A Case of Hemorrhagic Ascites Due to Endometriosis

Purpose: Introduction: The differential diagnosis for hemorrhagic ascites is limited; however, in women of child bearing age this must include endometriosis. Case Presentation: A 26 year-old nulliparous Nigerian woman presented with symptoms of abdominal distention and recurrent ascites for 2 years. Paracentesis revealed the following: WBC 200, Lymph 22%, RBC 660,000, SAAG 1.3, total protein 4 g/dL, LDH >1000 IU/mL, glucose <3 mg/dL, normal amylase and triglyceride. Cytology was negative for malignancy. Culture and PCR of the fluid were negative for TB although adenosine deaminase (ADA) level was elevated at 50 IU/L. She had a negative PPD and HIV testing. Chest X-ray, CT abdomen and pelvis were also negative. Workup for chronic liver disease was unremarkable despite the elevated SAAG. Laparoscopy revealed multiple areas of mucinous bubbles attached to the ovary and fallopian tube. The ovaries, fallopian tubes and uterus were all adherent with normal omentum and liver. Biopsies of the peritoneal implants showed fragments of tissue consistent with endometriosis in the secretory phase. She was started on 6 months of therapy with GnRH agonist; however, despite the cessation of menses she continued to have recurrent hemorrhagic ascites. Discussion: Hemorrhagic ascites due to endometriosis is a rare condition with only about 50 cases reported to date. Most cases are found in the surgical and gynaecological literatures as a diagnostic laparoscopy is almost always needed to exclude more serious conditions such as malignancy and peritoneal tuberculosis. Since most gastroenterologists have not encountered this condition it is important to keep this in mind when seeing a young woman of child bearing age with hemorrhagic ascites given it is treatable and can have a negative effect on fertility. Most reported cases involve black nulliparous women and about one quarter of patients has concurrent pleural effusion from endometriosis. These patients suffer from infertility due to anatomical distortions from endometrial implants and ascites. Common symptoms include worsening abdominal pain and distention corresponding to the menstrual cycle. In addition, it is common to have a long-standing history of dysmenorrhea. Therapy aims to temper the effect of estrogens on the endometrial tissue either medically with GnRH agonist or surgically by excising endometrial implants with or without a total abdominal hysterectomy and bilateral oophorectomy. Conclusion: Severe endometriosis resulting in hemorrhagic ascites is a rare condition that should be considered in otherwise healthy women of child bearing age given treatment availability and the impact on fertility.