PURPOSE: To present a rare case of hemorrhagic ascites due to endometriosis in a young, healthy patient

SUMMARY: Endometriosis is the ectopic growth of the endometrium. It is a common disease with a prevalence of approximately 6%-10% in women of reproductive age. It can have different presentations depending on its location; recurrent hemorrhagic ascites being a rare one. Since hemorrhagic ascites usually develops due to peritoneal tuberculosis, carcinomatosis or pancreatic ascites, it can be misdiagnosed when the cause is endometriosis. Delayed diagnosis of endometriosis impedes management and can lead to long-term complicated sequelae for women, including infertility and chronic pain. Therefore, we want to highlight the obstacles we faced in this case aiming to increase the awareness about this unique presentation to early-diagnose and better-manage this poorly understood disease. We report a previously healthy 25-year-old nulliparous African American woman with well-controlled asthma was referred to surgical oncology due to recurrent hemorrhagic ascites of unknown etiology. She had presented to a different hospital with abdominal discomfort and bloating 12 months earlier, and 5 liters was drained via paracentesis at that time. On her second presentation, paracentesis yielded 12.8 liters. Investigations via pelvic exam, pelvic ultrasound, CT scan, and cytology of the peritoneal fluid were inconclusive. Diagnostic laparoscopy confirmed the diagnosis of endometriosis. The patient was referred to gynecology for outpatient management

CONCLUSION: Endometriosis-related ascites is rare; the first reported case being in 1954 Since then approximately only 63 cases were reported, 63% of them were African American and 82% were nulliparous, similar to the current case. Most common presentations of endometriosis are adnexal masses, infertility, and dysmenorrhea. It rarely presents as recurrent hemorrhagic ascites, resulting in a challenging diagnosis. In conclusion, clinicians should keep in mind the possibility of endometriosis in a young woman presenting with recurrent hemorrhagic ascites without any previous chronic conditions. This can save time and avoid overwhelming the patient and the healthcare system as well with unnecessary tests and procedures. The delay in diagnosing endometriosis due to low clinical suspicion is too common for such a prevalent disease. Establishing early diagnosis of endometriosis is essential to control the disease before long-term consequences such as infertility and chronic pain occur.