Right-Shoulder Pain: An Unusual Sign of Hepatic Endometriosis

Abstract

Background: Endometriosis is a common, benign, estrogen-dependent, chronic gynecologic disorder associated with pelvic pain and infertility. Endometriotic lesions have also been found in several remote sites—including the omentum, gastrointestinal tract, peritoneum, operative scars, lymph nodes, umbilicus, skin, lungs, pleura, urinary bladder, kidneys, and pancreas. Only 19 cases of hepatic endometriosis have been found in English-language publications. Case: A 38-year-old female, with a 5-year history of pelvic endometriosis, was referred to the Aretaieion Hospital, University of Athens, in Athens, Greece. A detailed history of this patient revealed that her shoulder pain was associated with menstruation. A chest computed tomography scan showed a mass in the liver and, subsequently, liver magnetic resonance imaging was performed. The latter revealed a 4.4×3.8 cystic mass in segments 7 and 8 of the liver infiltrating the right diaphragm. At exploratory laparotomy, a tumor at the diaphragmatic portion of the liver infiltrating the diaphragm was found. A wedge excision of the tumor was performed with clear margins en bloc with part of the right diaphragm. A histology report confirmed a mixed cystic and solid mass, with endometrial-type epithelium, positive to estrogen receptors and progesterone receptors, and with cholangian differentiation in some sites. The diaphragm excised was infiltrated by endometrial tissue, while the liver margins were free of pathology. Results: The patient was discharged on the second postoperative day and remains free of symptoms 6 months later, as of this writing. Conclusions: Intrahepatic endometriosis is a rare condition. The diagnosis may only be reached preoperatively by high clinical suspicion of the condition, when symptoms are associated with menstruation. (J GYNECOL SURG 30:383)