Acute Abdomen Due to Ruptured Endometriomas-Case series from a Tertiary Care Centre

Ruptured endometriotic cyst should be considered in the differential diagnosis of acute abdomen in women of reproductive age, especially those with a history of dysmenorrhea or endometriosis. Laparoscopy remains a valuable diagnostic and therapeutic tool in such cases.

Endometriosis is a prevalent, estrogen-driven inflammatory condition where normal endometrial tissue is found outside the uterine cavity.[1] Endometriomas are the most frequent form of endometriosis found on the ovary. However, endometrial implants can also occur throughout the abdomen, including on the bowel, within previous surgical incisions, and in rare instances, in the distant areas of the body such as the cerebellum.[2] The etiology of endometriosis is a controversial. The oldest and most widely accepted theory for developing endometriosis is retrograde menstruation.[3] A fibrotic reaction to bleeding endometrial tissue is believed to create adhesions between endometriomas and the surrounding ovary and other pelvic structures. At the molecular level, fibrosis is thought to involve reactions to free iron and reactive oxygen species, along with various cellular factors such as transforming growth factor-β, Wnt1, activin A, connective tissue growth factor, sphingosine-1-phosphate, and plasminogen activator inhibitor-1.[4–6] With few exceptions, endometriomas are found exclusively in the ovaries and not in other anatomic locations. The relatively loose connective tissue of the ovarian medulla, dynamic expression of genes regulating extracellular matrix hardness, rapid vascular remodeling, and basement membrane mechanics may contribute to the biomechanic hospitality of the ovary to cyst formation.[7–9] The enriched concentration of hormones, growth factors, and cytokines in the ovary that is not present elsewhere has also been proposed to drive endometrioma growth in the ovaries specifically.[8] Although rare, it is more frequently reported in the literature that patients may present with ruptured endometriomas during pregnancy or following abdominal or pelvic trauma.[6] Endometriomas typically develop slowly, with symptoms depending on their size and external factors. As the condition progresses, symptoms may include dysmenorrhea, abdominal or pelvic pain, dyspareunia, dyschezia, and in some cases, rupture.[10–12] We represent the case series of three cases who presented as ruptured noninfected endometriotic cysts and were managed laparoscopically. CASE SERIES Case 1 A 41-year-old female, para 2, live 2, 2 cesarean section, postlaparoscopic hysterectomy, presented to us with complaints of diffuse abdominal pain for the past 20 days. She had history of dyschezia with incomplete emptying of stools for the past 20 days. Bladder habits were normal. No loss of appetite or weight. Hysterectomy was done for abnormal uterine bleeding with moderate dysmenorrhea. On clinical examination, there was no supraclavicular lymphadenopathy. On vaginal examination, tender cystic mass about 10 cm felt along the vault. Ultrasound was done and differential diagnosis of malignancy/endometriotic cyst was suggested. Human epidydimis protein-4 was 36.1 pmol/L. CA-125 and CA-19.9 were elevated (3612 U/mL and 338 U/mL, respectively). Upper gastrointestinal endoscopy and colonoscopy were normal. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis was done. Uterus was not seen. Well defined thin-walled nonenhancing cyst – 7 cm × 8.3 cm × 8.3 cm chocolate cyst in the pelvis wedged between the bladder and pelvic colon [Figure 1]. Contrast-enhanced computed tomography of abdomen and pelvis showing large cyst in pelvis-likely endometriotic After taking proper informed consent, she was planned for diagnostic laparoscopy. Intraoperatively, chocolate staining of omental and peritoneal surfaces noted. Endometriotic deposits noted on the undersurface of diaphragm. Around 200 mL of altered colored-free fluid noted. Omental adhesions noted to the pelvic walls. After releasing omental adhesions, right ovary was replaced with large 10 cm × 8 cm endometriotic cyst. Multiple small bowel loops were adherent to cyst. Sigmoid colon and appendix were adherent to the cyst. Left ovary was normal. Uterus was absent. After adhesiolysis, the cyst was found to be smooth and regular and showed no areas of rupture (sealed). As there was no gross evidence of malignancy and features were favoring ruptured endometriotic cyst, hence proceeded with laparoscopy. Cyst was released from surrounding adhesions with bowel and pelvic wall. Bilateral oophorectomy was done after delineating ureteric course by complete bilateral ureterolysis. The cyst was decompressed without spillage inside the endobag. Inner wall was smooth and no solid areas were seen. Specimen was sent for frozen section, which was suggestive of benign endometriotic cyst. Omental and peritoneal biopsies and cytology were taken. Appendix was released from surrounding adhesions and laparoscopic appendicectomy done [Figure 2]. (a) Endometriotic spots on right hemi-diaphragm and omental staining. (b) Chocolate cyst in pelvis Postoperative period was uneventful. She was discharged on the postoperative day (POD) 2. Final histopathology came as endometriotic cyst. She was planned for three doses of GnRH, monthly once. Her CA-125 was 136 U/mL after 2 weeks of surgery. It was again repeated after 2 weeks and value was normal (12.6 U/mL). Ultrasound was normal. After three doses of injection GnRH, she was given tablet Dienogest for 2 years. She is still on regular annual follow-up and is doing well [Figure 3]. Postoperative ultrasound - Uterus and ovaries absent. No pelvic collection Case 2 This 29 years, nulligravida, married for 3 years presented with complaints of pain abdomen and persistent vomiting for 2 days. She had a history of abdominal distension and loss of appetite for the past 2 months. She complained of severe dysmenorrhea with dyschezia for past 2 years. On examination, vitals were stable. Tense cystic mass was occupying whole abdomen up to epigastrium. On vaginal examination, tense cystic mass felt in POD, severe tenderness present, POD Scarring, and fibrosis present. Ultrasound was done outside-suggestive of huge bilateral endometriotic cysts. Magnetic resonance imaging (MRI) was done which was suggestive of huge endometriotic cysts with features of acute proximal small bowel obstruction and moderate left-sided hydro-ureteronephrosis [Figure 4]. Magnetic resonance imaging – Large endometriotic cysts Her hemoglobin was 9.1 g/dL and one packed red blood cell (PRBC) was transfused preoperatively. CA 125 and CA 19.9 were raised (2190 U/mL and 682.71 U/mL, respectively). C-reactive protein (CRP) was raised to 150 mg/L. The patient was planned for emergency diagnostic laparoscopy. Intraoperative findings were as follows: Chocolate staining of omentum, bowel loops, and undersurface of diaphragm noted. Multiple loops of the small bowel and omentum were adherent to the anterior abdominal wall. After releasing omental and bowel adhesions, huge cyst visualized, measuring approximately 20 cm × 18 cm. Omentum and bowel loops were adherent to the cyst wall. On the left side, the cyst was adherent to the left lateral abdominal wall with omentum adherent to it, appeared like sealed perforation. On releasing the adhesions between the cyst and the abdominal wall, thick chocolate-colored material was drained from the cyst which was suggestive of endometriotic cyst. After decompression, the cyst was seen arising from the left ovary, replacing entire ovary. After decompression, the cyst appeared multiloculated. One large loculus measuring 10 cm × 8 cm was seen extending up to right adnexa. Another large loculus measuring 10 cm × 10 cm was noted extending up to POD was found to be densely adherent to left lateral pelvic wall and posterior surface of uterus, to rectosigmoid medially and left uterosacral ligament inferiorly. Left ureter was pulled medially and was seen densely adherent to the cyst wall. Left complete ureterolysis done by the medial approach. Left ureter identified by indocyanine green (injected cystoscopically in retrograde manner into bilateral ureters). After ureterolysis, left ureter was found to be decompressed, appeared to be relieved form the distal obstruction. Surface of the cyst appears smooth, no surface excrescences. Left fallopian tube was dilated and thickened with altered coloured blood as content - s/o hematosalpinx. Left salpingo-oophorectomy done. On right side, another cyst measuring approximately 10 cm × 8 cm was seen arising from right ovary replacing almost entire ovary. The cyst was adherent to the right lateral pelvic wall and to posterior surface of uterus. While releasing the cyst from surrounding adhesions, Thick chocolate- coloured material was drained which is classical of endometriotic cyst. Right endometriotic cystectomy done. During cystectomy, the cyst wall was found to be thick and was densely adherent to the ovarian cortex. Right tube was normal. Uterus was mildly bulky with diffuse adenomyosis of posterior wall. Anterior pouch appeared normal. Right ovary reconstructed using 2-0 vicryl. specimen in the endobag retrieved via suprapubic mini-laparotomy incision. Endpmetrial biopsy was taken. At the end of the procedure, bilateral ureteric peristalsis noted [Figure 5]. (a) Multiple bowel loops adherent to anterior abdominal wall. (b) Large left endometriotic cyst with mesentry of sigmoid adherent to its surface. (c) ICG used for ureteric identification. (d) Left endometriotic cyst adherent to sigmoid colon Patient was doing well and was started on soft diet on POD 3. She was discharged on POD 5 after completing antibiotic course. Histopathology was consistent with endometriosis. Three doses of injection Goserelin were given, monthly once. CA125 and CA 19.9 levels were normal after 2 weeks. Case 3 A 41-year-old female presented to us with complaints of sudden onset severe abdominal pain and vomiting for the past 1 day. She had no history of fever. Bladder and bowel habits were normal. She had a history of new-onset severe dysmenorrhea for the past 6 months, which patient had ignored and was taking over-the-counter analgesics on her own. She did not have any systemic comorbidity. There was no significant family history. On examination, she had tachycardia (pulse rate – 125 beats/min) and tachypnea (respiratory rate – 32/min). She was febrile (temperature 101.4°F) and her blood pressure was normal (140/80). On per abdominal examination, abdomen was distended. There was diffuse tenderness in whole abdomen and guarding was present. On vaginal examination, severe POD tenderness and cervical motion tenderness were present. There was POD scarring. Rectal mucosa was free on rectal examination. Baseline blood investigations were done. Her hemoglobin was 9.6 g/dL. She had leukocytosis - total leukocyte count was 16,800 cells/mm3. CRP was raised (225.2 mg/L). CECT was done. There wa s adenomyosis of the uterus. A well-defined hypoechoic lesion measuring 7.2 cm × 2.6 cm seen in the region of left adnexa – Probably enlarged left ovary. Possibilities torsion/ruptured endometriotic cyst. Thickened omentum with minimal to moderate ascites. CA 125 was 1420 u/mL. CA 19.9 and CEA were normal. Due to the clinical suspicion of torsion/ruptured endometriotic cyst, she was taken for emergency diagnostic laparoscopy. Around 1 L of altered colored blood stained fluid in abdomen cavity seen in pelvis, para colic gutter up to peri-hepatic space. Chocolate-colored material staining of omental and peritoneal surfaces noted. Inflammatory bowel adhesions to anterior abdomen wall present. Left ovary replaced with large 10 cm × 8 cm endometriotic cyst adherent with the left side posterior leaf of the broad ligament, posterior surface of uterus, and anterior wall of sigmoid colon and plastered inferiorly with anterior surface of rectum. The cyst was smooth and regular. There was small rent in the cyst wall. Since left ovarian cyst was densely adherent with sigmoid and anterior wall of rectum proceeded with cystectomy after deroofing of the cyst. The residual cyst wall left over near rectum, as it was densely adherent. Right ovary adherent with posterior surface of the uterus and lateral pelvic wall-released with harmonic- and small endometriotic cyst 3 cm × 3 cm excised. Intraoperative 1 PRBC transfused [Figure 6]. (a) Chocolate coloured fluid under diagpragm. (b) Left ovarian endometriotic cyst deroofing being done Postoperative period was uneventful. She was discharged on second POD. CA-125 was normal after 2 weeks of surgery. Ultrasound was done after 2 weeks which was normal. Final histopathology came as endometriotic cyst and three doses of GnRH, monthly once were given followed by tablet dienogest for 2 years. She is doing well and is on regular follow-up with us [Figure 7]. Postoperative ultrasound - Uterus and ovaries normal

Spontaneous rupture of an endometriotic cyst is an uncommon occurrence, with only a limited number of cases documented, most of which are linked to early pregnancy. The cause of an endometrioma rupture is believed to be related to the increasing size of the ovarian cyst and the rising pressure within it, which are indicative of the rapid growth and proliferation of endometrial tissue.[13] During pregnancy, endometriomas may undergo decidualization, becoming softer and more fragile due to the pressure exerted by the cyst and the expanding uterus.[14] The clinician must distinguish a ruptured endometrioma from other gynecological conditions, including pelvic inflammatory disease, tubo-ovarian abscess rupture, or corpus luteum rupture. In addition, nongynecological causes, such as a ruptured appendix, diverticulitis, bowel obstruction, or perforation of a hollow organ, must also be ruled out. Endometrioma rupture should be included in the differential diagnosis of young females with acute abdominal pain and previous known ovarian cysts. The level of CA-125, a tumor-associated antigen, assists in the preoperative distinction of benign versus malignant ovarian tumors. Malignancy cannot be ruled out when the level is >300 IU/mL,[15] so a detailed history and survey are justified. All the three cases had an extremely high serum CA-125 level on the day of evaluation, which decreased to normal after laparoscopic enucleation of the ovarian tumor. This is in concurrence with an earlier report of a 24-year-old woman with a ruptured endometrioma with an extremely elevated serum CA-125 concentration mimicking ovarian malignancy and a rapidly decreasing serum CA-125 level after surgery.[16] Kurata et al.[17] presented a case of bilateral ovarian endometrioma rupture with an elevated CA-125 level in the serum (9537 IU/mL) as well as in the peritoneal fluid (16,000 IU/mL). They suggested the possibility of ascites-serum exchange involving the transfer of endometriotic cyst fluid throughout the peritoneal surface into the systemic circulation, resulting in an extremely high serum CA-125 level corresponding to the high level in the peritoneal fluid. This hypothesis can help explain why serum CA-125 levels in endometriosis can occasionally be as high as those observed during malignancy. It has been suggested that serum CA-125 levels are significantly higher in patients with more extensive adhesions to the peritoneum, omentum, ovary, fallopian tube, colon, and cul-de-sac or in those with a ruptured endometrioma.[18] From a clinical perspective, the presentations in our case series were varied. While some patients experienced sudden onset of severe pain, others had subacute symptoms, including abdominal distension. The variability in clinical presentation underscores the necessity of maintaining a high index of suspicion for endometriotic cyst rupture in reproductive age women with a history of dysmenorrhea, pelvic pain, or prior endometriosis-related surgeries. Imaging studies, including ultrasound and CECT or MRI, were instrumental in the preoperative evaluation. However, definitive diagnosis and treatment were achieved through laparoscopy, which provided both diagnostic clarity and therapeutic benefit. The presence of chocolate-colored peritoneal fluid and adhesions was a hallmark intraoperative finding, confirming the diagnosis of ruptured endometriotic cysts. Laparoscopic management remains the gold standard for endometriotic cysts, including those with rupture, due to its superior visualization, reduced postoperative morbidity, and faster recovery compared to open surgery. Postoperative medical therapy with GnRH agonists followed by long-term hormonal suppression with dienogest was administered in all cases to reduce recurrence risk. The normalization of CA-125 levels postoperatively further confirmed the benign nature of the lesions and the effectiveness of the interventions.

Ruptured endometriotic cysts, although rare, should be considered in the differential diagnosis of the acute abdomen in women with a history of endometriosis. Timely recognition and laparoscopic intervention can lead to favorable outcomes while minimizing complications. A multidisciplinary approach, including surgical expertise and long-term hormonal management, is essential to prevent recurrence and preserve reproductive potential when possible. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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