{"paper_id":"5d20f06d-09e2-420f-8a20-c17f6231b1ab","body_text":"CASE REPORT\nRecurrent haemorrhagic ascites secondary to endometriosis:\ncase report\nChristian Alabi & Isaac Evbuomwan &\nStephen Attwood & Jonathan Brady\nReceived: 28 January 2007 / Accepted: 15 March 2007 / Published online: 17 April 2007\n# Springer-V erlag 2007\nAbstract We present a case of a young black African\nwoman who presented with recurrent haemorrhagic ascites\nsecondary to endometriosis. This is a rare entity which can\nbe easily confused with bowel or ovarian malignancy and\nthe few reported cases have been managed by laparotomy\nunlike our case which was managed purely with laparo-\nscopic surgery.\nKeywords Massive haemorrhagic ascites . Endometriosis .\nAscites and endometriosis . Massive ascites\nIntroduction\nHaemorrhagic ascites assoc iated with endometriosis is\nuncommon, and reported cases in the European literature\nare scant. It is a diagnosis usually made after exhaustive\nexclusion and often after a surgical exploration of the\nabdomen has been undertaken. Most of the reported cases\nhave involved nulliparou s black women. This entity\nsimulates gynaecological malignancy and often involves\nmultiple disciplines. We describe such a case of a black\nwoman who presented with recurrent haemorrhagic ascites\nand who had just commenced a cycle of in vitro fertilisation\n(IVF) treatment. Consistent with other reported cases in the\nliterature, this proved to be a diagnostic dilemma to us and\ncolleagues in other disciplines. The case also highlights the\nusefulness of advanced laparoscopic surgery in obviating\nthe need for exploratory laparotomy as used in other cases.\nCase report\nMrs B.O., a 30-year-old married woman of black African\norigin, was diagnosed as having vaginal endometriosis\nfollowing biopsy of a vaginal nodule 4 years prior to\npresentation.\nDiagnostic laparoscopy later performed in view of a\nhistory of subfertility, deep dyspareunia, cyclical rectal pain\nand severe backache demonstrated endometriotic deposits\nin the pouch of Douglas and right ovary, the left tube and\novary were fixed and densely adherent to the pelvic side\nwall and the left adnexum obscured by omental adhesions.\nSuperficial laser vaporisation of posterior vaginal wall\nendometriosis was performed and she was commenced on a\n6-month course of treatment with a gonadotrophin-releas-\ning hormone analogue (GnRHa), goserelin (Zoladex,\nAstraZeneca). Her symptoms improved on Zoladex but\nreturned following cessation of treatment. She was subse-\nquently referred for IVF treatment (3-year history of\nsecondary subfertility and severe endometriosis).\nWithin 3 days of commencing pituitary down-regulation\ntreatment for IVF using GnRH agonist, she was admitted\ninto hospital. She presented with abdominal distension and\npain. Investigations undertaken included ultrasound (USS)\nof the pelvis and abdomen and a computed tomographic\nGynecol Surg (2007) 4:285 –287\nDOI 10.1007/s10397-007-0282-9\nC. Alabi\nHope Hospital,\nSalford, UK\nI. Evbuomwan\nQueen Elizabeth Hospital,\nGateshead, UK\nS. Attwood : J. Brady\nNorth Tyneside General Hospital,\nNorth Tyneside, UK\nC. Alabi ( *)\nStott Lane,\nSalford Manchester, Lancashire M6 8HD, UK\ne-mail: christianalabi@aol.com\n\n(CT) scan which demonstrated gross ascites, some bilateral\nbasal pleural thickening, no intra-peritoneal or pelvic\nlymphadenopathy, minimally enlarged ovaries, normal\nliver, spleen, pancreas, gall bladder and kidneys. There\nwere no peritoneal plaques. Other investigations included\nCa 125 [56 (normal: <35)], C-reactive protein [388\n(normal: <5)] and haemoglobin 8.5 g/dl. Haemorrhagic\nfluid from a diagnostic paracentesis proved negative for\nmalignant cells, but contained numerous haemosiderin-\nladen cells.\nHer IVF treatment was abandoned at this stage. She\nreturned home after a week, but was readmitted into\nhospital because of persistent abdominal distension and\npain. Her subsequent management was multi-disciplinary\nand included a gynaecologist, general surgeon and a\nphysician. Emergency diagnostic laparoscopy was per-\nformed and 5 l of haemorrhagic fluid were drained. There\nwere also endometriotic lesions on the right ovary, with the\nleft adnexum buried in a mass of small and large bowel. As\nshe was not bowel prepared, exploratory surgery was not\ncarried out.\nAt exploratory laparoscopy (Fig. 1) undertaken 1 week\nlater, the sigmoid colon, left ovary and fallopian tube were\nsuccessfully mobilised using Harmonic Scalpel. She made a\ngood recovery and was discharged home 2 days later.\nCulture of ascitic fluid drained grew Mycoplasma hominis\nand she was treated with doxycycline for 2 weeks. There\nwas no evidence of tuberculosis (TB).\nShe was re-admitted 2 months later with a recurrence of\nascites, confirmed on USS. She had paracentesis and 2,500 ml\nof haemorrhagic fluid were drained. She represented a month\nlater with the same symptom and a more extensive explor-\natory laparoscopy was therefore arranged in order to confirm\nno pathology was missed the last time as she was still not\nbetter clinically.\nThen 1,500 ml of haemorrhagic fluid were drained and\nthere were endometriotic deposits throughout the pelvis,\nwith the sigmoid colon being adherent to the left fallopian\ntube and left ovary. The right ovary was adherent to the\npelvic side wall. Separate endometriotic implants were\nfound on the caecum, anterior peritoneal wall and a nodule\nin the lesser sac. There were extensive adhesions between\nthe liver and the diaphragm. The lesser sac, pancreas and\nthe small bowel in its entire length otherwise appeared\nnormal.\nMultiple biopsies obtained from the pelvis, liver capsule,\nand peritoneum confirmed endometriosis, while the lesser\nsac nodule was reported as containing lots of haemosiderin-\nladen lymphocytes as did cytology of the ascitic fluid with\nno neoplastic cells.\nThe sigmoid colon was successfully mobilised along\nwith the left fallopian tube and left and right ovary which\nwere only partially mobilised. She made a good recovery\nand was discharged home 2 days later. She later conceived\nspontaneously whilst contemplating another attempt at\nhaving IVF treatment and she has since had a live term\nbaby.\nDiscussion\nHaemorrhagic ascites complicating endometriosis was first\ndescribed by Brews in 1954 [ 1]. It remains an uncommon\nphenomenon, with about 41 cases having been reported\nsince its first description [ 2]. Most of the reported cases are\nfrom the American literature, with a few in the Asian\nFig. 1 Extensive exploratory\nlaparoscopy. a Pool of haemor-\nrhagic ascitic fluid partially\ncovering loops of bowel. b\nEndometriotic implant on large\nbowel surface. c Dense adhe-\nsions between liver and dia-\nphragm. d Liver with\nendometriotic implants and pool\nof ascitic fluid in background\n286 Gynecol Surg (2007) 4:285 –287\n\nliterature. To our knowledge, there has been no reported\ncase in the UK.\nThis entity seems to have a predilection for black,\nnulliparous women, with most of the women being in their\nreproductive age [ 3, 4]. It often poses a diagnostic dilemma\nwhen it presents, the diagnosis only being established after\nexhaustive exclusion of other important conditions such as\nmalignancy (especially bowel and ovarian neoplasia). The\naetiology of the haemorrhagic ascites in endometriosis is\nstill unknown. There has been one report in the literature\nwhich has attempted to link this aetiology to ovulation\ninduction [ 5].\nIndeed, one is tempted to also suggest such a link in our\nown case, since she had only just commenced treatment for\nIVF. However, such a link would be very unlikely, given\nthat she only had 3 days of GnRHa, and the onset of her\nsymptoms did pre-date her commencement of IVF treat-\nment by about 2 months. A high index of suspicion is\nrequired for prompt diagnosis and further treatment.\nLaparoscopy is the gold standard to confirm endometriosis\nand symptomatic relief of gross abdominal distension by\ndrainage of significant ascites can be achieved (as in our\ncase) at the same time. Although ultrasound-guided para-\ncentesis can also be used for symptomatic relief of massive\nascites laparoscopy per se is not required. Once the\ndiagnosis is confirmed, the main difficulty is deciding\nwhich treatment modality is better suited. The obvious\nchoice as in this case would have been GnRHa, as in\nsimilarly young nulliparous women, and in fact a complete\nremission was described in one of the cases [ 6].\nHowever, using this treatment modality in this case\nwould have further delayed her infertility treatment and we\nspeculate our patient may have inadvertently been stimu-\nlated by the flare-up effect that initially occurs during\npituitary down-regulation with GnRHa.\nIn a woman who has completed her family, options can\ninclude laparotomy and extensive excision of endometriosis\nor in units where the expertise is available, laparoscopic\nsurgery may be more attractive or suitable.\nConclusion\nHaemorrhagic ascites complicating endometriosis remains a\nrare but very important entity because of the diagnostic\ndilemma it poses and its management implications espe-\ncially in women in the reproductive age who wish to\npreserve their fertility.\nIt is clear that this entity does exist, and although most\nclinicians may never encounter a single case, it nevertheless\nshould be borne in mind as a differential when evaluating a\nyoung patient, who presents with ascites and a history\nsuggestive of endometriosis.\nReferences\n1. Brews A (1954) Endometriosis including endometriosis of the\ndiaphragm in Meigs syndrome. Proc R Soc Med 10:309 –312\n2. Ekoukou D, Guiherne R, Desligneres S, Rotten D (2005)\nEndometriosis with massive hemorrhagic ascites: a case report\nand review of the literature (in French). J Gynecol Obstet Biol\nReprod (Paris) 34(4):351 –359\n3. Jenks JE, Artman LE, Hoskin WJ, Mireradi AK (1984) Endome-\ntriosis with ascites. Obstet Gynecol 63(3 Suppl):75S –77S\n4. Cheong ES, Lim DTH (2003) Massive ascites —an uncommon\npresentation of endometriosis. Singapore Med J 44(2):98 –100\n5. Feigin RD, Glikson M, Gur H, Galun E, Younis JF, Beyth Y (1988)\nInduction of ovulation causing recurrent bloody ascites in a woman\nwith endometriosis. Am J Obstet Gynecol 159(5):1161 –1162\n6. Dias CC, Andrade JM, Ferriani RA, Villanova MG, Meirelles RS\n(2000) Hemorrhagic ascites associated with endometriosis. A case\nreport. J Reprod Med 45(8):688 –690\nGynecol Surg (2007) 4:285 –287 287","source_license":"CC0","license_restricted":false}