Case Presentation: A 35-year-old female patient with a medical history significant for symptomatic uterine fibroids presented after a syncopal episode. Patient had experienced chronic abdominal pain throughout the past year, but she noted that the pain acutely worsened at the time of her syncopal episode. She also endorsed nausea, vomiting, and new abdominal distension. She denied any pre-syncopal symptoms such as vision changes, lightheadedness, palpitations, chest pain, or diaphoresis. She had not had any previous syncopal episodes. In the emergency department, patient was afebrile and hemodynamically stable with a blood pressure of 110/74 and heart rate of 71. Patient was ill-appearing and physical exam was significant for abdominal distention and generalized abdominal tenderness. Laboratory work-up revealed a hemoglobin of 6.4, down from a baseline of 10. CT abdomen and pelvis (CTAP) was obtained that showed abnormal hypoattenuating myometrial mass extending from endometrium, left ovarian cyst measuring 3.7cm, significant ascites, and cirrhotic liver morphology.Paracentesis was performed for evaluation of the patient’s ascites and revealed a serum-ascites albumin gradient (SAAG) of 0.8. Analysis of the ascitic fluid revealed 2,355,000 RBCs. Fluid cytology was negative for malignancy. Liver work-up was negative for organic liver disease. Echocardiogram showed no evidence of congestive heart failure. Urinalysis was inconsistent with nephrotic syndrome. No evidence of pancreatitis on the CTAP. No fevers, night sweats or risk factors for infectious ascites. However, endometrial biopsy demonstrated evidence of chronic endometriosis.
Discussion: Hemorrhagic ascites is a rare complication associated with chronic endometriosis, with less than 100 case studies of this phenomenon documented since it was first described in 1954 [1]. In the documented cases, patients typically presented with weeks to months of increasing abdominal pain, abdominal distension, anorexia/weight loss, though instances of rapid symptom development over hours to days have been reported as well, which may require expedited inpatient work-up [1,2]. Symptoms of endometriosis are not always expressed at the time of initial presentation, but many patients endorse dysmenorrhea, menometrorrhagia, primary infertility, dyspareunia, or exacerbation of symptoms during menstruation upon review of systems [1,3]. In addition to abdominal distension, pelvic masses were a notable exam finding observed in many reported cases. Demographically, this condition has been described primarily in premenopausal women, with 60-63% of cases observed in Black women and 82% in nulliparous women [4]. Furthermore, many patients had never received a formal diagnosis of endometriosis prior to developing hemorrhagic ascites, contributing to the difficulty of accurately recognizing endometriosis as a cause of hemorrhagic ascites [4].
Conclusions: Because endometriosis is often misdiagnosed or not diagnosed at all, endometriosis should be considered as a possible etiology in all pre-menopausal women presenting with hemorrhagic ascites, once can’t-miss diagnoses, like ovarian cancer, ectopic pregnancy, or non-gynecological cancers have been ruled out.