Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Bengaluru.
On Aug 2018




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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


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On Jan 2020

Important Notice

Case report
Year : 2008 | Month : December | Volume : 2 | Issue : 6 | Page : 1203 - 1206 Full Version

Umbilical Endometriosis


Published: December 1, 2008 | DOI: https://doi.org/10.7860/JCDR/2008/.381
RAI R *,SATHYAMOORTHY A** ,D’SOUZA C***

*,**,***Dept.of General Surgery,Fr Mullers Medical College,Mangalore,Karnataka,(India)

Correspondence Address :
Dr. Rakesh Rai,Dept.of General Surgery,Fr Mullers Medical College,Mangalore,Karnataka,Ph:9886494433,E-Mail:dr.rakeshrai@gmail.com

Abstract

Endometriosis is a disorder in which abnormal growth of tissues, histologically resembling that of the endometrium, are present in locations other than the uterus. The lesions are usually found in the peritoneal surface of reproductive organs, but also can be found anywhere in the body. Primary cutaneous endometriosis is uncommon. The frequency which arises in the skin of all endometriosis is 1.1%, and those which arise in the umbilical region are about 30%. Umbilical endometriosis is a very rare surgical condition, but should be considered in the differential diagnosis of any umbilical nodule. We report a case of a 28yr old lady who presented with a bluish nodule at the umbilicus for 3 months, with no associated discharge. It was histopathologically confirmed as umbilical endometriosis.

Keywords

Endometriosis, Umbilicus, Cutaneous endometriosis

In the late nineteenth century, the term endometriosis was coined by Sampson to characterize ectopic tissue possessing the histological structure and function of the uterine mucosa. It also includes those abnormal conditions which may result not only from the invasion of organs and other structures by this tissue, but also from its reaction to menstruation. Endometriosis is a well recognized gynaecological condition that presents infrequently to general surgeons. Cutaneous endometriosis presenting to general surgeons is often mistaken for a suture granuloma, abscess, cyst, lipoma or incisional hernia(1).Umbilical endometriosis is rare, with an estimated incidence of 0.5 to 1.0 percent of all patients with endometrial ectopia(2), Subcutaneous endometriosis should be suspected in any female presenting with cyclic pain emanating from a mass in the vicinity of an abdominal surgical scar or the umbilicus(3). We report our case to highlight the challenges involved in its diagnosis.

Case Report

A 28 year-old-woman presented to the surgical outpatient clinic with the history of a painful umbilical nodule, of three months duration. She had regular menstrual cycles without dysmenorrhoea. The patient had not conceived, following four years of married life. There was no past history of any surgeries. General physical examination was normal. Local examination revealed a 3 X 2 cm, non tender, not reducible, firm, lobulated umbilical nodule, without a cough impulse. There was no discharge or ulceration on the surface. Other systemic examination were unremarkable (Table/Fig 1).

Her routine haematological investigations were normal. Ultrasonography gave the diagnosis as umbilical adenoma. Hence, no FNAC was done. The patient was subjected for excision biopsy, with a differential diagnosis of umbilical adenoma and umbilical endometriosis. The swelling was found to have no communication with the peritoneal cavity. The excised specimen was sent for histopathological examination, which revealed glandular structures lined by endometrial epithelial cells and,surrounded by a cellular stroma. These features were suggestive of endometriosis (Table/Fig 2),(Table/Fig 3).

The patient was further evaluated to look for any other foci of endometriosis. The final diagnosis of isolated umbilical endometriosis was confirmed. The patient was discharged on the 3rd post operative day. Sutures were removed on the 7th post operative day. On 3 months follow up, the patient was asymptomatic.

Discussion

The prevalence of pelvic-endometriosis has been reported to be as high as 44% in asymptomatic women undergoing laparoscopy for non gynaecological symptoms, while the incidence of umbilical endometriosis is estimated to be only 0.5% to 1% of all women with an extragonadal endometriosis. The presentation of endometriosis to general surgeons is rare and atypical, and presents diagnostic difficulties(1).

Umbilical endometriosis occurs in women between 30 to 40 years of age. It is usually a solitary, firm, brownish or bluish nodule ranging from 0.5 to 3 cm in size .Umbilical endometriosis is rare, with an estimated incidence of 0.5 to 1.0 percent of all patients with endometrial ectopia(3). The mechanism of formation of umbilical endometriosis appears to be unknown, although there are two major theories: metastases and metaplasia. The metastasis theory suggests that the implantation is either by lymphatic or haematogenous spread(1),(2).

More commonly, cutaneous endometriosis occurs in a surgical scar from abdominal or pelvic procedures, which include hysterectomy, caesarean sections, episiotomy and laparoscopy. Endometriosis is usually present in the pelvic organs and is rarely described in the umbilicus, vagina, vulva and appendix(4). Cutaneous endometriosis is a rare condition, especially in patients without a history of abdominal or pelvic surgery or known preexisting endometriosis(5)

The lesion is often slightly tender and painful. At the time of menstruation, the pain becomes more pronounced and may be associated with swelling and slight bleeding of the lesion. Rare cases have undergone malignant transformation, and give rise to endometrial carcinoma. The possibility of coexisting genital-pelvic endometriosis should be investigated. Hormonal therapy may be a consideration when there is coexistent pelvic endometriosis.

The histopathologic features of endometriosis can be reminiscent of the main phases of the menstrual cycle. The proliferative phase has a uniform stromal cell population and pronounced epithelial mitotic activity; the secretory phase has decapitation secretion within the glandular cells and 2 stromal cell types: a large cell and a small clear cell that are morphologically similar to the uterine "predecidual cell" and the "endometrial granulocyte" respectively. Disintegration of the epithelium and dissociation from the stroma resemble menstruation(3).

The differential diagnosis of umbilical nodules includes: embryological rests, irreducible umbilical hernia, pyogenic granuloma, primary malignancy such as malignant endometriosis in the umbilicus, umbilical polyp, melanocytic nevus, seborrheic keratosis, epithelial inclusion cyst, desmoid tumour, haemangioma, granular cell tumour, keloid, and foreign body granuloma or secondary metastatic tumour from an intra-abdominal malignancy. Surgical excision of the umbilical endometrioma with sparing of the umbilicus when possible is necessary for proper histopathological diagnosis that will dictate the treatment plan(1),(3). Local recurrence after adequate surgical excision is uncommon(2).

The possibility of coexisting genital-pelvic endometriosis should be explored. The fact that up to 50% of these affected women may have concomitant pelvic endometriosis makes further pre-operative diagnostic investigations advisable in a non-emergent setting . Gyaecological referral should be made early for better preoperative planning. This is important as concurrent pelvic endometriosis needs to be treated to prevent reseeding of endometrial tissue from the pelvis. In suspicious cases where emergency surgical exploration is not warranted MRI is the most recommended investigation. This modality of imaging has been shown to be useful for delineating the size and location of extra-pelvic endometriosis and in excluding intra-abdominal extension of the disease(3),(7). Hormonal therapy may be a consideration when there is coexistent pelvic endometriosis.

Conclusion

Endometriosis at this site is not only rare it can also present diagnostic pitfalls to the general surgeon, as this case illustrates. Thus, it should be considered in the differential diagnosis of all pre-menopausal women presenting with umbilical swellings. For some patients, there may be no relationship between the swelling and menstruation, as alluded to above in our case. The diagnosis is often made incidentally by histologic examination after surgical exploration and excision of the lesion.

References

1.
. Seleem M I. Umbilical endometriosis: A diagnostic dilemma. Kuwait medical journal.2002; 34(4):303-05.
2.
. Tabbakh R, Halliday M. Endometriosis in general surgical practice .The internet journal of surgery TM ISSN: 1528-8242.
3.
. Munoz, Heidi, Waxtein, Leon, Vega, Elisa, Cortes, Roberto , Hojyo, Teresa M , Dominguez S, Luciano . An Ulcerated Umbilical Nodule. Archives of dermatology. 1999; 135(9): 1113-18
4.
. Mirei K, Shinichiro T, Hideki K, Taiichi Y, Hideya Y, Seiji K . Umbilical endometriosis. Rinsho derma. 2002; 44(7):824-25.
5.
. Elm MK, Twede JV, Turiansky GW. Primary cutaneous endometriosis of the umbilicus: a case report. Cutis. 2008; 81(2):124-6.
6.
. Schachter, Lee, Tash, Jennifer, Olgac, Semra, Bochner, Bernard H. Umbilical Endometriosis.The journal of Urology.2003; 170(6):2388-238.
7.
. Yuen J S P, Chow P K H, Koong H N, Ho j m s, Girija R. Unusual sites (thorax and umbilical hernia sac) of endometriosis. J. R. Coll. Surg. Edinb. 2001(46):313-15.

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