{"paper_id":"5f42abe3-16eb-4a44-ba75-6bcb75bdf21b","body_text":"CASE REPORTS\nUmbilical endometriosis-A simple but challenging diagnosis for surgeons \n1 1 1 2 1\nK.G.H. Jayathilake , S. Withana , R. Siriwardane , G. Mahendra , C. Liyanage\n1 Department of Surgery, Faculty of Medicine, University of Kelaniya, Sri Lanka.\n2 Department of Pathology, Faculty of Medicine, University of Kelaniya, Sri Lanka. \nKeywords: Umbilical; endometriosis; umbilical lump; \nextrapelvic endometriosis\nIntroduction\nEndometriosis is a challenging but common \ngynaecological condition which is characterized by the \npresence of endometrial glands and stroma outside the \nuterus [ ]. It presents mainly with involvement of the 1\npelvic organs. Extrapelvic presentations in almost all \nparts of the body have been reported and account for \nabout one percent of the total cases [1]. However, \nspontaneous umbilical endometriosis nodules or \nendometriosis secondary to surgery accounts for only \n0.5% to 1% of all endometriosis cases [2].\nCase presentation\nA 49 year-old parous woman who presented with an \numbilical lump for two years complained of cyclical \nmonthly pain and bluish discolouration. There was no \nhistory of bleeding or discharge from the site. She had \nundergone laparoscopic hysterectomy and left sided \nsalpingo-oophorectomy four years back due to \nendometriosis causing severe dysmenorrhea.\nAt the time of presentation she had a 1 × 1.5 cm purplish \nnodule at the umbilicus (Figure 1). It was not tender and \nthere were no signs of infection. There was a 1cm well \nhealed surgical scar  below the umbilicus. \nFine needle aspiration cytology of the umbilical nodule \nconfirmed the diagnosis as endometriosis at the \numbilicus.  Following a discussion with the patient and \nclear explanation about the possibility of recurrence and \nthe need to remove the umbilicus, the nodule was \ncompletely excised with the umbilicus and the defect \nwas repaired. As the patient was not concerned about the \ncosmetic outcome, umbilical reconstruction was not \nThe Sri Lanka Journal of Surgery 2014; 32(3): 49-50\n49\ncarried out.  The histology confirmed the diagnosis of \nendometriosis (Figure 2). \nDiscussion \nUmbilical endometriosis can be primary or secondary to \na surgical scar. Villar, in 1886, reported the first case of \numbilical endometriosis. Hence, this condition is also \ncalled Villar's nodule [ ]. Similar to our own case 1\numbilical endometriosis at the site of the laparoscopic \nentry is one of the commonest. The primary umbilical \nendometriosis is known to be associated with severe \npelvic endometriosis compared to those with scar \nendometriosis [3].\n In this patient, cyclical pain with a classical purplish \nnodule clinched the diagnosis; but clinical diagnosis of \numbilical endometriosis is, at times, difficult with \nvarying presentations in colour, character of pain and \nsize. Hence, malignant melanoma, paraumbilical \nhernia, granuloma, primary or metastatic \nadenocarcinoma (Sister Joseph nodule), nodular \nmelanoma, and cutaneous endosalpingosis should be \nconsidered.Correspondence: K.G.H. Jayathilake\nE-mail: g.hiroshi@yahoo.com\nFigure 1. Umbilical lump with bluish discolouration.                                                                                           \n\nSurgical excision is the treatment of choice for this \ncondition. If a wide excision and complete removal of \nthe umbilicus is anticipated, it should be discussed with \nthe patient, and reconstruction of the umbilicus can be \noffered [4].\nThe Sri Lanka Journal of Surgery 2014; 32(3): 49-50\n50\nIn our patient, endometriosis was previously diagnosed \nand treated by hysterectomy and left sided salpingo-\noophorectomy. However, in a newly diagnosed similar \ncase the chances of coexisting pelvic endometriosis \nshould be sought and treated with special concern for \nfertility. Pelvic endometriosis is a common condition, \nbut the diagnosis of primary umbilical endometriosis \nrequires a high degree of suspicion. \nReferences\n1. Sreelakshmi K, Muralidhar V P, Mary M; Umbilical \nlaparoscopic scar endometriosis. J Hum Reprod Sci. 2011 \nSep-Dec; 4(3): 150–152. \n2. Latcher JW; Endometriosis of the umbilicus. Am J Obstet \nGynecol. 1953;66:161–8. \n3. Agarwal A, Fong Y F; Cutaneous endometriosis, Singapore \nMed J 2008; 49(9): 704-709\n4. Bagade P, Guirgus MM;  Menstruating from the umbilicus \nas a rare case of primary umbilical endometriosis: A case \nreport. J Med Case Reports. 2009;3:9326\n \nFigure 2. Haematoxylin and eosin section (20x10) showing \ntortuous glands surrounded by dense cellular stroma lying in a \ncollagenous background. The glands are lined by tall \ncolumnar epithelium that resembles the endometrial \nglandular epithelium. The sub-epithelium is composed of \nsmall round cells that resemble the endometrial stroma.                                                                                     \nKey points:\n Umbilical endometriosis can be primary or secondary to a surgical scar.\n malignant melanoma, paraumbilical hernia, granuloma, primary or metastatic adenocarcinoma (Sister \nJoseph nodule), nodular melanoma and cutaneous endosalpingosis should be considered in the differential \ndiagnosis.\n Surgical excision and reconstruction of the umbilicus is the treatment of choice.","source_license":"CC0","license_restricted":false}