{"paper_id":"71d62b2a-496b-479b-b18e-1d93480f3a03","body_text":"~ 97 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(4): 97-99 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(4): 97-99 \nReceived: 19-05-2021 \nAccepted: 21-06-2021 \n \nDr. Jeevan Asha Chandra \nProfessor and Head, Department \nof Obstetrics & Gynaecology, Ras \nBihari Bose, Subharti University, \nDehradoon, Uttarakhand, India \n \nDr. Karishma Chaudhary \nJunior resident 3, Department of \nObstetrics & Gynaecology, \nSubharti Medical College, Meerut, \nUttar Pradesh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Karishma Chaudhary \nJunior resident 3, Department of \nObstetrics & Gynaecology, \nSubharti Medical College, Meerut, \nUttar Pradesh, India \n \nEndometrioma: Chocolate cyst case report \n \nDr. Jeevan Asha Chandra and Dr. Karishma Chaudhary \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i4b.970 \n \nAbstract \nBackground: Abdominal wall endometriomas are quite uncommon. Awareness of the details of this rare \ncondition is therefore essential for prompt diagnosis and adequate treatment. \nIntroduction: Endometriosis though a condition commonly seen in the pelvic region can also occur at \nextra-pelvic sites giving rise to a diagnostic dilemma.  \nCase Report: A case of abdominal wall  endometrioma diagnosed clinically and treated by wide surgical \nresection is presented to highlight the importance of clinical evaluation in the diagnosis of this condition. \nDiscussion: The presentation, investigations, and management are discussed briefly. \nConclusion: Clinical evaluation confirmed by supportive imaging is diagnostic. \n \nKeywords: endometrioma, chocolate cyst, abdominal wall \n \nIntroduction  \nEndometriosis, first described by German pathologist Carl von Rokitansky as cystosarcoma \nadenoids uterin um, defined as an estrogen -dependent condition in which ectopic endometrial \nglands and stroma are found outside the uterus. Most endometrial deposits are found in the \npelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal se ptum) \n[1]. The incidence of endometriosis is reported as 4%– 17% of all women during their \nreproductive age. The ovary is variously reported to be involved in 17% to 44% of \nendometriosis patients \n[2]. Classical studies suggested that 30% to 50% of women wit h \nendometriosis are infertile [3]. The endometrial implants may be categorized as cyst comtic, \nmixed or solid, with the cystic implants being most common. Although, in some cases \nendometrial implants may occur spontaneously. Endometriosis can be intra or e xtra pelvic in \nlocation. Most cases are intra pelvic, usually involving ovary, pouch of Douglas, pelvic \nperitoneum, uterosacral ligament, urinary bladder, rectum, broad and round ligament. \nThe presence of endometrium outside the uterine cavity can be expla ined by many theories; the \nmechanism most widely accepted is that of retrograde menstruation \n[4]. Other authors believe \nthat it is a result of celomic metaplasia  [5]. The structure most frequently affected by \nendometriosis is the ovary, but involvement of the fallopian tubes, pelvic serosa, rectum, \nretroperitoneal structures, and lungs has also been described. Endometriotic cysts typically \ncontain old blood and are also referred to as chocolate cysts or endometriomas  [6]. Generally, \nendometriomas are diagno sed by ultrasonograpic examination, but sometimes it is difficult to \nmake a differential diagnosis preoperatively. \n \nCase report  \nA 30 -year-old, 105 kg in weight, 1.75 cm in height, para 0 woman had been referred to our \nhospital with a pelvic mass. Married life of 13 yrs with the history of 1st baby 7 yrs back/missed \nabortion / 3 months of pregnancy and 2 nd baby 5 yrs back/ 3 months pregnancy /missed \nabortion / followed by suction and evacuation). She was suffering from secondary infertility \nsince 4 yrs and  complain of hypomenorrhoea associated with severe pain before and after \nmenses. On day of admission a lump of 7*8 cm in right iliac fossa, tender+ +, restricted mobility \nfrom side to side. In Per speculum examination no abnormality detected and Per -vaginal pap \nsmear taken. Uterus anteverted,  bulky, firm, mobile, non-tender, In right fornix a mass of 7*8 \ncm felt, tender, lower limit reachable and Left fornix free, non-tender. In pelvis ultrasonographic \nexamination a large cystic lesion of size 5.3*8.6*10 cm w ith internal echoes on right sided \nadnexa, a cystic lesion with internal reticular pattern of size 2*3*2 cm in left adnexa and \nBicornuate / septate uterus large ovarian chocolate cyst. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 98 ~ \nIn transvaginal ultrasonographic  examination, there was a \nbilaterally cystic mass that is 10 × 8 cm in right adnexa and 2× 3 \ncm i n left adnexa. Hysterosalpingogram (HSG) test were as \nfollows Left sided hydrosalpinx with no free spillage suggestive \nof left fallopian tube blockage and right sided fallopian tube \npatent. Acid F ast Bacilli were not seen in the histologic \nexamination of endometrial biopsy by zn stain and Bact. \nDecision for excision of endometriomas was taken, Abdominal \ncystectomy was performed under general anesthesia, and was \nsuccessfully performed (fig.1) Cut se ction of the cysts revealed \nchocolate coloured fluid (fig 2), and histopathological \nexamination confirmed the diagnosis of ovarian endometriosis. \nPostoperative recovery was unremarkable. \n \n \n \nFig 1: cystic mass removal \n \n \n \nFig 2: cysts revealed chocolate coloured fluid \n \nDiscussion \nThe presence of endometrial glandular and stromal tissue \noutside the uterus is called endometriosis. It is seen in women of \nactive reproductive age. The common sites for endometriosis are \nthe ovaries, pelvis, lower intestinal tract  which includes the \nsigmoid colon, and urinary system especially the bladder. \nEndometriosis is classified into 4 stages based on the severity, \namount, location, depth, and size of growths: stage I (minimal), \nstage II (mild), stage III (moderate), and stage IV (severe) [7]. \nEndometriosis is a relatively common gynaecological condition \naffecting 6-10% of women in the reproductive age group. It is \nthe presence of functional endometrial glands and stroma \noutside the uterine cavity and is usually characterized by chronic \npelvic pain and infertility. Risk factors for endometriosis include \nnulliparity, previous pelvic surgeries, imperforate hymen, \ncervical stenosis and gynaetresia. Several theories have been \nproposed to explain the pathogenesis of the condition wit h the \nmost popular theory being the retrograde menstruation. Others \nare the theory of coelomic metaplasia, immunologic theory, \nmullerianosis and transplantation theory. Another presentation \nof endometriosis is as a pelvic mass with the formation of an \nendometrioma. \nEndometriomas, commonly referred to as “chocolate cysts” are a \ncommon presentation of endometriosis seen in about 17 –44% of \nendometriosis and refers to cysts on the ovaries associated with \nectopic endometrial tissue and containing degraded hemorr hagic \ncontent hence the appearance of a chocolate -coloured effluent \nwhen ruptured. It is thought that endometriomas form from \ndeposition of endometriotic deposits with subsequent \ninvagination of the underlying ovarian cortex. Although \nmajority of chocolate  cysts arise from the ovaries, a significant \nproportion have been found in other sites including the \nperitoneum overlying the anterior and posterior cul de sac, \nwithin the broad ligament and inguinal canal as well as uterine \nserosa. In addition, these cyst s could be bilateral and are usually \nsmall to medium in size. However, a few have been reported to \ngrow to very large sizes  8. As in our case report presents an \natypical presentation of chocolate cyst be bil ateral small to \nmedium in size. \nInterestingly, al though the abdomino- pelvic ultrasound scan \nreported that the mass was extra-ovarian which was confirmed at \nsurgery, the abdominal CT scan erroneously reported the organ \nof origin as the ovary. Radiological features noted in this patient \nwhich were in keepi ng with those found in endometriosis \ninclude the fact that it was bilaterally unilocular containing \ninternal echoes though not the classical “ground -glass” \nappearance seen in endometrioma. \n  The differential diagnosis may include a variety of conditions \nsuch as hernia, lipoma, desmoid tumour, or primary or \nmetastatic malignancy. Therefore a careful history with proper \ninterpretation of radiological findings can help in making a \ncorrect preoperative diagnosis. \n \nConclusion \nExtra- ovarian chocolate cysts can grow to huge sizes presenting \ndiagnostic dilemma. Transvaginal ultrasound scan is still a very \nviable means of evaluating gynaecological patients and should \nnot be totally replaced by more advanced radiological \ntechniques such as CT scan and MRI. The pres ence of \nendometriomas or chocolate cysts does not always indicate \nsevere pelvic disease. Hence, extra ovarian endometrioma \nshould be entertained as a possible differential diagnosis in the \nevaluation of abdominopelvic masses. \n \nConflict of Interests \nThe author hereby declare that they do not have any conflict of \ninterests. \n \nReferences \n1. Ganesh AL , Chakravarty B . Spontaneous viable \npregnancies in cervical and rectal endometriosis: a report of \ntwo cases, Fertility and Sterility 2007;87(3):697.e1-697.e4. \n2. Ueda Y, Enomoto T, Miyatake T et al . A retrospective \nanalysis of ovarian endometriosis during pregnancy,  \nFertility and Sterility 2010;94(1):78-84. \n3. Endometriosis and Infertility: a Committee Opinion, t he \npractice committee of the American Society for \nReproductive Medicine Birmingham, Alabama, Fertil Steril  \n2010;98(3):591-598. \n4. Halme J, Hammond MG, Hulka JF et al . Retrograde \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 99 ~ \nmenstruation in healthy women and in patients with \nendometriosis. Obstet Gynecol 1984;64:151-4. \n5.  Bulun SE. Endometriosis. N Engl J Med 2009;360:268-79. \n6.  Gelbaya TA, Nardo LG. Evidence -based management of \nendometrioma. Reprod Biomed Online 2011;23:15-24. \n7. Olive DL. Endometriosis in Clinical Practice. London a nd \nNew York: Taylor and Francis 2005. \n8. Keyhan S, Hughes C, Price T, Muasher S. An Update on \nSurgical versus Expectant Management of Ovarian \nEndometriomas in Infertile Women. Biomed Res Int \n2015;2015:204792.","source_license":"CC0","license_restricted":false}