Initially the diagnosis of acute pancreatitis is based on the clinical examination associated with the lipase and amylase serum level. Apache II and SIRS are useful. The CT scan is not recommended directly but it is after 72 hours for moderate to severe acute pancreatitis to assess the presence of local complications [
Literature reports of cases of inguinoscrotal and other extension of pancreatitis local complications.
References + year of publication | Urologic clinical features | Side affected | Etiology of the pancreatitis | Atlanta classification | Invasive scrotal interventions |
---|---|---|---|---|---|
[ | Unknown | Unknown | Unknown | Supposed necrotizing acute pancreatitis | Unknown |
[ | Painful scrotum enlargement | Unknown | Alcohol | Interstitial edematous acute pancreatitis | NO |
[ | Transilluminating hydrocele | Right | Alcohol | Interstitial edematous acute pancreatitis | NO |
[ | Painful and swollen scrotum | Left | Unknown | Necrotizing acute pancreatitis | NO |
[ | Scrotal necrosis | Unknown | Unknown | Necrotizing acute pancreatitis | Excision of the testis and the scrotum |
[ | Scrotal mass, erythematous skin | Unknown | Latrogenic | Necrotizing acute pancreatitis | Invasive scrotal aspiration |
[ | Tender swollen scrotum | Left | Alcohol | Interstitial edematous acute pancreatitis | NO |
[ | Painful inguinal swelling | Right | Alcohol | Interstitial edematous acute pancreatitis | Percutaneous drainage |
[ | Painful scrotal swelling | Right | Alcohol | Interstitial edematous acute pancreatitis | Scrotal fluid punction |
[ | Inguinoscrotal mass | Left | Alcohol | Interstitial edematous acute pancreatitis | NO |
[ | Scrotal mobile mass | Right | Unknown | Interstitial edematous acute pancreatitis | Percutaneous drainage |
[ | Tender inguinoscrotal swelling | Left | Alcohol | Interstitial edematous acute pancreatitis | (Drainage of the retroperitoneal collection) |
[ | Scrotal exudation, fever | Bilateral | Alcohol | Interstitial edematous acute pancreatitis | Scrotal debridement |
[ | Painful scrotal swelling, fever, funiculitis | Left | Unknown | Interstitial edematous acute pancreatitis | Unknown |
[ | Painful scrotal swelling, macroscopic hematuria | Left | Alcohol | Interstitial edematous acute pancreatitis | NO |
[ | Painful scrotal swelling, discoloration of the scrotum | Left | Alcohol | Necrotizing acute pancreatitis | NO |
[ | Painful tender groin and scrotal swelling | Right | Unknown | Interstitial edematous acute pancreatitis | NO |
Our case report | Painful inguinoscrotal swelling + skin erythema | Right | Alcohol, hypertriglyceridemia | Interstitial edematous acute pancreatitis | NO |
| |||||
References + year of publication | Other expressions reported | Side affected | Etiology of the pancreatitis | Atlanta classification | Treatment reported |
| |||||
[ | Extension to the groin | Right | Alcohol | Interstitial edematous acute pancreatitis | Inguinal canal drainage |
[ | Extension to the groin | Left | Alcohol | Unknown | Laparotomy + peritoneal lavage |
[ | Extension to the thigh and the knee | Left | Gallstones | Interstitial edematous acute pancreatitis | Pseudocyst drainage |
[ | Extension to the psoas muscle | Left | Alcohol | Interstitial edematous acute pancreatitis | Laparotomy + pancreatectomy |
A 48-year-old male patient with a known diabetic, hypertensive, and hypercholesterolemic status called the Emergency Department for abdominal pain not responding to the paracetamol and butylhyoscine bromide. He complained about increasing broad abdominal pain, nausea, and sweating. His daily treatment was fenofibrate, moxonidine, metformin, and enoxaparin 60 mg. He was a chronic consumer of alcohol. There was an abdominal guarding and pain increased by palpation. His blood test showed high lipase level of 14069 UI/L (regular range: <67 UI/L), a hyperleukocytosis with 14670 units/
Ultrasound scan demonstrating an infiltration of the inguinal canal fat.
Axial contrast CT scan of the abdomen showing retroperitoneal and peritoneal effusion arising from the tail and the body of the pancreas 4 days after admission.
Frontal section contrast CT scan showing retroperitoneal effusion extending from the tail and the body of the pancreas.
Frontal section contrast CT scan showing involvement of the right scrotum after 4 days of admission.
We thought initially of local causes of unilateral inguinoscrotal swelling. That is the reason why we asked for an ultrasound scan and a Doppler to eliminate the diagnosis of testicle twist, orchiepididymitis, or even inguinal hernia, diagnosis that cannot be postponed. The testis was homogenous, normal sized, and well vascularized. It showed however an infiltration of the right inguinal canal fat with an heterogeneous effusion of the right scrotum. On the basis of the clinical findings and the high serum lipase level, the diagnosis of acute pancreatitis in a context of acute alcohol consumption was made. There were no biological and clinical criteria for a severe acute pancreatitis and so the patient was admitted in gastroenterology. There was no reason for intensive care. It occurred in a context of high consumption of alcohol, a high serum TG level, and a treatment by fenofibrate. We asked for a contrast abdominopelvic CT scan after 72 h which established a direct link between, on the one hand, the retroperitoneal effusion, what comes out the body and the tail of the pancreas and on the other hand the right inguinoscrotal swelling. This fluid dissects the anatomic plans and finds a way from the head and the tail of the pancreas to the scrotum. In this case we supposed that the processus vaginalis is well a remnant.
We decided to ensure the patient follow-up with a classic treatment because there was an absence of the pyretic signs usually indicating complications such as necrotizing infected tissues. There was a spontaneous resolution after 10 days (Figure
Comparative contrast CT scan after 1 month.
After having examined the seventeen cases found (Table There is no preference for a side affected. The most common etiology for much complicated acute pancreatitis remains the alcohol abuse. The etiology was indeed found mainly by the CT scan. Concerning the scrotum, the conservative treatment is mostly appropriate. The indications reported in the guidelines of acute pancreatitis remain the main source to justify an intra-abdominal invasive treatment (over infected collections not responding to antibiotics, etc.). Drainage of intra-abdominal pancreatic collection seems to improve the resolution of acute scrotum.
Because of this rare complication we shall suggest a management combining the pancreatitis and the acute scrotum. By doing so, the number of mistakenly reported pathologies as common may decrease. If the common diagnosis is rejected, the scrotal swelling due to an unknown cause could be identified by mistake as an acute idiopathic scrotal edema (AISE). The low number of case reports describing this complication could explain the fact that there were no appropriate investigations. We suggest confirming the “good diagnosis of AISE’’ by excluding an intra-abdominal origin with an abdominopelvic CT scan. In this case we have supposed that if we exclude intraabdominal causes, the percentage of hypervascularized and the percentage of hypereosinophilia among “the entity described as a real AISE’’ could maybe rise.
Yet, we have compared the evolution and the treatment of related cases. The spontaneous resolution seen in our case reinforces the benefits of a noninvasive management whereby we have to remain particularly watchful of possible overcomplications such as infections of necrotized tissues. That is why the patient’s supervision in the hospital is still required.
The management of a scrotal swelling should be the least invasive possible method but also the most complete possible method to avoid unnecessary interventions. The exclusion of a pathology that could affect the vital prognosis of the testis remains the absolute priority. An acute scrotum swelling must be carried out by the clinical management by a professional and must be completed with an ultrasonography of the scrotum. Despite all that, if the original etiology of the acute scrotum remains unknown, an abdominopelvic CT scan could provide more details and so could offer a different diagnosis of exclusion, different from the diagnosis of acute idiopathic scrotal edema (AISE). This rare complication of acute pancreatitis could be mistaken for a more common pathology and if that complication is identified, it will not require a surgical intervention if there is a correct management of the acute pancreatitis which could justify a broader CT scan.
The authors declare that they have no competing interests.