S3045 An Obscure Cause of Epigastric Pain: Endometriosis

Abstract

INTRODUCTION: Endometriosis is caused by endometrial gland implantation outside of the uterus. The prevalence of abdominal endometriosis is rare (0.03%–1.5% in the general population) and is commonly associated with cesarean delivery. Here we present a case of endometriosis as the cause of epigastric pain without typical symptoms or history of abdominal surgeries. CASE DESCRIPTION/METHODS: A 27-year-old female with past medical history of occasional pyrosis presented to Gastroenterology for evaluation of intermittent epigastric pain. The pain worsened with activity but was not associated with meals. She underwent esophagogastroduodenoscopy (EGD) which was negative for any abnormal findings. A CT scan with oral and IV contrast was done which was unremarkable except for fatty liver and 5 mm appendicolith without inflammatory changes. Gynecologic evaluation including ultrasound of the abdomen and pelvis was normal. She was seen in the office one month later where she continued to complain of a sharp pain near the umbilicus. Physical exam revealed a very small hernia palpable superior to umbilicus with mild tenderness on palpation. Unfortunately, she continued to experience worsening periumbilical pain which prompted her to consult with surgery one year later. Interestingly, her pain had progressed to a cyclical nature and was more noticeable just after her menstrual cycles which were reported to be normal. Patient deferred surgery of presumed umbilical hernia as she was planning on having children in the near future and pregnancy could cause recurrence. One year later, the patient opted for surgery due to the worsening of pain and increase in umbilical lesion size. Intraoperative biopsy of the umbilical lesion revealed endometriosis. DISCUSSION: Patients with endometriosis often present with dull or crampy abdominopelvic pain that begins a few days before menses and lasts for a few days afterward. However, endometriosis can present with a variety of non specific manifestations which makes the diagnosis challenging. The mean delay in diagnosis of endometriosis was 6.7 ± 6.2 years with a median delay of 5 years in a Norwegian study. Abdominal wall endometriosis is a rare cause of chronic abdominal pain in adult patients, most of which had vicinal surgical incision. In our patient, suspicion of endometriosis was initially low due to her nulliparous status and lack of abdominal surgeries. A high clinical alertness is warranted while evaluating female patients with abdominal pain of unclear etiology.Figure 1.: Cytology smear demonstrating columnar cells.Figure 2.: Ectopically located endometrial tissue consisting of both endometrial type glands and stroma.