Summary:
A 27-year-old morbidly obese female presents with worsening
abdominal pain centered in the region of her incision for a Caesarean section (C-section) 4 years
prior.
Diagnosis
Incisional Endometrioma
Findings
Axial and sagittal contrast-enhanced computed tomography (CT) images as well as a
grayscale ultrasound (US) image were acquired. The CT images demonstrate a
lobulated lesion within the deep subcutaneous tissues overlying the rectus
musculature, which is mildly hyperdense to the muscles. The lesion measured
approximately 76 Hounsefield units in attenuation. A small amount of
inflammation surrounds the lesion. The grayscale ultrasound image demonstrates
a hypoechoic, relatively well-defined subcutaneous lesion with posterior
acoustic shadowing.
Discussion
Endometriosis is the presence of functioning endometrial
glands and stroma outside of the uterus. Endometriosis is a common and
important gynecological disorder with ectopic endometrial tissue varying in
size from microscopic foci to large masses termed endometriomas. Endometriosis
occurs in women of child-bearing age and is a common cause of pelvic pain and
infertility. The most common locations for endometriosis include the ovaries
and the peritoneum, although cases involving the lungs and central nervous
system have been described.
Endometriosis can also occur within surgical scars, most
commonly following gynecologic procedures, such as C-sections. Patients often
present weeks to years after surgery with complaints of pain and a palpable
mass in the approximate location of the surgical scar. Many patients describe
pain, which is associated with menses.
The US appearance of an incisional endometrioma is variable with
the most common appearance being a well-defined hypoechoic lesion with
posterior acoustic shadowing. Some lesions may also demonstrate cystic changes.
The appearance of the endometrioma may change over time depending on the timing
relative to the patient’s menstrual cycle. On CT, incisional endometriomas are
relatively well-defined lesions, which enhance after the administration of
contrast material, a characteristic which helps differentiate them from
hematomas and seromas. A small amount of inflammation usually surrounds the
lesion. If imaging features are not diagnostic, fine needle aspiration may be
used to confirm the diagnosis.
Treatment of incisional endometriomas consists of wide surgical
resection in symptomatic patients.
- Wolf C, Obrist P, Ensinger C. Sonographic features of
abdominal wall endometriosis. AJR Am J
Roentgenol
- Miller WB, Jr, Melson GL. Abdominal wall endometrioma. AJR Am J Roentgenol 1979; 132:467-468.