Umbilical bleeding during menstruation in status post laparoscopic cholecystectomy of unknown/ambiguous aetiology

Ambreen Mannan, Suhail Ahmed Soomro, Aneeta Kumari, Fauzia Abdul Raheem Memon
In: International Surgery Journal · 2022 · vol. 9(6) , pp. 1250 · doi:10.18203/2349-2902.isj20221419 · W4281718324
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This case report describes a patient experiencing umbilical bleeding during menstruation post-laparoscopic cholecystectomy, with excision relieving symptoms despite inconclusive endometriosis diagnosis.

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This paper reports a single 25-year-old nulliparous woman who developed peri-umbilical pain and cyclical bleeding from an umbilical port scar that occurred specifically with menstruation six months after laparoscopic-assisted cholecystectomy of unclear cause. The authors conducted history, clinical examination, and abdominal/pelvic investigations including hematology, ultrasound, CT, and MRI to rule out other lesions, and excised the umbilical scar tissue for histopathology and immune-histochemistry, which were inconclusive and showed no evidence of endometriosis. The patient’s retrograde menstrual bleeding reportedly improved after total excision despite the diagnostic uncertainty. Relevance to endometriosis: the authors presume secondary umbilical port scar endometriosis as a presumptive extra-pelvic endometriosis explanation but could not confirm it on biopsy/immune-histochemistry, leaving diagnostic uncertainty in this post-laparoscopic setting.

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Abstract

Although umbilical endometriosis is a possible cause of cutaneous manifestation of retrograde menstruation during cyclical bleeding in status post laparoscopic surgery patient, Here in this case we presumed a diagnosis of endometriosis on the basis of its symptoms which couldn’t be proven in biopsy and on immune-histo-chemistry and casted a query that now what is the next possible aetiology which is responsible for umbilical bleeding specifically during menstruation in the patient with status post laparoscopic surgery. We report a case of presumed secondary umbilical port scar endometriosis in a 25-year-old lady nulliparous woman following laparoscopy-assisted cholecystectomy 6 months ago. Remarkably patient complained of peri umbilical pain and menstrual bleeding through umbilicus (retrograde) soon after surgery which was remarkably noticed only during her periodical cycle. History and clinical examination, haematology, ultrasound, computed tomography and MRI of abdomen and pelvis performed to rule out any primary lesions which all were found unremarkable. After counselling the patient about the presumptive causes and treatment options the umbilicus with its surgical scar mark excised and the tissue was sent for histopathological examination which was found inconclusive with no evidence of endometriosis at all. Remarkably it was further scrutinized by immune-histo-chemistry but remained fruitless. Fortunately, patient relieved her symptoms of retrograde menstrual bleeding after total excision of the umbilicus with scar mark post operatively but still left a diagnostic stigma for surgeons.
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Umbilical bleeding during menstruation in status post laparoscopic cholecystectomy of unknown/ambiguous aetiology DOI: https://doi.org/10.18203/2349-2902.isj20221419Keywords: Cyclical umbilical port scar bleeding, Presumptive extra pelvic endometriosis, Post laparoscopic cholecystectomy, Unknown aetiologyAbstract Although umbilical endometriosis is a possible cause of cutaneous manifestation of retrograde menstruation during cyclical bleeding in status post laparoscopic surgery patient, Here in this case we presumed a diagnosis of endometriosis on the basis of its symptoms which couldn’t be proven in biopsy and on immune-histo-chemistry and casted a query that now what is the next possible aetiology which is responsible for umbilical bleeding specifically during menstruation in the patient with status post laparoscopic surgery. We report a case of presumed secondary umbilical port scar endometriosis in a 25-year-old lady nulliparous woman following laparoscopy-assisted cholecystectomy 6 months ago. Remarkably patient complained of peri umbilical pain and menstrual bleeding through umbilicus (retrograde) soon after surgery which was remarkably noticed only during her periodical cycle. History and clinical examination, haematology, ultrasound, computed tomography and MRI of abdomen and pelvis performed to rule out any primary lesions which all were found unremarkable. After counselling the patient about the presumptive causes and treatment options the umbilicus with its surgical scar mark excised and the tissue was sent for histopathological examination which was found inconclusive with no evidence of endometriosis at all. Remarkably it was further scrutinized by immune-histo-chemistry but remained fruitless. Fortunately, patient relieved her symptoms of retrograde menstrual bleeding after total excision of the umbilicus with scar mark post operatively but still left a diagnostic stigma for surgeons. Metrics References Kodandapani S, Pai MV, Mathew M. Umbilical laparoscopic scar endometriosis. J Hum Reprod Sci. 2011;4:150-2. Rahi V, Michael PD, Johns DA. Villar's nodule: a case report and systematic literature review of endometriosis externa of the umbilicus. J Minim Invasive Gynecol. 2007;14(1):23-32. Latcher JW. Endometriosis of the umbilicus. Am J Obstet Gynecol. 1953;66:161-8. Seracettin E, Bedri AP, Semih H, Veli M. Primary umbilical endometriosis: A painful swelling in the umbilicus concomitantly with menstruation. Int J Surg Case Rep. 2016;28:78-80. Dorothy M, Timona O, Steve M, Felix O. Umbilical endometriosis: a case series. J Med Case Rep. 2020;14:142. Munkres B, Espinet M. Umbilical Endometriosis Following Laparoscopic Cholecystectomy. Cureus. 2021;13(4):e14538. Bhowmik DK, Mirza R, Hossain A. Primary Umbilical Endometriosis: Report of a Rare Case. Chattagram Maa-O-Shishu Hospital Med College J Vol. 2014;13(1):67-9. Tangri MK, Prasad L, Bal H, Tewari R, Majhi DM. Scar endometriosis: A series of 3 cases. Med J Armed Forces India. 2016;72(1):S185-8. Susanta M, Tushar SM, Prakash KS, Rakesh S, Bikram R. Umbilical Pilonidal Sinus: A Report of Two Cases and Recent Update of Literature. J Clin Diagn Res. 2016;10(9):PD20-22. Thais JJ, Tatiana J, Jaime P, Osvania M, Nogueira R. Umbilical endometriosis: report of a case and its dermoscopic features. An Bras Dermatol. 2013;88(1):121-4. Mechsner S, Bartley J, Infanger M, Loddenkemper C, Herbel J, Ebert AD. Clinical management and immunohistochemical analysis of umbilical endometriosis. Arch Gynecol Obstet. 2009;280:235-42. Dadhwal V, Gupta B, Dasgupta C, Shende U, Deka D. Primary umbilical endometriosis: a rare entity. Arch Gynecol Obstet. 2011;283:119-20. Vercellini P, Paola V, Edgardo S, Luigi F . Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261-75. Geeta P, Rashmi S, Rave KS, Tushar B. Scar Endometriosis: Diagnosis by fine needle aspiration. J Cytolo. 2015;32(1):65-7. Kyriakos K, Viviana L, Jean K. Spontaneous cutaneous umbilical endometriosis: report of a new case with immune histochemical study and literature review. Dermatol Online J. 2011;17(7):5. Hidetsugu F, Hideki M. Cutaneous endometriosis in the umbilical region: The usefulness of CD10 in identifying the interstitium of ectopic endometriosis. June. 2010;37(6):545-9. Rodolfo HG, Minakshi SS, Sara AH. Cutaneous Endometriosis: A case Report and Review of the literature. AM J Case Rep. 2021;21:22.

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