2531 A Bloody Mess: A Rare Cause of Ascites From a Different Field of Medicine

INTRODUCTION: After exclusion of a traumatic etiology, the development of progressive bloody ascites in a patient usually portends an ominous diagnosis. We present a rare, benign case of progressive bloody ascites due to a gynecologic cause. CASE DESCRIPTION/METHODS: A 40 yo healthy African American lady presented with 3 months of worsening abdominal enlargement and nausea. Physical exam and CT scan of the abdomen revealed massive ascites but were otherwise normal. Bloodwork showed a Hgb of 5.7 gm/dL, and normal PLT. Ferritin level, liver panel, hepatitis and HIV studies were all normal. Paracentesis showed 26,000 RBCs, 88 nucleated cells, 79 cholesterol crystals in pigmented macrophages, a SAAG of 0.5, a fluid protein of 5.5 g/dL, and negative cytology. Further testing showed a negative quantiferon-gold along with a normal CEA level and ANA. A CA-125 was mildly elevated at 82 U/mL. CT scan post-paracentesis showed diffusely thickened peritoneum without nodularity, and a 5 cm right pelvic cystic mass. Diagnostic laparoscopy found 4L bloody ascites and complete fibrotic abdominal structure encasement. Peritoneal biopsies and right oophorectomy showed endometriosis. She was treated with a high dose steroid taper and leuprolide with resolution of her ascites. DISCUSSION: Our case is one of a few reports describing endometriosis inducing encapsulating peritoneal sclerosis (EPS), and is the first to show asymptomatic endometriosis as the etiology. (EPS) is a syndrome of intestinal obstruction from diffuse thickened peritoneum. Typical symptoms are intermittent abdominal pain with nausea and vomiting related to the intermittent obstruction and reduced gut motility. Symptoms average 3.9 years before diagnosis. Primary EPS is extremely rare and while secondary EPS is usually due to chronic peritoneal dialysis (PD). Other causes include malignancy, infections, and various rheumatologic conditions. Management is based on the offending cause (e.g., stopping PD) but is largely empiric, based on case reports and series utilizing prednisolone and/or tamoxifen.