Endometrioza dijagnostika i lije enje
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Endometrioza-dijagnostika i liječenje. D.Barišić. Endometrioza. žarišta po peritoneju endometriom adenomioza duboka zdjelična endometrioza retrocervikalni čvor endometrioza u septumu rektovaginale čvor na rektumu čvor na sigmi infiltracija uretera +-parametrija.

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Endometrioza
Endometrioza

  • žarišta po peritoneju

  • endometriom

  • adenomioza

  • duboka zdjelična endometrioza

  • retrocervikalni čvor

  • endometrioza u septumu rektovaginale

  • čvor na rektumu

  • čvor na sigmi

  • infiltracija uretera +-parametrija


Biokemijski markeri istra ivanja
Biokemijski markeri - istraživanja

Übersicht der Studien zu Biomarkern als diagnostische Tests für Endometriose

StudieSensitivität (%) Spezifität (%)PPV (%) NPV (%)

Somigliana et al. [14] CA 125 im Serum 27 97 - -

Somigliana et al. [14] CA 125, CA 19-9 und IL-6 im Serum 42 71 - -

Somigliana et al. [15] CA 125 und ICAM-1 im Serum 28 92 - -

Gagne et al. 2003 [16] Endometriale Leukozytenmarker in Kombination mit CA-125-Werten im Serum, der Länge des Menstruationszyklus, histologischen Daten und Gravidität 61 95 - -

Zachariah et al. [22] Frei zirkulierende DNA 70 87 - -

Mihalyi et al. [23] Plasmakonzentrationen von IL-6, IL-8, TNF-α, hsCRP, CA 125 und CA 19-9 – mittelschwere bis schwere Endometriose 100 84 - -

Mihalyi et al. [23] Plasmakonzentrationen von IL-6, IL-8, TNF-α, hsCRP, CA 125 und CA 19-9 – minimale bis leichte Endometriose 87 71 - -

Tokushiga et al. [26]CYFRA 21-1 im Urin 94 98,2 95,6 97,5

CCR-1 in Leukozyten des peripheren Blutes 90 74 85 82

Agic et al. [28] CCR-1 in Leukozyten des peripheren Blutes, MCP-1 und CA 125 im Serum 92,2 81,6 92,3 83,2

PPV positiver prädiktiver Wert, NPV negativer prädiktiver Wert, CA „cancer antigen“, ICAM „intercellular adhesion molecule“, IL Interleukin, TNF Tumor-Nekrose-Faktor, hsCRP hochsensitives C-reaktives Protein, CYFRA 21-1 lösliches Fragment von Zytokeratin 19, CCR-1 G-Protein-gekoppelter Chemokinrezeptor, MCP-1 „monocyte









Endometrioza III i IV stupnja po rAFS smanjuje ovarijsku rezervu,mjerenu razinom antimullerovskog hormonaShebl O., i sur. Gynecol Endocrinol, 2009.Ekscizija endometrioma značajno smanjuje ovarijsku rezervu, mjerenu brojem antralnih folikula u slijedećim ciklusima i razinom AMHĆorić M., i sur. Arch Gynecol 2010.


The Cochrane Database of Systematic Reviews – “Pre and post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • Pre-operacijska medik. terapija pokazala je sniženje AFS skora ali bez boljeg ishoda liječenja po pacijentice.

  • Poslijeoperacijska terapija niskodozažnim monofaznim kontraceptivima značajno ne utječe na dugotrajni ishod tj.učestalost recidiva nakon kirurškog liječenja endometrioze. Odgoda recidiva je evidentna u life-table analizi


Adenomioza

Adenomioza post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Postotak ena s adenomiozom u korelaciji s ivotnom dobi
Postotak žena s adenomiozom u korelaciji s životnom dobi post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Uzv slike adenomioze
UZV slike adenomioze post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


stražnji forniks post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Kirur ke th opcije
Kirurške th opcije post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • histerektomija

  • kirurška resekcija (lpsc?)

  • selektivna embolizacija art. uterine - nema reprodukcijskih rezultata u lit.

  • budućnost - fokusirani uzv visokog intenziteta (HIFU) transvaginalno?


Hormonska th adenomioze
Hormonska th adenomioze post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • LNG IUD

  • gestageni

  • GnRH analozi


rASRM 1996. post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Rasrm klasifikacija
rASRM klasifikacija post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

---------------------------------------

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Enzian score dze
Enzian score DZE post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Za to boli duboka zdjeli na endometrioza
Zašto boli duboka zdjelična endometrioza? post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • kompresija okolnih struktura u zdjelici?

  • nervna vlakna nađena su u endometriju i u ektopičnim žarištima u žena s endometriozomAnaf V., i sur.Fertil Steril 2006.

  • endometrioza ima neuromodularna svojstva

  • invazija nervnih vlakana u endometriotične lezije mogući je uzrok boli


a post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practiceDarstellung eines mit Endometriose assoziierten Nervs in einer peritonealen EM-Läsion.

b Dreifachfärbung zur Darstellung von Nervenfasern (grün) in

Kolokalisation zu unreifen Gefäßen (rot).

L Lumen, E Epithel, S Stromazellen. c Durch Douglas-Flüssigkeit einer Patientin mit EM induzierte Nervenfaseraussprossung aus einem sensiblen Hinterwurzelganglion


DZE post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • blok u zdjelištu

  • reduciran Douglasov prostor

  • sa ili bez endometrioma

  • fibroza peritoneja

  • infiltracija sakrouterinih ligamenata

  • uterus s adenomiozom, “prelomljen”


Dze retroperitonealna bolest
DZE – retroperitonealna bolest! post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • retrocervikalni čvor

  • čvor u stražnjem forniksu rodnice

  • čvor u septumu rektovaginale

  • infiltracija rektuma

  • infiltracija sigme

  • stenoza uretera


rektum post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

čvor

< rodnica


Stenoza uretera
stenoza uretera post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice


Prosje no trajanje simptoma do dg endometrioze 9 godina za to
Prosječno trajanje simptoma do dg endometrioze: 9 godina post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practiceZašto?


Preporuka
Preporuka post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • dismenoreja u adolescentnoj dobi: NSAID kroz 3-6 mjeseci

  • bez poboljšanja – M.O.K. kroz 3-6 mj.

  • bez poboljšanja – dg. lpsc.


Preporuka1
Preporuka post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • detaljna anamneza

  • pažljiv gin.pregled u klasičnim spekulima,

  • palpacija forniksa rodnice, procjena fibroze sakrout.ligamenata i peritoneja zdjelice, te gibljivosti adneksa i uterusa

  • fiksirani uterus i rv = endometrioza?

  • bolnost pregleda= endometrioza?

  • svakako digitorektalni pregled


Uzv tek nakon palpacijskog pregleda
UZV tek nakon palpacijskog pregleda! post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • kod sumnje na DZE:

  • i.v.urografija ili barem uzv bubrega, pogotovo kod recidivirajućih uroinfekata

  • irigografija?!


Zaklju ak
Zaključak post operative medical therapy for endometriosis surgery”, Review 2005., conclusions - implications for practice

  • endometrioza je kompleksna proliferativna bolest i značajan je javnozdravstveni problem

  • razdoblje od početka tegoba do dg mora biti što kraće, pa će bolest biti otkrivena u ranoj fazi

  • za dg je potrebna detaljna anamneza i pažljiv ginekološki pregled

  • nužno je detaljno objasniti pacijentici što je endometrioza

  • terapijske opcije ovise o:

    • težini simptoma

    • životnoj dobi žene

    • lokalizaciji žarišta

    • uznapredovalosti bolesti

    • reprodukcijskom planu


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