Case report Abdominal Wall Endometriosis Presenting as a Bloody Mass in a Patient with a History of Four Cesarean Section

I report the case of 39-year-old married female, gravida 7 para 4 ( all were delivered by cesarean section ) last one 7 years ago and 3 miscarriages. She presented to me at her 1st visit at 30th of November 2024 with sever chronic and cyclical abdominal pain with painful, bloody mass in the abdominal wall and menorrhagia The lesion exhibited cyclical changes with menses and was associated with elevated serum estrogen levels. and CA125 A thorough clinical evaluation, imaging studies including ultrasound and CT scan, as well as hormonal assays, led to the diagnosis of abdominal wall endometriosis.

Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity. Cesarean scar endometriosis is a rare complication typically it affecting less than 1% of women who have had a cesarean section It occurs when endometrial tissue, grows in the scar tissue from the cesarean section. The exact cause of CSE is unknown, but it is thought to be related to the surgical procedure itself. During a cesarean section, the uterus is opened and there is a risk of endometrial tissue being implanted in the abdominal wall. This tissue can then grow and cause this dramatic condition. Here, I describe a rare presentation of abdominal wall endometriosis forming a bloody, cyclically active mass in a cesarean section scar. Case Presentation: Patient Profile: -Age: 39 years -Gravida 7, Para 4, miscarriage 3 -Past surgical history: 4 lower segment cesarean sections Chief Complaint: 39 y old women she presented to me at her 1st visit at 30th of November 2024 with sever chronic and cyclical abdominal pain and progressively enlarging, painful mass on the anterior abdominal wall with periodic bloody discharge from the overlying skin, exacerbated during menstruation with heavy menstrual period . Clinical Examination: -Vital signs: BP : 100\60 mm.hg PR: 110 b\m Temp.: 36,4 c -Local exam: A firm, tender, palpable lower abdominal mass approximately 8 x 7 cm located near the previous cesarean scar with skin involvement showing a bloody discharge. with cauliflower hyperpigmented skin lesion that is bleeding to touch. She complains of irregular menstrual cycle and menorrhagia. She was irritable, confused and worried regarding her condition. Investigations: 1. Laboratory Findings: CBC: anemic , Hg 9.3 mg\dl Serum Estradiol: Elevated 182.2.pg\ml CA-125: at 30-11-2024 which is the date of her 1st visit, was highly elevated, 137.3 u\ml normal range was <35 CA-125 at 31-12 -2024 which is the date of her 2nd visit was 21.8 u/ml , normal range was <35 CA-125 at 30-1- 2025 which is the date of her 3rd visit was 11.9U/ml normal range was <35 2. Ultrasound (Abdominal Wall): By 1st ultrasound at 8th of august 2023 the mass was (71 x 21)mm By 2nd ultrasound at 20th of august 2023 the mass was (51 x 19)mm By 3rd ultrasound at 27th of November 2023 the mas was (68 x 27)mm At 27th of April 2024 a hypoechoic heterogenous mass ( 9.5 x3.3 x 6.7) cm with irregular borders and internal vascularity located within the rectus sheath and anterior to the fascia, consistent with soft tissue lesion. All these readings were before 30th of November 2024 before the patient visiting me At 31 December 2024 while I treat the patient medically the US finding were show big regression of the mass to (38 x 35)mm, At March 15, 2025 the US report were show good response to treatment and the mass become ( 21x 12 mm) At in: 30 January 2025 the magic response was be report by the last US and the mass completely regressed to (14 x 13 mm ) and the skin lesion get complete healing and the patient completely cured : she had no abdominal pain , no bleeding no skin lesion no abdominal mass 3. Contrast-Enhanced CT Scan: At 2nd of December and before I will start treating the patient A well- demarcated soft tissue mass measuring ( 6.5 x 2.7 x 6 cm ) located within the anterior wall rectus abdominis muscle and rectus sheath. The mass enhanced heterogeneously post-contrast and was inseparable from the cesarean section scar. Provisional Diagnosis: Abdominal wall endometriosis (scar endometrioma) Management: The patient underwent full medical care inform of stabilization of her general condition. I start with her medical treatment and she got very good response inform of clinical features, laboratory investigation and ultrasound finding. surgical excisional biopsy was done to confirm he diagnosis Histopathology: Confirmed the presence of endometrial glands and stroma within fibrous tissue, consistent with endometriosis. Outcome and Follow-up: After 3 months of medical treatment recovery was uneventful. The mass was magically regressed, by late US was ( 11 x 12 mm ) and blood test marker was At 3-month and 5-month follow-ups, the patient reported complete resolution of the symptoms, including cessation of cyclic pain, bleeding and discharge. Following several weeks of treatment, and follow up the cured laboratory test showed magic improvement No evidence of recurrence on follow-up ultrasound.

Abdominal wall endometriosis is a rare but important differential in patients with cyclical pain and masses near cesarean section scars. Diagnosis may be missed due to nonspecific symptoms. Imaging, hormonal assays, and surgical histopathology are key to diagnosis. The medical management is the treatment of choice with excellent prognosis.

In women with a history of cesarean section presenting with a painful, bloody abdominal wall mass, abdominal wall endometriosis should be considered. A multidisciplinary approach including imaging, hormonal studies, and medical and surgical intervention leads to effective management and recovery. Documentation :