{"paper_id":"2198eb13-04dd-4811-b7fd-0f19784039df","body_text":"Abdelkader et al. \nThe Egyptian Journal of Internal Medicine           (2021) 33:50  \nhttps://doi.org/10.1186/s43162-021-00077-6\nCASE REPORT\nHemorrhagic ascites endometriosis could be \na cause: a case report\nNadia Abdelaaty Abdelkader1,2, Ahmed F. Sherief1, Enass Mohamed Soliman1*, Mahmoud Elsamman3, \nSalah T. Fayed4 and Mohamed A. Sakr1 \nAbstract \nBackground: Endometriosis is a condition in which tissue similar to the lining inside the uterus (called “the endome-\ntrium”) is found outside the uterus, where it induces a chronic inflammatory reaction that may result in scar tissue.\nEndometriosis with massive ascites causing abdominal distension and other symptoms simulating malignancy has \nbeen described in the literature.\nCase presentation: A case of a 27-year-old woman who presented to the Ascites Study Group  Tropical Medicine \ndepartment Ain Shams University  in collaboration with the Egyption Club of Ascites (ECA) with increased central \nabdominal contour, shifting dullness, and hemorrhagic transudate hypocellular ascites with no malignant cells and \nbilateral ovarian cysts.\nA long stepwise approach was conducted to the patient, and after exclusion of other causes of hemorrhagic ascites, \nthe patient was prepared for laparoscopy.\nThe diagnosis of endometriosis was made.\nThe patient was discharged on goserelin acetate subcutaneous injection every 28 days with good response, and she \nregularly follows up with our study group on scheduled visits monthly according to her clinical status.\nConclusions: Endometriosis could be a possible cause of massive hemorrhagic obscured ascites.\nThe unexplained infertility should increase the probability of the endometriosis.\nKeywords: Ascites, Endometriosis, Infertility, Ovarian cyst, Case report\n© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.\nBackground\nEndometriosis is a condition in which tissue similar to \nthe lining inside the uterus (called “the endometrium”) \nis found outside the uterus, where it induces a chronic \ninflammatory reaction that may result in scar tissue [1]. \nIt is primarily found on the pelvic peritoneum, on the \novaries, in the recto-vaginal septum, on the bladder, and \nbowel [2, 3].\nIn very rare cases it has been found on the diaphragm \nand in the lungs [4].\nEndometriosis affects an estimated 1 in 10 women dur -\ning their reproductive years (i.e., usually between the ages \nof 15 and 49), which is approximately 176 million women \nin the world [5, 6].\nMoreover, the diagnosis of extra-pelvic endometrio -\nsis is even more difficult given the variety of symptoms, \nsigns, and locations [7]. Although in some instances, \nendometriosis can be diagnosed noninvasively, difficulty \nmay be encountered in patients who lack typical symp -\ntoms or radiographic signs.\nHemorrhagic ascites due to endometriosis is an exceed-\ningly uncommon diagnosis rarely reported in the medical \nliterature [8].\nOpen Access\nThe Egyptian Journal of\nInternal Medicine\n*Correspondence:  enasssoliman91@gmail.com\n1 Department of Tropical Medicine, Faculty of Medicine, Ain Shams \nUniversity, Cairo, Egypt\nFull list of author information is available at the end of the article\n\nPage 2 of 3Abdelkader et al. The Egyptian Journal of Internal Medicine           (2021) 33:50 \nEndometriosis with massive ascites causing abdominal \ndistension and other symptoms simulating malignancy \nhas been described in the literature [9–11].\nCase presentation\nWe present a case of a 27-year-old woman who pre -\nsented to the Ascites Study Group Tropical Medicine \ndepartment Ain Shams University in collaboration with \nEgyptian Club of Ascites (ECA)  for abdominal enlarge -\nment and was found with increased central abdominal \ncontour, shifting dullness, and hemorrhagic transudate \nhypocellular ascites with no malignant cells and bilat -\neral ovarian cysts. This picture was suggestive of an \novarian hyper-stimulation syndrome. There is no his -\ntory of the problematic menstrual cycle, but she was \ninfertile for 6 years of an unknown obvious cause. A \nlong stepwise approach was conducted to the patient \nand after exclusion of other causes of hemorrhagic \nascites, the patient was prepared for laparoscopy. And \nthe result showed that there is grade III to IV pelvic \nendometriosis and right ovarian endometrioma, left \novarian surface lesion that was biopsied also, perihe -\npatic adhesions and encysted peritoneal adhesions \nin Douglas pouch, and its wall was biopsied too. The \novarian biopsy didn’t show any abnormality and the \nadhesion wall biopsy revealed hyalinized fibrovascular \nconnective tissue. The patient was discharged on goser -\nelin acetate subcutaneous injection every 28 days with \ngood response and she regularly follows up with our \nstudy group on scheduled visits monthly according to \nher clinical status.\nDiscussion\nEndometriosis affects an estimated 1 in 10 women \nduring their reproductive years [5 , 6]. Concern recent \nreview and analysis of previous cases found that 63% \nof women were of African ancestry, and 82% were nul -\nliparous [12]. However, the difficulty to reach a definite \ndiagnosis is related to the other late presentable causa -\ntive diseases such as tuberculosis, pelvic malignancy, \nand peritoneal metastases. Therefore, to reach the diag -\nnosis, an invasive maneuver is mandatory especially in \nthe absence of typical presentation related to endome -\ntriosis. The Definitive management consists of surgical \nresection of endometriotic tissue alone or combined \nwith the complete surgery (hysterectomy with oopho -\nrectomy) or long-term hormonal suppression therapy \n[13]. In young multi-parous patients, it is preferred to \nuse long-term hormonal suppressive therapy to pre -\nserve fertility in some cases.\nConclusions\nEndometriosis could be a possible cause of massive \nhemorrhagic obscured ascites. Hemorrhagic ascites \nshould be considered a complication of endometrio -\nsis, especially in nulliparous women of the childbearing \nage group with an abdominal distension, a pelvic mass, \ndysmenorrhea, and abdominal pain, even if there is \nno typical presentation of the endometriosis along the \nmenstrual history of the case.\nAcknowledgements\nNot applicable\nAuthors’ contributions\nNA analyzed and interpreted the patient data regarding the hepatological and \nradiological findings and read and approved the final manuscript. AF collected \nthe data and followed up with the patients clinically. ES was a major contribu-\ntor in writing the manuscript. MS read and approved the final manuscript. \nST analyzed and interpreted the patient data regarding the gynecological \ndisease. MAS analyzed and interpreted the patient data regarding the hepa-\ntological and radiological findings. The author(s) read and approved the final \nmanuscript.\nFunding\nNo funding was received.\nAvailability of data and materials\nNot applicable\nDeclarations\nEthics approval and consent to participate\nNot applicable\nConsent for publication\nWritten consent to publish this information was obtained from study \nparticipants.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1 Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, \nCairo, Egypt. 2 Founder of the Egyptian Club of Ascites (ECA), Cairo, Egypt. \n3 Department of Internal medicine, Faculty of Medicine, Sohag University, \nSohag, Egypt. 4 Obstetrics and Gynecology Department, Faculty of Medicine, \nAin Shams University, Cairo, Egypt. \nReceived: 28 May 2021   Accepted: 25 June 2021\nReferences\n 1. Bulletti C, Coccia ME, Battistoni S, Borini (2010) Endometriosis and \ninfertility. 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