Scar endometriosis presenting as a painful abdominal mass
Open accessAbstract
Abdominal wall scar endometriosis occurs in 1%-2% of women following a cesarean section delivery. We report a case of a 36-year-old woman with scar endometriosis, presenting with an acute, painful abdominal wall mass. She underwent a cesarean section 8 years before presentation. She was admitted to the emergency room for physical examination of the abdomen, which revealed a palpable mass. Abdominal computed tomography (CT) revealed an ill-defined soft-tissue lesion over the left rectus abdominis muscle (abdominal scar). Surgical removal of the abdominal wall mass was performed with adequate clearance margins with a preoperative diagnosis of postcesarean scar endometriosis. Postcesarean scar endometriosis is a rare cause of an abdominal mass; however, when this condition presents acutely, it can be difficult to diagnose. In this case, careful analysis of the patient's history, CT images, and histopathological results together confirmed the diagnosis. Surgical excision was performed under general anesthesia while maintaining adequate clearance margins.
AI snapshot
Written from the paper’s full text.
TL;DR
A 36-year-old woman presented with an acute painful abdominal wall mass 8 years after cesarean section, initially suspected as incisional hernia or stitch granuloma, and was diagnosed with scar endometriosis after surgical excision and histopathology. The case supports considering endometriosis in women with abdominal masses after gynecologic surgery and treating suspected cases with wide surgical excision.
Key findings
- Abdominal wall scar endometriosis occurs in 1%–2% of women after cesarean section; endometriosis overall has a prevalence of 5%–10% in young women.
- The patient had a cesarean section 8 years earlier, with pain near the incision for 2–3 years that was intermittent, positional, and worsened during menstruation; CT showed an ill-defined soft-tissue lesion over the left rectus abdominis muscle.
- Most patients with abdominal scar endometriosis present with a mass (96%) and pain (87%), but preoperative differentiation from other abdominal masses is difficult, with a diagnostic rate of 20%–50%.
- Surgical excision under general anesthesia with adequate clearance margins was performed; the patient was discharged 3 days after surgery, had no complications in 30 postoperative days, and had no recurring symptoms at 6-month follow-up.
Methods
- Single case report of a 36-year-old woman with a history of cesarean section, evaluated by physical examination, laboratory tests, abdominal CT, surgery, and histopathology.
- The abdominal wall mass was removed under general anesthesia; the fascia was closed with 2-0 Vicryl and skin with 3-0 Nylon sutures.
- Diagnosis was confirmed by final pathology showing endometriosis in muscle tissue, with H&E staining; follow-up included outpatient wound assessment and a 6-month symptom check.
Limitations
- The paper states no limitations.
- Evident from the text: this is a single case report, so findings are not generalizable and no comparative analysis is possible.
- Evident from the text: follow-up was only 6 months, which limits assessment of long-term recurrence; the figure caption states the lesion invaded the right rectus abdominis muscle while the case text says left rectus abdominis muscle.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
0 of 12 cited sources checked · 0 supported · 0 flagged
- Findingown data
The patient had undergone a cesarean section 8 years before presentation.
“She underwent a cesarean section 8 years before presentation.”
- Also stated in: § CASE REPORT · plain
“Her medical history was remarkable only for a cesarean section performed 8 years ago.”
Quote in the paperSubstantial claim - Also stated in: § CASE REPORT · plain
- Findingown data
After the cesarean section, the incision healed without symptoms for 5 years.
“Following the cesarean section, the incision was healed without any symptoms presented for 5 years.”
Quote in the paperNot a substantial claim - Findingown data
No recurring symptoms were noted in the 6-month follow-up.
“No recurring symptoms were noted in the 6-month follow-up.”
Quote in the paperNot a substantial claim - Findingown data
Physical examination revealed a bulging, palpable, nonmovable lesion with local tenderness in the left lower abdominal region, similar to an incisional hernia.
“In the emergency room, we performed physical examination and showed a bulging, palpable, and nonmovable lesion with local tenderness in the left lower abdominal region similar to an incisional hernia.”
Quote in the paperNot a substantial claim - Findingown data
The patient experienced pain in her left lower abdomen near the incision for 2-3 years before seeking treatment.
“Before seeking treatment, the woman experienced pain in her left lower abdomen near the incision for 2–3 years without any gastrointestinal symptoms (nausea, vomiting, or diarrhea).”
Quote in the paperNot a substantial claim
- Findingown data
The final pathology report revealed endometriosis.
“The final pathology report revealed endometriosis [Figure 2].”
Quote in the paperSubstantial claim - Findingown data
Abdominal CT revealed an ill-defined soft-tissue lesion over the left rectus abdominis muscle (abdominal scar).
“Abdominal computed tomography (CT) revealed an ill-defined soft-tissue lesion over the left rectus abdominis muscle (abdominal scar).”
Quote in the paperSubstantial claim - Interpretationnone given
When postcesarean scar endometriosis presents acutely, it can be difficult to diagnose.
“Postcesarean scar endometriosis is a rare cause of an abdominal mass; however, when this condition presents acutely, it can be difficult to diagnose.”
- Also stated in: § CONCLUSION · plain
“When it presents acutely, it can be difficult to diagnose in the clinical setting.”
Quote in the paperSubstantial claim - Also stated in: § CONCLUSION · plain
- Interpretationreasoning
Postcesarean scar endometriosis is a rare cause of an abdominal mass.
“Postcesarean scar endometriosis is a rare cause of an abdominal mass; however, when this condition presents acutely, it can be difficult to diagnose.”
- Also stated in: § CONCLUSION · plain
“However, postcesarean scar endometriosis is a rare cause of an abdominal mass.”
Quote in the paperSubstantial claim - Also stated in: § CONCLUSION · plain
- Premisecitation
A definite diagnosis of scar endometriosis is dependent on the pathology rather than visual identification.
“A definite diagnosis of scar endometriosis is dependent on the pathology rather than visual identification.[4]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4] American, 2000, ACOG practice bulletin.Clinical management guidelines for obstetrician-gynecologists, Int J Gynaecol Obstet
Not checked in the free run.
- Interpretationown data
In this case, careful analysis of the patient's history, CT images, and histopathological results together confirmed the diagnosis.
“In this case, careful analysis of the patient's history, CT images, and histopathological results together confirmed the diagnosis.”
- Also stated in: § CONCLUSION · plain
“In our case, careful attention to medical history combined with imaging and histopathology together confirmed the diagnosis.”
Quote in the paperSubstantial claim - Also stated in: § CONCLUSION · plain
- Premisecitation
Preoperatively, it is challenging to differentiate endometriosis from other abdominal masses (diagnostic rate: 20%-50%).
“Preoperatively, it is challenging to differentiate endometriosis from other abdominal masses (diagnostic rate: 20%–50%).[3]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Gidwaney, 2012, Endometriosis of abdominal and pelvic wall scars: Multimodality imaging findings, pathologic correlation, and radiologic mimics, Radiographics source
Not checked in the free run.
- Premisecitation
Scar endometriosis may appear as a hypoechoic lesion with thick echogenic strands, which often overlaps with fibrous lesions.
“Scar endometriosis may appear as a hypoechoic lesion with thick echogenic strands, which often overlaps with fibrous lesions.[3]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Gidwaney, 2012, Endometriosis of abdominal and pelvic wall scars: Multimodality imaging findings, pathologic correlation, and radiologic mimics, Radiographics source
Not checked in the free run.
- Premisecitation
Diagnosing endometriosis, particularly by physicians who are not gynecologists, remains a challenge.
“However, diagnosing endometriosis, particularly by physicians who are not gynecologists, remains a challenge.[6]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [6] Grundström, 2016, “A challenge” – Healthcare professionals' experiences when meeting women with symptoms that might indicate endometriosis, Sex Reprod Healthc source
Not checked in the free run.
- Premisecitation
Endometriosis may present with acute abdominal symptoms mimicking incarcerated or recurrent hernia.
“However, endometriosis may present with acute abdominal symptoms mimicking incarcerated or recurrent hernia.[7]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [7] Ducarme, 2007, Endometriosis mimicking hernia recurrence, Hernia source
Not checked in the free run.
- Premisecitation
Differential diagnoses for scar endometriosis include inguinal or incisional hernia.
“Differential diagnoses include inguinal or incisional hernia.[5]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] Horton, 2008, Abdominal wall endometriosis: A surgeon's perspective and review of 445 cases, Am J Surg source
Not checked in the free run.
- Classified as probably not a substantial claim. 13
- May combine two claims. 6
Probably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe patient presented with abdominal pain.
“A 36-year-old woman presented at our clinic with abdominal pain.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe patient was a 36-year-old woman.
“A 36-year-old woman presented at our clinic with abdominal pain.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingnone givenIn our case, a diagnosis of incisional hernia was suspected before imaging was conducted.
“In our case, a diagnosis of incisional hernia was suspected before imaging was conducted.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataLaboratory data showed a normal white blood cell count.
“Although the laboratory data showed a normal range of white blood cell count”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingnone givenRecently, the patient's symptoms got worse and became excruciating pain.
“Recently, her symptoms got worse and became excruciating pain.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataFollowing the CT scan, postcesarean section scar formation or stitch granuloma was suspected.
“Following the CT scan, postcesarean section scar formation or stitch granuloma was suspected.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataPreoperative diagnostic tests, including blood tests and chest radiography, revealed no obvious abnormalities.
“Preoperative diagnostic tests, including blood tests and chest radiography, revealed no obvious abnormalities.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe patient's pain was intermittent, could be induced by changing body position, and worsened during her menstrual period.
“Her pain presented intermittent pattern and could be induced by changing body position and worsened during her menstrual period.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataThe surgical wound healed gradually, and no complications occurred in the postoperative 30 days.
“During the outpatient follow-up, the surgical wound had gradually healed, and no complications occurred in the postoperative 30 days.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe patient was discharged 3 days after the procedure.
“The patient was discharged 3 days after the procedure.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataDuring surgery, dense tissue in the rectus abdominis muscle with some residual blood clots was noted.
“During the surgery, we noted a dense tissue in the rectus abdominis muscle with some residual blood clots.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationAbdominal wall scar endometriosis occurs in 1%-2% of women following a cesarean section delivery.
“Abdominal wall scar endometriosis occurs in 1%–2% of women following a cesarean section delivery.”
- Also stated in: § INTRODUCTION · plain
“Abdominal wall scar endometriosis is found in 1%–2% of women following cesarean section.[3]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Gidwaney, 2012, Endometriosis of abdominal and pelvic wall scars: Multimodality imaging findings, pathologic correlation, and radiologic mimics, Radiographics source
Not checked in the free run.
- Also stated in: § INTRODUCTION · plain
May combine two claims.
PremisecitationMost patients with abdominal scar endometriosis present with a mass (96%) and pain (87%).
“Most patients with abdominal scar endometriosis present with a mass (96%) and pain (87%).[5]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] Horton, 2008, Abdominal wall endometriosis: A surgeon's perspective and review of 445 cases, Am J Surg source
Not checked in the free run.
Probably not a substantial claim: may not pass S2 (checkable).
InterpretationcitationWide surgical excision with clear margins is recommended for suspected endometriosis to prevent localized recurrence.
“In clinical practice, we recommend performing a wide surgical excision with clear margins for suspected endometriosis to prevent localized recurrence.[9]”
- Also stated in: § CONCLUSION · plain
“Following the diagnosis, wide surgical excision was performed keeping adequate clearance margins to prevent recurrence of endometriosis as the definitive treatment.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [9] Francica, 2003, Abdominal wall endometriomas near cesarean delivery scars: Sonographic and color doppler findings in a series of 12 patients, J Ultrasound Med source
Not checked in the free run.
- Also stated in: § CONCLUSION · plain
May combine two claims.
PremisecitationFine-needle aspiration biopsy guided by imaging is not always successful, thus necessitating further surgical intervention to directly obtain a pathological specimen.
“However, fine-needle aspiration biopsy guided by imaging is not always successful,[9] thus necessitating further surgical intervention to directly obtain a pathological specimen.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [9] Francica, 2003, Abdominal wall endometriomas near cesarean delivery scars: Sonographic and color doppler findings in a series of 12 patients, J Ultrasound Med source
Not checked in the free run.
May combine two claims.
PremisecitationOh et al. reported nine patients with abdominal wall endometriosis, six of whom visited the general surgery clinic with suspected diagnoses of desmoid tumor, epidermal cyst, granuloma in the postoperative scar, or endometriosis.
“Oh et al. reported nine patients with abdominal wall endometriosis, six of whom visited the general surgery clinic with suspected diagnoses of desmoid tumor, epidermal cyst, granuloma in the postoperative scar, or endometriosis.[2]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [2] Oh, 2014, A surgeon's perspective of abdominal wall endometriosis at a caesarean section incision: Nine cases in a single institution, Surg Res Pract
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation20% of cases in one study showed spontaneous abdominal wall endometriosis.
“However, 20% of cases in one study showed spontaneous abdominal wall endometriosis.[5]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] Horton, 2008, Abdominal wall endometriosis: A surgeon's perspective and review of 445 cases, Am J Surg source
Not checked in the free run.
May combine two claims.
InterpretationreasoningOur patient had undergone cesarean section 8 years ago, which can result in endometrial cell implantation in the rectus abdominis muscle.
“Our patient had undergone cesarean section 8 years ago, which can result in endometrial cell implantation in the rectus abdominis muscle.”
Quote in the paperSubstantial claim- Rests on an assumption: Endometrial cells can implant in the rectus abdominis muscle during a previous gynecologic surgery (such as cesarean section) and cause scar endometriosis.
The paper relies on this without support.
Endometrial cells can implant in the rectus abdominis muscle during a previous gynecologic surgery (such as cesarean section) and cause scar endometriosis.
“Abdominal scar endometriosis may be associated with the implantation of endometrial cells during a previous gynecologic surgery.”
“Our patient had undergone cesarean section 8 years ago, which can result in endometrial cell implantation in the rectus abdominis muscle.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Sonography, CT, and MRI may help diagnose scar endometriosis.
“Sonography, CT, and magnetic resonance imaging (MRI) may help diagnose scar endometriosis [13].”
From Abdominal Wall Endometriosis at the Cesarean Section Scar (2023) · cites this paper as [13]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Figure 1 places the lesion on the opposite side
MinorThe Figure 1 caption says the lesion invaded the right rectus abdominis muscle, but the case report locates the mass in the left rectus sheath region and cites the same figure.
“Figure: Figure 1 Computed tomography scan revealed that the abdominal lesion invaded the right rectus abdominis muscle”
“We noted a mass in the left rectus sheath region under the incision [Figure 1], which led us to suspect postcesarean section-related granuloma tissue.”
Preoperative diagnosis differs between abstract and case report
MinorThe abstract states that scar endometriosis was diagnosed preoperatively, whereas the discussion says scar formation or stitch granuloma was suspected after CT. The case report says the final pathology revealed endometriosis.
“Surgical removal of the abdominal wall mass was performed with adequate clearance margins with a preoperative diagnosis of postcesarean scar endometriosis.”
“Following the CT scan, postcesarean section scar formation or stitch granuloma was suspected.”
Cites
Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases
Horton, J. D., DeZee, K. J., Ahnfeldt, E. P., & Wagner, M. (2008) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2007.07.035 · Cited by 391 · cited 4× · see citing works
“However, 20% of cases in one study showed spontaneous abdominal wall endometriosis.[5] Possible etiologies proposed include metaplasia of the peritoneal epithelium (the celomic metaplasia theory), hematogenous spread, and lymphatic dissemination.”
BackgroundInfluentialIncisional endometriosis after cesarean section, episiotomy and other gynecologic procedures
Gunes, M., Kayikcioglu, F., Ozturkoglu, E., & Haberal, A. (2005) · Journal of Obstetrics and Gynaecology Research · doi:10.1111/j.1447-0756.2005.00322.x · Cited by 169 · cited 2× · see citing works
“[2,8,9] However, postcesarean scar endometriosis is a rare cause of an abdominal mass.”
BackgroundFrancica, G., Giardiello, C., Angelone, G., Cristiano, S., Finelli, R., & Tramontano, G. (2003) · Journal of Ultrasound in Medicine · doi:10.7863/jum.2003.22.10.1041 · Cited by 122 · cited 3× · see citing works
“[8] However, fine-needle aspiration biopsy guided by imaging is not always successful,[9] thus necessitating further surgical intervention to directly obtain a pathological specimen.”
BackgroundMethodGidwaney, R., Badler, R. L., Yam, B. L., Hines, J. J., Alexeeva, V., Donovan, V., & Katz, D. S. (2012) · RadioGraphics · doi:10.1148/rg.327125024 · Cited by 120 · cited 5× · see citing works
“The lesion can also be observed on enhanced MRI, which has a superior resolution compared with CT.[3] This imaging modality can confirm the location and boundaries of the lesion to guide the surgeon.”
BackgroundInfluentialMedical management of endometriosis
Peckham, B. M. (2000) · International Journal of Gynecology & Obstetrics · doi:10.1016/s0020-7292(00)80034-x · Cited by 73 · see citing works
Mistrangelo, M., Gilbo, N., Cassoni, P., Micalef, S., Faletti, R., Miglietta, C., Brustia, R., Bonnet, G., Gregori, G., & Morino, M. (2014) · Surgery Today · doi:10.1007/s00595-012-0459-3 · Cited by 54 · cited 2× · see citing works
“When it presents in a cesarean section scar (57%), it is called as abdominal wall endometriosis, scar endometriosis, or surgical scar endometriosis.[1,5] However, endometriosis in an abdominal lesion or a foreign body diagnosed with scar with fibrosis is rare.”
BackgroundGrundström, H., Kjølhede, P., Berterö, C., & Alehagen, S. (2016) · Sexual & Reproductive Healthcare · doi:10.1016/j.srhc.2015.11.003 · Cited by 40 · see citing works
Oh, E. M., Lee, W., Kang, J. M., Choi, S. T., Kim, K. K., & Lee, W. K. (2014) · Surgery Research and Practice · doi:10.1155/2014/765372 · Cited by 23 · cited 3× · see citing works
“in young women[1] Extra-pelvic endometriosis is rare but was reported in a wide range of sites.[2] Abdominal wall scar endometriosis is found in 1%–2% of women following cesarean section.”
BackgroundEndometriosis mimicking hernia recurrence
Ducarme, G., Uzan, M., & Poncelet, C. (2007) · Hernia · doi:10.1007/s10029-006-0159-2 · Cited by 17 · cited 1× · see citing works
“[5] However, endometriosis may present with acute abdominal symptoms mimicking incarcerated or recurrent hernia.[7] Preoperatively, it is challenging to differentiate endometriosis from other abdominal masses (diagnostic rate: 20%–50%).”
Background
Flagged first, then by citations
1 of the 10 references couldn’t be matched to a known paper.
Research works printed but not linked: 1
- American, 2000, ACOG practice bulletin.Clinical management guidelines for obstetrician-gynecologists, Int J Gynaecol Obstet, 183
Cited by
Sorted by citations
Guan, L., Xue, L., Chu, J., et al. (2022) · Cellular and Molecular Biology · doi:10.14715/cmb/2021.67.4.43 · Cited by 4 · see citing works
“The endometrial estrogen receptor volume increases, resulting in changes in the endometrium (12-14).”
BackgroundScar endometriosis diagnosed as incisional hernia before surgery
Permatasari, N. U. I., Hutabarat, F. F., & Putri, H. M. A. R. (2021) · BMJ Case Reports · doi:10.1136/bcr-2020-239923 · Cited by 3 · see citing works
Abdominal Wall Endometriosis at the Cesarean Section Scar
Rexhepi, M., Asani, L. V., Mulaki, L., Koprivnjak, K., & Azemi, M. (2023) · PRILOZI · doi:10.2478/prilozi-2023-0055 · Cited by 1 · see citing works
Caesarean scar endometriosis: how to make an accurate diagnosis
Rodrigo, S. N. K., Kumarasinghe, I., & Gunasekera, E. D. (2024) · BMJ Case Reports · doi:10.1136/bcr-2024-261053 · Cited by 1 · see citing works
“9 Nonetheless, imaging studies may also prove invaluable in excluding other differential diagnoses prior to therapeutic decisions.”
- Authors
- Hsu, S.-D., & Chen, L.-Y.
- Affiliations
- Tri-Service General Hospital (TW)
- Corresponding author
- Hsu, Sheng-Der
- Venue
- Gynecology and Minimally Invasive Therapy
- Publisher
- Medknow
- Published
- 2020
- Volume
- 9
- Issue
- 2
- Pages
- 98
- ISSN
- 2213-3070 (ISSN-L)
- PMC
- PMC7354748
- OpenAlex
- W3020010489
- Cited by
- 4
- References
- 10
- Citations by year
- 2024: 1 · 2023: 1 · 2022: 1 · 2021: 1
- FWCI
- 0.66
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by-nc-sa
- Locations
- Gynecology and Minimally Invasive Therapy (publishedVersion, cc-by-nc-sa)
- PubMed Central (publishedVersion, cc-by-nc-sa)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- scar endometriosis, abdominal wall mass, cesarean section, rectus abdominis, surgical excision, histopathological diagnosis, computed tomography
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