{"paper_id":"5cb368c1-0102-4fde-83ab-a711ef0285a1","body_text":"iMedPub Journals\nwww.imedpub.com\n2021\nVol.7 No.5:135\nCase Report\n1© Under License of Creative Commons Attribution 3.0 License | This article is available in: http://gynecology-obstetrics.imedpub.com/\nGynaecology & Obstetrics Case report  \nISSN  2471-8165\nHerrera-Núñez M1,  \nNegreros-Osuna AA1 and \nSuárez-Alfaro O2\n1 Universidad Autónoma de Nuevo León, \nUniversity Hospital “Dr. José E. González” \nImage and Radiology Department, \nMonterrey, Nuevo León, México\n2 Universidad Autónoma de Nuevo León, \nUniversity Hospital “Dr. José E. González” \nPathology Department, Monterrey, \nNuevo León, México\n*Corresponding author:  \nMario Herrera-Núñez\n mariorra88@gmail.com\nUniversidad Autónoma de Nuevo León, \nUniversity Hospital “Dr. José E. González” \nImage and Radiology Department, \nMonterrey, Nuevo León, México.\nTel: +52-8120745413\nCitation: Herrera-Núñez M, Negreros-\nOsuna AA, Suárez-Alfaro O (2021) Ascitic \nEndometrioma Associated with CA125 and \nCA19-9 Elevation: A Case Report. Gynecol \nObstet Case Rep Vol.4 No.5:135\nIntroduction \nEndometriosis is the abnormal location of the endometrial and \nstromal glands. It occurs in 6-10% of women of reproductive \nage [1,2]. This number increases to approximately 40% in \ninfertile women and near 75% with chronic pelvic pain [3]. The \npathophysiology of endometriosis is controversial. One theory \npostulates that it can be caused by retrograde menstruation of \nhormonal sensitive endometrial cells and tissues, implanting in \nthe peritoneum, and causing inflammatory responses [4]. Classic \nsymptoms associated with endometriosis are dysmenorrhea and \npelvic pain, nonetheless, the painless presentation with infertility \nproblems or an incidental ovarian mass in image studies is not \ninfrequent [5]. Seldom endometriosis presents with hemorrhagic \nascites, and since it was first described in 1954 by Dr. Brews, less \nthan 100 cases have been described [6]. We present a case of \na 39-year-old woman with an endometrioma associated with \nhemorrhagic ascites. \nCase Report\nA 39-year-old woman with a history of type II diabetes mellitus and \nsystemic arterial hypertension presented hypogastric pain, early \nsatiety, and increased abdominal circumference in the prior nine \nmonths. The patient reported a regular menstrual cycle coursing \nher fourth day of menstruation. On physical examination, the \npatient presented decreased bowel sounds and a palpable mass \nin the hypogastrium.\nThe laboratory showed normal kidney, liver, and urine tests. \nElevated white blood cells count up to 19,510/mm 3 with 64.6% \npolymorphonuclear neutrophils. The CA125 and CA19-9 serum \nconcentrations were 473.6 U/ml (normal, <35 U/ml) and 172.2 U/\nml (normal, 34 U/ml), respectively. \nPelvic ultrasound showed plenty of peritoneal fluid (Figure 1). The \nuterus was normal in shape. We observed a right heterogeneous \novarian mass predominantly hypoechoic, without flow on color \nand power Doppler interrogation, measuring 10 x 9.7 x 8.5 cm \nand 428 cm 3 of volume (Figures 2 and 3) . We performed a CT \nabdomen with contrast showing hyperattenuating peritoneal \nfluid that suggested hemorrhagic ascites (Figure 4).\nThe patient underwent exploratory laparotomy finding 800 mL of \nchocolate-like liquid material in the peritoneal cavity. In the right \novary, they resected an encapsulated mass measuring 15 x 10 cm.  \nPathology confirmed the diagnosis of endometrioma (Figure 5). \nReceived: April 26, 2021; Accepted: May 17, 2021; Published: May 24, 2021\nAscitic Endometrioma Associated with CA125 \nand CA19-9 Elevation: A Case Report\nAbstract\nEndometriosis with ascites is a rare clinical presentation. We describe a case of a \n39-year-old nulliparous woman who presented with hypogastric pain. Laboratory \nanalysis showed an elevation of CA-125 and CA19-9 serum concentrations. Pelvic \nultrasound revealed an ovarian mass and free peritoneal fluid confirmed by \ncomputed tomography. The patient underwent exploratory laparotomy which \nrevealed a large amount of chocolate-like liquid material in the peritoneal cavity. In \nthe right ovary resected an encapsulated mass. Histologic examination confirmed \nendometrioma diagnosis. Endometriosis should be considered in the differential \ndiagnosis in women of childbearing age presenting with ascites.\nKeywords: Endometrioma; Ascites; CA125; CA19-9\n\n2021\nVol.7 No.5:135\n2  This article is available in: http://gynecology-obstetrics.imedpub.com/\nGynaecology & Obstetrics Case report  \nISSN  2471-8165\npresentation frequently results in an approach to malignancy due \nto ovarian cancer as the first suspicion diagnosis in more than half \nof patients presenting with hemorrhagic ascites [9].\nThe reason massive ascites can occur in association with \nendometriosis is unknown. Bernstein suggested that blood and \nendometrial cells are spread to the peritoneal cavity, irritating \nand stimulating the peritoneum, therefore, resulting in ascites \n[10]. Other authors have reported that endometrial cysts rupture \nwith subsequent peritoneal irritation and reactive exudated \nproduction can explain [11].\nEndometriosis associated with peritoneal fluid is commonly \nconfused with ascites due to pelvic neoplasm. Weight loss, \nDiscussion\nSimultaneous occurrence of ascites and endometriosis is rare, with \nless than 100 cases reported in the literature. Endometriosis is a \nchallenging condition in a reproductive age woman. The disease \nspectrum varies from asymptomatic to complete weakness, \nrequiring aggressive medical and surgical intervention. As \nmentioned above, the most common presentation of symptoms \nis dysmenorrhea and pelvic pain. Our endometriosis associated \nwith hemorrhagic ascites case represents a seldom complication \nof endometriosis. The patients with hemorrhagic ascites typically \ndebut with abdominal circumference increment pain in weeks \nto months, anorexia/weight loss, and dysmenorrhea [7,8]. This \nB-mode abdominal ultrasound. View of paracolic gutters \n(A) and iliac fossas (B) demonstrating free peritoneal \nfluid (L).\nFigure 1\nB-mode pelvic ultrasound. Shows a heterogeneous, \npredominant echogenic, well-defined mass in the \nhypogastrium.\nFigure 2\nColor Doppler pelvic ultrasound: Shows no internal flow \nwithin the mass.\nFigure 3\n \nContrasted abdominal computed tomography scan. \nAxial (A) and sagittal (B) venous phase CT-scan at \npelvic level showing an ovoid, partially-defined margin, \nheterogeneous mass associated with ascites.\nFigure 4\n\n2021\nVol.7 No.5:135\n3© Under License of Creative Commons Attribution 3.0 License\nGynaecology & Obstetrics Case report  \nISSN  2471-8165\npoor appetite, and a pelvic mass contribute to this dilemma. \nMoreover, the elevation of serum CA125 can be a confounding \nfinding compatible with malignancy [12-15].\nConclusion\nThe mechanisms related to the elevation of serum CA125 and \nCA19-9 are not well established. Kurata suggested that the \nspread of the molecules from a ruptured endometrioma to the \nperitoneal cavity and then into the circulation may explain the \nrapid increment of CA125 and CA19-9 concentrations. Another \nhypothesis by Takemori suggests that chronic inflammation in \nthe peritoneum causes damage in the cyst epithelium resulting \nin CA19-9 leakage to circulation resulting in the abnormal serum \nlevels of tumoral markers.\nMacroscopic photograph of endometriosis cyst. Macroscopic specimen of endometriosis cyst (A) with \nlight brown-pink capsule and congestive vessels. At the section (B) chocolate-brown and a soft internal \nsurface.\nFigure 5\nReferences\n1 Eskenazi B, Warner ML (1997) Epidemiology of endometriosis. \nObstet Gynecol Clin North Am 24: 235-258.\n2 Falcone T, Flyckt R (2018) Clinical management of endometriosis. \nObstet Gynecol 131: 557-571.\n3 Tanbo T, Fedorcsak P (2017) Endometriosis-associated infertility: \nAspects of pathophysiological mechanisms and treatment options. \nActa Obstet Gynecol Scand 96: 659-667.\n4 Giudice LC (2010) Clinical practice: Endometriosis. N Engl J Med 362: \n2389-2398.\n5 Sinaii N, Plumb K, Cotton L, Lambert A, Kennedy S, et al. \n(2008) Differences in characteristics among 1,000 women with \nendometriosis based on extent of disease. Fertil Steril 89: 538-545.\n6 Brews A (1954) Endometriosis including endometriosis of the \ndiaphragm and Meigs’ syndrome. Proc R Soc Med 47: 461-465.\n7 Magalhães TF, Augusto K, Mota L, Costa A, Puster R, et al. (2018) \nAscites and encapsulating peritonitis in endometriosis: a systematic \nreview with a case report. Bras de Ginecol e Obstet 40: 147-155.\n8 Sait KH (2008) Massive ascites as a presentation in a young woman \nwith endometriosis: A case report. Fertil Steril 90: 17-19.\n9 Gungor T, Kanat-Pektas M, Ozat M, Zayifoglu-Karaca M (2011) A \nsystematic review: Endometriosis presenting with ascites. Arch \nGynecol Obstet 283: 513-518. \n10 Bernstein JS, Perlow V, Brenner JJ (1961) Massive ascites due to \nendometriosis. Am J Dig Dis 6: 1-7.\n11 El-Newihi HM, Antaki JP , Rajan S, Reynolds TB (1995) Large bloody \nascites in association with pelvic endometriosis: Case report and \nliterature review. Am J Gastroenterol 90: 632-634.\n12 Goumenou A, Matalliotakis I, Mahutte N, Koumantakis E (2006) \nEndometriosis mimicking advanced ovarian cancer. Fertil Steril 86: \n23-25.\n\n2021\nVol.7 No.5:135\n4  This article is available in: http://gynecology-obstetrics.imedpub.com/\nGynaecology & Obstetrics Case report  \nISSN  2471-8165\n13 Park BJ, Kim TE, Kim YW (2009) Massive peritoneal fluid and markedly \nelevated serum CA125 and CA19-9 levels associated with an ovarian \nendometrioma. J Obstet Gynaecol Res 35: 935-939.\n14 Kurata H, Sasaki M, Kase H, Yamamoto Y , Aoki Y , et al. (2002) Elevated \nserum CA125 and CA19-9 due to the spontaneous rupture of ovarian \nendometrioma. Eur J Obstet Gynecol Reprod Biol 105: 75-76.\n15 Takemori M, Sugimura K (1991) Ovarian chocolate cyst with markedly \nelevated serum CA19-9 level: A case report. Eur J Obstet Gynecol \nReprod Biol 42: 241-244.","source_license":"CC0","license_restricted":false}