{"paper_id":"b992d953-57b3-4b15-9397-88ddd3bf8f80","body_text":"Scar Endometriosis Presenting as Chronic Lower Abdominal Pain:  \nA   Surgeon's Perspective\n1\nBhaskaran A, Ambikavathy M, Kalyani R\n1\nDepartment of General Surgery, Pathology\nSri DevarajUrs Medical College, Kolar\nABSTRACT\nEndometriosis  is defined as the abnormal presence of endometrial tissue outside the uterus. Scar \nendometriosis could go unnoticed  or can present with symptoms such as pain in the lower abdomen or \nas tender nodular lesions over the surgical scar which are usually misdiagnosed as keloid, haematoma, \nhypertrophied scar, desmoids tumour, cutaneous tumour and stich granuloma. W e report a case in a 35 \nyears old female patient who was treated for pelvic inflammatory disease with no relief. W e diagnosed \nthe scar lesion as stich granuloma/hypertrophied scar/desmoid tumour. She underwent wide local  \nexcision of the  Nodular swellings on the caesarean scar with primary closure. HPE confirmed it as \nscar endometriosis. Patient is relieved of pain abdomen and is symptom  free with no recurrence  on \nfollow up till date.  \nKEY  WORDS :  Scar endometriosis, PID, Abdominal wall endometriosis.\nScar endometriosis patients are usually  \nmisdiagnosed  as  it   is  often confused  with  \nother  surgical  conditions  as  they  have  similar  \nclinical  presentations  and  features. Sometimes \nthese patients present with painful nodular \nswellings on the previous caesarean scars and are \nmisinterpreted as hypertrophied scar, keloid, \nhaematoma, stitch granuloma or cutaneous \n[4]\ntumors.\n              W e report a case in a 35 years old patient \nwh o wa s treated for Pelvic Inflamma tory \nDisease for almost one and a half years with no \nrelief.  On examination we diagnosed the lesion \nover the caesarean scar as hypertrophied scar / \nstich granulom a / desm oids tum or. She \nunderw ent exploration w ith w ide local               \nexcision of the two nodular swellings and \nhistopathological examination  confirmed as \nCase Report\nINTRODUCTION\nEndometriosis is called as a disease of \ntheories. This was first described by Rokitansky \nin 1860 as the presence of endometrial tissue \n[1 ,2 ]\noutside the uterus.  A bdom inal w all \nendom etriosis is usually seen follow ing  \nobstetric and gynaecological  surgeries. Scar \nendometriosis may also go unnoticed  when a \npatient presents with symptoms  such as acute or \nchronic  lower abdomen pain and  are  treated     \n[3]\nas Pelvic inflammatory disease or cystitis.             \nCorresponding  author:\nDr.  Ambikavathy . M,\nAsst. prof, Dept  of General  Surgery,\nSri Devaraj Urs Medical College, \nKolar,  Karnataka.\nE-mail: Ambikaashri67@live.com\nMob : 9980337428\nJ Clin Biomed Sci 2012 ; 2 (4)192\n\nBhaskaran A  et al\nscar endometriosis. W e report this case to stress \non the modes of presentation of endometriosis \ncases  to  the surgical out patient departments.\nCASE  ILLUSTRA TION\nA  35 Y ears old female patient with  a \nhistory of previous caesarean section for her first \npregnancy about one and a half years  back, \npresented to us with chronic  pain in the lower \nabdomen and  on  the caesarean scar region, after  \none month following surgery. She had been \ntreated as PID conservatively with no relief.\nOn thorough abdomen examination we \nfound  two tender nodular swellings on either \nends of the pfannenstiel surgical scar measuring \n3x2 cms firm and indurated at skin surface  on \nthe right of scar and 4x3cms raised above the \nskin surface to the left of scar [Fig-1]. Surface \nwas nodular, tender, red to black in colour,               \nfirm  in consistency, present in the skin            \nand subcutaneous plane. Rest of the abdomen                  \nwas normal. W ith a diagnosis of stich granuloma \n/ hypertrophied scar/ desmoids tumour, we got \nan FNAC of the lesion and it was inconclusive. \nUltrasound of the abdomen and pelvis reported \nas cystic swellings in the subcutaneous plane \nabove the rectus sheath.\nThe patient underwent exploration and \nwide local excision with 1cm margin of the \nlesion along w ith  the underlying fasia. \nOperatively  the lesion  was very vascular with \ndense adhesions in the skin and subcutaneous \ntissue abutting on rectus sheath . There was no \nperitoneal extension of the lesion. The wound \nwas primarily closed after thorough wash with \nsaline [Fig-1 inset]. \nHistopathological exam ination of the \nspecimen reported as section shows epidermis, \ndermis, subcutaneous tissue and fascia. Dermis \nand subcutaneous tissue show s illdefined \nnodular areas consisting of fibrofatty tissue, and \nfibromuscular tissue within which are seen \nendometrial glands lined by columnar and \ncuboidal epithelium. Some glands show dilation. \nEndometrial stroma are seen at places. No \nFig: 1- preoperative photograph showing \nnodular lesions on the caesarean scar. \nInset - operative photograph showing \nwide excision of the lesion followed by \nprimary closure of the wound.\nFig: 2 - Microphotograph showing skin \nwith dilated endometrial glands in dermis. \n(H&E 400x)\nJ Clin Biomed Sci 2012 ; 2 (4) 193\n\nBhaskaran A  et al\nevidence of granulom a or m alignancy                     \nseen. Features are consistent w ith scar \nendometriosis.[Fig- 2]\nThe patient was discharged  with danazol \n100 mg tid for  six months and  is symptom free \non follow up till date with  no recurrence .\nDISCUSSION\nEndometriosis is known  to occur in 10 -\n15% of women  during their  reproductive age \n[1] \nand upto 50% in  infertile women. Scar \nendometriosis has an incidence of  0.03%-\n0.15% usually occurring following obstetric and \ngynaecological surgeries and laparoscopic \nprocedures. V arious theories have been put \nforward to explain this condition. Iatrogenic \ndissemination or implantation of the endometrial \nfragments  during surgical procedures into                   \nthe incision site is known to cause scar \nendometriosis. Patients have seven times risk of \nendometriosis if a first degree relative is \n[2,3]  \naffected. The presentations of symptoms vary \nfrom each individual some have cyclical pain at \nmenses, chronic lower abdominal pain/ chronic \npelvic pain. Some times patients present with \nnodular swellings in the scar region or may be \nfound incidently as seen in our case who was \n[3,4]\npreviously treated for PID.\nL iteratures have described m any \ndiagnostic modalities such as FNAC, MRI, \n[5,6,7]\nUSG, CT  SCAN, etc.  In our case FNAC                 \nw as in conclusive. E xcision biopsy and \nhistopathological examination has been very \naccurate  in diagnosing this condition.\nMedical treatment  with gonodotropin \nagonists, oral contraceptives, danozol, \nleuprolide acetate have been tried with no \nregress in the size of the  lesions, but they                   \ngive only sym ptom atic relief. M alignant \ntransformation are known to occur hence follow \n[8,9]\nup is advised.\n CONCLUSION\nScar endometriosis should be considered \nwhen a female  patient presents to the surgeons \nwith pain in the lower abdomen and painful \nnodules on the surgical scar following caesarean \nsections or hysterectomy.\nD ifferen tial d iag n o sis o f scar \nendometriosis should be included among the \nother surgical diagnosis such as hypertrophied \nscar, haematoma, stich granuloma, desmoids \ntumour and soft tissue tumours at the site of \ncaesarean/hysterectomy scars.\nW ide local excision is the surgical \ntreatment of choice for scar endometriosis. \nRegular follow up is mandatory  in these patients \nas they are known to recur. Adequate care during \nand after obstetric/gynaec surgery with thorough \nsaline wash of surgical wound can prevent scar \nendometriosis.\nREFERENCES\n1. D ouglas C , R otym i O . E xtragenital \nendometriosis.  A  Clinicopathological review of \na G lasgow  hospital experience w ith case \nillustrations. J O bstet G ynaeccol 2004; \n24(7):804-808.\n2.  Gunes M, Kayikcioglu F, Ozturkoglu E, H \nA berala A . Incisional endom etriosis after \ncaesarean section, episiotom y and other \ngynaecological procedures. J Obstet Gynaecol \nRes  2005; 13(5): 471- 475.\n3.   Khoo  J. Scar endometriosis presenting as an \nJ Clin Biomed Sci 2012 ; 2 (4)194\n\nBhaskaran A  et al\nacute abdomen: A  case report. Aust N Z J Obstet \nGynaecol 2003;43(2): 164-165.\n4.  Thapa A, Kumar A, Gupta.  Abdominal       \nwall  endometriosis ;  Report  of  a case  and  \nhow  much  we  know  about  it?.  The  Internet  \nJournal of Surgery 2007;9(2). DOI:10.5580 \n/1690\n5.   Catalina-fernadezi, Lopez-presa D, Saenz-\nsantamaria J. Fine needle aspiration cytology in \ncutaneous and subcutaneous endome triosis. \nActa Cytol 2007; 51:380-4.\n6. Francina G, Giardiello C, Angelone G, \nCristaino S, Finelli R, Tromonto  G.  Abdominal  \nwall  endometriosis  in  delivery  scars :  \nSonographic and  color  Doppler  findings  in  a  \nseries  of   12  patients.  J  Ultrasound  Med  \n2000; 22:10.\n7.   Balleyguir C, Chapron C,  Chopin N, Heleno \nO, Menu Y. Abdominal  wall  and  surgical   scar   \nendometriosis.  Magnetic  resonance  imaging. \nGynecol Obstet   Invest  2003 ;  55 : 220-4.\n8. Rivlin ME, Das SK, Patel RB, Meeks GR. \nLeuprolide  acetate  in  the management   of  \ncaesarean  scar  endometriosis.  Obstet Gyneco  \n1995 ;  85 : 838-9. \n9.  Javert CT .  Pathogenesis  of  endometriosis  \nbased  on  endom etrial  hom eoplasis                        \ndirect  extension,  exfoliation,  lymphomatic  \nand  haematogenous   metastasis. Cancer  1949 ; \n2(3) 399-410.\nSource of Support: Nil    Conflict of Interest: Nil\nJ Clin Biomed Sci 2012 ; 2 (4) 195","source_license":"CC0","license_restricted":false}