A systematic review: endometriosis presenting with ascites. Arch Gynecol Obstet. 2011;283:513-518. [PMID: 20821226 DOI: 10.1007/s00404-010-1664-1]

Serum concentrations of IL-16 and its genetic polymorphism rs4778889 affect the susceptibility and severity of endometriosis in Nigerian women

BACKGROUND

Endometriosis is the presence of active ectopic endometrial glands and stroma at other sites outside the uterine cavity. It is a common cause of chronic pelvic pain which is sometimes debilitating, and inflammation is one of the known triggers of endometriosis. Interleukins 6 and 16 (IL-6 and IL-16) are proinflammatory cytokines which play essential roles in inflammatory diseases. We therefore investigated the relationship between genetic polymorphisms of interleukins 6 and 16, and the development of endometriosis in Nigerian women.

METHOD

One hundred and thirty (130) consenting women were consecutively enrolled, sixty-five (65) of whom had endometriosis and 65 age-matched women as reference group, surgically confirmed as not having endometriosis. Spectrophotometric determination of serum concentrations of Interleukins 6 and 16 was carried out and the genotyping of IL-6 (rs1800795) and IL-16 (rs4778889, rs11556218, rs4072111) genes were performed using TaqMan assays.

RESULTS

Serum IL-16 concentration was significantly higher in women with severe chronic pelvic pain compared to those with mild pain (p = 0.023). The C allele of rs4778889 was associated with endometriosis (OR: 1.80, 95% CI: 1.08 - 3.02, p = 0.024).

CONCLUSION

Serum IL-16 and IL-16 rs4778889 may be important markers for endometriosis in Nigerian, and by extension, African women. Multicentre African studies would clarify this.

Peritoneal endometriosis presenting as fever of unknown origin, ascites and peritoneal miliary spread: A rare case report and review of the literature

Endometriosis associated with ascites is a rare form of endometriosis. We identified only 81 publications describing women with this pathology. The purpose of this review was to search the existing literature and to understand the clinical presentations and possible treatment options. A 28-year-old patient was admitted due to a fever of unknown origin and lower abdominal pain. Her CT scan was normal with some non-specific lymph-node enlargement up to 1.6 cm and the presence of ascites. Diagnostic laparoscopy revealed a large amount of hemorrhagic ascites. The entire peritoneal surface was covered with milliary nodules. The pathology report revealed peritoneal stromal endometriosis. Endometriosis is an important differential diagnosis in women with ascites and treatment of this form of endometriosis is a real dilemma.

Clinicopathological Characteristics and Outcomes of Patients With Endometriosis-Related Hemorrhagic Ascites: An Updated Systematic Review of the Literature

The presence of ascites is a common clinical presentation in gynecologic oncology patients. Hemorrhagic ascites (HA) due to endometriosis is a rare presentation that can be easily misdiagnosed as ovarian malignancies. The present study aims to update the currently available knowledge on the characteristics of patients presenting with HA due to endometriosis.

A systematic search was conducted for articles published from January 2000 to July 2020 using the Medline, Scopus, and Google Scholar databases along with the references of the full-text articles retrieved. Papers describing cases of women over 18 years with or without previous history of endometriosis were assessed. Only cases with histologically proven hemorrhagic ascites of endometriosis origin were included.

Twenty-nine studies (27 case reports and two case series) comprising 32 patients were evaluated. The mean patients’ age was 32 years, while six of the patients had a previous history of endometriosis. The mean amount of drained ascitic fluid was 4,200 mL, whereas three patients underwent thoracentesis due to pleural effusions. The treatment options included not only medical but also surgical therapies. Fertility preservation was achieved in 27 patients, while two of them achieved pregnancy with in vitro fertilization (IVF) techniques.

Endometriosis-related hemorrhagic ascites is a relatively rare expression of the disease. Endometriosis-related hemorrhagic ascites should be considered in the differential diagnosis (DD) of women with ascites and clinical suspicion of endometriosis. The available literature is limited to case reports and case series and thus indicates further research in the field to decode the pathophysiology of the disease and decide on the optimal treatment.

Genetic polymorphisms of Vascular Endothelial Growth Factor (VEGF) associated with endometriosis in Nigerian women

OBJECTIVE

To determine if genetic polymorphism of VEGF is associated with the development of endometriosis in Nigerian women.

STUDY DESIGN

Case control study of 100 women (50 healthy controls and 50 with endometriosis). Serum VEGF concentration of participants were determined using enzyme-linked immunosorbent assay (ELISA) technique. Genomic DNAs were isolated from peripheral blood samples and quantified by nanodrop spectrophotometer one. Single nucleotide polymorphisms genotyping was carried out by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Mean age of participants was 32.96 ± 6.91 years for control and 32.04 ± 7.56 years for cases. VEGF levels in case and control groups were not statistically different (82.68 pg/ml [69.11-121.11 pg/ml] vs. 82.81 pg/ml [72.90-113.82 pg/ml] respectively; p = 0.967). All four genotypes examined were in Hardy-Weinberg equilibrium. Minor allele frequency of - 460T > C, - 1154G > A, + 936C > T and + 2578C > A were 24%, 8%, 6% and 10% in the control and 19%, 9%, 5% and 14% in endometriosis patients. However, allele and genotype distributions of - 460T > C, - 1154G > A, + 936C > T and + 2578C > A VEGF polymorphisms in endometriosis patients and control were not significantly different (p > 0.05).

CONCLUSION

Our preliminary findings revealed no association between endometriosis and - 460T > C, - 1154G > A, + 936C > T and + 2578C > A of VEGF genes among Nigerian women.

Gross Ascites Secondary to Endometriosis: A Rare Presentation in Pre-Menopausal Women

Ascites caused by endometriosis is an unusual phenomenon with approximately 60 cases described since it was first reported in 1954. Moreover, such a case has rarely been reported in the Caribbean literature. Ascites is frequently treated with surgical options that do not preserve fertility. This is due to the association of ascites with gynaecological malignancies in women with elevated serum cancer antigen (CA-125). We describe three cases of severe endometriosis associated with massive ascites, successfully treated with hormonal therapy while preserving fertility.

Novel triple therapy for hemorrhagic ascites caused by endometriosis: A case report

BACKGROUND

Massive hemorrhagic ascites caused by endometriosis is exceedingly rare, and the treatment strategy remains controversial. Here, we report a case of endometriosis with massive hemorrhagic ascites treated with a novel triple therapy including conservative surgery, gonadotropin-releasing hormone agonist, and then dienogest.

CASE SUMMARY

A 28-year-old nulliparous patient was admitted to Shengjing Hospital of China Medical University, and exploratory laparoscopy was performed. A total of 9500 mL of brown ascites was aspirated from the pelvic cavity, the bilateral ovaries strongly adhered to the posterior of the uterus and were fixed to the pelvic floor, and endometriotic cysts were not observed in either ovary. The pelvic and abdominal peritonea were covered with patchy red, white, and brown endometriotic lesions and defects. Partial surgical resection of endometriotic lesions on the peritoneum was performed while we simultaneously collected multiple peritoneal biopsies. The final pathological diagnosis was endometriosis coupled with hemorrhagic necrotic tissue.

CONCLUSION

Postoperative injection of gonadotropin-releasing hormone agonist was provided three times, followed by dienogest administration, and we will continue to follow up with this ongoing treatment.

Endometriosis-induced massive hemoperitoneum misdiagnosed as ruptured ectopic pregnancy: a case report

Background

Endometriosis, an estrogen-dependent inflammatory disease, is commonly observed in gynecologic practice. Spontaneous hemoperitoneum is a rare but serious complication of endometriosis. Most cases of endometriosis-induced hemoperitoneum are attributable to a ruptured endometrioma or utero-ovarian vessel hemorrhage. We report a case of massive hemoperitoneum secondary to intra-abdominal bleeding from the peritoneal endometriotic deposits with spontaneous abortion that was misdiagnosed as a ruptured ectopic pregnancy.

Case presentation

A 36-year-old Korean woman was admitted to our hospital for acute abdominal pain and vaginal bleeding. She was suspected of ruptured ectopic pregnancy on the basis of a positive serum human chorionic gonadotropin test result and ultrasonographic evidence of pelvic fluid collection. During hospitalization, her symptoms deteriorated with peritoneal irritation sign on physical examination, hypotension, and tachycardia. Emergency exploratory laparoscopy was performed and revealed active bleeding from the peritoneal endometriotic deposit, which was treated with laparoscopic electrocoagulation. The patient’s postoperative course was uneventful. Spontaneous abortion was diagnosed on the basis of decreased serial serum human chorionic gonadotropin level estimation.

Conclusions

Although rare, gynecologists should consider endometriosis-induced hemoperitoneum with spontaneous abortion in the differential diagnosis in women of reproductive age presenting with a positive serum human chorionic gonadotropin test result and acute abdomen with intra-abdominal bleeding.

Endometriosis-Associated Massive Ascites in an Asian Woman: A Case Report of a Rare Clinical Entity

Massive ascites as a presentation of endometriosis is a rare clinical entity that is most commonly seen in black nulliparous females. Herein, we describe a case of a 32-year-old multiparous Thai woman who presented with a two-year history of abdominal distension. Computerized tomography of the abdominopelvic region showed an infiltrative enhancing lesion involving the cul-de-sac and perirectal region with massive loculated ascites, suggesting carcinomatosis peritonei. Abdominal paracentesis was performed to yield fluid samples for evaluation, which revealed no malignant cells, and polymerase chain reaction (PCR) was negative for tuberculosis. The patient underwent exploratory laparotomy which revealed a large amount of serosanguinous ascites, thickened matted bowel loops, and necrotic debris covering the entire surface of the peritoneum and visceral organs. The surgical procedures included drainage of 6.5 liters of ascites, lysis adhesion, biopsy of the peritoneum, and right salpingo-oophorectomy. Histologic examination revealed benign endometrial glands with stroma at the peritoneum tissue and broad ligament. Other causes of ascites were excluded. The ascites responded to drainage and hormonal suppression. A final diagnosis of endometriosis was made based on these findings. Endometriosis should therefore be considered in differential diagnosis in women of childbearing age who present with ascites.

Dye diffusion during laparoscopic tubal patency tests may suggest a lymphatic contribution to dissemination in endometriosis: A prospective, observational study

Aim

Women with adenomyosis are at higher risk of endometriosis recurrence after surgery. This study was to assess if the lymphatic vessel network drained from the uterus to near organs where endometriosis foci lied.

Methods

A prospective, observational study, Canadian Task Force Classification II-2, was conducted at Sacro Cuore Don Calabria Hospital, Negrar, Italy. 104 white women aged 18–43 years were enrolled consecutively for this study. All patients underwent laparoscopy for endometriosis and a tubal dye test was carried out.

Results

Evidence of dye dissemination through the uterine wall and outside the uterus was noted in 27 patients (26%) with adenomyosis as it permeated the uterine wall and a clear passage of the dye was shown in the pelvic lymphatic vessels regardless whether the tubes were unobstructed. Histological assessment of the uterine biopsies confirmed adenomyosis.

Conclusion

Adenomyosis is characterized by ectatic lymphatics that allow the drainage of intrauterine fluids (the dye and, perhaps, menstrual blood) at minimal intrauterine pressure from the uterine cavity though the lymphatic network to extrauterine organs. Certainly, this may not be the only explanation for endometriosis dissemination but the correlation between the routes of the dye drainage and location of endometriosis foci is highly suggestive.

Endometriosis presenting with recurrent massive hemorrhagic ascites and diagnosed by core needle biopsy: A case report

RATIONALE

Recurrent massive hemorrhagic ascites secondary to endometriosis is extremely rare in the medical literature.

PATIENT CONCERNS

We report the case of a 24-year-old nulliparous woman presenting with severe abdominal distention, massive ascites, moderate anemia, menstrual pain, and an elevated CA-125 level.

DIAGNOSIS

We found a thickened peritoneum in the left lower abdomen by ultrasound during the follow-up period, and endometriosis was subsequently diagnosed by performing core needle biopsy (CNB).

INTERVENTIONS AND OUTCOMES

The patient received medical treatment for endometriosis and had a good response to the treatment.

LESSONS

This is the first case in which endometriosis ectopic to peritoneum was diagnosed by CNB. Endometriosis should be considered a differential diagnosis when recurrent massive hemorrhagic ascites occur. CNB should be valued as a method for diagnosing endometriosis.

Massive abscess with prolonged respiratory failure due to newly diagnosed myotonic dystrophy: A case report

RATIONALE

Myotonic dystrophy is a progressive multisystem genetic heterogeneous disorder. General anesthesia with opioids increases the risk of prolonged postanesthetic respiratory recovery in myotonic dystrophy patients.

PATIENT CONCERNS

A 20-year-old previously healthy woman was transferred to our emergency department for further workup of respiratory failure, and massive ascites with abscess caused by endometriosis. Hypercapnic respiratory failure persisted under intensive care unit (ICU) management, but finally improved after cessation of fentanyl as a sedative agent.

DIAGNOSIS

Myotonic dystrophy type 1.

INTERVENTIONS

Massive ascites with abscess was accordingly managed by drainage, antibiotics, and an antifungal agent. Myotonic dystrophy type 1 was confirmed after molecular genetic testing revealed a cytosine-thymine-guanine repeat length of 400 to 450 in the DMPK gene.

OUTCOMES

The patient was discharged without complications on hospital day 69.

LESSONS

Myotonic dystrophy should be considered when hypercapnic respiratory failure persists in sedated ICU patients. Opioids should not be used for perioperative management of patients with myotonic dystrophy.

Benign endometriosis masquerading as intra-abdominal malignancy: One of the most extreme cases reported and a review of the literature

Introduction:

To elicit key clinical lessons from an extreme case of endometriosis associated with massive ascites and a review of the literature.

Methods:

We report one of the most extreme cases of massive ascites caused by endometriosis. For literature review, MEDLINE via OVID (from 1946 to 2016) database was searched. As a result, all the publications based on the keywords relating to the review topic were acquired.

Case:

A 32-year-old nulliparous woman, with stage 4 endometriosis and primary infertility, presented with massive ascites, complex pelvic mass, pleural effusion, weight loss, anaemia and elevated CA-125 suggesting ovarian malignancy. Six litres of ascites was drained. After extensive investigations to exclude malignancy, endometriosis-related ascites was diagnosed. Red-cell transfusion, nasogastric-tube-feeding and gonadotrophin-releasing-hormone analogue were initiated and long-term follow-up is planned. Ablation of ovarian function either by surgical oophorectomy or ovarian irradiation appears to cure the condition without recurrence. Endocrine therapy, in the form of gonadotrophin-releasing-hormone analogue or progestins, is useful if surgery is undesirable, as most women with this condition are young and wish to preserve fertility. Endocrine therapy alone resolves the problem in the majority, but ascites reappears after stopping treatment.

Conclusion:

Endometriosis associated with massive ascites and pleural effusion is rare. There are less than 30 similar case reports in the literature. In women of reproductive age who present with clinical and imaging features to suggest ovarian malignancy, a diagnosis of endometriosis should be considered. Although permanent cure is by oophorectomy, endocrine therapy is useful if surgery is undesirable.

Endometriosis inflammation mimicking pseudomyxoma peritonei: A case report

•

Endometriosis may mimic other pathologic processes

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Fertility preservation can be considered in young women with atypical endometriosis

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Referral to experienced surgeons for maligancy is warranted in atypical endometriosis.

Recurrent massive ascites due to mossy endometriosis

OBJECTIVE

To report the medical and surgical management of a rare case of recurrent moss-like endometriosis and associated hemorrhagic ascites.

DESIGN

Video description of the case, demonstration of the surgical technique, discussion of the histology, and review of endometriosis-associated ascites.

SETTING

Tertiary referral center.

PATIENT(S)

A 26-year-old nulliparous woman of Nigerian heritage with recurrent hemorrhagic ascites due to endometriosis. Three years previously she underwent an exploratory laparotomy for similar symptoms, and 7 L of hemorrhagic ascites were evacuated from her abdomen. Friable lesions covering the peritoneum of the uterus, bladder, and pouch of Douglas were biopsied and consistent with endometriosis. After her initial surgery, the patient was hormonally suppressed with goserelin for 3 months and oral medroxyprogesterone for 1 year. She then stopped the medications to attempt pregnancy but was unsuccessful. She used clomiphene for 3 months, and the ascites reaccumulated. The patient was started on depot leuprolide and oral norethindrone, but the ascites persisted.

INTERVENTION(S)

The patient underwent small-diameter laparoscopy using a multipuncture technique, evacuation of 7.8 L of hemorrhagic ascites, enterolysis, appendectomy, chromopertubation, and treatment of the endometriosis.

MAIN OUTCOME MEASURE(S)

Diffuse olive-green "mossy" endometriosis lesions blanketed the pelvic and abdominal peritoneum. The endometriosis was surgically resected with a combination of peritoneal stripping, excision with carbon dioxide laser, and ablation with neutral argon plasma. Examination of the ascites showed scattered hemosiderin-laden macrophages in a background of red blood cells. Histology of the olive-green mossy lesions revealed dense sheets of hemosiderin-laden macrophages and rare foci of endometriosis. Surgical reports in deidentified patients are exempted from Institutional Review Board approval. The patient gave consent to use photography and images for the video article.

RESULT(S)

No postoperative hormone suppression was given to the patient because she desired pregnancy. At 6 months after her second surgery, the patient had not achieved pregnancy, but the ascites had not reaccumulated. She was referred for further infertility care.

CONCLUSION(S)

This rare form of mossy endometriosis often mimics ovarian cancer, pelvic tuberculosis, and other gynecologic conditions, but when identified, the endometriosis can be treated and symptoms can subside with drainage of the ascites, thorough ablation of the diffuse, superficial lesions, and restoration of anatomy.

Endometriosis and Ascites: A Strategy to Achieve Pregnancy

Deep endometriosis presenting with ascites and preserved fertility is an unusual combination. This report describes a unique case of deep endometriosis and primary infertility, with a successful pregnancy after an optimal surgical approach and personalized ovarian stimulation protocol for in vitro fertilization, which shows the importance of a multidisciplinary approach in these patients.

Endometriosis: a rare and interesting cause of recurrent haemorrhagic ascites

Recurrent haemorrhagic ascites as a cause of endometriosis is rare. We report the case of a 36-year-old woman presenting acutely with abdominal distension, ascites and an elevated CA-125 raising the suspicion of ovarian malignancy. Tissue biopsies retrieved during laparoscopy confirmed the diagnosis of endometriosis associated with haemorrhagic ascites. Gonadotropin-releasing hormone (GnRH) analogues were started to manage symptoms, with good effect. Subsequently, in vitro fertilisation resulted in a successful singleton pregnancy and by the second trimester, there was full resolution in symptoms. During the early puerperal period, the development of massive ascites recurred, requiring symptomatic relief through repeated ascitic drainage and GnRH analogues. Long-term follow-up is planned with the hope of continuing with medical management at least until the patient's family is complete when the surgical option of bilateral salpingo-oophorectomy with or without hysterectomy will be discussed.

Dienogest was effective in treating hemorrhagic ascites caused by endometriosis: a case report

Hemorrhagic ascites caused by endometriosis is extremely rare, and its treatment is under discussion. We report a case of recurrent endometriosis-related ascites treated with dienogest (DNG). A 35-year-old nulliparous Japanese woman with a history of infertility presented with worsening dysmenorrhea and abdominal distention caused by massive ascites. The patient underwent exploratory laparotomy, and hemorrhagic ascites (5500 mL) was drained. She had a normal-sized uterus, and the bilateral ovaries could not be observed because of extensive adhesion in the abdominal cavity. Endometriosis was diagnosed by histopathological evaluation of the omental biopsy, and this was considered to be the cause of ascites. After laparotomy, she had recurrence of ascites. For the next 8 years, the patient was treated conservatively with gonadotropin-releasing hormone agonist therapy and drainage during the intermittent periods followed by DNG administration. She has been treated continuously with DNG for 1 year with no recurrence of ascites. DNG could be an effective treatment for recurrent ascites associated with endometriosis, especially when surgical therapy is undesirable.

A young woman with abdominal distension

We present the case of a 34-year-old woman with haemorrhagic ascites and an extrinsic rectal mass on endoscopy. Endometrioma was subsequently confirmed by laparoscopy and biopsy. Intestinal endometriosis is common, and often mimics other gastrointestinal pathology. Haemorrhagic ascites or intestinal masses are rare presentations of endometriosis, and this is the only reported case of both occurring together. Endometriosis and ascites are more common in women of African descent, and although histological diagnosis requires laparoscopy, MRI has a high negative predictive value; 95% for intestinal endometriosis. Re-accumulation of ascites were prevented by starting a gonadotrophin antagonist.

Endometriosis Presenting with Massive Ascites and Pleural Effusion: A Case Report

Endometriosis is a complex disease commonly encountered by gynecologists. We report the case of an otherwise healthy young nullipara who presented with massive ascites, pleural effusion and shortness of breath and was subsequently diagnosed with endometriosis. This case demonstrates that, with a careful history, physical examination and appropriate tests, patients may be effectively treated with minimally invasive procedures and gonadotropin-releasing hormone (GnRH) agonists, and avoid major emergency surgery.

Endometriosis presenting with hemorrhagic ascites, severe anemia, and shock

Hemorrhagic ascites due to endometriosis is an exceedingly uncommon diagnosis rarely reported in the medical literature. We present a case of a 27-year-old woman who presented to the emergency department for flank and neck pain and was found to be hypotensive with massive hemorrhagic ascites and severe anemia. After emergency department resuscitation and hospitalization, her condition was found to be due to complications of endometriosis. A paracentesis of more than 4000 mL of bloody ascitic fluid revealed no evidence of cancer, and she was discharged on hospital day 3 with hormone therapy and no recurrence of symptoms upon outpatient follow-up. This case illustrates the clinical management, diagnostic approach, and underlying etiology of an infrequent but life-threatening complication of endometriosis.