Atypical Clinical Presentation of Primary Umbilical Endometriosis

Case Report

Atypical Clinical Presentation of Primary Umbilical Endometriosis

Bachir Elias¹, Elias Adam², Hanane Ziadeh³^* and Clemence Matta⁴
¹Department of General Surgery, CHR Metz-Thionville, Bel-Air hospital, Thionville 57126, France
²Department of General Surgery, Centre Hospitalier Universitaire Notre Dame De Secours, Byblos, Lebanon
³Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Notre Dame De Secours, Byblos,
Lebanon ⁴Department of Hematology/Oncology, Centre Hospitalier Universitaire Notre Dame De Secours, Byblos, Lebanon

^*Corresponding author: Hanane Ziadeh, Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Notre Dame De Secours, Byblos, Lebanon

Published: 27 Sep, 2017
Cite this article as: Elias B, Adam E, Ziadeh H, Matta C. Atypical Clinical Presentation of Primary Umbilical Endometriosis. Clin Surg. 2017; 2: 1635.

Abstract

Primary umbilical endometriosis is a rare condition. Clinical presentation is usually a painful umbilical nodule or bleeding during menstruation. We report a case of this rare condition with atypical clinical presentation. Also is discussed the management of umbilical endometriosis. Keywords: Endometriosis; Umbilicus; Pain; Surgery

Introduction

Umbilical endometriosis is a rare clinical condition, which accounts for 0.5% to 1% of all cases of non-genital endometriosis [1]. When it occurs without any previous surgery is called primary umbilical endometriosis. We report a case of 29 year old female without any surgical history who presented with a painful umbilical mass. Histopathological examination after surgery confirms the endometriosis nature of the lesion. Surgical excision remains the treatment of choice for umbilical endometriosis.

Case Presentation

A 29 year old female without any past medical or surgical history, consulted at the emergency department for pain at the umbilicus since three days. She had no gastrointestinal or gynaecological symptoms. She did not notice previous painful episodes even during menstruation. Physical exam showed a 1 cm brownish umbilical mass. The first diagnosis was small incarcerated umbilical hernia with necrotic fat content (Figure1). The patient underwent surgical exploration and excision of the umbilicus and a 2 cm nodule (Figure 2); the nodule was completely extraperitoneal. A reconstruction of a new umbilicus was done (Figure 3), and the patient was discharged at the same day without any complications. The diagnosis of umbilical endometriosis was confirmed by the pathology results. The patient had an asymptomatic follow-up with a good aesthetic result (Figure 4). Because of absence of symptoms related to pelvic endometriosis, laparoscopic exploration for pelvis endometriosis was not done.

Figure 1

Figure 1
Umbilical brownish mass de 1 cm.

Figure 2

Figure 2
Wide excision of the umbilicus with the nodule.

Figure 3

Figure 3
Reconstruction of the umbilicus.

Figure 4

Figure 4
The umbilicus after 1 month.

Discussion

Cutaneous endometriosis variant is rare: primary umbilical endometriosis called sometimes nodule de Villar in French is a rare clinical condition, which accounts for 0.5% to 1% [1]; less than 150 cases were reported in the literature [2]. There are two type of umbilical endometriosis: primary endometriosis in patients without any past surgical history and the secondary endometriosis occurring after gynaecological operations usually at the trocard site [3]. The pathophysiology is an ectopic migration of endometrial tissue out of the uterus. The exact mechanism of this process is still controversial. Three theories were described: an intraperitoneal migration of endometrial cells during menstruation [4]; or coelomic metaplasia [5] or metastatic dissemination of endometrial by lymphatics or haematogenous spread [2]. Endometriosis was described in many localisations such as ovaries, peritoneum, digestive tract, urinary tract, pleura, lungs, liver, brain, umbilicus and even nasal [6]. Clinical presentation of umbilical endometriosis is usually pain during menstruation and/ or bleeding. Differential diagnoses are umbilical hernia as in our case, malignant tumour, lipoma, or dermoid cyst [7]. Ultrasound, MRI and percutaneous biopsy are used to confirm the diagnosis of umbilical endometriosis before surgery [8-10]. The final diagnosis is obtained by pathology after surgery. Surgical excision of umbilical endometriosis is the treatment of choice. The operative options are a complete umbilical resection, with or without repair of the underlying fascia and peritoneum or local excision of the nodule, sparing the umbilicus. Total removal of the umbilicus is the most frequently performed operation [11]. Some authors have reported some success in relieving symptoms and reducing the size of the endometriosic nodule by using medical hormonal treatment [12]. Once primary umbilicus endometriosis is confirmed, laparoscopic exploration can be recommended to rule out pelvic endometriosis but remains debatable in asymptomatic patients [11,13]. Umbilical endometriosis is a rare condition. It should be considered as a differential diagnosis in any female presenting an umbilical nodule even without previous surgeries. The clinical presentation of painful nodule or bleeding during menstruation is not always typical. Our patient presented atypical clinical symptoms of her primary umbilical endometriosis.

Case Report