The Diagnostic Dilemma of Ascites in Women

Introduction

Ascites is pathological accumulation of fluid within the peritoneal cavity [1,2]. The most common causes of ascites are liver disease, congestive heart failure, pericarditis, vascular occlusion, nephrotic syndrome and malignancy [3-6]. In women, gynecological benign diseases are one of the predisposing factors for ascites presenta¬tion. As the healthcare worker often gynecological causes for asci¬tes are less frequently considered as a differential diagnosis.

In this article we describe a case series of patients with ascites as a common presentation, but each case with a different etiopathogen- esis related to a gynecological disease.

This case series highlights the importance, to consider benign gynecologic problems such as abdominopelvic tuberculosis, ad¬enomyosis, endometriosis, fibroma and leiomyoma; among the potential differential diagnoses in women with ascites for early management and timely intervention [7-11].

Methods

After getting the verbal and written consent from the patients, we identified female patients older than 18 years between January 2019 to January 2021, who presented with abdominal distention as common clinical presentation. Patients with only underlying be¬nign gynecological conditions were included in the study.

We reviewed their medical records to assess demographic data, comorbidities, clinical presentation, imaging findings, histopathol-ogy findings and management. We then did manual chart review of identified medical records to verify which of these patients, were given the diagnosis of ascites with an underlying benign gyneco¬logical etiology. Once patients were included in the study their data was de-identified and coded using alphabets as (Patient A, B, C, D, E). Then variables like patient’s age, affected organs, associ¬ated conditions, disease course and management were abstracted on to a standardised assessment sheet.

Results

Between January 2019 and January 2021, a total of five female patients were clinically diagnosed with ascites.

Table 1 highlights the demographic data, clinical features, co-mor-bidities, and imaging study of the 5 female cases. The ages varied from 39 to 44 years, and all were Asian. All the five patients pre¬sented with abdominal distension as a common presenting symp¬tom. Patient A presented with fever, abdominal pain, abdominal distension, weight loss and irregular vaginal bleeding. Patient B presented with menorrhagia and abdominal distension. Patient C presented with dysmenorrhea dyspareunia abdominal bloating and abdominal distension. Patient D presented with only abdominal distension and patient E presented with menorrhagia and abdom¬inal distension.

                     Table 1: Demographic and Clinical Features of Female Patients with Ascites (n=5)

ID= Identification, P= Parity, A= abortion, L= Live

A few co-morbid conditions were identified, including hyperten-sion (n=1) and hypothyroidism (n=1). None of the patients were diagnosed with an underlying liver disease, kidney disease, vas-cular occlusive disease, congestive heart failure nor pericarditis. None of the patients were diagnosed with a malignancy based on routine age-based cancer screening guidelines at the time this manuscript was written with follow-up ranging from 1 to 2 years. The presence of ascites in all the patients was confirmed with ul¬trasound abdomen and pelvis, later these patients underwent ex-plorative laparotomy. All the patients had significant amount of free fluid in the peritoneal cavity (Table 2). The ascitic fluid analy¬sis in all the patients resulted to be exudate.

            Table 2: Different Treatment Modalities Depending On the Diagnosis in Female Patients with Ascites (n=5)

Patient A had free fluid in the peritoneal cavity, multiple yellow-ish-white nodules on the visceral and parietal peritoneum, with significant peritoneal and visceral adhesions and left beaded fallo-pian tubes. The histopathology of endometrium biopsy specimen showed multiple epithelioid cell granulomas scattered in the endo-metrium, with Langhan’s giant cells suggestive of granulomatous disease like tuberculosis. After initiating antitubercular treatment patient was noted to have complete resolution of symptoms within 3 months. The patient was treated with antitubercular regimen for a total of nine months.

Patient B had free fluid in the peritoneal cavity with uniformly enlarged uterus. The histopathology of myometrium biopsy spec-imen showed endometrial stroma and glandular tissue within the smooth muscle of the myometrium suggestive of adenomyosis. Patient underwent total abdominal hysterectomy. There was com¬plete resolution of symptoms in 3 weeks.

Patient C had complete obliteration of the pouch of Douglas and bladder was densely adherent to the lower uterus right sided en-dometrioma with free fluid in the peritoneal cavity. The histopa-thology of Cul de sac biopsy showed multiple cuboidal glands and columnar glands with endometrial origin suggestive of endome-triosis. The patient treated with gonadotrophin releasing hormone analogues and there was complete resolution of symptoms in 6 months.

Patient D had large amount of free fluid in the peritoneal cavity with round, oval, lobulated, well-circumscribed, grayish white, right sided ovarian solid tumor. The right ovarian biopsy showed epithelioid round cells in vague cords and small nests separated by collagen fibers suggestive of fibroma. Patient underwent right sided oophorectomy with complete resolution of symptoms in 3 weeks.

Patient E had enlarged uterus with multiple subserosal masses with free peritoneal fluid. The uterine mass biopsy showed spin-dle shaped smooth muscle cells suggestive of leiomyoma. Patient underwent total abdominal hysterectomy. There was complete res¬olution of symptoms in 3 weeks

All the patients had different gynecological etiopathogeneses but with common clinical presentation as ascites. A detailed history and appropriate physical examination helps to consider benign gy-necological diseases as a potential etiology for ascites in women [12].

Discussion

Ascites is the excessive fluid collection in the abdominopelvic cavity, as a response to an underlying pathology [1,2]. The most common etiopathogenesis for ascites is related to hepato-renal diseases, cardiac disease and malignant diseases [3-6]. There is limited literature about benign gynaecological conditions causing ascites. This case series highlights the importance of considering benign gynaecological diseases like abdominopelvic tuberculosis, adenomyosis, endometriosis, fibroma and lieomyoma, as a differ¬ential diagnosis in women presenting with ascites [7-11].

Tuberculosis is a mycobacterial infection that most commonly manifests as pulmonary disease, but may affect multiple extra pulmonary sites, including abdominopelvic region [7]. The ab-dominopelvic tuberculosis is usually manifested in women of reproductive age [13-15]. These patients with abdomino-pelvic tuberculosis usually present with vague pelvic pain, abdominal distension, weight loss, fever and infertility [13-16]. On diagnostic imaging, pelvic tuberculosis may appear as ascites, peritoneal nod¬ules, omental or peritoneal thickening, or adnexal masses [15,16]. In this case series, patient A had similar signs and symptoms and radiological presentation which were confirmed on laparotomy. Patient A had a satisfactory response to anti-tuberculosis therapy and ascites resolved after anti-tuberculosis treatment [14,15].

Adenomyosis is a benign gynaecological disease characterised by the presence of ectopic endometrium within the myometrium [8]. The diffuse nature of the disease, makes it very difficult to clinical¬ly diagnose patients with adenomyosis [17-19]. It typically affects multiparous women over 30 years of age and may cause dysmen¬orrhea, menorrhagia, and abnormal vaginal bleeding [17,18]. In our case series, patient B was multiparous 39-year-old female with similar clinical presentation. noted to have adenomyosis, on ultra¬sound image. (Figure 1) She underwent total abdominal hysterec-tomy with complete resolution of symptoms. Till date, hysterecto¬my remains the standard of care [8,17-29].

Endometriosis is a gynaecological condition characterized by the presence of endometrial glands and stroma outside the endometrial cavity [9]. Patients usually present with dysmenorrhea, dyspareu¬nia and dyschezia [20]. The ectopic nature of the endometrial tis¬sue makes it difficult to diagnose endometriosis [9,20]. The pres¬ence of ascitic fluid in endometriosis is usually due to irritation on the serosal surfaces caused by free blood in the peritoneal cavi¬ty during the menstruation [20-22].

Gonadotropin analogues are widely used as a way to induce hypoestrogenism, causing regres¬sion of the ectopic endometrial tissue [9,20-22]. In our case series, the patient C was diagnosed with endometriosis and right sided endometrioma.( Figure:2) She was treated with gonadotropin re¬leasing hormone analogues, which resulted in complete resolution of symptoms in 6 months [20-22]. Ovarian fibromas are benign ovarian tumors [10]. These tumors are composed of spindle, oval, or round cells forming variable amounts of collagen [23-25]. The patients usually present with as¬cites pleural effusion and abdominal pain [10,23,24]. In this case series patient D presented with abdominal distension, secondary to ascites. After confirming the diagnosis, she underwent right sided oopherectomy with complete resolution of symptoms [23-25].

Uterine leiomyoma is the benign tumor of uterine smooth mus-cle [11]. Patients usually present with dysmenorrhea, menorrhagia and abdominal distension [26]. An ultrasonography is the initial diagnostic tool for the confirmation of the diagnosis [11,26]. The current management strategies involve mainly surgical interven¬tions which include total hysterectomy versus partial myomecto-my depending on the patient’s age and her desire to preserve fer-tility [27]. In this case series patient E is a 38-year-old female who had completed her family with four children, she presented with menorrhagia and abdominal distension. Uterine leiomyoma was noted on the ultrasound imaging.(Figure:3) As she did not desire any further children she opted for total abdominal hysterectomy.

Figure 1: Adenomyosis

Figure 2: Anterior Wall Leiomyoma

Figure 3: Endometriosis with Right Sided Endometrioma

Conclusion

As a healthcare worker, initial evaluation of a female patient with ascites, should rely on a detailed history and physical examination [12]. In women with ascites, gynaecologic problems such as ab¬dominopelvic tuberculosis, adenomyosis, endometriosis, fibroth-ecoma and leiomyoma should be considered among the potential differential for appropriate diagnosis and timely intervention.

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