Case report: hepatic and retro-peritoneal endometriosis presenting as obstructive jaundice with ascites: a case report and review of the literature

Diagnosis, surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment. Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion. A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively. Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.

Hepatic pedicle endometriosis: Case report and review of the literature

The localization of endometriotic disease in the hepatic pedicle has never been reported to date. We report the first case of a 67-year-old postmenopausal patient having presented an endometriotic lesion in the hepatic pedicle. A surgical biopsy was needed to confirm the diagnosis after a first radiologic biopsy that concluded the presence of a mucinous cystic tumor with low-grade dysplasia. Medical treatment with aromatase inhibitors was carried out because of the inextirpable nature of the lesion. The diagnosis and therapeutic management of this rarely occurring lesion of atypical localization in a postmenopausal patient is presented here. A review of the literature on this localization could have led to a damaging surgical treatment due to the different diagnoses suggested. Management of endometriosis relies on a multidisciplinary approach that each practitioner must know how to broach with patients of all ages.

Micrometastasis of endometriosis to distant organs in a murine model

Endometriosis is an inflammatory gynecological disorder among reproductive-aged women caused by the engraftment and proliferation of endometrial cells outside the uterus, most commonly in the pelvis. It is thought that the disease arises primarily from retrograde menstruation where cells from the endometrium travel through the fallopian tubes to the peritoneal cavity. However, migration of endometriosis-derived cells to distant organs outside of the peritoneal cavity have not been explored. In the present study, we developed and validated a mouse model of disseminated endometriosis using syngeneic DsRed endometrial tissue introduced into the peritoneum of immunocompetent mice. Flow cytometry and immunofluorescence analysis, demonstrated the presence of endometriosis-derived cells in multiple organs (including lung, spleen, liver and brain) in the murine endometriosis model. Immunostaining revealed the presence of DsRed+/CD45- cells in brain, liver and lung. Engraftment occurred in all experimental animals examined. Cells from endometriotic lesions are capable of migration to and engraftment of multiple organs outside of the peritoneal cavity. Micrometastasis of endometriosis is a novel and frequent phenomenon. These data suggest that widespread dissemination of endometriosis may be common, clinically unrecognized and contribute to the diffuse clinical manifestations of this disease.

Subcapsular hepatic endometriosis: case report and review of the literature

Hepatic endometriosis is a very rare medical condition characterized by the implantation of ectopic endometrial tissue within the hepatic parenchyma. Preoperative diagnosis is difficult via cross-sectional imaging and histopathologic evaluation remains the gold standard for diagnosis. We report a case of hepatic endometrioma in a 44-year-old woman with history of endometriosis. The literature is reviewed, and magnetic resonance imaging findings together with differential diagnosis of hepatic endometriosis are highlighted.

Focal Liver Lesion Secondary to Endometriosis: Case Report and Literature Review

Introduction

Hepatic endometriosis is a rare disorder, without preoperative imaging findings are unclear. A diagnosis of endometriosis in a heterogeneous cystic liver mass should be considered, especially in patients with known endometriosis.

Case Report

A 40-year-old female patient complaining of sporadic abdominal and pelvic pain, not related to the menstrual cycle and without previous history of endometriosis, underwent routine sonographic evaluation, which indicated a lesion in the right hepatic lobe, apparently solid-cystic to ultrasonography. Upon further investigation using computed tomography (CT) and magnetic resonance imaging (MRI), image patterns consistent with hemorrhagic spots were also found; however, without the characteristics compatible with the most common focal hepatic lesions. It was suggested a possible diagnosis of metastasis by tumor of unknown site, due to the presence of a heterogeneous and hypodense nodule in the paracolic gutter, right to the CT, and then established the correlation with the clinical condition. The histological analysis has found a liver endometriosis, and the patient was referred surgical treatment.

Conclusions

Based on the analysis of this case, the authors present a review of the cases of liver endometriosis described so far, exposing and comparing the most common clinical and image findings.

Hepatic endometriosis: a rare case and review of the literature

Hepatic endometriosis is one of the rarest disorders characterized by the presence of ectopic endometrium in the liver. To our knowledge, only 21 cases of hepatic endometrioma have been described in the medical literature. We report a case of a 36-year-old primiparous female with hepatic endometriosis forming a large cystic mass. The patient presented once with severe right quadrant pain as her only symptom and no history of endometriosis. Complete blood count and biochemical tests were normal. Abdominal ultrasonography and computed tomography scans suggested the presence of a 6.5 × 6.0 cm cystic mass in segment III of the liver. The mass was completely removed by local liver resection. The intraoperative frozen sections suggested a diagnosis of hepatic endometriosis. The diagnosis was confirmed through histological immunostaining without intrinsic abnormality. A preoperative diagnosis of hepatic endometriosis is made on the basis of considering the possibility in advance. Hepatic endometriosis should be considered in the differential diagnosis of a cystic liver mass despite conducting exhaustive investigations in the absence of characteristic clinical and radiological features. Histological examination is essential, and surgery remains the treatment of choice.

Hepatic Uterus-Like Mass Misdiagnosed as Hepatic Abscess

Background. Hepatic endometriosis/uterus-like mass is rare and may be overlooked during hepatic cyst workups. We report a case of uterus-like mass, misdiagnosed as hepatic abscess. Case Report: A 47-year-old woman developed abdominal pain and vomiting. Infectious colitis with hepatic abscess was diagnosed, and remained antibiotic-refractory. Fine-needle aspiration and core biopsies showed benign contents. The patient presented to our institution with symptoms and normal blood work. Laparoscopic excision demonstrated a 1.4-cm cyst composed of endometrial glands (estrogen receptor+ and progesterone receptor+) and stroma (CD10+) with smooth muscle actin (SMA+), arranged in an organoid fashion. The patient, status-post hysterectomy, had no history or symptoms of endometriosis. Conclusion. This rare case illustrates the merit of considering uterus-like mass/endometriosis in the differential diagnosis of antibiotic-refractory hepatic cysts. Cyst heterogeneity may confound needle biopsy. We report the first instance of a hepatic uterus-like mass, with a review of related entities, postulated histogenesis, and important clinical associations.

Endometrial cysts within the liver: a rare entity and its differential diagnosis with mucinous cystic neoplasms of the liver

Endometrial cysts within the liver are rare but can present as diagnostic challenges on small biopsies or frozen sections and may mimic mucinous cystic neoplasms (MCN) of the liver. Five cases of endometrial cysts and 6 cases of MCNs within the liver were collected. The clinicopathological, imaging, and immunohistochemical features were systematically reviewed and compared. The average size of the endometrial cysts was 8.3 cm. Four patients had a prior pelvic operation and coexisting endometriosis at other sites. All 5 cases of endometrial cysts had positive ER staining within both the epithelium and the stroma. PR was also positive in both epithelial and stromal cells in 4 cases. Four cases had additional immunostains performed, which all showed cytokeratin 19 and cytokeratin 7 positivity (only in epithelium) and CD10 positivity (only in stroma). α-Inhibin and calretinin were negative for both the epithelium and the stroma in all 4 cases. All 6 MCN cases (mean size, 11.1 cm) had positive ER, PR, and α-inhibin staining only in the stroma. ER and PR were positive in both the epithelium and stromal cells in endometrial cysts, whereas they were positive only in the stromal cells of MCNs. The stromal cells were CD10 positive and α-inhibin negative in endometrial cysts as opposed to the opposite staining pattern in MCNs. Awareness of this distinct staining pattern and the possibility of endometrial cysts in the liver can lead to accurate diagnoses and appropriate treatment modalities.

Hepatic endometriosis mimicking metastatic disease: a case report and review of the literature

Endometriosis of the liver is an uncommon disease characterized by the presence of endometrial tissue in the liver. There are no pathognomonic radiological features for hepatic endometriosis and preoperative diagnosis is difficult by imaging. Most cases are diagnosed after surgery. We report atypical imaging features of hepatic endometriosis in a 61 year-old female that mimic metastatic disease to the liver. She was referred to our institution with a presumed diagnosis of metastatic neuroendocrine tumors to the liver. After imaging guided core biopsy and histologic and immunohistochemical analysis, the diagnosis of hepatic endometrial stromal proliferation was made. We review the literature and provide imaging features that may help in reaching the correct diagnosis of hepatic endometriosis.

A systematic review: endometriosis presenting with ascites

BACKGROUND

The present review aims to increase the awareness of the gynecologists by analyzing all the case reports which refer to endometriosis presenting either with only ascites or with massive ascites with pleural effusion.

METHODS

To conduct the present review, the CENTRAL (in the Cochrane Library, current issue), MEDLINE (Silver Platter, from 1950 to 2010), and EMBASE (from 1950 to 2010) electronic databases were searched. As a result, all the publications based on the keywords relating to the review topic were acquired.

RESULTS

Since the description of first case in 1954, endometriosis-related ascites was reported to occur in a total of 63 women who were aged between 19 and 51 years. Approximately 63.0% of the recruited women for whom ethnicity was specified were of African origin (29 out of 46). Of the 50 subjects with known obstetric history, 41 (82.0%) were nulliparous. Abdominal distention, anorexia/weight loss, abdominal pain, and menometrorrhagia were the most frequently encountered clinical symptoms, whereas pelvic mass was the most common physical finding. The serum concentrations of CA 125 were between 20 and 3,504 IU/ml for 19 women whose CA 125 levels were determined. Pleural effusion was also present in 38.1% of the reviewed subjects (24 out of 63). The clinical features of the women with endometriosis-related ascites and pleural effusion were similar to those of the women who had only endometriosis-related ascites.

CONCLUSION

Endometriosis-related ascites and/or pleural effusion refers to extensive disease with a high risk for recurrence which usually affects non-Caucasian, nulliparous women of reproductive age and leads to clinical symptoms resembling those of an ovarian malignancy. Therefore, clinicians should consider endometriosis in differential diagnosis of pelvic masses and also include endometriosis in diagnostic workup of ascites or pleural effusion.

Subhepatic retroperitoneal endometrioma: report of a case

A 38-year-old woman with a history of pelvic endometriosis was referred to our surgical department for the treatment of a cystic lesion most probably originating from the liver. At the laparotomy a solitary cyst was found in the retroperitoneum, connected to the inferior surface of the liver, and was resected. Histopathological examination of the resected specimen revealed that it was an endometriotic cyst. The occurrence of endometriotic cyst in the upper abdomen is very rare: there are no published reports of an endometriotic cyst in that anatomic location. The literature on this subject is reviewed.

Laparoscopic management of hepatic endometriosis: Report of two cases and review of the literature

Hepatic endometriosis is rare. Only 15 cases have been reported in the literature. All 15 were treated by laparotomy. We report two additional cases of hepatic endometriosis managed for the first time laparoscopically. Endometriosis is a progressive disease especially in women of reproductive age. One of the differential diagnoses of liver endometriosis is malignancy. Currently, there are no reports in the literature regarding complications arising from the progression of hepatic endometriosis. However, this lack of evidence does not deny its existence.