Spontaneous Abdominal Wall Endometriosis, A Case Report And A Literature Review
Correspondence Address :
Endometriosis is a well defined but not such well understood benign gynaecological condition that consists on the presence of endometrial gland and stroma outside the uterus and that affects 10- 15 % of reproductive age woman (Kovacs P. Conference Report 2002). The abdominal wall is the commonest extra pelvic implantation site, usually on previous laparotomic or laparoscopic scars. In this paper we report un uncommon case of spontaneous endometriosis of the abdominal wall with no previous surgery or delivery.
â€˘ Introduction Abdominal wall endometriosis is a relatively rare condition, usually presented in a previously performed abdominal incision.
â€˘ Case presentation We present a case of a young female patient with an abdominal mass, with no previous surgery, that the histopathology report revealed to be an endometriotic lesion.
â€˘ Conclusion Abdominal endometriosis can develop spontaneously supporting the coelomatic metaplasia theory, developed by Metzger by 1991.
Endometriosis is a well defined but not such well understood benign gynaecological condition that consists on the presence of endometrial gland and stroma outside the uterus. The endometriotic implants, like the uterus itself, obey to all the hormonal changes present during the menstrual cycle.
Those ectopic implants are most commonly found in the peritoneal cavity, isolated or spread, localized mainly on the pelvic organs but they can also been found on the pleural cavity, diaphragm, liver, kidneys, muscles and abdominal surgery scars.
The typical extra pelvic abdominal endometriosis consists of the presence of a lump or nodule, localized on abdominal surgery scars, usually caesarean sections, with an incidence of 0.03 to 1 %(1). Whereas surgical scar endometriosis is well defined, even if poorly understood, spontaneous presentation of the disease has been only accidentally reported.
A 28 years old, Caucasian, female patient of Portuguese nationality, G0P0, presented in the general surgery department with complaints of a dysaesthetic abdominal lump, localized in the left iliac fossa, with vague cyclic pain, related to the menses, with 2 years of evolution.
On the objective exam, she presented an ill defined painless subcutaneous nodule, fixed on the aponeurotic plane and no abdominal incision has been identified. The patient denied any relevant anamnestic data.
She was proposed to have an excisional biopsy under local anaesthesia, with no other radiological or histological investigation.
After skin infiltration with Lidocaine 2%, a 3 cm skin incision was made and during the tissue dissection there a bluish nodule was identified fixed on the rectus sheath aponeurosis.
An en-bloc excision of 4 cm tissue, including rectus aponeurotic sheath was performed and a prolene mesh was applied on the aponeurotic plane, in order to correct the surgical provoked defect respecting the no-tension principle.
The skin stitches were removed on the seventh day.
The histopathology report revealed macroscopically a hard bluish nodule and microscopically the presence of endometrial gland with intraglandular haemorrhage and stroma (Table/Fig 4) and (Table/Fig 5), typical features of endometriosis that confirmed the clinical suspicion.
A diagnostic laparoscopy was proposed for the patient in order to determine the existence of intra-abdominal disease, since MRI was negative, but the patient denied. Actually she remains asymptomatic.
In the international literature, after a pub-med search under the abdominal wall endometriosis search key, 15 reports of spontaneous abdominal wall endometriosis (2),(3),(4),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14),(15),(16) were identified. The most common site was the umbilical scar, with 14 cases, followed by 1 supra pubic , 1 rectus abdominis, 1 thoracic wall and 4 abdominal wall endometriotic foci.
Are we dealing with a miss-diagnosis or with a non reported fact?
In the teamâ€™s personal experience of 6 years there have been counted 3 cases of abdominal wall endometriosis leaning on previous caesarean section scars (Table/Fig 1) and 1 case of scar less subcutaneous endometriosis.
The microscopic features of scar endometriosis are shown on the(Table/Fig 2) and (Table/Fig 3), while(Table/Fig 4) and (Table/Fig 5) show the microscopic features of the spontaneous abdominal wall lesion (intraglandular haemorrhage).
Surgical resection provides the healing, but the underlying physiopathology has to be defined.
The current theories on endometriosis aetiology (17) are the following:
a) SampsonÂ´s theory of retrograde transplantation of endometrial tissue during menstrual flux through the fallopian tubes
b) MeyerÂ´s theory of coelomic epithelium metaplasia, according to which there is a â€śtransformationâ€ť of the epithelium susceptible to the hormonal influence.
c) HalbanÂ´s theory of lymphatic and haematogenous spread of endometrial cells.
The authors believe that this rare case supports the coelomatic metaplasia theory which evocates the transformation of coelomatic epithelium that lines the surface of the body wall and abdominal organs, present in various organs and tissues, into endometrial tissue under the influence of estrogens
Extra-pelvic endometriosis, especially the ones that arise on surgical scars; need to be reported, as we believe to be an often but not reported condition.
G0P0, gesta 0, para 0
MRI, magnetic resonance
"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."
â€śThe author(s) declare that they have no competing interestsâ€™'.
ZS performed the surgery and the literature review
AC and PG, oriented the management of the patients and supervised the case
RM is responsible for the pathology examination of the samples.
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