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Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman☆ Abstract Endometriosis is well known as a chronic condition associated with significant morbidity. Umbilical endometriosis, however, may go unrecognized because of its rarity, leading to multiple medical visits and a delayed diagnosis. Chronic umbilical drainage is an unusual presentation for umbilical endometriosis. Even more unusual is the development at this location in a patient without previous abdominal surgery. There are very few published case reports about primary umbilical endometriosis. A 24-year-old nulliparous African American woman presents to the emergency department with a complaint of chronic umbilical drainage of 3-year duration and undergoes a computed tomographic scan and subspecialty referral, which lead to the diagnosis of primary abdominal wall endometriosis and a new left ovary endometrioma. Although this is an unusual occurrence, it may be considered in patients with chronic umbilical drainage without other cause. Endometriosis affects approximately 10% of women of reproductive age [1]. Extragenital endometriosis has an incidence closer to 9% [2], and primary umbilical endometriosis is estimated to affect less than 1% of those with extragenital involvement [1,3]. Extragenital endometriosis may be asymptomatic or may include similar symptoms to pelvic endometriosis. Sites outside the pelvis where endometriosis can develop include the gastrointestinal tract, urinary tract, pulmonary system, and umbilicus [4]. Clinical examination can be misleading as many women have nonspecific findings and the diagnosis is only confirmed by laparoscopy and histology [4]. Imaging studies to aid in the diagnosis include ultrasound, computed tomography, and magnetic resonance imaging; however, these studies often add more cost than benefit. There is also no blood test that is helpful in diagnosing endometriosis [4]. Umbilical endometriosis can be primary or secondary. Secondary endometriosis is typically found in patients with previous abdominal surgery [5]. Affected patients may present to primary or subspecialty offices for initial evaluation [4]. Making the diagnosis of endometriosis early may help to alleviate some of the associated morbidities such as pelvic pain, infertility, and possibly types of ovarian cancers [4]. Unfortunately, for all types of endometriosis, the length of time between onset of symptoms and confirmed diagnosis is an average of 9 to 12 years [4]. This case illustrates a patient's long journey to definitive care with a final diagnosis of primary umbilical endometriosis and left ovary endometrioma.
☆ Consent: Written informed consent was obtained from the patient for publication of this case report. A copy is available for review by the corresponding author.
A 24-year-old G0 female presents to the emergency department (ED) for concerns of umbilical drainage. She has noted bloody and brown-colored drainage from her umbilicus with her menstrual periods intermittently over the past several years. The patient reports the drainage is foul smelling and often associated with abdominal pain. She denies fever or other systemic symptoms during these episodes. She is able to control the bleeding with a cotton pad over the area, which she changes several times a day. Review of the patient's electronic medical records reveals 3 previous related visits, 2 of which had the same complaint of umbilical drainage. On the first visit at her primary care physician, she had complained of umbilical discharge with odor for about 4 years and was prescribed bacitracin and hexachlorophene wash for the umbilical area as well as sulfamethoxazole-trimethoprim with followup recommended only as needed. Her subsequent visit was to the ED where she presented with “naval bleeding” for 3 years with “foulsmelling” drainage. A culture was obtained at that visit; she was continued on sulfamethoxazole-trimethoprim and referred to surgery. The patient was seen an additional time in the ED after this visit with a chief complaint of abdominal pain and had routine blood work drawn, which was all within normal limits. She was discharged with famotidine and a diagnosis of gastroesophageal reflux. The patient reports menarche in the fifth grade with irregular periods every 2 to 3 months. She was seen several years ago for irregular periods and was diagnosed with polycystic ovarian syndrome. The patient had been on oral contraceptive pills intermittently for several years. She has a history of allergic rhinitis, hypertension, obstructive sleep apnea, and asthma. She has no previous surgeries. She does use alcohol or drugs. She is sexually active and monogamous. Patient arrived to the ED with stable vital signs. Her abdomen was soft and nondistended, with tenderness in the periumbilical and epigastric regions. She had a small amount of bloody drainage on a cotton ball in the umbilicus. There was no active bleeding visualized on examination, no signs of purulent drainage, or abscess formation. There were no masses or organomegaly. The remainder of her examination was unremarkable. The differential diagnoses included fistula, abscess, endometriosis, or endometrioma. A computed tomography was obtained and showed a structure suggestive of a left ovarian cyst and enhancing tissue along the surface and fascia in the region of the umbilicus (Fig.). The radiologist concluded that the implant likely represented endometriosis involving the abdominal wall at the umbilicus. The report recommended further evaluation with an ultrasound of the pelvis to assess the left ovary. Results were discussed with the patient; she was referred to surgery and discharged with pain control. Review of the electronic medical records and further contact with the patient showed that her visit with general surgery corroborated
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
Please cite this article as: Kahlenberg LK, Laskey S, Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.024
2
L.K. Kahlenberg, S. Laskey / American Journal of Emergency Medicine xxx (2014) xxx–xxx
keep a high index of suspicion. Remembering the diagnosis of umbilical endometriosis in any patient with an umbilical lesion and endometriosis for any female with recurrent abdominal pain can expedite the diagnosis. Lindsay K. Kahlenberg DO Department of Pediatrics, Akron Children's Hospital One Perkins Square Akron, OH 44308, USA E-mail address: [email protected] Sara Laskey MD Department of Emergency Medicine MetroHealth Medical Center, 2500 MetroHealth Drive Cleveland, OH 44109, USA
http://dx.doi.org/10.1016/j.ajem.2013.12.024
References Fig. Computed tomography of the patient shows endometriosis at the umbilicus.
the diagnosis of endometriosis within the abdominal wall, and they suggested medical management. The gynecologist also agreed that this was umbilical endometriosis and ordered an ultrasound of the pelvis, which confirmed a left ovarian endometrioma. Primary umbilical endometriosis is extremely uncommon, and education by way of case report is necessary to ensure that providers
[1] Efremidou EI, Kouklakis G, Mitrakas A, Liratzopoulos N, Polychronidis A. Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis. Int J Gen Med 2012;5:999–1002. [2] Jafferbhoy S, Symeonides P, Levy M, Shiwani MH. Chronic umbilical discharge: an unusual presentation of endometriosis. Sultan Qaboos Univ Med J 2013;13(1): 143–6. [3] Dadhwal V, Gupta B, Dasgupta C, Shende U, Deka D. Primary umbilical endometriosis: a rare entity. Arch Gynecol Obstet 2011;283(Suppl 1):119–20. [4] Berek JS, Berek DL, Hengst TC, Barile G, Novak E. Berek & Novak's gynecology. 15th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012. [5] Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases. Am J Surg 2008;196(2):207–12.
Please cite this article as: Kahlenberg LK, Laskey S, Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.024
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman☆ Abstract Endometriosis is well known as a chronic condition associated with significant morbidity. Umbilical endometriosis, however, may go unrecognized because of its rarity, leading to multiple medical visits and a delayed diagnosis. Chronic umbilical drainage is an unusual presentation for umbilical endometriosis. Even more unusual is the development at this location in a patient without previous abdominal surgery. There are very few published case reports about primary umbilical endometriosis. A 24-year-old nulliparous African American woman presents to the emergency department with a complaint of chronic umbilical drainage of 3-year duration and undergoes a computed tomographic scan and subspecialty referral, which lead to the diagnosis of primary abdominal wall endometriosis and a new left ovary endometrioma. Although this is an unusual occurrence, it may be considered in patients with chronic umbilical drainage without other cause. Endometriosis affects approximately 10% of women of reproductive age [1]. Extragenital endometriosis has an incidence closer to 9% [2], and primary umbilical endometriosis is estimated to affect less than 1% of those with extragenital involvement [1,3]. Extragenital endometriosis may be asymptomatic or may include similar symptoms to pelvic endometriosis. Sites outside the pelvis where endometriosis can develop include the gastrointestinal tract, urinary tract, pulmonary system, and umbilicus [4]. Clinical examination can be misleading as many women have nonspecific findings and the diagnosis is only confirmed by laparoscopy and histology [4]. Imaging studies to aid in the diagnosis include ultrasound, computed tomography, and magnetic resonance imaging; however, these studies often add more cost than benefit. There is also no blood test that is helpful in diagnosing endometriosis [4]. Umbilical endometriosis can be primary or secondary. Secondary endometriosis is typically found in patients with previous abdominal surgery [5]. Affected patients may present to primary or subspecialty offices for initial evaluation [4]. Making the diagnosis of endometriosis early may help to alleviate some of the associated morbidities such as pelvic pain, infertility, and possibly types of ovarian cancers [4]. Unfortunately, for all types of endometriosis, the length of time between onset of symptoms and confirmed diagnosis is an average of 9 to 12 years [4]. This case illustrates a patient's long journey to definitive care with a final diagnosis of primary umbilical endometriosis and left ovary endometrioma.
☆ Consent: Written informed consent was obtained from the patient for publication of this case report. A copy is available for review by the corresponding author.
A 24-year-old G0 female presents to the emergency department (ED) for concerns of umbilical drainage. She has noted bloody and brown-colored drainage from her umbilicus with her menstrual periods intermittently over the past several years. The patient reports the drainage is foul smelling and often associated with abdominal pain. She denies fever or other systemic symptoms during these episodes. She is able to control the bleeding with a cotton pad over the area, which she changes several times a day. Review of the patient's electronic medical records reveals 3 previous related visits, 2 of which had the same complaint of umbilical drainage. On the first visit at her primary care physician, she had complained of umbilical discharge with odor for about 4 years and was prescribed bacitracin and hexachlorophene wash for the umbilical area as well as sulfamethoxazole-trimethoprim with followup recommended only as needed. Her subsequent visit was to the ED where she presented with “naval bleeding” for 3 years with “foulsmelling” drainage. A culture was obtained at that visit; she was continued on sulfamethoxazole-trimethoprim and referred to surgery. The patient was seen an additional time in the ED after this visit with a chief complaint of abdominal pain and had routine blood work drawn, which was all within normal limits. She was discharged with famotidine and a diagnosis of gastroesophageal reflux. The patient reports menarche in the fifth grade with irregular periods every 2 to 3 months. She was seen several years ago for irregular periods and was diagnosed with polycystic ovarian syndrome. The patient had been on oral contraceptive pills intermittently for several years. She has a history of allergic rhinitis, hypertension, obstructive sleep apnea, and asthma. She has no previous surgeries. She does use alcohol or drugs. She is sexually active and monogamous. Patient arrived to the ED with stable vital signs. Her abdomen was soft and nondistended, with tenderness in the periumbilical and epigastric regions. She had a small amount of bloody drainage on a cotton ball in the umbilicus. There was no active bleeding visualized on examination, no signs of purulent drainage, or abscess formation. There were no masses or organomegaly. The remainder of her examination was unremarkable. The differential diagnoses included fistula, abscess, endometriosis, or endometrioma. A computed tomography was obtained and showed a structure suggestive of a left ovarian cyst and enhancing tissue along the surface and fascia in the region of the umbilicus (Fig.). The radiologist concluded that the implant likely represented endometriosis involving the abdominal wall at the umbilicus. The report recommended further evaluation with an ultrasound of the pelvis to assess the left ovary. Results were discussed with the patient; she was referred to surgery and discharged with pain control. Review of the electronic medical records and further contact with the patient showed that her visit with general surgery corroborated
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
Please cite this article as: Kahlenberg LK, Laskey S, Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.024
2
L.K. Kahlenberg, S. Laskey / American Journal of Emergency Medicine xxx (2014) xxx–xxx
keep a high index of suspicion. Remembering the diagnosis of umbilical endometriosis in any patient with an umbilical lesion and endometriosis for any female with recurrent abdominal pain can expedite the diagnosis. Lindsay K. Kahlenberg DO Department of Pediatrics, Akron Children's Hospital One Perkins Square Akron, OH 44308, USA E-mail address: [email protected] Sara Laskey MD Department of Emergency Medicine MetroHealth Medical Center, 2500 MetroHealth Drive Cleveland, OH 44109, USA
http://dx.doi.org/10.1016/j.ajem.2013.12.024
References Fig. Computed tomography of the patient shows endometriosis at the umbilicus.
the diagnosis of endometriosis within the abdominal wall, and they suggested medical management. The gynecologist also agreed that this was umbilical endometriosis and ordered an ultrasound of the pelvis, which confirmed a left ovarian endometrioma. Primary umbilical endometriosis is extremely uncommon, and education by way of case report is necessary to ensure that providers
[1] Efremidou EI, Kouklakis G, Mitrakas A, Liratzopoulos N, Polychronidis A. Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis. Int J Gen Med 2012;5:999–1002. [2] Jafferbhoy S, Symeonides P, Levy M, Shiwani MH. Chronic umbilical discharge: an unusual presentation of endometriosis. Sultan Qaboos Univ Med J 2013;13(1): 143–6. [3] Dadhwal V, Gupta B, Dasgupta C, Shende U, Deka D. Primary umbilical endometriosis: a rare entity. Arch Gynecol Obstet 2011;283(Suppl 1):119–20. [4] Berek JS, Berek DL, Hengst TC, Barile G, Novak E. Berek & Novak's gynecology. 15th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012. [5] Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases. Am J Surg 2008;196(2):207–12.
Please cite this article as: Kahlenberg LK, Laskey S, Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.024