Massive recurrent hemoperitoneum with encapsulating peritonitis: another enigmatic clinical feature of endometriosis

OBJECTIVE: To describe the clinical characteristics and laparoscopic findings of a very uncommon presentation of a patient with endometriosis. DESIGN: Video presentation of case report (Canadian Task Force classification III). (The institutional review board of the Hospital Naval Pedro Mallo, Buenos Aires, Argentina, has ruled that approval was not required for the publication of this case report.) SETTING: Hospital. PATIENT(S): Thirty-two-year-old woman with endometriosis presenting with hemorrhagic ascites. INTERVENTION(S): We demonstrate the laparoscopic appearance of the peritoneal organs in the presence of massive hemoperitoneum and encapsulating peritonitis and also describe the diagnosis and management options of an uncommon clinical presentation of endometriosis. The patient is a 32-year-old woman, gravida 0, who presented with abdominal pain and ascites. Initially, she underwent exploratory laparotomy with drainage of 5 liters of ascites and excision of endometrial peritoneal implants. She then presented 4 months later with sudden worsening abdominal pain and distention, weight gain, bloating, and shortness of breath. A diagnostic laparoscopy was performed with the findings of over 10 liters of dark hemoperitoneum and diffuse pelviperitonitis with loose necrotic, easy to remove, dense peritoneal tissue. Patient was started on triptorelin acetate with great response. MAIN OUTCOME MEASURE(S): Resolution of the symptomatology secondary to hemorrhagic peritonitis. RESULT(S): Clinical improvement of symptomatology of a patient with endometriosis and hemorrhagic ascites. CONCLUSION(S): Endometriosis can have different clinical presentations. Endometriosis should be a differential diagnosis in women of reproductive age presenting with massive hemorrhagic ascites. Hemorrhagic ascites, considered an exceedingly rare clinical course of endometriosis, represents a challenge to the surgeon who is unfamiliar with this condition. Bilateral oophorectomy is the definitive treatment, but conservative therapy is indicated for women of childbearing age. Diagnostic laparoscopy with drainage of hemoperitoneum is a feasible option to obtain a pathology-confirmed diagnosis in patients presenting with hemoperitoneum secondary to pelvic endometriosis. Awareness of this condition will prevent unnecessary aggressive resection, as is commonly performed when the condition is confused with ovarian cancer.