Belly full of blood: a rare presentation of endometriosis

Abstract

Endometriosis is a chronic, benign, hormonally dependent gynecologic condition affecting 6%-10% of reproductiveage women and is one of the most prevalent diagnoses associated with chronic pelvic pain. Endometriosis is defined by the presence of endometrial glands and stroma outside of the uterine cavity, with common ectopic locations including the rectovaginal septum, abdominal wall, pelvic peritoneum, and pelvic viscera. The pathophysiology is likely multifactorial and is a result of an interplay between genetic factors, environmental stimuli, aberrant hormonal signaling, and an improper immune response. Commonly, patients present to the health care setting with complaints of abdominopelvic pain, dysmenorrhea, or deep dyspareunia, but they are often asymptomatic and as such, the presentation of endometriosis is highly variable and largely unpredictable. A rare and potentially reproductive organ threatening presentation of endometriosis is recurrent hemorrhagic ascites.The symptomatic presentation of ascites often occurs in the late stages with multiple liters of fluid causing pain, distention, and shortness of breath. In cases of hemorrhagic ascites, this can be life-threatening with presentation including anemia and hypovolemic shock. Modern imaging tools can quickly discern free fluid, but determining etiology is a more complex owing to the broad differential. In young women of reproductive age with suspected hemorrhagic ascites, once the exclusion of hemoperitoneum due to ectopic pregnancy and trauma are established, attention is turned to ruling out ovarian malignancy, ruptured ovarian cysts, and endometriosis. Because these patients are presenting with symptoms, most cases reported in the literature have been approached surgically with drainage of the fluid, evaluation of the pelvis, and plan for clinical or pathologic diagnosis.