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Journal of Postgraduate Medicine, Vol. 57, No. 4, October-December, 2011, pp. 335-337 Case Report Anterior abdominal wall abscess with epididymo-orchitis: An unusual presentation of acute pancreatitis PM Kamble, A Patil, S Jadhav, SA Rao Department of General Surgery, K.E.M Hospital, Mumbai, Maharashtra, India Date of Submission: 22-May-2011 Code Number: jp11092 PMID: 22120865 Abstract Keywords: Abscess, epididymo-orchitis, inflammation, pancreatitis Introduction Acute pancreatitis is an inflammatory disease of the pancreas. Initial presentation of patient is typical and most common symptom is upper abdominal pain which gradually increases in intensity. Sometimes acute pancreatitis has an atypical presentation due to delayed manifestation of loco-regional or systemic complications of the disease. We present such a rare case of acute pancreatitis presenting as anterior abdominal abscess and epididymo-orchitis. Case Report A 52-year-old male patient presented with history of pain and fullness in lower abdomen since 3 weeks. He was also complaining of scrotal pain. Patient was a chronic alcoholic. No other significant history was elicited. On admission patient′s pulse rate was 100 per minute and blood pressure was 110/70 mmHg. He was dehydrated and tachypneic. On systemic examination, air entry was decreased bilaterally at bases. Abdominal examination revealed tenderness over lower abdomen with fullness of abdomen in infra-umbilical region. External genitalia examination showed swelling of right side of scrotal sac and on palpation there was severe tenderness over scrotum especially right testis and over the cord structure. Bowel sounds were absent. Blood investigations indicated hemoglobin 10 gm%, total leukocyte count 13000/cubic mm. Serum BUN and creatinine levels were within normal limit. PT/INR was 1.34. Serum amylase and lipase levels were elevated as 400IU/l and 1200 IU/l, respectively. After hydration, contrast-enhanced CT scan (CECT) of abdomen was done which showed peripancreatic stranding [Figure - 1] and fluid collection tracking in the retroperitoneum till scrotum forming lower abdominal preperitoneal as well as retroperitoneal abscess [Figure - 2]. The tracking of fluid into scrotum causing epididymo orchitis explained his scrotal pain [Figure - 3]. There was no evidence of intraperitoneal collection. The anterior abdominal wall abscess, retroperitoneal abscess as well as the scrotal abscess were all in communication with each other; however, only anterior abdominal wall abscess was treated by pigtail catheter placement which showed no bacteriological growth. Hence the patient was empirically started on cefoperazone sulbactam and metronidazole. For the scrotal swelling, support bandage was given. Fluid amylase was 40000 IU. As pigtail started draining, pain and swelling subsided within 2 days. Thereafter patient′s recovery was uneventful. Discussion Acute pancreatitis is an inflammation of pancreas most commonly caused by alcohol and gall stones. [1] Exocrine pancreas produces several digestive enzymes that are potentially injurious to it. Several factors that prevent auto digestion of pancreas include production of proenzymes or zymogens which are secreted and transported outside the gland and synthesis of trypsin inhibitors which are transported and stored along with digestive enzymes zymogens. The usual presentation of acute pancreatitis is sudden onset abdominal pain which is characteristically vague that gradually intensifies in severity. Most often, it is located in the epigastric region, but maybe perceived more on the left or right side depending on which portion of the gland is involved and usually radiates to back. [2] It is often associated with nausea, vomiting and may be relieved by leaning forward. [1] It is found that pancreatic fluid accumulates in the lesser sac, pararenal space and in the mediastinum. [1] As pancreas is a retroperitoneal organ, pancreatic fluid tracks superiorly into mediastinum or thorax and inferiorly till the scrotal sac. The fluid can extend into peritoneal and retroperitoneal space. This can lead to periumbilical bruising (Cullen′s sign), flank bruising (Grey Turner′s sign) and lastly bilateral renal halo sign. [3],[4] Accumulation of pancreatic fluid into the extraperitoneal space of lower abdomen and scrotum leading to lower abdomen fullness, scrotal swelling and pain is rare. [1] Other conditions presenting in this manner are diverticulitis, appendicitis, hemorrhage from leaking abdominal aneurysm or a ruptured spleen and psoas abscess. [4] But all have abdominal signs and symptoms which give clue to a diagnosis and confirmed by CECT abdomen and pelvis. Acute pancreatitis may present atypically as an isolated inguinoscrotal swelling, scrotal pain mimicking testicular torsion or strangulated hernia, retroperitoneal abscess mimicking appendicular abscess or psoas abscess, isolated left flank pain and cutaneous pseudo abscesses. [2],[3],[4],[5],[6] Isolated left flank pain is rare and easily confused with pain caused due to urolithiasis. [7] Vascular complications such as hemorrhages and thrombosis have been documented in acute pancreatitis. Blue toe syndrome due to microembolism to the distal vasculature including fat embolism has been demonstrated in literature. [8] Peripancreatic vessels most commonly involved are portal vein, mesenteric vein, splenic vein and left renal vein. Among these, splenic vein is most commonly involved in pancreatitis. [7] Hepatic artery and superior mesenteric artery are also susceptible to thrombosis. Sometime patients with acute pancreatitis may be found to have inferior vena cava thrombosis which is very rare and spinal artery thrombosis leading to paraplegia due to systemic hypercoagubility induced by pancreatitis. [7],[9] Possible mechanism for thrombosis to develop is due to proteolytic effect of pancreatic enzymes, erosion of blood vessel and perivascular inflammation. Downward tracking of fluid into scrotum was first described in 1979. [1] Involvement of scrotum in acute severe pancreatitis is rare but reported in literature and can be mistaken for acute scrotum due to torsion which may lead to unnecessary surgery. Extra abdominal complications like epididymo-orchitis and pancreaticopleural fistula with mediastinal pseudocyst due to acute pancreatitis, though rare, do occur. [10] Scrotum necrosis secondary to acute pancreatitis has also been reported. [1] In this case, lower abdominal swelling and scrotal pain appeared after the diagnosis of acute pancreatitis was already made. The diagnosis is made with CECT abdomen which enables the scrotal and lower abdominal collection to be traced to an inflamed pancreas. After making the diagnosis, the condition can then be managed conservatively by percutaneous drainage of the abscess by pigtail catheter placement and addressing the pancreas. Definitive surgical correction of underlying pancreatic disease like duct decompression, drainage or treatment of pseudocyst is necessary to avoid recurrence of the disease and further complications of advanced chronic pancreatitis. [10] So here we would like to conclude that when a patient presents with inguinoscrotal swelling or lower abdomen abscess, acute pancreatitis should be kept in mind as a possible etiology of the condition. In such a case, patient can be managed conservatively and unnecessary exploration or surgery can be avoided. [1],[6] Treatment includes percutaneous drainage of the fluid collection or the abscess and supportive care. Acknowledgment We would like to thank our Director, Dr. Sanjay N. Oak for allowing us to publish the hospital data. References
Copyright 2011 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp11092f3.jpg] [jp11092f2.jpg] [jp11092f1.jpg] |
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