{"paper_id":"c8333c3d-8fc5-4809-99d7-3daee17330cf","body_text":"Edorium Journal of Gynecology and Obstetrics, Volume 7, Issue 2, 2023; Pages 5–9.\nEdorium J Gynecol Obstet 2023;7(2):5–9. \nwww.edoriumjournalofgyneobst.com\nSabiri et al. 5\nCASE REPORT OPEN ACCESS \nUmbilical endometriosis: A case report\nRachida Sabiri, Yasmine Gourja, Sanaa Benrahal, Boufettal Houssin, \nMahdaoui Sakher, Naima Samouh\nABSTRACT \nIntroduction: Cutaneous and umbilical involvement \nis very rare and represents only 0.5–1% in the various \nseries. Its clinical diagnosis is difficult but it should be \nsuspected in the presence of any bluish, painful umbilical \nnodule, sometimes with a brownish discharge, the \nevolution regulated by the menstrual cycle. Ultrasound of \nthe abdominal wall points to the diagnosis of umbilical \nendometriosis despite the absence of characteristic signs \non imaging. Wide surgical excision is the treatment of \nchoice because of its resemblance to a primary tumor or \nmetastasis.\nCase Report: We report the case of a 31-year-old female \npatient with no history of abdominal-pelvic surgery or \ntrauma to the umbilicus, consulted for a painful umbilical \nswelling measuring approximately 1–2 cm diagnosed with \numbilical endometriosis. Endometriosis of the umbilical \nwall is a rare condition, representing only 0.03–2% of \nextra-genital endometriosis. It is associated with pelvic \nendometriosis in 26% of cases. Its clinical diagnosis is \ndifficult but it should be suspected in the presence of \nany bluish, painful umbilical nodule, sometimes with \na brownish discharge, the evolution regulated by the \nmenstrual cycle. Ultrasound of the abdominal wall with \na high frequency probe is the initial, easily accessible \nexamination that points to the diagnosis of umbilical \nendometriosis, but it is not pathognomonic. The formal \ndiagnosis of umbilical endometriosis is only obtained \nwith the help of histological examination. The presence \nRachida Sabiri 1, Yasmine Gourja 1, Sanaa Benrahal 1, \nBoufettal Houssin 1, Mahdaoui Sakher 1, Naima Samouh 1\nAffiliations:  1Department of Gynecology, IBN Rochd Uni -\nversity Hospital, Casablanca, Morocco.\nCorresponding Author:  Rachida Sabiri, Service de Gy -\nnecologie, Aile 8, Chu IBN Rochd, Casablanca, Morocco; \nEmail: rachida.sabiri91@gmail.com.\nReceived: 05 September 2023\nAccepted: 19 October 2023\nPublished: 23 November 2023\nof endometrial glands (epithelial cells) and a cytogenic \nchorion in the ectopic endometrial tissue is necessary to \nestablish the histological diagnosis. In general, medical \ntreatment with danazol, norethisterone, or luteinizing \nhormone-releasing hormone (LHRH) analogues is \nrecommended before surgery. It would allow a reduction \nin the size of the endometriotic nodules.\nConclusion: Umbilical endometriosis is a very rare \nform of extra-genital endometriosis. The diagnosis is \nmade when a nodule is present with pain and catamenial \nbleeding. The diagnosis of certainty is based on a \nhistological study.\nKeywords: Cutaneous, Endometriosis, Nodule, Um -\nbilical\nHow to cite this article\nSabiri R, Gourja Y, Benrahal S, Houssin B, Sakher M, \nSamouh N. Umbilical endometriosis: A case report. \nEdorium J Gynecol Obstet 2023;7(2):5–9.\nArticle ID: 100033G06RS2023\n*********\ndoi: 10.5348/100033G06RS2023CR\nINTRODUCTION\nEndometriosis is a condition characterized by the \npresence of ectopic endometrial structures which have \nthe histological and biological characteristics of the \nendometrium, but which remain anatomically separate \nfrom it. It affects women during their genital period [1]. \nCutaneous and umbilical involvement is very rare and \nrepresents only 0.5–1% in various series.\nTwo types of umbilical endometriosis can be \ndistinguished, the pathophysiology of which still remains \na challenge for research. The primary form appears on \nan abdomen unaffected by any surgical intervention and \nCASE REPORT PEER REVIEWED | OPEN ACCESS   \n\nEdorium Journal of Gynecology and Obstetrics, Volume 7, Issue 2, 2023; Pages 5–9.\nEdorium J Gynecol Obstet 2023;7(2):5–9. \nwww.edoriumjournalofgyneobst.com\nSabiri et al. 6\nthe secondary form on a scar following a gyneco-obstetric \nintervention or laparoscopy [2]. Its clinical diagnosis is \ndifficult but it should be suspected in the presence of \nany bluish, painful umbilical nodule, sometimes with \na brownish discharge, the evolution regulated by the \nmenstrual cycle. Ultrasound of the abdominal wall points \nto the diagnosis of umbilical endometriosis despite \nthe absence of characteristic signs on imaging. Wide \nsurgical excision is the treatment of choice because of its \nresemblance to a primary tumor or metastasis. We report \na case of umbilical endometriosis explored by ultrasound. \nThrough the analysis of this rare observation, we \nhighlight the difficulties related to clinical and ultrasound \ndiagnosis and advanced theories of the pathophysiology \nof umbilical endometriosis [3].\nCASE REPORT\nA 31-year-old woman, multiparous, with no history \nof abdominal-pelvic surgery or trauma to the umbilicus, \nconsulted for a painful umbilical swelling measuring \napproximately 1–2 cm, which had been evolving for two \nyears, becoming purplish and sensitive at the beginning \nof menstruation (Figure 1B), causing a minimal discharge \nof brownish fluid, and appears thick at the end. She had \nbeen experiencing mild dysmenorrhea for several years, \nwith inconstant deep dyspareunia.\nOn clinical examination, a bluish nodule about 1 cm \nin diameter was found at the bottom of the umbilical \ndepression, which was tender to palpation (Figure 1A). \nThe rest of the abdominal examination was normal.\nThe gynecological examination was normal. The \ncyclical nature of the bleeding and the symptomatology, \nwhich was accompanied by menstruation, made us \nsuspect a primary umbilical endometriosis.\nUltrasound of the abdominal wall: skin thickening \nat the level of the umbilicus with a 5 mm umbilical \nnodule, well limited and finely echogenic, suggesting an \nendometrial nodule (Figure 2).\nPelvic magnetic resonance imaging (MRI) examination \ndid not identify any lesions of pelvic endometriosis. Skin \nhistology showed papillomatous acanthotic epidermis \nwith orthokeratosis. The dermis has an interstitial \ninfiltrate with siderophages and hemosiderin deposits. \nWith the presence of a glandular structure partially \nrepresented as a regular cubocylindrical epithelium \nwithout atypia (Figures 3–5). The diagnosis of primary \numbilical endometriosis is retained.\nAs a result, treatment with leuprolide acetate was \ninstituted and surgical removal was recommended as \na secondary procedure. After one month of leuprolide \n(LHRH analogue), the patient noted a disappearance \nof menstrual symptoms (pain, bleeding, and abdominal \nswelling) and she is awaiting surgery after two months of \ntreatment.\nFigure 1: Clinical appearance of endometriotic nodules.\nFigure 2: Ultrasound image showing endometriotic nodule.\nFigure 3: Presence of interstitial inflammatory infiltrate with \nsiderophages and hemosiderin deposits.\nFigure 4: Papillomatous hyperplastic epidermis surmounted by \northokeratosis.\n\nEdorium Journal of Gynecology and Obstetrics, Volume 7, Issue 2, 2023; Pages 5–9.\nEdorium J Gynecol Obstet 2023;7(2):5–9. \nwww.edoriumjournalofgyneobst.com\nSabiri et al. 7\nDISCUSSION\nEndometriosis is characterized by the presence of \nfunctional endometrial tissue outside the uterine cavity, \nand skin involvement is very rare, representing only \n0.5–1% in various series. It affects 15% of women in \nthe genitally active period between the ages of 20 and \n40 and 5% of cases are discovered in postmenopausal \nwomen. The usual locations of endometriosis are ovarian, \nperitoneal, in the partition separating the bladder, the \nuterus, and the vagina or the rectum [3].\nA distinction is made between internal endometriosis \nor adenomyosis, which is the implantation of endometrial \ncells in the myometrium, and external endometriosis, \nwhich is the location of endometriotic tissue outside \nthe myometrium and endometriotic tissue outside the \nuterine cavity and myometrium.\nExtra-genital locations are thought to represent 5% of \nlesions and seem to be underestimated in the literature. \nThe existence of these lesions often calls for different \nphysiopathological theories to explain their extra-pelvic \nlocation [1]. The lesions may be multiple or single, with a \nwide variety of sites. Diagnosis can be difficult due to the \natypical and unexpected symptoms described by patients. \nHowever, the catamenial nature of the pain or symptoms \nis a characteristic and highly suggestive feature regardless \nof location. It is essential to make the diagnosis, as these \nconditions can also have a real impact on the patient’s \nhealth and quality of life [4].\nEndometriosis of the abdominal wall, particularly the \numbilicus is a rare condition, representing only 0.03–2% \nof extra-genital endometriosis. It is associated with pelvic \nendometriosis in 26% of cases.\nTwo types of umbilical endometriosis can be \ndistinguished: primary endometriosis, which is \nexceptional, occurs in women with no history of \nabdominal surgery, and secondary endometriosis, which \nis uncommon, appears on a scar following a gyneco-\nobstetric operation or on the site where the laparoscopic \ntrocar passes [5].\nThe umbilical location could also be explained \nby the venous or lymphatic metastatic theory, when \nendometriotic cells migrate to the umbilicus through \nthe periumbilical venous network. Finally, according \nto a third theory, that of metaplasia, cells derived from \nthe coelomic epithelium undergo metaplasia toward \nendometrial cells, under the effect of various infectious, \ntoxic, or hormonal factors [6].\nThe most common differential diagnoses with \numbilical endometriosis include umbilical hernia, primary \nmalignancy such as melanoma or metastasis, lipoma, \ninflammatory or infectious granuloma, complicating cyst, \ncongenital cyst of the urachus and endometriosis [7]. \nUmbilical hernia is a real dilemma in acute abdominal \nsymptomatology, as in the case of our patient. Ultrasound \nof abdominal wall with a high frequency probe is the \ninitial, easily accessible examination that points to \nthe diagnosis of umbilical endometriosis, but it is not \npathognomonic. It confirms the presence of an umbilical \nnodule, specifies its size, its contours, its limits with the \nadjacent superficial and deep structures, its homo or \nheterogeneous content, its solid or cystic nature [8].\nEndometriosis of the abdominal wall, particularly \nthe umbilical wall, is a rare condition, representing only \n0.03–2% of extra-genital endometriosis. It is associated \nwith pelvic endometriosis in 26% of cases.\nPercutaneous biopsy of the nodule evokes the \ndiagnosis by showing a cylindrical glandular epithelium \nsurrounded by a stroma. A study by Catalina-Fernandez \net al. showed that in cytological smears of cutaneous \nendometriosis there is a high cellularity containing \nmacrophages loaded with hemosiderin and epithelial \ncells on old bleeding. It is still contraindicated by some \nauthors because of the increased risk of dissemination in \ncases of suspected endometriosis [7].\nFinally, the formal diagnosis of umbilical endometriosis \nis only obtained with the help of histological examination. \nThe presence of endometrial glands (epithelial cells) and \na cytogenic chorion in the ectopic endometrial tissue \nis necessary to establish the histological diagnosis. It \nconsists of small foci of inflamed endometrial tissue and \nhemosiderin-laden macrophages secondary to acute and \nchronic bleeding. The typical histological appearance \nof endometriosis excludes a primary malignant tumor, \numbilical metastasis, or a benign lesion [4].\nThe treatment for umbilical endometriosis is wide \nsurgical excision because of its similarity to malignant \ntumors and to avoid recurrence. Malignant transformation \ninto carcinoma of endometriotic nodules is rare.\nIn general, medical treatment with danazol, \nnorethisterone, or LHRH analogues is recommended \nbefore surgery. It would allow a reduction in the size of \nthe endometriotic nodules [9].\nCONCLUSION\nUmbilical endometriosis is a rare, atypical form \nof extra-genital endometriosis. The diagnosis should \nbe made in the presence of cyclical symptomatology, \nenabling a therapeutic protocol to be instituted after \nhistological confirmation.\nFigure 5: Presence of a few glands bordered by regular \ncubocylindrical epithelium without atypia.\n\nEdorium Journal of Gynecology and Obstetrics, Volume 7, Issue 2, 2023; Pages 5–9.\nEdorium J Gynecol Obstet 2023;7(2):5–9. \nwww.edoriumjournalofgyneobst.com\nSabiri et al. 8\nREFERENCES\n1. Tropicale TS. Santé Maghreb - Bibliothèque de \nSanté Maghreb. APIDPM Santé Tropicale. 2021. \n[Available at: http://www.santemaghreb.com/biblio.\nasp?id=1951&action=lire]\n2. 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Extragenital \nendometriosis: Parietal, thoracic, diaphragmatic \nand nervous lesions. CNGOF-HAS Endometriosis \nGuidelines. [Article in French]. Gynecol Obstet Fertil \nSenol 2018;46(3):319–25.\n9. Malic CC, Spyrou GE, Hough M, Fourie L. \nPatient satisfaction with two different methods of \numbilicoplasty. Plast Reconstr Surg 2007;119(1):357–\n61.\n*********\nAuthor Contributions\nRachida Sabiri – Conception of the work, Design of the \nwork, Acquisition of data, Drafting the article, Revising \nit critically for important intellectual content, Final \napproval of the version to be published, Agree to be \naccountable for all aspects of the work in ensuring that \nquestions related to the accuracy or integrity of any part \nof the work are appropriately investigated and resolved\nYasmine Gourja – Conception of the work, Design of the \nwork, Analysis and interpretation of data, Drafting the \narticle, Final approval of the version to be published, \nAgree to be accountable for all aspects of the work in \nensuring that questions related to the accuracy or integrity \nof any part of the work are appropriately investigated and \nresolved\nSanaa Benrahal – Conception of the work, Design of the \nwork, Drafting the article, Final approval of the version to \nbe published, Agree to be accountable for all aspects of the \nwork in ensuring that questions related to the accuracy \nor integrity of any part of the work are appropriately \ninvestigated and resolved\nBoufettal Houssin – Conception of the work, Design of \nthe work, Drafting the article, Revising it critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nSakher Mahdaoui – Conception of the work, Design of \nthe work, Drafting the article, Revising it critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nNaima Samouh – Conception of the work, Design of \nthe work, Drafting the article, Revising it critically for \nimportant intellectual content, Final approval of the \nversion to be published, Group4-Agree to be accountable \nfor all aspects of the work in ensuring that questions \nrelated to the accuracy or integrity of any part of the work \nare appropriately investigated and resolved\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nSource of Support\nNone.\nConsent Statement\nWritten informed consent was obtained from the patient \nfor publication of this article.\nConflict of Interest\nAuthors declare no conflict of interest.\nData Availability\nAll relevant data are within the paper and its Supporting \nInformation files.\nCopyright\n© 2023 Rachida Sabiri et al. This article is distributed \nunder the terms of Creative Commons Attribution \nLicense which permits unrestricted use, distribution \nand reproduction in any medium provided the original \nauthor(s) and original publisher are properly credited. \nPlease see the copyright policy on the journal website for \nmore information.\n\nEdorium Journal of Gynecology and Obstetrics, Volume 7, Issue 2, 2023; Pages 5–9.\nEdorium J Gynecol Obstet 2023;7(2):5–9. \nwww.edoriumjournalofgyneobst.com\nSabiri et al. 9\nAccess full text article on\nother devices\nAccess PDF of article on\nother devices\n\nSubmit your manuscripts at\nwww.edoriumjournals.com","source_license":"CC0","license_restricted":false}