Endometriosis Presenting as Recurrent Massive Ascites

Endometriosis typically presents as dysmenorrhea, pelvic pain, dyspareunia, and infertility. Less common clinical presentations of endometriosis from implantation on the kidney, lung, or colon include hematuria, pleural effusions and hemoptysis and gastrointestinal bleeding. Ascites complicating endometriosis is rare. We report an unusual case of endometriosis presenting as recurrent massive ascites. A 30 year old African-American woman with worsening abdominal pain and distension over 2 months presented to the emergency room. The patient had a history of abdominal distension and pain occuring with every menses for several years. the symptoms had always resolved at the end of each menstrual cycle. Over the two months prior to presentation, the abdominal distension did not subside. After developing worsening abdominal pain, she presented to the emergency room for evaluation. She denied any nausea, vomiting, diarrhea, jaundice, or fever. Past medical history was significant for an elective abortion 7 years prior. Menarche had occured at age 13 with subsequent regular cycles, no excessive bleeding. On physical examination, she was a healthy female in mild distress. She has a grossly distended abdomen with mild diffuse non-localizing abdominal tenderness, no stigmata of liver disease and no lower extremity edema. Laboratory studies were significant for a mild normocytic anemia. The remainder of the laboratory findings, including liver function tests, was normal. CA-125 was within normal limits. Pregnancy test was negative. Computer assisted tomography of the abdomen and pelvis revealed ascites, but no other significant intra-abdominal pathology. A paracentesis was performed. Four liters of serosanguinous fluid was aspirated. Fluid white cell count was 1650 cells/mm3 with a differential of 88% neutrophils. Red blood cell count in the fluid was 110,000 cells/mm3. Fluid albumin was 3.2 g/dL. total protein 5.4 g/dL. Cytology was negative. With an absence of an etiology for the ascites, the patient underwent diagnostic laparoscopy. Laproscopic exam was grossly normal, random biopsies revealed endometrial proliferative tissue. This case demonstrates that endometriosis should be considered in the differential diagnosis of ascites. The diagnosis may be difficult, and as this case demonstrates, random biopsies of the peritoneum may be necessary in establishing the diagnosis.