Hindawi

Case Reports in Obstetrics and Gynecology

Volume 2020, Article ID 8879643, 4 pages
https://doi.org/10.1155/2020/8879643

Case Report
Endometriosis-Associated Massive Ascites in an Asian
Woman: A Case Report of a Rare Clinical Entity

Nuntasiri Eamudomkarn , Naratassapol Likitdee, Pilaiwan Kleebkaow,

and Chumnan Kietpeerakool
Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Correspondence should be addressed to Nuntasiri Eamudomkarn; [email protected]

Received 11 April 2020; Revised 20 July 2020; Accepted 24 July 2020; Published 4 August 2020

Academic Editor: Maria Grazia Porpora

Copyright © 2020 Nuntasiri Eamudomkarn et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.

Massive ascites as a presentation of endometriosis is a rare clinical entity that is most commonly seen in black nulliparous females.
Herein, we describe a case of a 32-year-old multiparous Thai woman who presented with a two-year history of abdominal
distension. Computerized tomography of the abdominopelvic region showed an infiltrative enhancing lesion involving the
cul-de-sac and perirectal region with massive loculated ascites, suggesting carcinomatosis peritonei. Abdominal paracentesis
was performed to yield fluid samples for evaluation, which revealed no malignant cells, and polymerase chain reaction (PCR)
was negative for tuberculosis. The patient underwent exploratory laparotomy which revealed a large amount of serosanguinous
ascites, thickened matted bowel loops, and necrotic debris covering the entire surface of the peritoneum and visceral
organs. The surgical procedures included drainage of 6.5 liters of ascites, lysis adhesion, biopsy of the peritoneum, and
right salpingo-oophorectomy. Histologic examination revealed benign endometrial glands with stroma at the peritoneum
tissue and broad ligament. Other causes of ascites were excluded. The ascites responded to drainage and hormonal
suppression. A final diagnosis of endometriosis was made based on these findings. Endometriosis should therefore be
considered in differential diagnosis in women of childbearing age who present with ascites.

1. Introduction sive ascites, significant weight loss, and peritoneal lesions

mimicking malignancy. For literature review, we searched
Endometriosis is a benign, estrogen-dependent disease PubMed using the following key words; endometriosis,
characterized by endometrial tissue outside the uterine cavity ascites, and pathogenesis.
[1, 2]. Endometrial implantation can be in either the pelvic or
extrapelvic region with the former being more prevalent 2. Case Report
[3, 4]. Clinical presentations vary by endometrial implan-
tation site. Typical symptoms include chronic pelvic pain, A 32-year-old woman, G1P1001, presented with two years of
dysmenorrhea, dyspareunia, and infertility [5]. increasing abdominal distension. She had also experienced
The occurrence of ascites secondary to endometriosis is poor appetite and weight loss. Her menstrual period was
rarely encountered. It appears to occur more often in black regular, and she had neither abnormal vaginal bleeding nor
nulliparous females [6]. Therefore, the accumulation of case pelvic pain.
reports regarding this rare clinical entity, particularly cases Six years prior to this visit, she experienced chronic pelvic
with distinct clinical backgrounds, is necessary in order pain and had been treated with injectable progestin for
to investigate its clinical course. Herein, we report a case clinical suspicion of pelvic endometriosis.
of massive ascites associated with endometriosis in a One year prior to this visit, she had visited the provin-
reproductive-aged Thai woman who presented with mas- cial hospital due to abdominal distension. A computerized
2 Case Reports in Obstetrics and Gynecology

tomography (CT) scan of the abdominopelvic region

revealed a large amount of ascites with peritoneal nodule
and pleural effusion. Abdominal paracentesis and pleural
tapping were performed, which indicated exudative fluid,
but no malignant cells were noted. She was then referred to
another hospital for further work-up. Another CT scan of
the abdominopelvic region was performed, which revealed
circumferential wall thickening at the mid to upper rectum
suggesting rectal cancer with a large amount of ascites and Figure 1: Physical examination revealed a markedly distended
right pleural effusion. Colonoscopy and tissue biopsy at the abdomen secondary to a large amount of ascites.
rectum showed only acute colitis with no dysplasia or malig-
nancy detected. However, she did not return to follow up 3. Discussion
after this operation.
Upon presentation at our hospital, the patient appeared Although endometriosis has been implicated as a precursor
chronically ill and emaciated with a body mass index of for certain types of epithelial ovarian cancer [7, 8], the
14.9 kg/m2. Her abdomen was markedly distended due to a occurrence of ascites secondary to endometriosis is rarely
large amount of ascites (Figure 1). There were no masses or encountered, particularly among Asian women. This entity
pain upon palpation. Vaginal examination revealed bulging simulates gynecological malignancy and is seldom recog-
of the anterior vaginal wall due to ascites with no palpated nized before surgical exploration of the abdomen. The occur-
pelvic mass. A CT scan of the abdominopelvic region per- rence of this condition in a multiparous Asian woman is
formed at our hospital showed infiltrative enhancing lesions unique in the case literature.
involving the cul-de-sac and perirectal region with massive The term ascites describes the pathologic accumulation
loculated ascites and internal septation. The uterus and both of fluid within the peritoneal cavity [9]. Cirrhosis of the liver
ovaries appeared unremarkable (Figure 2). A chest X-ray is the most common cause of ascites, but other conditions,
revealed bilateral pleural effusion and passive atelectasis of such as heart failure, kidney failure, infection (such as tuber-
both lower lobes. Her CA-125 level was 112 IU/mL, CA19-9, culosis), cancer, or gynecological malignancy can also cause
and CEA levels were within the normal range. this condition [10]. When a woman presents with ascites,
We performed abdominal paracentesis, which yielded exclusion of certain gynecological disorders, including ovar-
a clear yellowish fluid. Cytologic examination suggested ian cancer, primary peritoneal cancer, fallopian tube cancer,
inflammation without malignant cells. The ascites sample and pelvic tuberculosis, is necessary. Ascites secondary to
was also sent for tuberculosis PCR and acid-fast bacilli endometriosis is a rare phenomenon, of which the first case
staining, both of which were negative. Exploratory laparot- was reported in 1954 [11] and only approximately 60 cases
omy was scheduled for tissue diagnosis. Upon laparotomy, have been reported worldwide [6, 12]. The clinical presenta-
we noted a large amount of serosanguinous ascites, thickened tion in our patient is generally consistent with those that have
matted bowel loops, and necrotic debris covering the entire previously been reported, except with regard to the patient’s
peritoneal surface (Figure 3). The right adnexa and uterus parity status and ethnicity. Reported cases have mostly been
were partially identified. No gross focal mass lesions were in African (82%) and nulliparous (85%) women [13]. The
found. The surgical procedures included drainage of 6.5 liters main presenting symptoms in these cases were abdominal
of ascites, lysis adhesion, biopsy of the peritoneum, and right distention, pain, and/or weight loss [6, 12–18]. Significant
salpingo-oophorectomy. weight loss occurred in one-third of reported cases, and
Histologic examination of peritoneum tissue showed concurrent pleural effusion was found in 38% of cases [6].
benign endometrial glands with stroma deposited within a Additionally, as in our report, the patient usually had a
thick fibrous tissue and chronic inflammation background history of endometriosis-related symptoms including dys-
(Figure 4). Immunohistochemical studies of peritoneal tissue menorrhea and pelvic pain.
showed positive staining for estrogen receptor (ER) and Owing to the rarity of massive ascites associated with
progesterone receptor (PR) within the foci of endometriosis. endometriosis, the diagnosis of this clinical entity is made
Endometriotic foci at the broad ligament were found adja- after the exclusion of other more common causes. The pre-
cent to an unremarkable right fallopian tube (Figure 5). sentation of ascites, weight loss, and peritoneal lesions mimic
Sections of the right ovary were unremarkable. There were advanced gynecologic malignancy and peritoneal tuberculo-
no malignant cells in any of the tissues examined. Cytologic sis. Consequentially, most of the cases reported, including
examination of ascites fluid revealed inflammation without that in this report, underwent abdominal paracentesis to
malignant cells. A final diagnosis of endometriosis was made obtain an ascites fluid sample for cytological examination in
based on these pathological and cytological findings. order to exclude malignant cells and tuberculosis infection.
The patient’s postoperative course was uneventful. The appearance of ascites fluid secondary to endometriosis
GnRH analog was prescribed for six months postoperatively. could be bloody, dark brown, or serosanguineous [6, 12, 13].
The patient has subsequently been on a daily regimen of oral Serum CA-125 levels were also investigated in most reported
progestin. At fifteen months following the operation, the cases and varied from 20 to 5,000 IU/mL [12]. In our case,
patient had no symptoms and the results of a physical exam- the patient’s CA-125 levels were slightly elevated. Although
ination were unremarkable. an associated cancer or other diseases were not found and
Case Reports in Obstetrics and Gynecology 3

Figure 2: Computed tomography of the abdominopelvic region shows massive loculated ascites with internal thin septation, causing
posterior displacement of the intraperitoneal organs.

Figure 3: Intraoperative findings revealed thickened matted bowel Figure 5: Microscopic examination of broad ligament adjacent to
loops and necrotic debris covering the entire peritoneal surface the right fallopian tube revealed endometriotic foci (H&E staining;
and viscera. 10x).

nation of a biopsied tissue. Extensive adhesions have often

been encountered upon operation. Extrapelvic endometriosis
has usually involved surrounding structures including the
omentum, bowel, or pelvic organs [17]. Intraoperative find-
ings in our case were similar to those previously reported.
A definite diagnosis was made upon histological confirma-
tion of endometrial tissue in the peritoneum and board
ligament.
The pathogenesis of endometriosis-associated massive
ascites remains unknown, so there is yet no specific treatment
for this rare clinical entity [5, 19, 20]. Since endometriosis
is estrogen-dependent, suppression of ovarian function
through surgery and/or medication is necessary to prevent
recurrence. Surgical management can be either conservative
or radical depending on patients’ age, the severity of the dis-
ease, and the desire for fertility. If feasible, radical surgery
Figure 4: Microscopic examination of the peritoneum revealed may be the treatment of choice for women who present with
benign endometrial glands with stroma in a thick fibrous tissue ascites. Long-term medical treatment is required following
with background of chronic inflammation (H&E staining; 10x). conservative treatment [5].
Due to the fact that almost all patients with endometriosis-
were not likely, long-term surveillance is required to reaffirm associated massive ascites have been of reproductive age and
the final diagnosis. nulliparous, conservative surgery and postoperative medi-
The definitive diagnosis of endometriosis with ascites is cation has been the most common treatment protocol. Med-
made upon the operative assessment and histological exami- ications for suppressing ovarian function include GnRH
4 Case Reports in Obstetrics and Gynecology

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