{"paper_id":"c05436e0-c2ef-47d2-9068-154a01bfe772","body_text":"Alamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report \nCitation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: \nCase Report. J Clin Med Res. 2022;5(1):12-16. \nDOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 \n \n \nJournal of Clinical and Medical Research \nISSN: 2582-4333 \nAlamri MA, et al., 2023- J Clin Med Res \nCase Report \n \n \nPrimary Umbilical Endometriosis: \nCase Report \nMusab Atif Alamri *, Jaber Abdulwhab Asiri, Ahmed Ali \nAlRizqi, Shahd Ali Alasmri  and Abdulaziz Abdulrahman \nAlzahrani \nAbstract \nEndometriosis is a benign condition that occurs during the \nproductive age in women However, one of the r are disorders of \nendometriosis location -wise is the umbilical endometriosis. \nUmbilical endometriosis had been into divided primary and \nsecondary umbilical endometriosis depending on the causes; \neither after laparoscopic or open procedures which are \nsecondary. The primary happened unexpectedly. MRI sensitivity \nis superior to detecting small lesions. According to a study done \nin 2002, MRI sensitivity and specificity to detect biopsy -was \nproven 69% and 75%. In this case report, the patient was a 38 -\nyear-old si ngle girl with primary umbilical endometriosis. For \ntreatment, most cases with umbilical endometriosis have been \ntreated with surgery. However, treatment with medication needs \nto be researched and requires more investigation. \nKey words: Primary umbilical endometriosis; Gynecology; MRI. \nIntroduction \nThe presence of endometrial tissue outside \nthe uterine cavity is called endometriosis. It \naffects 10 -15 % of the female population \nworldwide. Endometriosis is a benign \ncondition that occurs during the productive \nage in women. However, endometriosis can \nbe located in different anatomy parts such as \novarian fossa, pelvic, and bladder. However, \none of the rare disorders of endometriosis, \nlocation-wise, is in umbilical [1]. \nUmbilical endometriosis had been divided \ninto primary and secondary umbilical \nendometriosis depending on the causes, \neither after laparoscopic or open procedures, \nwhich is secondary umbilical endometriosis. \nThe primary happens unexpectedly. The \nfirst-time umbilical endometriosis was \nmentioned was in 1886 by Villa r [1]. For this \nMedical Imaging Department King Saud \nMedical City Ulaishah, Riyadh, Saudi \nArabia \n*Corresponding Author:  Musab Atif \nAlamri, MD, Body Imaging Consultant, \nKing Saud Medical City Ulaishah, Riyadh, \nSaudi Arabia. \nReceived Date: 03-12-2023 \nAccepted Date: 03-20-2023 \nPublished Date: 04-12-2023 \nCopyright© 2022 by Alamri MA, et al . All \nrights reserved. This is an open access \narticle distributed under the terms of the \nCreative Commons Attribution License, \nwhich permits unrestricted use, \ndistribution, and reproduction in any \nmedium, provided the original author and \nsource are credited. \n\nAlamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report \nCitation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: \nCase Report. J Clin Med Res. 2022;5(1):12-16. \nDOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 \n \n \nreason, the term Villar’s nodule was used to \ndescribe patients with primary umbilical \nendometriosis [2]. \nNevertheless, the pathophysiology of \nprimary umbilical endometriosis is \nundetermined [2]. In addition, primary \numbilical endometriosis is rare compared \nwith secondary umbilical endometriosis. \nAccording to Fernandes et al, the frequency \nof 0.5% to 1% of all patients is with \nendometrial ectopia [3]. Common symptoms \nare flesh colored nodules, in some cases red, \nor brown nodules, pain, bleedi ng, and \nswelling. The pain and swelling will increase \nduring menstruation [2]. A systematic review \ndone in 2022 established that 66% and 43.3% \nof cases with umbilical endometriosis \nsymptoms were abdominal pain and \nbleeding from the umbilical area . \nUnfortunately, umbilical endometriosis \nsymptoms match with other pelvic disorders \nsuch as pelvic infections, nongynecological, \nurologic, and gastrointestinal [4]. In fact, \numbilical endometriosis can be associated \nwith pelvic endometriosis; 20% of patients \nwith pr imary umbilical endometriosis have \nbeen diagnosed with pelvic endometriosis, as \nwell [6]. Ultrasound and magnetic resonance \nimaging (MRI) can be helpful to diagnose \numbilical endometriosis; however, MRI \nsensitivity is superior to detect small lesions. \nAccording to a study done in 2002, MRI \nsensitivity and specificity to detect biopsy -\nproven was 69% and 75%. The study was \ndone on 36 women and the detection was \nconfirmed in 25 women [4]. Regarding \ntreatment, most cases with umbilical \nendometriosis have been t reated with \nsurgery [5 ,6]. However, another option was \nmentioned in some cases which is medical \ntherapy, even though medical therapy is not \nwidely used and performed as often as \nsurgical solution. In fact, until 2007, there \nwere 5.9% of the cases reported that \nunderwent medical therapy. On the other \nhand, the majority of the cases (67.6%) \nunderwent surgical approach [7]. In this case \nreport, the patient was a 38 -year-old single \ngirl with primary umbilical endometriosis. \nCase report \nA 38-year-old single women present to King \nSaud Medical City gynecology clinic referred \nfrom primary health care complaining of \nsevere pain, swelling, and bleeding from the \numbilical area. The patient had experienced \nthese symptoms since 2021 and  decided to \ncome to the hospital in July 2022. In \naddition, visually, the patient has a blackish \ncolored nodule in the umbilicus (Fig ure 1). \nThe bleeding and pain increased every \nmonth, associated with the menstruation. \nThe patient did not have any surgery or \nprocedure before. Mo reover, the patient did \nnot have any trauma in the interested area. \nThe gynecologist highly suspects the patient \nhas primary umbilical endometriosis based \non the symptoms. For further confirmation, \nthe patient was sent to do pelvic MRI with \ncontrast. \nMRI was done on a 3T magnet (Siemens) by \nusing a pelvic coil resulting T2 weighted \nsequences and T1 fat suppressed. Sagittal and \ntransverse T2 weighted fast spin were taken. \nIn addition, there were transverse and \nsagittal T1 weighted spin echo images. The \nslide thickness was 5 mm and intravenous \ncontrast material (Gadolinium) was injected \n0.2 mL/kg. \n\nAlamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report \nCitation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: \nCase Report. J Clin Med Res. 2022;5(1):12-16. \nDOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 \n \n \nThe matrix size was 256 × 192, and the field \nof view was 35 cm. The patient was injected \nwith 20 mg IM Buscopan before the scan \nacquisition. \n \nFigure 1: Umbilical Endometriosis, with active bleeding during the menstrual period. blackish colored \nnodule in the umbilicus. \nThe first MRI report on 28th of June 2022 \nindicated the bilateral ovaries are adherent \nto the posterior uterine wall associated with \nhemorrhagic component, representing \nbilateral ovarian endometrioma. It \nmeasured1.7 × 2.1 cm for the right side and \n1.7 × 0.9 cm for the left side. The lesions \nshow bright signal intensity in T1 -weighted \nimages (Fig ure 2A) and shading in T2 -\nweighted images (Fig ure 2B). with no \nenhancement on post -contrast subtracted \nimages. No signs of malignant \ntransformation. There is a linea r plaque-like \nlesion seen on the posterior uterine wall \nassociated with tethering of rectal wall \nrepresenting deep pelvic endometriosis. \nThere was also a well -defined umbilical \nlesion seen in a few sequences. It measured \n1.2 × 1 cm and showed int ermediate to low \nsignal intensity in T2 -weighted images, and \nbright signal intensity in T1 post -contrast \nimages (Fig ure 2C), representing umbilical \nendometriosis.\n \nFigure 2: MRI (A) Axial precontrast T1 WI, and (B) Axial T2 WI shows bilateral ovarian endometrioma and \ndeep pelvic endometriosis. (C) Axial T1 post contrast show umbilical small hemorrhagic lesion represent \nendometriosis. \n\n\nAlamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report \nCitation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: \nCase Report. J Clin Med Res. 2022;5(1):12-16. \nDOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 \n \n \nThe gynecologist presented the surgical \noption to  the patient. The patient  refused \nand started an oral hormonal therapy \n(Dienogest): one tablet 2 mg daily. However, \nthe patient had another MRI on September \n1st, 2022, to evaluate the progress. The \nsecond MRI showed slight interval reduction \nin the size of  the umbilicus nodule (Fig ure 3 \na and b), currently measuring 0.8 × 0.8 cm \n(was 1.3 × 0.9 cm). No intra -abdominal \nextension, sinus or fistulous tract formation.\n \nFigure 3: Follow up MRI after three months post Dienogest treatment. A and B axial T1 pre and \npost contrast images, showed slightly reduction in the size of the umbilicus endometriosis \n(comparison with Figure 2C).\nDiscussion  \nEndometriosis is a benign condition that \noccurs during the productive age in women \nHowever, one of the rare disord ers of \nendometriosis location-wise is the umbilical \nendometriosis [1]. Umbilical endometriosis \nhad been into divided primary and \nsecondary umbilical endometriosis \ndepending on the causes; either after \nlaparoscopic or open procedures which are \nsecondary. Th e primary happened \nunexpectedly. The first -time umbilical \nendometriosis was mentioned was in 1886 by \nVillar [1]. For this reason, the term Villar’s \nnodule was used to describe patients with \nprimary umbilical endometriosis. The \ncommon symptoms are flesh col ored \nnodules, in some cases red, or brown \nnodules, pain, bleeding, and swelling. The \npain and swelling will increase during \nmenstruation [2]. MRI sensitivity is superior \nto detecting small lesions. According to a \nstudy done in 2002, MRI sensitivity and \nspecificity to detect biopsy -was proven 69% \nand 75%. The study was done on 36 women \nand the detection was confirmed in 25 \nwomen [4]. For treatment, most cases with \numbilical endometriosis have been treated \nwith surgery [5]. In this case, the patient \nrejected the surgical option and preferred a \nhormonal treatment. According to the three \nMRI done during different periods of time, \nthere was noticeable slight reduction in the \nsize of the umbilicus nodule between the \npretreatment MRI and the second. The \npatient’s pain decreased, and the bleeding \nstopped. This result was observable on t he \npatient after one month of the treatment. \n\n\nAlamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report \nCitation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: \nCase Report. J Clin Med Res. 2022;5(1):12-16. \nDOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 \n \n \nConclusion   \nPrimary umbilical endometriosis is a very \nrare disorder, particularly in single \nnulliparous patients. According to the \nliteratures, surgical option is recommended \nand offers a satisfactory  result. However, \nmedical treatment needs to be researched.\nReferences \n1. Makena D, Obura T, Mutiso S, Oindi F. Umbilical Endometriosis: A Case Series. J Med Case Rep. 2020;14:1 -4. \nPubMed | CrossRef \n2. Sahli H, Boularab J, El Mandour J, Allali N, Chat L, El Haddad S. Primary Umbilical Endometriosis: Case \nReport and Literature Review  of an Unusual Cause of Catamenial Umbilical Pain. Radiol Case Rep. \n2022;17(6):2133-6. PubMed | CrossRef \n3. Fernandes H, Marla NJ, Pailoor K, Kini R. Primary Umbilical Endometriosis -Diagnosis by Fine Needle \nAspiration. J Cytol. 2011;28(4):214. PubMed | CrossRef \n4. Stratton P, Winkel C, Premkumar A, Chow C, Wilson J, Hearns -Stokes R, et al. Diagnostic Accuracy of \nLaparoscopy, Magnetic Resonance Imaging, and Histopathologic Examination for the Detection of \nEndometriosis. Fertil Steril. 2003;79(5):1078-85. PubMed | CrossRef \n5. Purvis RS, Tyring SK. Cutaneous and Subcutaneous Endometriosis: Surgical and Hormonal Therapy. J \nDermatol Surg Oncol. 1994;20(10):693-5. PubMed | CrossRef \n6. Dridi D, Chiaffarino F, Parazzini F, Donati A, Buggio  L, Brambilla M, et al. Umbilical Endometriosis: A \nSystematic Literature Review and Pathogenic Theory Proposal. J Clin Med. 2022;11(4):995. PubMed | CrossRef \n7. Victory R, Diamond MP, Johns DA. Villar’s Nodule: A Case Report and Systematic Literature Review of \nEndometriosis Externa of the Umbilicus. J Minim Invasive Gynecol. 2007;14(1):23-32. PubMed | CrossRef","source_license":"CC0","license_restricted":false}