SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
Scribd wird den Betrieb von SlideShare ab 1. Dezember 2020 übernehmen.Ab diesem Zeitpunkt liegt die Verwaltung Ihres SlideShare-Kontos sowie jeglicher Ihrer Inhalte auf SlideShare bei Scribd. Von diesem Datum an gelten die allgemeinen Nutzungsbedingungen und die Datenschutzrichtlinie von Scribd. Wenn Sie dies nicht wünschen, schließen Sie bitte Ihr SlideShare-Konto. Mehr erfahren
Massive ascites as a presentation in a young woman
Massive ascites as a presentation in a young woman
with endometriosis: a case report
Khalid H. Sait, M.Bch.B., F.R.C.S.C.
Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Objective: To report a case of endometriosis associated with massive ascites and an elevated CA-125 level.
Design: Case report.
Setting: Tertiary care center.
Patient(s): A 26-year-old woman presented with massive ascites and an increased CA-125 level suggestive of
Intervention(s): Ultrasonography, laparotomy, and bilateral ovarian cystectomy and reconstruction. Endometri-
osis was diagnosed postoperatively on the basis of histopathology. The patient received 6 months of treatment
with a GnRH analogue.
Main Outcome Measure(s): Ultrasound examination 6 months after surgery to evaluate for ascites or recurrent
Result(s): Frozen sections obtained at laparotomy and ovarian cystectomy ruled out a malignancy. The ﬁnal
histologic report was compatible with a diagnosis of endometriosis. After 6 months of treatment with the
GnRH analogue, the patient experienced a progressive reduction of the ascitic ﬂuid and full remission after 2 years.
Conclusion(s): Endometriosis associated with massive bloody ascites is an unusual occurrence. This report draws
attention to this condition as a complication of endometriosis. For this reason, endometriosis should be included in
the differential diagnosis of reproductive-age women presenting with an apparent ovarian malignancy. (Fertil
SterilÒ 2008;90:2015.e17–e19. Ó2008 by American Society for Reproductive Medicine.)
Key Words: Endometriosis, ovarian cancer, ascites
Endometriosis is deﬁned as the presence of endometrial
tissue outside the uterine cavity, generally involving the
peritoneum, ovaries, and rectovaginal septum. However, it
may also occur at remote sites with unusual manifestations.
Rare examples include pulmonary endometriosis and
endometriosis associated with ascites (1). Endometriosis as-
sociated with massive ascites causing abdominal distension
and other symptoms simulating a malignancy has been de-
scribed in the literature (2–6). Here, we report a case of this
unusually severe form of endometriosis in a patient who
was initially diagnosed with advanced ovarian cancer before
surgery. She presented with an increase in abdominal girth
and was found to have bilateral ovarian cysts, massive hem-
orrhagic ascites, and an elevated CA-125 level.
A 26-year-oldsinglewoman reported a history of an increased
of regular normal menstrual periods associated with severe
dysmenorrhea. A review of systems was unremarkable. The
medical and surgical history was noncontributory.
Physical examination revealed a generally well woman
without pallor. Her chest and heart examinations were nor-
mal. Her abdomen was distended with ascites but with no
hepatosplenomegaly or pain upon deep palpation. No masses
could be palpated. Pelvic and abdominal ultrasonography re-
vealed massive ascites with a normal uterus and bilateral
ovarian cysts measuring 8 Â 7 Â 6 cm. They were multiloc-
ular with thick capsules, and the ultrasound appearance was
hypoechogenic. The CA-125 level was 3,140 mIU/mL, and
levels of other tumor markers were all normal. The patient
was counseled regarding the possibility of metastatic ovarian
cancer, and consent was obtained for surgery.
Laparotomy was performed with the following ﬁndings: 5
L hemorrhagic ascites, bilateral ovarian cysts with extensive
pelvic adhesions, and areas of reddish color within the pelvic
peritoneum. The uterus was ﬁrmly adhered to the rectum and
bladder. Rupture of a cyst during dissection revealed that it
contained a reddish ﬂuid. Bilateral ovarian cystectomy was
performed with reconstruction of both ovaries. Frozen sec-
tions of all biopsy specimens submitted showed benign-look-
ing cysts with no evidence of malignancy. Multiple peritoneal
Received March 1, 2008; revised May 21, 2008; accepted July 9, 2008.
K.S. has nothing to disclose.
Reprint requests: Khalid Sait, M.Bch.B., F.R.C.S.C., Consultant, Gyneco-
logic Oncology, Department of Obstetrics and Gynecology, King Abd
Alaziz University Hospital, Jeddah 21589, PO Box 80215, Saudi Arabia
(FAX: 026408316; E-mail: firstname.lastname@example.org).
0015-0282/08/$34.00 Fertility and Sterilityâ Vol. 90, No. 5, November 2008 2015.e17
doi:10.1016/j.fertnstert.2008.07.021 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
biopsy specimens were also obtained. Final histopathologic
analysis of the operative specimens conﬁrmed the diagnosis
of endometriosis, and the peritoneal biopsy specimens
showed a lot of inﬂammation and hemosiderin deposition,
but no evidence of malignancy.
The patient’s postoperative course was unremarkable, and
the patient was discharged home 5 days after surgery. The pa-
tient received 6 months of GnRH analogue treatment.
Ultrasound examination 6 months later revealed no ascites
and no recurrent cysts. Two years later, the patient had no
complaints and was experiencing a regular normal period
while on maintenance treatment consisting of combined birth
The incidence of endometriosis in the general population is
unknown; however, in women undergoing evaluation for in-
fertility it is generally approximately 30%, and in women
undergoing evaluation for dysmenorrheal/pelvic pain it is
approximately 40%–50% (7). The pathogenesis of endome-
triosis has not yet been fully elucidated. Although endometri-
osis is generally conﬁned to the pelvis, it may occur at remote
The association of endometriosis with massive bloody as-
cites is extremely rare. Brews (8) reported the ﬁrst case in
1958. Thirty additional cases have been reported since
then, representing a diagnostic dilemma for gynecologists,
owing to their rarity and to the fact that these cases mimic
malignant ovarian neoplasms (2–6, 9–32).
In the previously reported cases, the endometriosis in-
volved mainly the peritoneum, frequently occurring in its
most severe form in association with multiple adhesions
and ovarian endometriomas (50% of cases). Ascitic ﬂuid,
the common denominator in all of the cases, was detected
in large volumes (4,254 mL on average) and was bloody in
50% of cases and brown in the other 50% of cases. Ascitic
ﬂuid associated with endometriosis is of an exudative nature
(19, 21, 33) and may originate as a result of peritoneal irrita-
tion caused by the presence of blood in the cavity due to the
rupture of endometrial cysts. The rapid production of ﬂuid by
inﬂamed tissue and the obstruction of subdiaphragmatic
lymph vessels, which impair its reabsorption, may be respon-
sible for the large volumes detected (5, 9, 19, 24, 28, 29).
There has been no consistency regarding the treatment of as-
cites associated with endometriosis in young patients. In the
present case, therewas no recurrence of ascites during an obser-
vation period of approximately 2 years after conservative surgi-
Endometriosis-associated ascites is commonly mistaken
for ascites caused by ovarian neoplasms, especially when as-
sociated with an elevated CA-125 level, which is a tumor
marker for ovarian neoplasms. The CA-125 level may be
so strikingly elevated that the diagnosis of ovarian malig-
nancy appears certain. Kahraman et al. reported values as
high as 7,900 mIU/mL associated with endometriosis (34).
Endometriosis associated with massive bloody ascites is an
The present report draws attention to this condition as
a complication of endometriosis and may suggest that
GnRH therapy could be used to prevent the accumulation
of ascites after surgical resection in young patients who
wish to preserve fertility. Our ﬁndings also suggest that endo-
metriosis associated with massive bloody ascites should be
included in the differential diagnosis of reproductive-age
women presenting with an apparent ovarian malignancy.
1. Jubanyik K, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin
North Am 1997;24:411–40.
2. London S, Parmley T. Endometriosis and ascites. South Med J 1993;86:
3. Schlueter F, McClennan B. Massive ascites and pleural effusions associ-
ated with endometriosis. Abdom Imaging 1994;19:475–6.
4. Jose R, George S, Seshadri L. Massive ascites associated with endome-
triosis. Int J Gynaecol Obstet 1994;44:287–8.
5. Spitzer M, Benjamin F. Ascites due to endometriosis. Obstet Gynecol
6. Dias C, Andrade J, Ferriani R, Villanova M, Meirelles R. Hemorrhagic
ascites associated with endometriosis. J Reprod Med 2000;45:688–90.
7. Mahutte N, Arici A. Medical management of endometriosis-associated
pain. Obstet Gynecol Clin N Am 2003;30:1, 2, 4–23, 26–29, 133–50.
8. Brews A. Endometriosis including endometriosis of the diaphragm and
Meigs’ syndrome. Proc R Soc Med 1958;47;461.
9. Bernstein JP, Perlow V, Brenner JJ. Massive ascites due to endometriosis.
Am J Dig Dis 1961;6:1–7.
10. Cantor JO, Fenoglio CM, Richard RM. A case of extensive abdominal
endometriosis. Obstet Gynecol 1979;134:846–7.
11. Charles D. Endometriosis and hemorrhagic pleural effusion. Obstet
12. Charran D, Roopnarinesingh S. Haemothorax and ascites associated with
endometriosis. West Ind Med J 1993;42:40–1.
13. Chervenak FA, Greenlee RM, Lewenstein L, Tovell HM. Massive ascites
associated with endometriosis. Obstet Gynecol 1981;57:379–81.
14. Chichareon SB, Wattanakitkrailert S. Endometriosis with ascites. Acta
Obstet Gynecol Scand 1988;67:187–8.
15. El-Newihi HM, Antaki JP, Rajan S, Reynolds TB. Large bloody ascites in
association with pelvic endometriosis: case report and literature review.
Am J Gastroenterol 1995;90:632–4.
16. Flanagan KL, Barnes NC. Pleural ﬂuid accumulation due to intra-
abdominal endometriosis: a case report and review of the literature. Tho-
17. Gaulier A, Jouret-Mourin A, Marsan C. Peritoneal endometriosis: A re-
port of a case with cytologic, cytochemical and histopathology study.
Acta Cytol 1983;27:446–9.
18. Halme J, Chafe W, Currie JL. Endometriosis with massive ascites. Obstet
19. Irani S, Atkinson L, Cabaniss C, Danovitch SH. Pleuroperitoneal endo-
metriosis. Obstet Gynecol 1976;47:72S–4S.
20. Iwasaka T, Okuma Y, Yoshimura T, Kidera Y, Sugimori H. Endometri-
osis association with ascites. Obstet Gynecol 1985;66:72S–5S.
21. Jenks JE, Artman LE, Hoskins WJ, Miremadi AK. Endometriosis with
ascites. Obstet Gynecol 1984;63:75S–7S.
22. Muneyyirci-Delale O, Neil G, Serur E, Gordon D, Maiman M, Sedlis A.
Endometriosis with massive ascites. Gynecol Oncol 1998;69:42–6.
23. Myers TJ, Arena B, Grania CO. Pelvic endometriosis mimicking
advanced ovarian cancer: Presentation with pleural effusion, ascites,
and elevated serum CA 125 level. Am J Obstet Gynecol 1995;173:966–7.
24. Naraynsingh V, Raju GC, Ratan P, Wong J. Massive ascites due to omen-
tal endometriosis. Postgrad Med J 1985;61:539–40.
2015.e18 Sait Ascites in a woman with endometriosis Vol. 90, No. 5, November 2008
25. Olubuyide IO, Adebajo AO, Adeleye JA, Solanke TF. Massive ascites as-
sociated with endometriosis in a Nigerian African. Int J Gynaecol Obstet
26. Shek Y, De Lia JE, Pattillo RA. Endometriosis with a pleural effusion and
ascites: report of a case treated with nafarelin acetate. J Reprod Med
27. Singer JA, Kaplan MM, Katz RL. Cirrhotic pleural effusion in the
absence of ascites. Gastroenterology 1977;73:575–7.
28. Taub WH, Rosado S, KalayciogluM, Booher D,Barnes DS. Hemorrhagic
ascites secondaryto endometriosis. JClinGastroenterol1989;11:458–60.
29. WilliamsRS,WagamanR.Endometriosis associatedwithmassiveascites
and absence of pelvic peritoneum. Am J Obstet Gynecol 1991;164:45–6.
30. Yu J, Grimes D. Ascites and pleural effusion associated with endometri-
osis. Obstet Gynecol 1991;78:533–4.
31. Goumenou A, Matalliotakis I, Mahutte N,Koumantakis E. Endometriosis
mimicking advanced ovarian cancer. Fertil Steril 2006;86:219. e23–5.
32. Francis M, Badero O, Borowsky M, Lee Y, Abulaﬁa O. Pericardial effu-
sion, right-sided pleural effusion and ascites associated with stage IV
endometriosis. A case report. J Reprod Med 2003;48:463–5.
33. Brosens IA. Endometriosis: Current issues in diagnosis and medical
management. J Reprod Med 1998;43:281–6.
34. Kahraman K, Ozguven I, Gungo M, Atabekoglu C. Extremely elevated
serum CA-125 level as a result of unruptured unilateral endometrioma:
the highest value reported. Fertil Steril 2007;88:968.e15.
Fertility and Sterilityâ