Care pathway · Imaging / Gynecology / MRI · for licensed clinicians

Deep Endometriosis Imaging (#Enzian)

DIE invades >5 mm; MRI/TVUS localizes, map by #Enzian compartments to guide multidisciplinary surgery.

Based on: #Enzian 2021 / IDEA · nodes are our own synthesis of the guideline's decision logic, not the guideline verbatim
Clinical takeaway

Deep multi-compartment → #Enzian mapping: Deep multi-compartment involvement — report by #Enzian compartments (A vagina/rectovaginal septum, B uterosacral/cardinal ligaments/pelvic …

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Step 1 · TVUS/MRI localization
TVUS/MRI localization (by #Enzian compartments)?
💡 DIE = invasion >5 mm. MRI is best for localization/preoperative staging: T2-low fibrous nodules/plaques with stellate margins; small T1/T2 high-signal foci = ectopic glands; T1 fat-suppressed to find endometriomas (T1-bright, T2 shading). TVUS (IDEA consensus) is comparable to MRI for the rectosigmoid/uterosacral/rectovaginal septum.

Full pathway

  1. [Decision] TVUS/MRI localization
    TVUS/MRI localization (by #Enzian compartments)? (DIE = invasion >5 mm. MRI is best for localization/preoperative staging: T2-low fibrous nodules/plaques with stellate margins; small T1/T2 high-signal foci = ectopic glands; T1 fat-suppressed to find endometriomas (T1-bright, T2 shading). TVUS (IDEA consensus) is comparable to MRI for the rectosigmoid/uterosacral/rectovaginal septum.)
    • Localized lesion (ovarian endometrioma/superficial) → Localized/ovarian endometrioma
    • Deep multi-compartment involvement (uterosacral/rectovaginal septum/bowel/bladder/ureter) → Deep multi-compartment → #Enzian mapping
  2. [End] Localized/ovarian endometrioma
    Ovarian endometrioma/superficial lesion: T1-bright + T2 shading is typical; assess the contralateral side and deep disease (often coexisting DIE); medical or surgical by symptoms/fertility need.
  3. [End] Deep multi-compartment → #Enzian mapping
    Deep multi-compartment involvement — report by #Enzian compartments (A vagina/rectovaginal septum, B uterosacral/cardinal ligaments/pelvic wall, C rectum, + FA adenomyosis/FB bladder/FU ureter/FI bowel); complete preoperative mapping guides multidisciplinary surgery (bowel segment/ureteric involvement needs the relevant surgical teams), avoiding incomplete surgery and complications.

Source guidelines & references

  • Deep endometriosis MRI and #Enzian classification (Eur Radiol 2023)
  • Deep endometriosis ultrasound IDEA consensus

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

⚠️ This pathway is for clinical reference and teaching by licensed clinicians as decision support; it does not replace clinical judgement or individualized care. In emergencies, follow resuscitation protocols first.
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MRIPelvic Congestion Syndrome (PCS) ImagingImaging / Gynecology / InterventionalEarly Pregnancy Viability Assessment (SRU 2013)Imaging / Obstetrics and gynecology / UltrasoundEctopic Pregnancy Ultrasound DiagnosisImaging / Obstetrics and gynecology / UltrasoundIntrauterine Adhesions (Asherman) Imaging DiagnosisImaging / Gynecology / Reproductive medicineHysterosalpingography (HSG) Tubal Patency AssessmentImaging / Gynecology / Reproductive medicineGestational Trophoblastic Neoplasia (GTN) Staging and RiskImaging / Gynecologic oncologyCervical Length · Cervical Insufficiency Transvaginal UltrasoundImaging / Obstetrics / UltrasoundOvarian Vein Thrombosis (Postpartum) ImagingImaging / Obstetrics / VascularFetal Ventriculomegaly MRIImaging / Fetal medicine / Prenatal diagnosisFetal Agenesis of the Corpus Callosum MRIImaging / Fetal medicine / Prenatal diagnosisFetal Posterior Fossa Malformation MRI (Dandy-Walker Continuum)Imaging / Fetal medicine / Prenatal diagnosisCongenital Diaphragmatic Hernia (CDH) Fetal MRIImaging / Fetal medicine / Pediatric surgeryCongenital Pulmonary Airway Malformation (CPAM) Fetal · CVRImaging / Fetal medicine / Pediatric surgeryOpen Spina Bifida · Fetal Surgery Candidacy (MOMS)Imaging / Fetal medicine / Pediatric neurosurgeryDynamic Pelvic Floor MRI · Pelvic Organ Prolapse (HMO)Imaging / Gynecology / Pelvic floorCongenital Cytomegalovirus (CMV) Brain MRIImaging / Fetal medicine / Prenatal diagnosisSacrococcygeal Teratoma (Altman) Fetal MRIImaging / Fetal medicine / Pediatric surgeryFetal Neck Mass · EXIT AssessmentImaging / Fetal medicine / ENTHoloprosencephaly (HPE) Fetal MRIImaging / Fetal medicine / Prenatal diagnosisPulmonary Sequestration (BPS) Fetal MRIImaging / Fetal medicine / Pediatric surgeryFetal Lower Urinary Tract Obstruction (LUTO)Imaging / Fetal medicine / Pediatric urologyFetal Hydrops (Immune/Non-immune) Diagnostic WorkflowImaging / Fetal medicine / Maternal-fetal medicineTwin-Twin Transfusion Syndrome (TTTS · Quintero)Imaging / Fetal medicine / Maternal-fetal medicineFetal Abdominal Wall Defect (Gastroschisis vs Omphalocele)Imaging / Fetal medicine / Pediatric surgeryCongenital High Airway Obstruction (CHAOS)Imaging / Fetal medicine / ENTFetal Pleural Effusion / ChylothoraxImaging / Fetal medicine / Pediatric surgeryVein of Galen Aneurysmal Malformation (VGAM) Fetal MRIImaging / Fetal medicine / NeurointerventionFetal Malformation of Cortical Development (MCD) MRIImaging / Fetal medicine / Prenatal diagnosisFetal Microcephaly Diagnostic WorkflowImaging / Fetal medicine / Prenatal diagnosisFetal Aqueductal Stenosis (Obstructive Hydrocephalus)Imaging / Fetal medicine / Pediatric neurosurgeryFetal Intracranial Hemorrhage (IVH Grading)Imaging / Fetal medicine / Prenatal diagnosisFetal Encephalocele / Cranium BifidumImaging / Fetal medicine / Pediatric neurosurgeryFetal Tuberous Sclerosis (Rhabdomyomas + Brain Nodules)Imaging / Fetal medicine / Pediatric cardiologyFetal Abdominal Cyst Differential DiagnosisImaging / Fetal medicine / Pediatric surgeryFetal Gastrointestinal Obstruction Imaging DifferentiationImaging / Fetal medicine / Pediatric surgeryFetal Esophageal Atresia ± TEFImaging / Fetal medicine / Pediatric surgeryFetal Renal Anomaly (Cystic/Dysplastic)Imaging / Fetal medicine / Pediatric urologyFetal Skeletal Dysplasia (Lethality Prediction)Imaging / Fetal medicine / Clinical geneticsFetal Arachnoid Cyst / Midline CystImaging / Fetal medicine / Pediatric neurosurgeryFetal Hydronephrosis (UTD Classification)Imaging / Fetal medicine / Pediatric urologyFetal Adrenal/Retroperitoneal Mass DifferentiationImaging / Fetal medicine / Pediatric surgeryFetal Growth Restriction (FGR · Doppler)Imaging / Fetal medicine / Maternal-fetal medicineFetal Anemia (MCA-PSV)Imaging / Fetal medicine / Maternal-fetal medicineTwin Anemia-Polycythemia Sequence (TAPS)Imaging / Fetal medicine / Maternal-fetal medicineTwin Reversed Arterial Perfusion (TRAP · Acardiac Twin)Imaging / Fetal medicine / Maternal-fetal medicineFetal Goiter (Hypothyroid/Hyperthyroid)Imaging / Fetal medicine / Maternal-fetal medicine