Ascites and Encapsulating Peritonitis in Endometriosis: a Systematic Review with a Case Report

► endometriosis ► ascites ► peritonitis ► systematic review ► treatment

Endometriosis can have several different presentations, including overt ascites and peritonitis; increased awareness can improve diagnostic accuracy and patient outcomes. We aim to provide a systematic review and report a case of endometriosis with this unusual clinical presentation. The PubMed/MEDLINE database was systematically reviewed until October 2016. Women with histologically-proven endometriosis presenting with clinically significant ascites and/or frozen abdomen and/or encapsulating peritonitis were included; those with potentially confounding conditions were excluded. Our search yielded 37 articles describing 42 women, all of reproductive age. Ascites was mostly hemorrhagic, recurrent and not predicted by cancer antigen 125 (CA-125) levels. In turn, dysmenorrhea, dyspar- eunia and infertility were not consistently reported. The treatment choices and outcomes were different across the studies, and are described in detail. Endometriosis should be a differential diagnosis of massive hemorrhagic ascites in women of reproductive age. Palavras-chave ► endometriose ► ascite ► peritonite ► revisão sistemática ► tratamento Resumo A endometriose pode ter várias apresentações, incluindo ascite e peritonite, que são apresentações incomuns. O aumento da conscientização sobre essa doença pode melhorar a precisão diagnóstica e os resultados das pacientes. Nosso objetivo é fornecer uma revisão sistemática e relatar um caso de endometriose com esta apresentação clínica incomum. O banco de dados PubMed/MEDLINE foi revisado sistematicamente até outubro de 2016. Foram incluídas mulheres com endometriose demonstrada histologicamente, com presença de ascite clinicamente significativa e/ou abdômen congelado e/ou peritonite encapsulante; foram excluídas aquelas com comorbidades que pudessem provocar confusão. A pesquisa selecionou 37 artigos que descrevem 42 mulheres, todas em idade reprodutiva. A ascite foi principalmente hemorrágica, recorrente, e não indicada pelos níveis de antígeno associado ao câncer 125 (AC -125). Por sua vez, a dismenorreia, a dispareunia e a infertilidade não foram relatadas de forma consistente. As escolhas e os resultados do tratamento foram diferentes entre os estudos, e são descritos em detalhes. A endometriose deveria ser um diagnóstico diferencial de ascite hemorrágica maciça em mulheres em idade reprodutiva. received September 12, 2017 accepted December 20, 2017 published online March 19, 2018 DOI https://doi.org/ 10.1055/s-0038-1626700. ISSN 0100-7203. Copyright © 2018 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil THIEME Review Article 147

Endometriosis is de fined as the presence of endometrial tissue outside of the uterine cavity, which, like the eutopic endometrium, responds to hormonal stimuli. 1 Although the symptoms related to endometriosis may be associated with the location of the implant, they are unrelated to the extent of the disease, and a variety of clinical presentations have been described, including the presence of a small amount of peritoneal fluid. 2 It is very rare, however, for endometriosis to present as overt ascites, and the presence of such a condition should prompt the investigation of differential diagnoses, such as malignancy. 3 The occurrence of encapsu- lating peritonitis, described as the encapsulation of bowel loops by a thick fibrinogenous case, is even rarer, with only five cases previously described in the medical literature. 3–8 Women who present with ascites due to endometriosis often undergo multiple diagnostic procedures, including invasive ones, before the underlying cause for ascites is found.9 This results in increased patient risks and health care costs. 10 General and emergency physicians, as well as gynecologists, should be aware of endometriosis as a poten- tial cause of ascites and encapsulating peritonitis to prompt- ly diagnose it. With this in mind, this study aims to bring attention to the case of a woman presenting with encapsulating peritonitis and multiple episodes of massive ascites. We also provide a systematic review of the literature regarding the association between histologically-proven endometriosis and clinically- significant ascites, frozen abdomen or encapsulating perito- nitis, including detailed characteristics of their presenta- tions, proposed treatments and outcomes.

For this systematic review, we used the protocol outlined by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement ( ►Fig. 1 ). The electronic PubMed database was searched until October 2016 using the detailed strategy described in ►Table 1 . The case of a woman with endometriosis, recurrent ascites and encapsulating peritonitis observed at our clinic is also described. The review has been approved by the Ethics in Research Com- mittee under the protocol number 006.01.2017. Eligibility Criteria Original articles, clinical trials, case series and case reports of women of any age with histologically-proven endometriosis, presenting with clinically signi ficant ascites and/or frozen abdomen and/or encapsulating peritonitis, published in English, Portuguese, French or Spanish, were eligible for this review. Because other causes that may occur concurrently with endometriosis can cause the clinical presentations de- scribed, we excluded papers describing patients with: cancer of the ovaries, appendix or peritoneum, or other intra- abdominal cancers; tuberculosis; ovarian hyperstimulation syndrome; ovarian induction or other known causes of massive ascites; and ascites beginning in the immediate or early post-operative period of exploratory laparotomy/lapa- roscopy. Animal studies; articles published in languages other than the aforementioned ones; and reviews of the literature were also excluded. Study Selection The references retrieved were independently screened by two investigators, KA and TM. Initially, the screening was made by title and abstract; then, the full-text versions of the selected papers were obtained, and each article was reviewed for final inclusion. If a consensus could not be reached, another author (LB) made the final decision regarding inclusion. Data Extraction A standardized table was used for data extraction on each selected paper, and information regarding the first author, the country of origin, the journal and year of publication, the study type, patient/sample age, patient origin or ethnicity, the clinical presentation, the proposed treatment, and the outcome were included. The characteristics of the ascitic fluid and data regarding the presence or absence of encap- sulating peritonitis were also recorded. Data extraction was performed independently by two investigators (KA and TM). Case Description A 28-year-old woman presented to the internal medicine clinic at our institution with wasting syndrome, increased abdominal girth, progressive shortness of breath, dark stools and decreased appetite. She also complained of progressive abdominal and thoracic pain during menses, as well as cyclic dyspareunia that had started five years before. She denied infertility or any other chronic medical conditions. Her cancer antigen 125 (CA-125) values were 107.8 and 889.6 on two measurements performed when she was an internal medicine inpatient. Abdominal ultrasound and contrasted computed tomog- raphy (CT) studies showed loculated, cystic -like ascites pro- ducing a mass effect. A paracentesis procedure revealed a thick, hemorrhagic fluid with low albumin, high cellularity and large concentration of red blood cells ( ►Fig. 2 ). The fluid analysis was negative for bacterial growth or cancer cells. During the diagnostic laparoscopy, multiple adhesions and peritoneal lesions were noticed, and the patient ’sa b d o m e n was described as “frozen,” due to the presence of encapsu- lating peritonitis, which did not enable the separation of the peritoneal layers and the confection of the pneumoperito- neum. Eight liters of fluid were removed. Histopathology of a peritoneal biopsy taken at this time described chronic peri- tonitis and scarce hemosiderin deposits. One month after the initial imaging exam, another con- trasted abdominal CT suggested the presence of sclerosing encapsulating peritonitis ( ►Fig. 3 ). At this point, the patient was referred to our gynecology clinic due to suspected endometriosis. This diagnosis was further suggested by a gynecological exam, ultrasound mapping and a magnetic resonance imaging (MRI) scan, which showed evidence of fibrosis in the anterior vaginal fornix, multiple peritoneal Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al.148 nodules, and apparently hemorrhagic bilateral ovarian cysts. The chest CT and the colonoscopy at that time were normal. A new laparoscopy was performed, and a biopsy con- firmed the diagnosis of endometriosis. Due to peritoneal adhesions, it was not possible to access the pelvic and abdominal organs. This patient was treated with goserelin acetate, with good clinical response. At the six-month follow- up, she was asymptomatic and had regained a considerable amount of weight.

Study Characteristics Our systematic review yielded 37 articles describing 42 patients with clinically signi ficant ascites, encapsulating peritonitis, or frozen abdomen. One author had a series of three cases, while another had a series of four cases; all of the remaining articles reported only one case each. 11,12 The publication dates ranged from 1978 to 2016. Patient Characteristics and Clinical Presentation The ages of the women who ful filled the eligibility criteria ranged from 20 years to 47 years. 13,14 A total of 8 women in the included articles were described as “black”;3 ,a s “African-American ”;a n d2 ,a s “Afro-Caribbean. ”12,13,15–22 One patient described herself as “African;” another patient, as “caucasian;” a third one, as “Hispanic;” and another one, as “negro.”23–26 Seven studies did not describe ethnicity, but reported that the patients were Nigerian ( n ¼ 3), Malay ( n ¼ 2), Brazilian ( n ¼ 1) or Japanese ( n ¼ 1). 3,6,8,27–30 Ethnicity or origin was not de- scribed at all for the remaining 16 patients. 5,7,11,14,31 –42 Records identified through a database search (n = 234) ScreeningIncluded Eligibility Identification Additional records identified through other sources (n = 2) Records after duplicates were removed (n = 233) Records screened (n = 233) Records excluded (n = 163) Full-text articles assessed for eligibility (n=70) Full-text articles excluded, with reasons (n = 33): - Full-texts unavailable online (21) - No histologically-proven endometriosis (3) - Ascites not clinically significant (3) - Post-operative ascites (2) - Post-chemotherapy ascites (1) - Post ovarian stimulation ascites (1) - Post-trauma ascites (1) - Presence of abdominopelvic abscess (1) Studies included in the qualitative synthesis (n = 37) Fig. 1 Flow diagram describing the steps in the study sel ection for inclusion in this systematic review. Table 1 Detailed search strategy used in the advanced tool of the PubMed/MEDLINE database Search Keywords #1 peritoneal fibrosis OR encapsulating peritoneal sclerosis OR sclerosing encapsulating peritonitis OR abdominal cocoon OR frozen abdomen OR ascites #2 endometriosis OR endometrioma OR endometriotic OR hemosiderophage Final search #1 AND #2 Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al. 149 The ascites was of acute onset in 8 women, and gradual in 24 patients ( ►Supplementary Material 1) . The type of onset was not reported in six cases. In most patients, the ascites was described as “hemor- rhagic” and “recurrent,” but descriptions such as “yellow,” “clear yellow, ”“ brownish green ” and “loculated” were also observed.3,6,8,13,25,32,33 Ascites was present but not charac - terized in five cases. 5,14,15,19,34 The volume of asciticfluid was not shown in some studies, but there are reports of 4.2 L, 4.8 L, 5.0 L and 7 L.13,29,36,41There was associated pleural effusion in eleven patients.3,12,18,19,21,23,32,33,40 Liver involvement by endometriosis was cited in four cases, including one with cysts and another with non-specified focal lesions. 3,34 Twenty-two articles reported CA-125 levels. Normal levels were observed in six patients. The biomarker was elevated (> 35 U/mL) in 14 patients, ranging from 49 U/mL to > 5,000 U/mL. One case had normal CA-125 levels at first, but they became elevated (455 U/mL) after ascites recurrence. 12 The most common main clinical presentation was abdo- minal distension, which was sometimes accompanied by other symptoms such as abdominal pain, abdominal tender- ness, abdominal mass, shortness of breath, signs of hypovole- mia, weight loss, nausea or vomiting, asthenia, malaise, cachexia or loss of appetite. In 25 of the 42 women described, at least one symptom of the classic dysmenorrhea, dyspareunia and infertility triad was reported. Of these, dysmenorrhea was the most common, and it was reported in 20 women. 8,11–13,15,16,18,20,22–24,27,30–32,36,38–41 Infertility was reported in 11 patients. 11,18,19,22–24,29–31,40,41 Dyspareunia was reported in 4 patients. 15,22,24,36 All three symptoms were present in two studies. 22,24 However, in 15 articles (describing 17 patients), the presence or absence of dysmenor- rhea was not mentioned at all. 5–7,12,14,19,21,25,26,28,29,33–35,37 A total of 33 studies (with 38 patients) were regarding the presence or absence of dyspareunia,3,5–8,11–14,16–21,25–35,37–42 and 25 studies (with 28 patients) were regarding the presence or absence of infertility.3,5–8,11–17,21,25–28,32–39 Fifteen articles did not mention if any of these three symptoms were present or absent in the cases they reported. 5–7,12,14,21,25,26,28,33–35,37 Besides our patient, only five cases of encapsulating peritonitis due to endometriosis have been described in the medical literature. 3,5–8 Treatments Used and Outcomes The treatment choices for the patients included in this review involved hormonal therapies, surgery, anti-in flam- matory drugs (steroidal or non-steroidal) or a combination of Fig. 2 Thick, hemorrhagic ascitic fluid sample. Fig. 3 Contrasted computed tomography (CT) showing massive ascites, centrally encased bowels, and thickened peritoneum. Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al.150 Table 2 Treatment choices and respective outcomes in each study. Outcomes written as described in each article Treatment for ascites Outcome Dun et al, 2016 29 Leuprolide þ oral norethindrone Ascites persisted Laparoscopic evacuation of ascites and excision of endometriosis No recurrence (6-month follow-up) Hasdemir et al, 2015 40 Leuprorelin acetate for 6 months Resolution of symptoms until 2 months after cessation Dienogest Resolution of symptoms (3-month follow- up) Hinduja et al, 2016 42 Leuprolide 3.75 mg monthly Recurrence after 6 months TAH þ BSO Ascitic fluid leakage through vaginal suture l i n e( 1 0d a y sa f t e rt h eo p e r a t i o n ) Short-acting GnRH agonist þ oral danazol followed by GnRH only No recurrence (1-year follow-up) Setubal et al, 2015 24 Continuous OCP for 3 months Ascites persisted GnRH agonist, then laparoscopic excision of lesions followed by GnRH agonist Minimal ascites Underwent IVF protocol Minimal ascites OCP Symptom-free Appleby et al, 2014 28 GnRH antagonist No recurrence (6-month follow-up) Asano et al, 2014 30 GnRH agonist Ascites recurred Oral dienogest No recurrence (1-year follow-up) Bignall et al, 2014 22 GnRH agonists Ascites recurred GnRH agonists þ tibolone þ NSAIDs þ pregabalin Symptoms well-controlled Cosma et al, 2014 41 Laparoscopic excision of lesions Modest recurrence (250 mL) after 42 days Shabeerali et al, 2012 11 CASE 1: GnRH analogue No recurrence (6-month follow-up) CASE 2: Subtotal abdominal hysterectomy þ BSO No recurrence (1-year follow-up) CASE 3: GnRH analogues for 1 year; then, TAH þ BSO Partial response; then, relatively asympto- matic at 1-year follow-up Ferrero and Remorgida, 2011 36 Norethindrone acetate (25 mg daily) No recurrence (1-year follow-up) Ignacio et al, 2010 18 GnRH analogue No recurrence (8-month follow-up) Lin et al, 2010 37 Laparoscopic electrocauterization of lesions Condition stabilized Suchetha et al, 2010 7 GnRH analogues for 1 year Good response Park et al, 2009 39 Laparoscopic excision of endometrioma þ GnRH agonist for 6 months þ tibolone No recurrence (1-year follow-up) Sait, 2008 38 Bilateral ovarian cystectomies þ GnRH analogue for 6 months followed by OCP No recurrence (2-year follow-up) Santos et al, 2007 6 Laparoscopy þ laparotomy NR. Patient died after 5 months Palayekar et al, 2007 20 TAH þ BSO No recurrence (1-year follow-up) Fortier et al, 2005 23 Ovarian cystectomy þ GnRH analogue for 6m o n t h sþ laparoscopic excision of lesions þ oral progesterone for 6 months Two recurrences Ceased treatment and started clomiphene due to pregnancy desire Ascites recurrence GnRH for 2 months Ascites recurrence GnRH for 6 months Ascites recurrence Mohd Noor et al, 2004 8 Laparotomy þ excision of lesions No recurrence (4-week follow-up) Zeppa et al, 2004 35 NR NR (Continued ) Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al. 151 them. Ascites recurrence or persistence was frequent. Three articles did not report how the patients were managed (►Table 2 ).3,14,35 The hormonal therapies used included long-acting go- nadotropin-releasing hormone (GnRH) agonists (namely goserelin and leuprolide), short-acting GnRH agonists, GnRH antagonists, progestational hormones (speci fically dienogest, medroxyprogesterone and norethindrone), estra- diol, conjugated estrogens, synthetic combined hormones (namely tibolone), steroids with antigonadotropic and anti- estrogenic activity (danazol), and oral contraceptive pills (OCPs). Other conservative treatments used were isolated pred- nisolone, which did not prevent ascites recurrence, and Table 2 (Continued ) Treatment for ascites Outcome Cheong and Lim, 2003 3 NR NR Jeanes et al, 2002 34 Double hysterectomy þ left oophorect- omy followed by estradiol for 6 months followed by goserelin No recurrence (3-year follow-up) Moffatt and Mitchell, 2002 19 Leuprolide þ premarin Recurrence after 4 weeks TAH þ BSO þ leuprolide No recurrence (9-month follow-up) Bhojawala et al, 2000 17 TAH þ RSO No recurrence (6-week follow-up) Samora-Mata and Feste, 1999 25 TAH þ RSO NR Myneyyirci-Delale et al, 1998 12 Laparoscopic excision of lesions followed by GnRH agonist for 6 months; then, excision of new ovarian cyst þ danazol daily for 6 months followed by norethin- drone acetate Recurrence after 1 year; then, no recur- rence (3-year follow-up) Laparotomy þ monthly depo provera injections; then, TAH þ BSO Recurrence after 3 years; then, no recur- rence (6-month follow-up) Appendectomy and left ovarian wedge resection þ lupron No recurrence L y s i so fa d h e s i o n sþ LSO followed by lupron followed by norethindrone acetate NR Frigerio et al, 1997 5 TAH þ BSO þ appendectomy þ omen- tectomy No recurrence (3-year follow-up) Mejia et al, 1997 16 Laparotomy No recurrence (15-month follow-up) Flanagan and Barnes, 1996 21 Laparotomy þ GnRH agonist for 6 months Recurrence (twice in 1 year) Prednisolone 30 mg daily Recurrence Leuprorelin for 5 months Recurrence Myers et al, 1995 33 TAH þ BSO þ lysis of adhesions No recurrence (8-month follow-up) Jose et al, 1994 32 LSO Recurrence after 1 year Laparotomy þ danazol NR Schlueter an McClennan, 1994 13 Leuprolide acetate monthly No recurrence (3-month follow-up) Williams and Wagaman, 1991 15 Medroxyprogesterone acetate Recurrence after 1 month Depot lupron for 3 months Some ascites TAH þ BSO Recurrence after 3 months Tenckhoff catheter placed for 2 weeks No recurrence (9-month follow-up) Chichareon and Wattanakitkrailert, 1988 31 TAH þ BSO No recurrence (6-month follow-up) Olubuyide et al, 1988 27 Oral norethisterone No recurrence (1-year follow-up) Naraynsingh et al, 1985 26 Depo provera for 6 months No recurrence (4-year follow-up) Cantor et al, 1979 14 NR NR Abbreviations: BSO, bilateral salpingo-oophorectomy; GnRH, gonadotrop in-releasing hormone; IVF, in vitro fertilization; LSO, left salpingo- oophorectomy; NR, not reported; NSAIDs, non-steroidal anti-in flammatory drugs; OCP, oral contraceptive pills; RSO, right salpingo-oophorectomy; TAH, total abdominal hysterectomy. Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al.152 nonsteroidal anti-in flammatory drugs (NSAIDs) in combina- tion with pregabalin and hormonal therapies, which were effective in controlling the symptoms. The surgical procedures involved drainage of the ascites, excision or electrocauterization of the endometriotic lesions through laparotomy or laparoscopy, lysis of adhesions, abdom- inal hysterectomy, uni- or bilateral salpingo-oophorectomy, ovarian cystectomy, omentectomy, appendectomy, placement of Tenckhoff catheter and/or ovarian wedge resection. After the initial treatment, due to the desire to achieve pregnancy, one woman underwent in vitro fertilization (IVF), with minimal ascites afterwards. 24 Another patient started clomiphene, with ascites recurrence. 23 A summary of the treatments used for ascites and its respective outcomes, including the time until recurrence, is shown in ►Table 2 .

All patients shown in this review were of childbearing age, likely due to hormonal levels and occurrence of menses. This is, indeed, the most common age range for the presentation of endometriosis in general, which can also rarely occur in older women. 43 Endometriosis most commonly affected women of African descent, but it was present in patients of multiple other ethnicities, implying that this diagnosis should not be restricted to patient origin, and must be suspected if the clinical presentation is suitable. Fluid accumulation was most commonly progressive, but acute onset of symptoms has also been described. The reasons for such a presentation remain unclear, but can be related to the rapid accumulation of fluid and to the sponta- neous rupture of a cyst. 37 Endometriosis-associated ascites is rare, and encapsulat- ing peritonitis is even less common. Since we excluded women with potentially confounding conditions, it appears that endometriosis itself is the cause of such clinical pre- sentations. It has been hypothesized that the peritoneal irritation caused by endometriosis results in extensive fibro- sis and in flammation, further optimizing the microenviron- ment for more secondary implants, which in turn exacerbate inflammation. In fact, this theory could also explain the high rate of recurrence of ascites due to endometriosis ( ►Table 2 ), ultimately resulting in encapsulating peritonitis, which is described in our case and in four other ones. Abdominal distension related to ascites was the most common clinical sign, but non-speci fic signs and symptoms such as malaise and weight loss were also described (►Supplementary Material 1 ). Additionally, most women had symptoms suggestive of endometriosis, but these were not always reported, bringing attention to the high level of suspicion needed to diagnose this condition. Not all women present with classic symptoms; however, in order for diag- nostic accuracy to be improved, physicians in general (in- cluding emergency room physicians) need to ask about them specifically during history-taking. Moreover, in some cases, ascitic volume was large and related to pleural effusion, resembling Meigs syndrome. Great volumes can be caused by the rapid production of fluid, in association with the obstruction of subdiaphrag- matic lymph vessels. In turn, pleural fluid may be due to the transdiaphragmatic flow of ascites through the lymphatic channels, as has been proposed by Meigs et al, 44 or due to local reactive in flammation.38 The fluid was generally hemorrhagic, but could have different aspects, such as clear yellow or green-brownish color. On this matter, Bernstein proposed a mechanism by which chocolate cysts would rupture into the peritoneal cavity, leading to irritation and ascites formation; corre- spondingly, other explanations relate to excessive ovarian transudation, super ficial endometriosis, open endometriosis lesions or angiogenesis. 45–47 Part of the included studies also measured and reported serum CA-125 levels. This biomarker is known to not be accurate for the diagnosis of endometriosis in general; likewise, it was not reliable in the diagnosis of endometriosis presenting with ascites. Although no statistical comparisons were made, it is clear that the values were not intimately correlated to the characteristics of ascites. Furthermore, endometriosis caused CA-125 levels > 5,000 U/mL in one case, which commonly indicates malignancy; this further contributes to the need of including endometriosis in the list of differentials of suspected malignancies due to massive ascites. Several treatment choices were observed in the included articles; the options were similar to the therapies available for endometriosis in general. For the speci fic treatment of women presenting with ascites, no speci fic protocol exists, and empirical data does not evidently favor one therapy over another ( ►Table 2 ). Among the strengths of our review are the fact that only articles with histologically proven endometriosis were se- lected; the exclusion of patients with conditions that com- monly cause ascites; and the systematic approach. It is limited, however, in that articles in only four languages were included, and in the fact that some older articles initially screened could not be included because they were not available online, even for purchase. Further research is needed to better de fine optimal diagnostic and therapeutic approaches in women with unusual presentations of endometriosis.

Clinically signi ficant ascites, frozen abdomen and/or encap- sulating peritonitis related to endometriosis are rare con- ditions. It can present with abdominal distension, symptoms classically related to endometriosis, and other non-speci fic symptoms. The clinical presentations were heterogeneous. Endometriosis should be a differential diagnosis of massive hemorrhagic ascites in women of reproductive age, but the exclusion of other potential causes, especially malignancy, is needed for the diagnosis of this condition. The treatment options include hormonal therapy, anti-in flammatory drugs and/or surgery. There are no speci fic protocols for the treatment of this condition. Rev Bras Ginecol Obstet Vol. 40 No. 3/2018 Ascites and Encapsulating Peritonitis in Endometriosis Magalhães et al. 153 Contributors Magalhaes TF, Augusto KL, Mota LP, Costa AR, Puster RA, and Bezerra LRPS contributed with the project and inter- pretation of data, writing of the article, critical review of the intellectual content and final approval of the version to be published. Conflicts of Interest The authors have no con flicts of interest to declare.

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