Endometriosis presenting with hemorrhagic ascites, severe anemia, and shock

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.

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.

Massive recurrent hemoperitoneum with encapsulating peritonitis: another enigmatic clinical feature of endometriosis

OBJECTIVE

To describe the clinical characteristics and laparoscopic findings of a very uncommon presentation of a patient with endometriosis.

DESIGN

Video presentation of case report (Canadian Task Force classification III). (The institutional review board of the Hospital Naval Pedro Mallo, Buenos Aires, Argentina, has ruled that approval was not required for the publication of this case report.) SETTING: Hospital.

PATIENT(S)

Thirty-two-year-old woman with endometriosis presenting with hemorrhagic ascites.

INTERVENTION(S)

We demonstrate the laparoscopic appearance of the peritoneal organs in the presence of massive hemoperitoneum and encapsulating peritonitis and also describe the diagnosis and management options of an uncommon clinical presentation of endometriosis. The patient is a 32-year-old woman, gravida 0, who presented with abdominal pain and ascites. Initially, she underwent exploratory laparotomy with drainage of 5 liters of ascites and excision of endometrial peritoneal implants. She then presented 4 months later with sudden worsening abdominal pain and distention, weight gain, bloating, and shortness of breath. A diagnostic laparoscopy was performed with the findings of over 10 liters of dark hemoperitoneum and diffuse pelviperitonitis with loose necrotic, easy to remove, dense peritoneal tissue. Patient was started on triptorelin acetate with great response.

MAIN OUTCOME MEASURE(S)

Resolution of the symptomatology secondary to hemorrhagic peritonitis.

RESULT(S)

Clinical improvement of symptomatology of a patient with endometriosis and hemorrhagic ascites.

CONCLUSION(S)

Endometriosis can have different clinical presentations. Endometriosis should be a differential diagnosis in women of reproductive age presenting with massive hemorrhagic ascites. Hemorrhagic ascites, considered an exceedingly rare clinical course of endometriosis, represents a challenge to the surgeon who is unfamiliar with this condition. Bilateral oophorectomy is the definitive treatment, but conservative therapy is indicated for women of childbearing age. Diagnostic laparoscopy with drainage of hemoperitoneum is a feasible option to obtain a pathology-confirmed diagnosis in patients presenting with hemoperitoneum secondary to pelvic endometriosis. Awareness of this condition will prevent unnecessary aggressive resection, as is commonly performed when the condition is confused with ovarian cancer.

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.

Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review

The incidence of endometriosis is increasing. Particularly during pregnancy and labour, clinicians should be alert to possible endometriosis-associated complications or complications of previous endometriosis treatment, despite a low relative risk. In addition to an increased rate of early miscarriage, complications such as spontaneous bowel perforation, rupture of ovarian cysts, uterine rupture and intraabdominal bleeding from decidualised endometriosis lesions or previous surgery are described in the literature. Unfavourable neonatal outcomes have also been discussed. We report on an irreducible ovarian torsion in the 16th week of pregnancy following extensive endometriosis surgery, and an intraabdominal haemorrhage due to endometriosis of the bowel in the 29th week of pregnancy.

A rare case of endometrioma in a bitch

Background

Endometriosis is ectopic development of endometrial glands and stroma in extra-uterine sites and if the lesions occur as a well-defined mass is referred to as endometrioma. In the literature, endometrioma has been reported in only women and there are no reports of endometrioma in animals, including non-human primates.

Case presentation

A rare case of endometrioma is reported in an 11-year-old female German Shepherd with clinical signs of dehydration, anemia and prostration. Necropsy revealed ascites, generalized pallor, and a well-demarcated reddish mass adjacent to the left ovary and uterus and adherent to the retroperitoneum. The mass measured 25.0 × 20.0 cm with intermingled soft and firm areas. Upon incision, the mass was found to be solid with variable sized cystic cavities filled with coagulated blood. Microscopically, the mass was composed of cuboidal or prismatic epithelial cells arranged in tubules or acini. The epithelium of the mass had similar characteristics to the normal endometrium with PAS-positive secretions. The stroma was prominent and formed by loose connective tissue and smooth muscle fibers as confirmed by Masson trichrome. Extensive multifocal areas of hemorrhage were also observed in the stroma of the mass and in the interior of some epithelium-lined, cystic structures. Most of the epithelial cells had strong and diffuse cytokeratin expression, and some had vimentin expression. Epithelial and stromal cells also showed ERβ, AR, VEGF and COX2 expression. The stroma showed areas with strong and diffuse vimentin expression. Factor VIII expression was observed only in the endothelium of blood vessels in the stroma.

Conclusions

The macroscopic, microscopic and immunohistochemical findings are consistent with an endometrioma.

A very rare case of endometriosis presenting with massive hemoperitoneum

Endometriosis is a cause of acute abdomen because of the leakage or rupture of endometriotic cyst and tubo-ovarian abscess. However, massive hemoperitoneum as a cause of acute abdomen with endometriosis is very rare. We herein present a case of a 48-year-old woman who was urgently referred to our clinic with colic, abdominal distension, and hypovolemic shock during menstruation. Ultrasonography revealed massive hemorrhagic ascites. Exploratory laparoscopy was urgently performed to achieve hemostasis. The volume of hemoperitoneum evacuated from the pelvis was 1,890 mL. Although the uterus and bilateral ovaries were normal, fresh bleeding was observed from endometriosis on the left cul-de-sac peritoneum, and hemostasis was successfully performed. The potential occurrence of hemorrhagic shock associated with endometriosis, depending on the implantation site, needs to be recognized.

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.