Primary Umbilical Endometriosis: Case Report

Endometriosis is a benign condition that occurs during the productive age in women However, one of the r are disorders of endometriosis location -wise is the umbilical endometriosis. Umbilical endometriosis had been into divided primary and secondary umbilical endometriosis depending on the causes; either after laparoscopic or open procedures which are secondary. The primary happened unexpectedly. MRI sensitivity is superior to detecting small lesions. According to a study done in 2002, MRI sensitivity and specificity to detect biopsy -was proven 69% and 75%. In this case report, the patient was a 38 - year-old si ngle girl with primary umbilical endometriosis. For treatment, most cases with umbilical endometriosis have been treated with surgery. However, treatment with medication needs to be researched and requires more investigation. Key words: Primary umbilical endometriosis; Gynecology; MRI.

The presence of endometrial tissue outside the uterine cavity is called endometriosis. It affects 10 -15 % of the female population worldwide. Endometriosis is a benign condition that occurs during the productive age in women. However, endometriosis can be located in different anatomy parts such as ovarian fossa, pelvic, and bladder. However, one of the rare disorders of endometriosis, location-wise, is in umbilical [1]. Umbilical endometriosis had been divided into primary and secondary umbilical endometriosis depending on the causes, either after laparoscopic or open procedures, which is secondary umbilical endometriosis. The primary happens unexpectedly. The first-time umbilical endometriosis was mentioned was in 1886 by Villa r [1]. For this Medical Imaging Department King Saud Medical City Ulaishah, Riyadh, Saudi Arabia *Corresponding Author: Musab Atif Alamri, MD, Body Imaging Consultant, King Saud Medical City Ulaishah, Riyadh, Saudi Arabia. Received Date: 03-12-2023 Accepted Date: 03-20-2023 Published Date: 04-12-2023 Copyright© 2022 by Alamri MA, et al . All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Alamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report Citation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: Case Report. J Clin Med Res. 2022;5(1):12-16. DOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 reason, the term Villar’s nodule was used to describe patients with primary umbilical endometriosis [2]. Nevertheless, the pathophysiology of primary umbilical endometriosis is undetermined [2]. In addition, primary umbilical endometriosis is rare compared with secondary umbilical endometriosis. According to Fernandes et al, the frequency of 0.5% to 1% of all patients is with endometrial ectopia [3]. Common symptoms are flesh colored nodules, in some cases red, or brown nodules, pain, bleedi ng, and swelling. The pain and swelling will increase during menstruation [2]. A systematic review done in 2022 established that 66% and 43.3% of cases with umbilical endometriosis symptoms were abdominal pain and bleeding from the umbilical area . Unfortunately, umbilical endometriosis symptoms match with other pelvic disorders such as pelvic infections, nongynecological, urologic, and gastrointestinal [4]. In fact, umbilical endometriosis can be associated with pelvic endometriosis; 20% of patients with pr imary umbilical endometriosis have been diagnosed with pelvic endometriosis, as well [6]. Ultrasound and magnetic resonance imaging (MRI) can be helpful to diagnose umbilical endometriosis; however, MRI sensitivity is superior to detect small lesions. According to a study done in 2002, MRI sensitivity and specificity to detect biopsy - proven was 69% and 75%. The study was done on 36 women and the detection was confirmed in 25 women [4]. Regarding treatment, most cases with umbilical endometriosis have been t reated with surgery [5 ,6]. However, another option was mentioned in some cases which is medical therapy, even though medical therapy is not widely used and performed as often as surgical solution. In fact, until 2007, there were 5.9% of the cases reported that underwent medical therapy. On the other hand, the majority of the cases (67.6%) underwent surgical approach [7]. In this case report, the patient was a 38 -year-old single girl with primary umbilical endometriosis. Case report A 38-year-old single women present to King Saud Medical City gynecology clinic referred from primary health care complaining of severe pain, swelling, and bleeding from the umbilical area. The patient had experienced these symptoms since 2021 and decided to come to the hospital in July 2022. In addition, visually, the patient has a blackish colored nodule in the umbilicus (Fig ure 1). The bleeding and pain increased every month, associated with the menstruation. The patient did not have any surgery or procedure before. Mo reover, the patient did not have any trauma in the interested area. The gynecologist highly suspects the patient has primary umbilical endometriosis based on the symptoms. For further confirmation, the patient was sent to do pelvic MRI with contrast. MRI was done on a 3T magnet (Siemens) by using a pelvic coil resulting T2 weighted sequences and T1 fat suppressed. Sagittal and transverse T2 weighted fast spin were taken. In addition, there were transverse and sagittal T1 weighted spin echo images. The slide thickness was 5 mm and intravenous contrast material (Gadolinium) was injected 0.2 mL/kg. Alamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report Citation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: Case Report. J Clin Med Res. 2022;5(1):12-16. DOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 The matrix size was 256 × 192, and the field of view was 35 cm. The patient was injected with 20 mg IM Buscopan before the scan acquisition. Figure 1: Umbilical Endometriosis, with active bleeding during the menstrual period. blackish colored nodule in the umbilicus. The first MRI report on 28th of June 2022 indicated the bilateral ovaries are adherent to the posterior uterine wall associated with hemorrhagic component, representing bilateral ovarian endometrioma. It measured1.7 × 2.1 cm for the right side and 1.7 × 0.9 cm for the left side. The lesions show bright signal intensity in T1 -weighted images (Fig ure 2A) and shading in T2 - weighted images (Fig ure 2B). with no enhancement on post -contrast subtracted images. No signs of malignant transformation. There is a linea r plaque-like lesion seen on the posterior uterine wall associated with tethering of rectal wall representing deep pelvic endometriosis. There was also a well -defined umbilical lesion seen in a few sequences. It measured 1.2 × 1 cm and showed int ermediate to low signal intensity in T2 -weighted images, and bright signal intensity in T1 post -contrast images (Fig ure 2C), representing umbilical endometriosis. Figure 2: MRI (A) Axial precontrast T1 WI, and (B) Axial T2 WI shows bilateral ovarian endometrioma and deep pelvic endometriosis. (C) Axial T1 post contrast show umbilical small hemorrhagic lesion represent endometriosis. Alamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report Citation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: Case Report. J Clin Med Res. 2022;5(1):12-16. DOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128 The gynecologist presented the surgical option to the patient. The patient refused and started an oral hormonal therapy (Dienogest): one tablet 2 mg daily. However, the patient had another MRI on September 1st, 2022, to evaluate the progress. The second MRI showed slight interval reduction in the size of the umbilicus nodule (Fig ure 3 a and b), currently measuring 0.8 × 0.8 cm (was 1.3 × 0.9 cm). No intra -abdominal extension, sinus or fistulous tract formation. Figure 3: Follow up MRI after three months post Dienogest treatment. A and B axial T1 pre and post contrast images, showed slightly reduction in the size of the umbilicus endometriosis (comparison with Figure 2C).

Endometriosis is a benign condition that occurs during the productive age in women However, one of the rare disord ers of endometriosis location-wise is the umbilical endometriosis [1]. Umbilical endometriosis had been into divided primary and secondary umbilical endometriosis depending on the causes; either after laparoscopic or open procedures which are secondary. Th e primary happened unexpectedly. The first -time umbilical endometriosis was mentioned was in 1886 by Villar [1]. For this reason, the term Villar’s nodule was used to describe patients with primary umbilical endometriosis. The common symptoms are flesh col ored nodules, in some cases red, or brown nodules, pain, bleeding, and swelling. The pain and swelling will increase during menstruation [2]. MRI sensitivity is superior to detecting small lesions. According to a study done in 2002, MRI sensitivity and specificity to detect biopsy -was proven 69% and 75%. The study was done on 36 women and the detection was confirmed in 25 women [4]. For treatment, most cases with umbilical endometriosis have been treated with surgery [5]. In this case, the patient rejected the surgical option and preferred a hormonal treatment. According to the three MRI done during different periods of time, there was noticeable slight reduction in the size of the umbilicus nodule between the pretreatment MRI and the second. The patient’s pain decreased, and the bleeding stopped. This result was observable on t he patient after one month of the treatment. Alamri MA | Volume 5; Issue 1 (2023) | Mapsci-JCMR-5(1)-128 | Case Report Citation: Alamri MA, Abdulwhab Asiri JA, AlRizqi AA, Alasmri SA, Alzahrani AA . Primary Umbilical Endometriosis: Case Report. J Clin Med Res. 2022;5(1):12-16. DOI: https://doi.org/10.37191/Mapsci-2582-4333-5(1)-128

Primary umbilical endometriosis is a very rare disorder, particularly in single nulliparous patients. According to the literatures, surgical option is recommended and offers a satisfactory result. However, medical treatment needs to be researched.

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