Endometriosis is characterized by endometrial glands
and stroma outside the uterine cavity. Endometriosis is a
common condition that occurs in 6-10% of all reproductive
age women (
This article aims to present a case of a 32 year-old woman who presented with recurrent haemorrhagic ascites. We will discuss the patient’s clinical course and surgical findings. A comprehensive review of the literature on medical/surgical management of patients with this rare finding will be presented.
A 32-year-old nulligravida Hispanic female was referred to our department with complaints of general malaise, abdominal distention, loss of appetite, diffuse abdominal pain and difficulty breathing that had worsened over the last few days. She was known to have endometriosis that was diagnosed at the time of an exploratory laparotomy due to massive haemorrhagic ascites performed two years before. She was started on oral contraceptives at that time with poor response and was subsequently treated with monthly 3.75 mg leuprolide IM (Lupron®) but she selfdiscontinued the treatment due to the desire to conceive.
The patient provided consent for publication of the case report. The IRB was consulted and the IRB committee at Hospital Pedro Mallo, Buenos Aires, Argentina deemed this work exempt of approval.
Initial imaging with ultrasound and computed tomography (CT) scan revealed a large amount of intraperitoneal
fluid. A paracentesis was performed that obtained 5 litres
of thick bloody peritoneal fluid with a red blood cell count
of >50000/µL that was negative for bacteria or malignant
cells. The patient had symptomatic relief and was discharged
home after the procedure. She then returned eight days later
complaining of recurrence of the same symptoms. A repeat
ultrasound was performed along with magnetic resonance
imaging (MRI), which revealed massive ascites (Figes
A large amount of intraperitoneal fluid is visualized on computed tomography (CT) of the abdomen and pelvis.
Massive ascites with small intestine floating inside the peritoneal cavity visualized on transabdominal ultrasound.
Bloody ascites filling the abdominopelvic cavity. Note necrotic omental adhesions on the anterior abdominal wall.
Note the complete obliteration of the vesicouterine space. The uterus is encapsulated from dense inflammatory plastic peritonitis and densely adheres to the pelvic side walls.
The liver is encapsulated by a dense parietal peritoneal inflammation. The liver is densely adherent to the anterior abdominal wall and the gallbladder is not visualized.
Peritoneal biopsy confirming the diagnosis of endometriosis. The endometriosis glands with periglandular endometriotic stroma that contain blood vessels are visualized.
Massive ascites associated with endometriosis is extremely rare with less than 100 cases described in the literature (
While the majority of patients with haemorrhagic ascites present with a gradual onset of symptoms, reports
of acute onset of symptoms have been published. A 2013
case report described a 27-year-old who presented with a
one day onset of neck and flank pain, abdominal distention, light-headedness and palpitations. She was initially
stable, but progressively decompensated and required
transfusion of numerous units of packed red blood cells.
Ultimately, a diagnostic paracentesis was performed and
4.5 litres of grossly bloody ascitic fluid was removed (
Patients with haemorrhagic ascites often pose a difficult diagnostic dilemma on initial presentation. The different diagnosis must include large haemorrhagic ovarian
cyst rupture, ovarian cancer, ectopic pregnancy, endometriosis, Meigs’ syndrome, trauma, or other processes that
could cause large hemoperitoneum. If necessary, initial
stabilization measures with IV fluids and possible transfusion of blood products should be performed. As this presentation is so rare, no agreed upon workup is in place, but
should be focused on ruling out the more common causes
of hemoperitoneum. In a review of the literature, laboratory analyses that include complete blood count (CBC),
basic metabolic panel (BMP), urine pregnancy and Ca-
125 were typically performed, along with basic imaging
with either ultrasound, CT scan or MRI (
Haemorrhagic ascites has been treated both medically
and surgically. Medical management was attempted in
97% of patients with the use of hormonal therapy (e.g.,
GnRH agonist, danazol, progesterone, combination oral
contraceptive pills or a combination of these) (
The exact cause of haemorrhagic ascites in patients with
endometriosis is unknown. It has been suggested that the
ascites is caused by a ruptured endometrioma or by exudation of widespread pelvic endometriosis. However, Ussia
et al. (
Management needs to take into account a patient’s age, surgical history, medical history and future fertility plans. In patients who have no desire for future fertility and desire definitive surgical treatment, a bilateral salpingo-oophorectomy would be most effective. Subtotal surgical management (e.g., unilateral oophorectomy or cystectomy) alone should be avoided as the recurrence rate is high. Medical management with GnRH agonists are proven to be highly effective and should be used with a patient who desires future fertility, and for those who want to avoid surgical intervention.
Haemorrhagic ascites is a poorly understood and rare manifestation of pelvic endometriosis. The differential diagnosis includes a variety of benign conditions, but malignant pathology must be ruled out. There are no specific protocols for the treatment of this rare condition. Current theories regarding the pathophysiology point to the ovary and excessive ovarian transudation. Management therefore involves surgical removal of bilateral ovaries or medical management with ovarian suppression. Patients who desire future fertility should be managed with a GnRH agonist. Clinicians should consider endometriosis in the differential diagnosis on female patients of reproductive age who present with haemorrhagic massive ascites.