Hemorrhagic ascites endometriosis could be a cause: a case report

Background: Endometriosis is a condition in which tissue similar to the lining inside the uterus (called “the endome- trium”) is found outside the uterus, where it induces a chronic inflammatory reaction that may result in scar tissue. Endometriosis with massive ascites causing abdominal distension and other symptoms simulating malignancy has been described in the literature. Case presentation: A case of a 27-year-old woman who presented to the Ascites Study Group Tropical Medicine department Ain Shams University in collaboration with the Egyption Club of Ascites (ECA) with increased central abdominal contour, shifting dullness, and hemorrhagic transudate hypocellular ascites with no malignant cells and bilateral ovarian cysts. A long stepwise approach was conducted to the patient, and after exclusion of other causes of hemorrhagic ascites, the patient was prepared for laparoscopy. The diagnosis of endometriosis was made. The patient was discharged on goserelin acetate subcutaneous injection every 28 days with good response, and she regularly follows up with our study group on scheduled visits monthly according to her clinical status.

Endometriosis could be a possible cause of massive hemorrhagic obscured ascites. The unexplained infertility should increase the probability of the endometriosis.

Ascites, Endometriosis, Infertility, Ovarian cyst, Case report © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

Endometriosis is a condition in which tissue similar to the lining inside the uterus (called “the endometrium”) is found outside the uterus, where it induces a chronic inflammatory reaction that may result in scar tissue [1]. It is primarily found on the pelvic peritoneum, on the ovaries, in the recto-vaginal septum, on the bladder, and bowel [2, 3]. In very rare cases it has been found on the diaphragm and in the lungs [4]. Endometriosis affects an estimated 1 in 10 women dur - ing their reproductive years (i.e., usually between the ages of 15 and 49), which is approximately 176 million women in the world [5, 6]. Moreover, the diagnosis of extra-pelvic endometrio - sis is even more difficult given the variety of symptoms, signs, and locations [7]. Although in some instances, endometriosis can be diagnosed noninvasively, difficulty may be encountered in patients who lack typical symp - toms or radiographic signs. Hemorrhagic ascites due to endometriosis is an exceed- ingly uncommon diagnosis rarely reported in the medical literature [8]. Open Access The Egyptian Journal of Internal Medicine *Correspondence: [email protected] 1 Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt Full list of author information is available at the end of the article Page 2 of 3Abdelkader et al. The Egyptian Journal of Internal Medicine (2021) 33:50 Endometriosis with massive ascites causing abdominal distension and other symptoms simulating malignancy has been described in the literature [9–11]. Case presentation We present a case of a 27-year-old woman who pre - sented to the Ascites Study Group Tropical Medicine department Ain Shams University in collaboration with Egyptian Club of Ascites (ECA)  for abdominal enlarge - ment and was found with increased central abdominal contour, shifting dullness, and hemorrhagic transudate hypocellular ascites with no malignant cells and bilat - eral ovarian cysts. This picture was suggestive of an ovarian hyper-stimulation syndrome. There is no his - tory of the problematic menstrual cycle, but she was infertile for 6 years of an unknown obvious cause. A long stepwise approach was conducted to the patient and after exclusion of other causes of hemorrhagic ascites, the patient was prepared for laparoscopy. And the result showed that there is grade III to IV pelvic endometriosis and right ovarian endometrioma, left ovarian surface lesion that was biopsied also, perihe - patic adhesions and encysted peritoneal adhesions in Douglas pouch, and its wall was biopsied too. The ovarian biopsy didn’t show any abnormality and the adhesion wall biopsy revealed hyalinized fibrovascular connective tissue. The patient was discharged on goser - elin acetate subcutaneous injection every 28 days with good response and she regularly follows up with our study group on scheduled visits monthly according to her clinical status.

Endometriosis affects an estimated 1 in 10 women during their reproductive years [5 , 6]. Concern recent review and analysis of previous cases found that 63% of women were of African ancestry, and 82% were nul - liparous [12]. However, the difficulty to reach a definite diagnosis is related to the other late presentable causa - tive diseases such as tuberculosis, pelvic malignancy, and peritoneal metastases. Therefore, to reach the diag - nosis, an invasive maneuver is mandatory especially in the absence of typical presentation related to endome - triosis. The Definitive management consists of surgical resection of endometriotic tissue alone or combined with the complete surgery (hysterectomy with oopho - rectomy) or long-term hormonal suppression therapy [13]. In young multi-parous patients, it is preferred to use long-term hormonal suppressive therapy to pre - serve fertility in some cases.

Endometriosis could be a possible cause of massive hemorrhagic obscured ascites. Hemorrhagic ascites should be considered a complication of endometrio - sis, especially in nulliparous women of the childbearing age group with an abdominal distension, a pelvic mass, dysmenorrhea, and abdominal pain, even if there is no typical presentation of the endometriosis along the menstrual history of the case.

Not applicable Authors’ contributions NA analyzed and interpreted the patient data regarding the hepatological and radiological findings and read and approved the final manuscript. AF collected the data and followed up with the patients clinically. ES was a major contribu- tor in writing the manuscript. MS read and approved the final manuscript. ST analyzed and interpreted the patient data regarding the gynecological disease. MAS analyzed and interpreted the patient data regarding the hepa- tological and radiological findings. The author(s) read and approved the final manuscript. Funding No funding was received. Availability of data and materials Not applicable Declarations Ethics approval and consent to participate Not applicable Consent for publication Written consent to publish this information was obtained from study participants. Competing interests The authors declare that they have no competing interests. Author details 1 Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt. 2 Founder of the Egyptian Club of Ascites (ECA), Cairo, Egypt. 3 Department of Internal medicine, Faculty of Medicine, Sohag University, Sohag, Egypt. 4 Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Received: 28 May 2021 Accepted: 25 June 2021

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