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Endometriosis Presenting as Bloody Ascites and Shock
The Journal of Emergency Medicine, Vol. 38, No. 1, pp. 30 –32, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $–see front matter
doi:10.1016/j.jemermed.2008.03.031
Clinical Communications: OB/GYN
ENDOMETRIOSIS PRESENTING AS BLOODY ASCITES AND SHOCK Jiun-Nong Lin, MD,* Hsing-Lin Lin, MD,† Chun-Kai Huang, MD,* Chung-Hsu Lai, Hsing-Chun Chung, MD,* Shiou-Haur Liang, MD,* and Hsi-Hsun Lin, MD*
MD,*
*Department of Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan, and †Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Reprint Address: Hsi-Hsun Lin, MD, 1, E-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, Taiwan, 824
e Abstract—Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patient’s condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock. © 2010 Elsevier Inc.
though asymptomatic in many patients, endometriosis is associated with a wide variety of symptoms depending on the site of endometrial implantation. Massive ascites has been reported as a manifestation of endometriosis, but shock is not a usual presentation (1). We report a case of endometriosis presenting as bloody ascites and shock.
CASE REPORT A 29-year-old female, G2P2, presented to our Emergency Department (ED) with the chief complaints of light-headedness and palpitations over several hours duration. She had been well before and was experiencing her third day of menstruation. On arrival, her blood pressure was 70/50 mm Hg, pulse rate 112 beats/min, respiratory rate 19 breaths per minute, and body temperature was 37°C. Physical examination revealed a pallid face, moist skin, and distended abdomen. There was no palpable abdominal mass, but mild, diffuse tenderness was present without abdominal rigidity or rebound. Auscultation revealed decreased bowel sounds. Laboratory findings were hemoglobin 12.9 g/dL, hematocrit 38.8%, white blood cell count 7,850/mm3, aspartate aminotransferase (AST) 140 IU/L, alanine aminotransferase (ALT) 133 IU/L, blood urea nitrogen 16.6 mg/dL and creatinine 0.9 mg/dL. Urine and blood -human chorionic gonadotrophin (-hCG) were negative. A central venous catheter was inserted in the right internal jugular vein to evaluate her intravascular fluid sta-
e Keywords— endometriosis; endometrial implantation; shock; ascites; female urogenital disease
INTRODUCTION Endometriosis is defined as the presence of ectopic foci of endometrial glands and stroma outside the uterine cavity. This condition is a common gynecologic disorder and occurs exclusively in women during their reproductive years or in women receiving estrogen replacement therapy. Al-
RECEIVED: 31 October 2007; FINAL ACCEPTED: 25 March 2008
SUBMISSION RECEIVED:
20 December 2007; 30
Endometriosis and Shock
tus, and the central venous pressure was only 2 cm H2O. Based on a working diagnosis of hypovolemic shock, we began fluid resuscitation with 2,000 mL of normal saline, and her blood pressure improved to 90/60 mm Hg. We performed abdominal ultrasonography to evaluate the cause of shock and found fluid accumulation in the peritoneal and pelvic cavities (Figure 1). Paracentesis produced bloody ascites. Testing revealed a red blood cell count of 16,562/ mm3, white blood cell count 753/mm3, and differential count of polymorphonuclear neutrophils 8% with mononuclear cells 92%. Abdominal computed tomography (CT) scan disclosed a small amount of right pleural effusion and moderate amount of fluid over the intraperitoneal and intrapelvic cavities. Liver, spleen, intestines, uterus, ovaries, and other visible organs were unremarkable. The patient had exploratory laparoscopy for a presumptive diagnosis of bloody ascites of unknown origin. Endometriosis over the left broad ligament was discovered with bloody fluid accumulation over the cul-de-sac (Figure 2). Approximately 2,000 mL of bloody ascites was drained. The gross examination of the uterus, ovaries, ovarian tubes, intestines, liver, spleen, and omentum were normal. The surgeon performed electrocauterization for the endometriosis. Her condition stabilized after surgery, and she was discharged from the hospital five days after admission.
DISCUSSION Ectopic endometrium is frequently found in the ovary, cul-de-sac, broad ligament, and uterosacral ligament (2). The symptoms of endometriosis are associated with the locations of disease. The most frequent complaint is pelvic pain; however, unusual symptoms, such as cyclic hemoptysis, headache, pleural effusion, or cutaneous manifestations can present (3–5). Moreover, life-threatening
31
Figure 2. Laparoscopy shows endometriosis over the left broad ligament and bloody fluid accumulation over the culde-sac.
presentations, such as subarachnoid hemorrhage and hemopneumothorax, have also been reported (4,6). Patients with massive ascites caused by endometriosis have been reported, but none presented with hypovolemic shock (1). In our case, the patient complained of light-headedness and palpitations that are signs and symptoms and of shock. Low central venous pressure suggested inadequate intravascular volume; however, her hemoglobin and hematocrit were only a little lower than normal. In addition to the blood loss from the endometriosis, the main cause of hypovolemic shock may be attributed to the large amount of intravascular fluid shifting into the intraperitoneal cavity due to irritation from endometrial blood. That would explain the mild anemia and low red blood cell count in the ascites. Once her intravascular fluid volume was supplemented with normal saline, her blood pressure stabilized. CONCLUSIONS In conclusion, endometriosis has protean presentations depending on the sites of the ectopic endometrial glands. Bloody ascites is an unusual presentation of endometriosis, especially combined with hypovolemic shock. Although bloody ascites is frequently caused by intraabdominal trauma, infection, malignancy or ectopic pregnancy, this case demonstrates that endometriosis can be the cause of bloody ascites and hypovolemic shock. REFERENCES
Figure 1. Abdominal ultrasonography reveals fluid accumulation over the pelvic cavity (arrows).
1. Muneyyirci-Delale O, Neil G, Serur E, Gordon D, Maiman M, Sedlis A. Endometriosis with massive ascites. Gynecol Oncol 1998; 69:42– 6.
32 2. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstet Gynecol 1986;67:335– 8. 3. Hachiya T, Okada M, Takamizawa A, Hasegawa M, Honda T, Kubo K. Catamenial hemoptysis. Intern Med 2003;42:765– 6. 4. Duke R, Fawcett P, Booth J. Recurrent subarachnoid hemorrhage due to endometriosis. Neurology 1995;45:1000 –2.
J.-N. Lin et al. 5. Luisi S, Gabbanini M, Sollazzi S, Calonaci F, Razzi S, Petraglia F. Surgical scar endometriosis after Cesarean section: a case report. Gynecol Endocrinol 2006;22:284 –5. 6. Morcos M, Alifano M, Gompel A, Regnard JF. Life-threatening endometriosis-related hemopneumothorax. Ann Thorac Surg 2006; 82:726 –9.
doi:10.1016/j.jemermed.2008.03.031
Clinical Communications: OB/GYN
ENDOMETRIOSIS PRESENTING AS BLOODY ASCITES AND SHOCK Jiun-Nong Lin, MD,* Hsing-Lin Lin, MD,† Chun-Kai Huang, MD,* Chung-Hsu Lai, Hsing-Chun Chung, MD,* Shiou-Haur Liang, MD,* and Hsi-Hsun Lin, MD*
MD,*
*Department of Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan, and †Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Reprint Address: Hsi-Hsun Lin, MD, 1, E-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, Taiwan, 824
e Abstract—Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patient’s condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock. © 2010 Elsevier Inc.
though asymptomatic in many patients, endometriosis is associated with a wide variety of symptoms depending on the site of endometrial implantation. Massive ascites has been reported as a manifestation of endometriosis, but shock is not a usual presentation (1). We report a case of endometriosis presenting as bloody ascites and shock.
CASE REPORT A 29-year-old female, G2P2, presented to our Emergency Department (ED) with the chief complaints of light-headedness and palpitations over several hours duration. She had been well before and was experiencing her third day of menstruation. On arrival, her blood pressure was 70/50 mm Hg, pulse rate 112 beats/min, respiratory rate 19 breaths per minute, and body temperature was 37°C. Physical examination revealed a pallid face, moist skin, and distended abdomen. There was no palpable abdominal mass, but mild, diffuse tenderness was present without abdominal rigidity or rebound. Auscultation revealed decreased bowel sounds. Laboratory findings were hemoglobin 12.9 g/dL, hematocrit 38.8%, white blood cell count 7,850/mm3, aspartate aminotransferase (AST) 140 IU/L, alanine aminotransferase (ALT) 133 IU/L, blood urea nitrogen 16.6 mg/dL and creatinine 0.9 mg/dL. Urine and blood -human chorionic gonadotrophin (-hCG) were negative. A central venous catheter was inserted in the right internal jugular vein to evaluate her intravascular fluid sta-
e Keywords— endometriosis; endometrial implantation; shock; ascites; female urogenital disease
INTRODUCTION Endometriosis is defined as the presence of ectopic foci of endometrial glands and stroma outside the uterine cavity. This condition is a common gynecologic disorder and occurs exclusively in women during their reproductive years or in women receiving estrogen replacement therapy. Al-
RECEIVED: 31 October 2007; FINAL ACCEPTED: 25 March 2008
SUBMISSION RECEIVED:
20 December 2007; 30
Endometriosis and Shock
tus, and the central venous pressure was only 2 cm H2O. Based on a working diagnosis of hypovolemic shock, we began fluid resuscitation with 2,000 mL of normal saline, and her blood pressure improved to 90/60 mm Hg. We performed abdominal ultrasonography to evaluate the cause of shock and found fluid accumulation in the peritoneal and pelvic cavities (Figure 1). Paracentesis produced bloody ascites. Testing revealed a red blood cell count of 16,562/ mm3, white blood cell count 753/mm3, and differential count of polymorphonuclear neutrophils 8% with mononuclear cells 92%. Abdominal computed tomography (CT) scan disclosed a small amount of right pleural effusion and moderate amount of fluid over the intraperitoneal and intrapelvic cavities. Liver, spleen, intestines, uterus, ovaries, and other visible organs were unremarkable. The patient had exploratory laparoscopy for a presumptive diagnosis of bloody ascites of unknown origin. Endometriosis over the left broad ligament was discovered with bloody fluid accumulation over the cul-de-sac (Figure 2). Approximately 2,000 mL of bloody ascites was drained. The gross examination of the uterus, ovaries, ovarian tubes, intestines, liver, spleen, and omentum were normal. The surgeon performed electrocauterization for the endometriosis. Her condition stabilized after surgery, and she was discharged from the hospital five days after admission.
DISCUSSION Ectopic endometrium is frequently found in the ovary, cul-de-sac, broad ligament, and uterosacral ligament (2). The symptoms of endometriosis are associated with the locations of disease. The most frequent complaint is pelvic pain; however, unusual symptoms, such as cyclic hemoptysis, headache, pleural effusion, or cutaneous manifestations can present (3–5). Moreover, life-threatening
31
Figure 2. Laparoscopy shows endometriosis over the left broad ligament and bloody fluid accumulation over the culde-sac.
presentations, such as subarachnoid hemorrhage and hemopneumothorax, have also been reported (4,6). Patients with massive ascites caused by endometriosis have been reported, but none presented with hypovolemic shock (1). In our case, the patient complained of light-headedness and palpitations that are signs and symptoms and of shock. Low central venous pressure suggested inadequate intravascular volume; however, her hemoglobin and hematocrit were only a little lower than normal. In addition to the blood loss from the endometriosis, the main cause of hypovolemic shock may be attributed to the large amount of intravascular fluid shifting into the intraperitoneal cavity due to irritation from endometrial blood. That would explain the mild anemia and low red blood cell count in the ascites. Once her intravascular fluid volume was supplemented with normal saline, her blood pressure stabilized. CONCLUSIONS In conclusion, endometriosis has protean presentations depending on the sites of the ectopic endometrial glands. Bloody ascites is an unusual presentation of endometriosis, especially combined with hypovolemic shock. Although bloody ascites is frequently caused by intraabdominal trauma, infection, malignancy or ectopic pregnancy, this case demonstrates that endometriosis can be the cause of bloody ascites and hypovolemic shock. REFERENCES
Figure 1. Abdominal ultrasonography reveals fluid accumulation over the pelvic cavity (arrows).
1. Muneyyirci-Delale O, Neil G, Serur E, Gordon D, Maiman M, Sedlis A. Endometriosis with massive ascites. Gynecol Oncol 1998; 69:42– 6.
32 2. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstet Gynecol 1986;67:335– 8. 3. Hachiya T, Okada M, Takamizawa A, Hasegawa M, Honda T, Kubo K. Catamenial hemoptysis. Intern Med 2003;42:765– 6. 4. Duke R, Fawcett P, Booth J. Recurrent subarachnoid hemorrhage due to endometriosis. Neurology 1995;45:1000 –2.
J.-N. Lin et al. 5. Luisi S, Gabbanini M, Sollazzi S, Calonaci F, Razzi S, Petraglia F. Surgical scar endometriosis after Cesarean section: a case report. Gynecol Endocrinol 2006;22:284 –5. 6. Morcos M, Alifano M, Gompel A, Regnard JF. Life-threatening endometriosis-related hemopneumothorax. Ann Thorac Surg 2006; 82:726 –9.