{"paper_id":"0ad78ef8-898b-4897-859d-1c7bbcd4a0f2","body_text":"Medical Case Studies Vol. 3(4), pp. 26-29,  November  2012  \nAvailable online at http://www.academicjournals.org/MCS    \nDOI: 10.5897/MCS12.012  \nISSN 2141-6532 ©2012 Academic Journals   \n \n \n \n \n \nCase Report \n \nEndometriosis-induced hemoperitoneum in the  \ncolonic serosa \n \nTae-Hee Kim, Hae-Hyeog Lee*, Soo-Ho Chung and WooSeok Lee \n \nDepartment of Obstetrics and Gynecology, College of Medicine, Soonchunhyang University, Bucheon, 420-767, \nRepublic of Korea. \n \nAccepted 31 August, 2012 \n \nEndometriosis is an inflammatory disease. The etiology of endometriosis is exactly unknown. A 42-year-\nold virgin experienced a sudden increase in pain that began one day prior to examination. She had been \nsuffering from dysmenorrhea and menorrhagia. The patient had abdominal guarding with severe \nrebound tenderness. On computed tomography, both ovaries were normal, and sigmoid colon was seen \nin the peripheral portion of the pelvic hematoma. Pathologic findings revealed endometriosis in the \ncolonic serosa cyst. Our data provide a new diagnostic key for hemoperitoneum c aused by \nendometriosis in the colonic serosa.  \n \nKey words: Hemoperitoneum, endometriosis, colon. \n \n \nINTRODUCTION \n \nEndometriosis is a chronic inflammatory gynecologic \ndisease. Infertility is the primary complication associated \nwith endometriosis, and dysmen orrhea or dyspareunia \nmay also be associated. The etiology of endometriosis is \nunknown, but prevailing theories include coelomic \nmetaplasia and retrograde menstruation (Bellelis et al., \n2011).  \nExtrapelvic endometriosis results from an endometriotic \nimplantation, observed most commonly in the \ngastrointestinal tract, but also found in the urinary, \npulmonary or central nervous system, skin, or other \norgan (Dimoulios et al., 2003).  \nThis condition is rare and its prevalence is unknown. \nBecause patients with intestinal endometriosis frequently \nreport symptoms of rectal bleeding, bowel obstruction, \nand rarely, perforation, they are often misdiagnosed with \ncancer (Dimoulios et al., 2003).  \nThe present case study reports on a patient with a \nhemoperitoneum that was misdiagnosed as ovarian cyst \nrupture.  \n \n \n \n*Corresponding author. E-mail: hhl22@schmc.ac.kr or \nhhl22@chol.com. Tel: +82 -32-621-5378 or +82 -10-5273-7840. \nFax: +82-2-6008-6874. \nCASE REPORT \n \nA 42-year-old woman arrived in the emergency room with \nsymptoms of a bdominal pain. Her obstetric history \nrevealed that she has never been pregnant or given birth \n(TPAL 0 -0-0-0) and she had no relevant family history . \nShe had been suffering from dysmenorrhea and \nmenorrhagia, and reported cyclical abdominal pain during \nmenstruation. According to her past history, she had \nexperienced lymphedema during cardiac surgery. Direct \ntenderness and  rebound tenderness were  noted upon \nabdominal examination. The patient’s blood pressure was \nnormal (100/70 mmHg) and her pulse rate was 100 bpm. \nHer hemoglobin level was 10.9 g/d and a urine human \nchorionic gonadotropin test  was negative. \nUltrasonography revealed a collection of fluid and a left \nadnexal mass (4.2 × 2.8 cm). On computed tomography, \nboth ovaries appeared normal and the sigmoid colon was \nobserved in the peripheral portion of the pelvic hematoma \n(Figure 1A to C). \nLaparoscopy revealed a subserosal myoma in the \nuterus, bilateral normal ovaries, and a 1000 -cc \nhemoperitoneum. A serosal cyst with a hematoma and \nsubserosal myoma were rem oved from the colon (Figure \n2). Pathologic findings revealed endometriosis in the \ncolonic  serosal  cyst.  No   abnormal   complication   was  \n\nKim et al.       27 \n \n \n \n  \n                       A                                                       B \n                           \n                                                       C \n \n \nFigure 1.  (A, B) In lower abdominal cavity, about 13 × 5 × 9 cm sized hematoma is seen. In the \nhematoma, multiple cystic lesions are seen with a high density spot indicating active bleeding \n(arrow). Both ovaries are noted on the posterior aspect of the hematoma (arrowheads). Sigmoid \ncolon is seen on the peripheral portion of the pelvic hematoma (thick arrow).  (C) Coronal reformatted \nimage of enhanced CT scan showed pelvic hematoma with active bleeding spot. Multiple low density \nround lesions are also seen within the hematoma and the hematoma was abutting cecum and \nsigmoid colon (arrows). \n \n \n \nnoted following surgery and the patient was treated with a \ngonadotropin-releasing hormone agonist for 6 months. \n \n \nFINDINGS AND DISCUSSION \n \nEndometriosis is an inflammatory disease that affects  10 \nto 15% of reproductive -aged women (Bulun, 2009) . \nIncreased exposure to estrog en at an early age (that is, \nearly menarche), short menstrual cycle length, and \nnulliparity increase the risk for endometriosis (Trabert et \nal., 2011) . Other risk factors include a diet low in beta -\ncarotene and fruit.  Environmental risk factors for \nendometriosis have also been investigated recently.  \n\n28       Med. Case Stud. \n \n \n \n \n \nFigure 2. Serosal cyst (9 × 6 × 2 cm in size) with hematoma in colon was removed.  \n \n \n \nDuring pregnancy, women with endometriosis may \nexperience preeclampsia and antepartum hemorrhage \n(Stephansson et al., 2009). Ultrasonographic diagnosis of \nendometriosis is difficult due to the variable appearance \nof this condition (Woodward et al., 2001).  \nMagnetic resonance imaging has greater specificity \nthan other noninvasive imaging techniques for the \ndiagnosis of e ndometriomas. Endometriosis shows \nrelatively homogeneous high signal intensity on T1 -\nweighted images (Woodward et al., 2001).  \nPrevious studies have reported that ovarian \nendometriosis, but not non-ovarian endometriosis, can be \naccurately diagnosed on the basis of high -resolution \nultrasonographic findings in combination with symptoms \nof dysmenorrhea, pelvic pain, and dyspareunia (Eskenazi \net al., 2001).  \nMost cases of extrapelvic endometriosis are \nmisdiagnosed, because the symptoms are ambiguous on \nphysical examination. A confirmed diagnosis can only be \nmade following laparoscopy and positive histologic \nlaboratory results. In the urinary tract, the bladder is the \nmost common site of endometriosis (Cho et al., 2007).  \nA previous study reported an urohemoperitoneum \nduring pregnancy in a patient with deep endometriosis \nthat resulted in fetal death (Chiodo et al., 2008) . \nEndometriosis of the appendix has also been \nmisdiagnosed as appendicitis (Abrao et al., 2005) . \nIntestinal endometriosis occurs with asymptomatic, small, \nsuperficial serosal implants (Garg et al., 2009)  and may \ninvolve bowel resection. Most commonly, it is diagnosed \nincidentally following an operation. Typically, intestinal \nendometriosis is observed as granular, bluish -red \nnodules located on the se rosa in the small intestine \n(Prystowsky et al., 1988).  \nTo our knowledge, no previous report has described \nthe development of a hemoperitoneum due to serosal \nendometriosis. Previous studies have reported a large \nhemoperitoneum due to actively bleeding endo metriosis \nin the fallopian tube, a spontaneous uterine wall vessel \nrupture, and bleeding from endometriotic implants \n(Janicki et al., 2002). \nAn increased risk of bleeding as a result of infiltrating \nendometriosis should be considered in the diagnosis. Our \npatient reported cyclic pain during menstruation and \ndysmenorrhea. Her menstrual symptoms were not typical \nfor intestinal endometriosis, but cyclic pain during \nmenstruation should be considered in the diagnosis of \nambiguous extrapelvic endometriosis. Our data provide a \nnew diagnostic key for hemoperitoneum caused by \nendometriosis in the colonic serosa. \n \n \nREFERENCES \n \nAbrao MS, Podgaec S, Carvalho FM, Goncalves MO, Dias JA, Jr., \nAverbach M (2005). Bowel endometriosis and mucocele of the \nappendix. J. Minim. Invasive Gynecol. 12:299-300. \nBellelis P, Podgaec S, Abrão MS (2011). Environmental factors and \nendometriosis. Rev. Assoc. Med. Bras. 57: 448-452. \nBulun SE (2009). Endometriosis. N. Engl. J. Med. 360: 268-279. \nChiodo I, Somigliana E, Dousset B, Chapron C (2008 ). \nUrohemoperitoneum during pregnancy with consequent fetal death \nin a patient with deep endometriosis. J. Minim. Invasive Gynecol. \n15:202-204. \nCho HK, Lee GW, Kim JM, Kim YH, Kim ME (2007). Ureteral \nendometriosis. Korean J. Urol. 48:1179-1181. \nDimoulios P, Koutroubakis IE, Tzardi M, Antoniou P, Matalliotakis IM,  \n\n \n \n \n \nKouroumalis EA (2003). A case of sigmoid endometriosis difficult to \ndifferentiate from colon cancer. BMC Gastroenterol . 3:18. \nEskenazi B, Warner M, Bonsignore L, Olive D, Samuels S, Vercellini  P \n(2001). Validation study of nonsurgical diagnosis of endometriosis. \nFertil. Steril. 76:929-935. \nGarg NK, Bagul NB, Doughan S, Rowe PH (2009). Intestinal \nendometriosis--a rare cause of colonic perforation. World J . \nGastroenterol. 15:612-614. \nJanicki TI, David LJ, Skaf R (2002). Massive and acute \nhemoperitoneum due to rupture of the uterine artery by erosion from \nan endometriotic lesion. Fertil. Steril. 78:879 -881. \nPrystowsky JB, Stryker SJ, Ujiki GT, Poticha SM (1988). \nGastrointestinal endometriosis. Inci dence and indications for \nresection. Arch. Surg. 123:855-858. \n \n \n \nKim et al.       29 \n \n \n \nStephansson O, Kieler H, Granath F, Falconer H (2009). Endometriosis, \nassisted reproduction technology, and risk of adverse pregnancy \noutcome. Hum. Reprod. 24:2341-2347. \nTrabert B, Peters  U, De Roos AJ, Scholes D, Holt VL (2011). Diet and \nrisk of endometriosis in a population -based case-control study. Br. J. \nNutr. 105:459-467. \nWoodward PJ, Sohaey R, Mezzetti TP, Jr. (2001). Endometriosis: \nradiologic-pathologic correlation. Radiographics  21:193-216.","source_license":"CC0","license_restricted":false}