{"paper_id":"c0c16945-dd48-4ad3-b47b-fa2dad2e1cf4","body_text":"CASE REPORT\nSevere endometriosis may be considered in the differential\ndiagnosis in young women presenting massive\nhemorrhagic ascites\nLuiz Flavio Cordeiro Fernandes & Sergio Podgaec &\nGuilherme Cutait Castro Cotti & Mauricio Simoes Abrao\nReceived: 29 April 2011 / Accepted: 8 June 2011 / Published online: 29 June 2011\n# Springer-V erlag 2011\nKeywords Ascites . Endometriosis . Ovarian cancer\nIntroduction\nEndometriosis, the presence of endometrial tissue outside\nthe uterine cavity, affects 10% of women in reproductive\nage and has immunological aspects conferring the disease\nan indubitable inflammatory trace [ 1]. Patients may present\ndysmenorrhea, chronic pel vic pain, dyspareunia, and\ninfertility but rarely develops massive hemorrhagic ascites.\nOne of the components of peritoneal fluid in normal\nmenstrual cycles is an ovarian exudate. The increase in\nvascular permeability along with some other factors as\nextremely high estrogen concentrations, and the presence of\nangiogenic factors, prostaglandins, histamines, and cyto-\nkines, may play an important role in the appearance of\nmassive ascites. Inflammation increase the volume of\nexudation and, consequently, of the peritoneal fluid [ 2].\nIn the USA, cirrhosis represents 81% of the causes of\nascites followed by cancer (10%), heart failure (3%),\ntuberculosis (2%), dialysis (1%), pancreatic disease (1%),\nand other causes (2%). Ovarian tumors, ovarian hyperstimu-\nlation syndrome, pelvic or peritoneal tuberculosis, and Meigs\nsyndrome also can cause ascites. The correct and successful\ntreatment depends on a precise diagnosis of its cause [ 3].\nMost gynecologists are unaware that endometriosis can be\nrelated to massive ascites, leading to a misdiagnosis,\nespecially when the symptoms includes loss of weight. To\nimprove the knowledge of this kind of clinical case, we\ndescribe a patient that presented hemorrhagic ascites due to\nendometriosis [2, 4].\nCase presentation\nA 28-year-old nulliparous Afro-Brazilian woman sought\nmedical care because of a progressive increase in abdominal\ngirth and a weight loss of 5 kg over a period of 7 months. The\npatient did not present either fever, coughing, night sweats,\ndigestive, or urinary complaints. She related regular menstrual\nperiods with intense dysmenorrhea and deep dyspareunia.\nPhysical examination revealed a distended, nontender abdo-\nmen with positive shifting dullness. No other clinical\nabnormalities were observed. Diagnostic hypothesis included\nperitoneal tuberculosis, hepatopathy, and ovarian tumor.\nLaboratory tests were requested and results revealed\nhemoglobin level of 9.5 g/dL, normal liver biochemistry,\nnormal tumor marker levels (CA 125, CEA, β-HCG, and α-\nfetoprotein), and negative serology for HIV and hepatitis B and\nL. F. Cordeiro Fernandes : S. Podgaec : M. S. Abrao\nEndometriosis Clinic, Department of Obstetrics and Gynecology,\nHospital das Clínicas, School of Medicine,\nUniversity of São Paulo,\nSão Paulo, Brazil\nG. C. Castro Cotti\nDepartment of Colorectal Surgery, Hospital das Clínicas,\nSchool of Medicine, University of São Paulo,\nSão Paulo, Brazil\nS. Podgaec ( *)\nRua João Moura 627, conjunto 23, Jardim América,\nCEP 05412-911 São Paulo, Brazil\ne-mail: sergiopodgaec@me.com\nGynecol Surg (2011) 8:459 –461\nDOI 10.1007/s10397-011-0690-8\n\nC. PPD was negative. Chest X-ray was normal. An abdominal\nand pelvic ultrasound was performed. It showed no liver\nlesions, massive ascites, and no signs of deep endometriosis.\nNo other abnormalities were found. It should be emphasized\nthat spleen, pancreas, kidneys, uterus, and ovaries were normal.\nAn abdominal tap was performed and a “dark brown ”\nbloody fluid was aspirated, revealing hemorrhagic ascites.\nLaboratory analysis revealed a cell count of 6,800/mm 3,\nwhite cell count of 2,720/mm 3 (44% segmented, 46%\nlymphocytes, and 10% monocytes) with intense erythro-\nphagocytosis, and an albumin level of 3.2 g/dL leading to a\nserum–ascites albumin gradient (SAAG) of 1.2. Cytology\nfor malignant cells and cultures were negative. Gram\nstaining failed to detect any pathogen.\nAs diagnosis remained undefined, laparoscopy was per-\nformed and a total of 9.4 L of hemorrhagic fluid was drained\nfrom the peritoneal cavity (Fig. 1). Extensive adhesions were\nobserved between the liver, transverse colon, sigmoid,\nuterus, and adnexa. Lesions suggestive of endometriosis\nwere seen in the peritoneum, and the pouch of Douglas was\ncompletely obliterated. A biopsy was performed on a black\nlesion in the mesosigmoid. Histology confirmed the diagno-\nsis of endometriosis due to fibrosis and extensive hemosid-\nerin deposition, as well as the presence of endometrial glands\nand stroma, and no evidence of malignancy.\nThe patient’s postoperative course was irreproachable, and\nthe patient was discharged home 2 days after the surgery. She\nreceived 3 months of GnRH analogue treatment followed by\ncontinuous estrogen –progestin hormonal treatment. Ultra-\nsound examination 3 and 6 months later revealed no ascites.\nOne year later, the patient had no complaints and continued\nwith no menses, using continuous combined birth control\npills, once she has no fertility desires at the present moment.\nDiscussion\nAscites is usually related to h epatic disorders, abdomi-\nnal–pelvic neoplasias, or infections such as peritoneal\ntuberculosis. Its correct dia gnosis consists of a combina-\ntion of a physical exam associated to an imaging test and\nto an adequate ascitic fluid analysis (abdominal para-\ncentesis). As soon as the paracentesis is done, the gross\nappearance of the fluid can be extremely helpful in the\ndifferential diagnosis. The most common cause of ascites,\ncirrhosis, usually presents as a translucent yellow fluid.\nWhen it is infected, it appears normally turbid or cloudy.\nBloody fluid usually is due to a “traumatic tap ”,b u t\nascites is bloody in approximately 50% of patients with\nhepatocellular carcinoma and 22% of malignancy-related\nascites at total. When it is brown, the patient may be\ndeeply jaundice, what is easily seen in the physical\nexam, or has a ruptured gallbladder or perforated\nduodenal ulcer, both with a relevant history of a sudden\npain [ 5]. The first three questio ns that we expect to answer\nwhen an abdominal tap is performed and we test the\nascitic fluid are: (1) Is it infected?; (2) Is it related to a\nmalignancy?; and (3) Does it show any signs of portal\nhypertension?\nAlthough our patient showed a white cell count of\n2,720/mm\n3 with 44% (1,197/mm 3)o fs e g m e n t e da n d\nintense erythrophagocytosis when the normal value would\nbe a polymorphonuclear count <250/mm 3,w ed i dn o t\nconsider antibiotic treatment because of her history of\n7 months of evolution with no fever, added to the appearance\nof the fluid. Decision proved correct when the culture showed\nno germs. Different from what we expected, the ascites of our\npatient had the traces of a transudate, with a SAAG of 1.2\n(≥1.1 g/dL has an accuracy of 97% indicating portal\nhypertension), typical to hepatic origin, even though she had\nnot any other feature going to this direction [ 2].\nEndometriosis is a common, estrogen-dependent,\nbenign, chronic inflammatory gynecological disease that\nis characterized by the presence of an endometrium-like\ntissue outside the uterine cavity, mainly on the pelvic\nperitoneum and ovaries. It affects 5% to 10% of women\nof reproductive age in the USA. The main clinical\nsymptoms are dysmenorrhea, chronic pelvic pain, deep\ndyspareunia, and infertility [ 6].\nThe association of endometriosis and massive ascites is\nan extremely unusual condition. It was first related in 1958\nand has been described in about 60 women up to date [ 4]. It\nconstitutes an enormous dilemma for gynecologists owing\nto their scarcity and to their similarity to malignant ovarian\nneoplasias [ 7].\nWomen diagnosed with massive ascites related to\nendometriosis usually presents abdominal distention\n(71.4%), weight loss (60.3%), and abdominal pain\n(52.4%). Ascites with endome triosis origin normally has\nthe characteristics of an exuda te, probably demonstrating\na peritoneal etiology of the fluid due to peritoneal\ninflammation [ 8].\nFig. 1 Bloody massive ascites and multiple adhesions around the liver\n460 Gynecol Surg (2011) 8:459 –461\n\nThose ascites are normally massive (4,470±2,625 L) and\nmay be simultaneous to pleural effusion (42%). It usually\nappears as dark brown or hemorrhagic, but without clots.\nProbably, the individual inflammatory reaction determines\nthe clinical occurrence of ascites and/or pleural effusion.\nThey also commonly come to a resolution after the excision\nof the endometriosis foci. These characteristics of the\neventual concomitance of ascites and pleural effusion,\nadditional to the normal resolution of the complication\nafter the treatment and considering endometriosis as a\nbenign condition, they all fit the criteria of Meigs\nsyndrome, which is defined as the presence of ascites with\nhydrothorax in association with a benign ovarian tumor and\nthe rapid resolution of fluid accumulation after tumor\nresection [ 9].\nThe definitive diagnosis is usually made during the\nsurgical procedure, after excluding other clinical entities\ncausing ascites. Once the correct diagnosis is made, the\ntreatment is the same as that of endometriosis, consisting of\nsupressing the ovarian function either surgically or with\nhormonal medications. Since the mean age of presentation\nis 31.9±8.8 years and most of these patients are nullipa-\nrous, endocrine therapy may be preferred to surgical\ncastration. Medical castration is normally less efficient than\nthe surgical one and cannot prevent recurrence in some\ncases. That is why women receiving medical treatment need\nlong follow-up with hormonal supression. The decision for\nthe definitive surgical treatment is made based on several\nfactors such as responsiveness to medical treatment and the\ndesire for fertility [ 8].\nDuring the follow-up, a question is raised when\ninfertility is present and a controlled ovarian hyperstimula-\ntion (COH) is needed. Will the symptons recur? Unfortu-\nnately, only some cases with ascites and endometriosis have\nbeen described and, as far as we are concerned, no data\nabout this issue can be found. Although, taking into\naccount that Benaglia et al. showed that in vitro fertilization\nand, consequently, COH did not seem to be associated to a\nhigher rate of endometriosis recurrence, we expect the same\nfindings regarding the recurrence rate of ascites. However, a\nmulticenter prospective cohort study is warranted to address\nthis specific question [ 10].\nConclusion\nGynecologists must be aware that endometriosis may cause\nmassive ascites mimicking ovarian neoplasia. It should be\nconsidered in the differential diagnosis of hemorrhagic\nascites in women at reprodutive age. The medical treatment\nis preferred than the radical surgical approach.\nConflicts of interest The authors report no conflicts of interest. The\nauthors alone are responsible for the content and writing of the paper.\nReferences\n1. Bellelis P , Dias JA Jr, Podgaec S, Gonzales M, Baracat EC, Abrao\nMS (2010) Epidemiological and clinical aspects of pelvic\nendometriosis: series of cases. Rev Assoc Med Bras 56(4):467 –\n471\n2. Ussia A, Betsas G, Corona R, De Cicco C, Koninckx PR (2008)\nPathophysiology of cyclic hemorrhagic ascites and endometriosis.\nJ Minim Invasive Gynecol 15(6):677 –681. doi: 10.1016/j.\njmig.2008.08.012\n3. 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Fertil Steril 90(5):2015\ne2017–2019. doi: 10.1016/j.fertnstert.2008.07.021\n9. Lurie S (2000) Meigs' syndrome: the history of the eponym. Eur J\nObstet Gynecol Reprod Biol 92(2):199 –204\n10. Benaglia L, Somigliana E, V ercellini P , Benedetti F, Iemmello R,\nVighi V , Santi G, Ragni G (2010) The impact of IVF procedures\non endometriosis recurrence. Eur J Obstet Gynecol Reprod Biol\n148(1):49–52. doi: 10.1016/j.ejogrb.2009.09.007\nGynecol Surg (2011) 8:459 –461 461","source_license":"CC0","license_restricted":false}