Introduction
Endometriosis with ascites and pleural effusion is a rare presentation of a common gynecological disease. We present a case of a 30 year old female presenting with recurrent episodes of ascites requiring paracentesis.
Case Description and Operative Findings
A 30 year old nulliparous African female was referred with right upper quadrant pain, increasing abdominal girth, exertional dyspnea, and early satiety. Outpatient ultrasound revealed extensive ascites, left pleural effusion, and bulky cystic left
Past medical history included stage IV endometriosis, recurrent ascites, and sickle cell trait. The patient had undergone an unconfirmed number of laparoscopies in Ghana for treatment of endometriosis. After exclusion of other causes of ascites, the patient’s recurrent episodes had been deemed due to endometriosis, and in the past three years had been effectively managed with regular goserelin injections.
On examination, the patient had distended abdomen with shifting dullness and hyper resonant flanks. Decreased air entry and percussion dullness at the base of both lungs was noted. CA 125 and CA 19-9 were mildly elevated at 46 and 52 respectively
An intraperitoneal drain was inserted under ultrasound guidance. A total of 2200mL of blood stained fluid was drained. Microscopy of the fluid revealed presence of leucocytes. Cultures were negative, and cytology and cell block were negative for malignancy.
Repeat ultrasound demonstrated a haemorrhagic left ovarian cyst, a small right endometrioma, pelvic organ tethering, and significant ascites in the pelvis and upper abdomen with the appearance of blood.
After recommencing Zoladex the patient was discharged with follow up in the outpatient clinic. The patient was consented for diagnostic laparoscopy and treatment of endometriosis. Laparoscopy revealed 1500 mL of bloody ascites, extensive abdominal and pelvic adhesions, and widespread superficial peritoneal endometriosis over the bladder, pelvic structures and the anterior abdominal wall. Extensive adhesiolysis, radical excision of all endometriosis, and chromotubation were performed. Repeat cytology of the ascitic fluid identified foamy macrophages and haemosiderophages and was negative for malignancy.istopathological examination of all excised specimens confirmed endometriosis.
The patient’s postoperative course was uneventful. The patient was discharged with planned follow up in the outpatient clinic and ongoing goserelin injections.
Discussion and Conclusion
Endometriosis associated with ascites and pleural effusion is a rare presentation of this complex disease. A total of 63 case of endometriosis related ascites were reported between 1950 and 2010. 1 The pathophysiology of the development of ascites in the setting of endometriosis is not well understood.