Bowel Endometriosis Presenting With Massive Ascites Relapses in Ovaries: a Case Report and Literature Review

Background: About 10% reproductive aged women are affected by endometriosis. Deep infiltrative endometriosis (DIE) is the most severe form of endometriosis which has a high risk of recurrence. Bowel is the most common extragenital involved organ. The clinical features of bowel endometriosis vary by location, size, and infiltrative depth of lesions, which makes diagnosis and treatment difficult. Endometriosis presenting with massive ascites is rare and hard to diagnose before histopathology. There are no authoritative guidelines on the management of DIE at present. Case presentation: A 37-year-old woman presenting with massive ascites and pelvic mass was diagnosed with bowel endometriosis after laparoscopy. Bowel resection and anastomosis followed by gonadotropin-releasing hormone agonists (GnRH-a) therapy was performed. Two levonorgestrel-releasing intrauterine devices and two levonorgestrel-releasing subcutaneous silastic implants were inserted subsequently. Recurrence was found in bilateral ovaries 25 months after surgery. Cystectomy of bilateral ovarian cysts, bilateral salpingectomy and postoperative GnRH-a therapy was performed. The patient showed no recurrence at follow-up by May 2021 (22 months).Conclusions: In the presence of massive ascites and pelvic mass, DIE should be considered as a differential diagnosis for ovarian cancer. Endometriosis in different organs may have different pathogenesis, which leads to different treatment focus. On the basis of complete resection and postoperative GnRH-a therapy, our application of high dose levonorgestrel-releasing systems creatively improves the treatment effect of bowel endometriosis. The mechanism of recurrent endometriosis that occurs in different organs may relate to lymph node involvement and individual immune state.