnosis: Liver Cystadenoma or Liver Cystadenocarcinoma.
Intra-operative Diagnosis: Endometriosis (based upon operative frozen section tissue sample. Positive Immunostaining of CD10 and CK7f (estrogen and progesterone sensitivity) and HepPar-1 (verified that the cyst was composed of tissue origins from epithelium).
After removal of lesion, patient concerns were resolved.
Once again, Sampson’s Theory of Retrograde Menstruation does not explain the present of endometriosis INSIDE the Liver.
This theory cannot explain distant and intraparenchymal lesions in atypical cases while the hematogenous or lymphatic dissemination may offer a better explanation for these atypical locations -Kai L et al.
It is important to consider the fact that cells that are ‘similar to’ those of the uterus may originate in areas other than the uterus. Further investigation into bone marrow stem cells and the ‘intended’ versus ‘altered’ specialization, location and internal/external influences that impact a cells identity warrants.
Right upper quadrant pain with/without referred pain to the right shoulder area once again, the differential diagnosis begins with the numerous organs and structures which can present with similar patterns. Here, the case of a 17 year old adolescent female with recurrent colicky abdominal pain and chronic anemia (Gallbladder Endometriosis as a cause of occult bleeding. World Journal of Gastroenterology. 2007 Sept.7;13(33):4517-4519. K Saadat-Gilani, L Bechmann, A Frilling, G Gerken, A Canbay
Her symptoms began about a year earlier, at age 16yrs. It is unclear if this adolescent experienced a history of pelvic pain and/or heavy menses. However, the presence of anemia would give this a consideration. Based upon her presentation and process of differential diagnostics, which used multiple forms of imaging, the primary diagnosis involved the Gallbladder (GB).
This is where the key differential lies in the history of symptoms – with specific attention to what and when, did/did not impact her symptoms. With normal gallbladder disease, symptoms most often increase after meals, especially those heavy with fried and high fat content foods. GB disease is not a common dysfunction before the fourth to fifth decade of life unless the individual is heavier. For some, pain in the right shoulder area or even shoulder blade occurs (similar to pain referred from the liver).
So how did they differentiate the exact cause of the gallbladder pain? The patient noted SPECIFICALLY that symptoms occurred with menstruation (Catamenial). The care team employed imaging throughout specific points in monthly hormone cycle. They detected enlargement and reduction of a lesion throughout the month.
Surgical dx- Endometriosis of gallbladder. Assessment of the entire abdominopelvic cavity found No other Endometriosis lesions (that could be identified by the surgeon). At the time of publication, she remained symptom free following removal of the gallbladder. Her anemia was speculated to be the result of the GB lesion.
Referring back to the page ‘Encyclopaedia of Endometriosis’, numerous theories of origin are provided. Examination of this case determined it is physiologically impossible that her disease was the result of Retrograde Menses. Isn’t it time we invest more energy and resources to look at why these cases cannot be explained by this theory? Perhaps the key to understanding endometriosis is to look at the cases that cant be explained – they may hold the real answers.
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