S2553 Endometriosis: A Rare Cause of Ascites

INTRODUCTION: Ascites is the pathological accumulation of fluid within the peritoneal cavity. These are mostly due to portal hypertension resulting from cirrhosis but there are non cirrhotic rarer causes of ascites. It is important to investigate the etiology of non-cirrhotic ascites as treatment of the underlying etiology can reverse it. CASE DESCRIPTION/METHODS: A 34-year-old female with history Cerebral Palsy presented to the clinic with 3 months of increasing abdominal distention. No associated jaundice, changes in urine color or constitutional symptoms. Examination revealed 10 cm reducible umbilical hernia along with abdominal fullness. No signs of portal hypertension or cirrhosis noted. Labs showed normal metabolic panel, blood counts and coagulation profile. Abdominal ultrasound revealed moderate to large ascites with nodular liver suggesting developing cirrhosis. She underwent paracentesis with removal of 5 liters of black-brown colored fluid showing many RBCs, 500 WBCs, Albumin of 3.5, Protein of 5.8, LDH of 978, SAAG of 0.6 and negative cytology. CT scan showed large abdominal and pelvic ascites, nodular liver and a 7 × 7 cm pelvic mass. MRI showed multiseptated pelvic collection with solid component in the right adnexal region. She underwent an exploratory laparoscopy with a right salpingo-oophorectomy and adnexal mass biopsy. Pathology showed ovarian fibroma with endometriosis. Follow up 3 months into the surgery, the patient was doing well and had no ascites. DISCUSSION: Cirrhosis is the most common cause of ascites. Ovarian fibroma and endometriosis are some of rare non cirrhotic causes as seen in this case. Ascites related to endometriosis was first described in 1954. A systematic review noted 63 cases with endometriosis related ascites between 1950 to 2010 who were mostly nulliparous women of African origin of ages 19 to 51 years. Diagnosis of endometriosis is usually delayed as it mimics gynecological malignancy and requires surgical exploration. Bilateral oopherectomy is the definite treatment. Here, right salpingo-oophorectomy was considered per patient preference. Ovarian fibromas are benign sex cord-stromal tumours seen in postmenopausal women which can present with ascites as a component of Meigs syndrome. Atypical causes such as these need to be considered especially in the young nulliparous females. Peritoneal fluid analysis and imaging may be misleading as they both can mimic malignancy, hence surgery is diagnostic. Therefore a broader differential is critical in evaluating ascites.Figure 1.: Initial CT scan of abdomen and pelvis with IV contrast showing soft tissue density structure within the anterior midline pelvis measures 6.5 × 7.5 × 7 cm.