Abdominal Imaging

ª Springer Science+Business Media, LLC 2010 Published online: 27 July 2010

Abdom Imaging (2011) 36:218–221 DOI: 10.1007/s00261-010-9638-0

Scrotal swelling caused by acute necrotizing pancreatitis: CT diagnosis Sung-Bum Kim,1 Bo-Kyung Je,2 Seung Hwa Lee,2 Sang Hoon Cha2 1

Department of Internal Medicine, Dongshin Hospital, 430, Hongeun-Dong, Seodaemun-Gu, Seoul, Republic of Korea Department of Radiology, College of Medicine, Korea University Ansan Hospital, 516, Gojan1-Dong, Danwon-Gu, Ansan-City, Gyeonggi-Do, Republic of Korea 2

Abstract Scrotal involvement is a rare complication of acute pancreatitis. It presents as scrotal swelling and skin color change, which mimics the presentations of testicular torsion, epididymitis, and testicular tumor. Its differential diagnosis is important because scrotal involvement of acute pancreatitis can be treated conservatively. Abdominopelvic CT provides a useful means of diagnosing this complication. Here, the authors present a case of acute pancreatitis extending to the left scrotum, mimicking a testicular tumor. A CT scan helped avoid unnecessary orchiectomy. Key words: Pancreatitis, Acute necrotizing— Pancreatitis, Alcoholic—Scrotum—Tomography, X-ray computed—Radiographic image interpretation, computer assisted

Scrotal swelling with inflammation is a rarely reported complication of acute pancreatitis, and is believed to be caused by fat necrosis of soft tissue of scrotum due to the destructive effect of pancreatic fluid. Here, we present the clinical features and the serial CT images of a young male with acute pancreatitis extending to the left scrotum.

Case report A 28 year-old-male, previously healthy, presented with a sudden-onset of severe epigastric pain and nausea after binge drinking (half a bottle of whisky, two bottles of Korean rice wine, and four bottles of distilled liquor). Initial laboratory tests revealed a normal serum amylase level of 89 IU/L (reference range 30–110 IU/L) and an elevated serum lipase level of 577 IU/L (reference range, Correspondence to: Bo-Kyung Je; email: [email protected]

23–300 IU/L). He was then admitted under the impression of acute alcoholic pancreatitis. The day after admission, serum amylase and lipase levels increased to 376 IU/L and 2470 IU/L, respectively. Abdominopelvic CT (Brilliance 6; Philips Medical Systems, Cleveland, Ohio) demonstrated inhomogeneous attenuation of the pancreas and ill-defined increased attenuation in the peripancreatic fat, especially that surrounding the pancreatic head and uncinate process (Fig. 1). At the time, no focus of fluid collection was evident, and therefore, we concluded grade C acute pancreatitis according to Balthazar’s grading system [1]. Over the next 5 days, he was kept fasting with parenteral nutrition for sustained ileus. On admission day 6, he complained of painful swelling, tenderness, and discoloration of the left scrotum (Fig. 2A). The pain was dull and not relieved by scrotal elevation (negative Prehn’s sign). The patient also complained of a constant dull pain with a heating sensation in the left lower abdomen. Physical examination revealed a 20 9 20 cm sized soft palpable mass with a red overlying skin color in his left lower abdomen and a bluish flank discoloration with ecchymosis, which was regarded as Grey Turner’s sign [2] (Fig. 2B). Two genitourinary doctors were then consulted. Scrotal ultrasonography showed fluid collection around the left spermatic cord and epididymis, and color Doppler ultrasound demonstrated intact blood flow bilaterally in the testes. One of the genitourinary doctors was under the impression of epididymitis and recommended conservative management such as ice bag, scrotal elevation, and antibiotics. However, the other doctor recommended excision of the left testis, due to the elevated LDH level of 2294 IU/L (reference range 313–618 IU/L), to rule out a testicular malignancy. The patient refused orchiectomy and requested conservative treatment. On admission day 8, follow-up abdominopelvic CT was performed. As compared with the initial CT, this second CT showed more aggravated and

S.-B. Kim et al.: Scrotal swelling caused by acute necrotizing pancreatitis: CT diagnosis

Fig. 1. The initial CT demonstrates ill-defined increased attenuation in the peripancreatic fat, mainly surrounding the pancreatic head and uncinate process (i.e. grade C acute pancreatitis).

extensive peripancreatic inflammation and fluid accumulation in the retroperitoneal space, including the peripancreatic, perigastric, perisplenic, left perirenal, and left paracolic spaces, which was consistent with grade E acute pancreatitis according to Balthazar’s grading system [1] (Fig. 3). Furthermore, the retroperitoneal fluid ran down through the left inguinal canal to the left scrotum, and therefore, we concluded pancreatitis-related scrotal swelling and pain. His bowel movement recovered after 14 days. He was kept fasting for 14 days and was treated conservatively by parenteral nutrition and intravenous antibiotic (carbapenem) injections for 22 days. As his general condition improved, the scrotal swelling and pain diminished. When oral feeding was found not to cause relapse of pancreatitis, he was discharged. Just before discharge, serum amylase level was 41 IU/L and serum lipase level was 166 IU/L. One week after discharge, his LDH level was found to have dropped dramatically to 931 IU/L, and subsequently, the scrotal swelling gradually resolved.

Discussion Involvement of the genitourinary tract system, especially of the scrotum is a rare complication of pancreatitis. The first case report of an accumulation of pancreatic fluid in the scrotum was published in 1979 [3], and since then six case reports [4–9] have been published. In this case re-

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port, we present serial CT images, which were found to be very helpful for achieving the correct diagnosis. The first CT scan suggested a diagnosis of acute pancreatitis, and the second, which was performed after the development of scrotal swelling, showed extension of the pancreatic inflammation to the left scrotum in coronal images (Fig. 3). Tracking the course of the extravasated pancreatic enzymes as definitively as possible ties the coronal CT images (Fig. 3) with the pathologic anatomy; left anterior pararenal space extending inferiorly within the pelvic extraperitoneal tissues and then involving the scrotal sac. The development of this complication can be rationalized by considering the anatomy concerned. In the fetus, two structures, namely, the gubernaculums testis and the processus vaginalis peritonei play a major role in the formation of the inguinal canal [10]. In males, the gubernaculums testis forms the scrotum and assists the descent of the testis into the scrotum, and the processus vaginalis peritonei, a tubular fold of the peritoneum, invaginates into the inguinal canal and ends in the scrotum. In our patient, ascites with pancreatic fluid in the retroperitoneal space was assumed to course through the processus vaginalis into the scrotum. The scrotal involvement of acute pancreatitis presents as unilateral or bilateral scrotal swelling and skin color change, and thus, sometimes it is indistinguishable from other acute scrotal lesions, such as, testicular torsion, acute epididymitis, or a testicular tumor. Several reports have described the ultrasound and Doppler features of pancreatitis-related scrotal swelling [5, 6], but its correlation with pancreatitis is difficult to achieve, especially if the scrotal swelling is the main problem in a patient with acute pancreatitis. The differential point is that the testes are typically not affected in pancreatitis-related scrotal swelling, because the fibrous tunica albuginea and tunica vaginalis cover the testes [6]. According to the report issued by Lin et al. [7], hemorrhagic and necrotic spots were grossly evident over the tunica vaginalis, and microscopically, fat necrosis was present in the tunica vaginalis, but no testicular torsion-related testicular infarction was evident. The differential diagnosis of scrotal lesions is crucial because the scrotal involvement of acute pancreatitis can be treated conservatively. We agree with Lee et al. who insisted in his case report [8] that CT can certainly diagnose scrotal swelling resulting from pancreatitis. In our case, the second abdominopelvic CT was very helpful, because it allowed tracing fluid from the pancreas and retroperitoneum into the scrotum. In fact, our patient could have undergone unnecessary left orchiectomy had a second CT not been performed, which could have lead to serious cosmetic or even legal problems, given his age and unmarried status. In the event, conservative management resolved the pancreatitis. And scrotal swelling, tenderness, and discoloration were relieved.

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S.-B. Kim et al.: Scrotal swelling caused by acute necrotizing pancreatitis: CT diagnosis

Fig. 2. A Clinical photography shows the left scrotal swelling. The patient complained of painful swelling, tenderness and discoloration over the left scrotum. B Clinical photography

depicts a typical Grey Turner’s sign which means a bluish flank discoloration on the left lower abdomen.

Fig. 3. The second CT performed on admission day 8 presents more increased fluid accumulation in the retroperitoneal space, including the peripancreatic, perigastric, perisplenic,

left perirenal, and left paracolic spaces (i.e. grade E acute pancreatitis). The retroperitoneal fluid courses through the left inguinal canal to the left scrotum (A).

Conclusion

mulation of pancreatic fluid. The clinical presentation of this complication is similar to those of testicular torsion and epididymitis. Abdominal CT was found to be helpful for accurately diagnosing this complication of acute

During the management of acute pancreatitis, scrotal swelling can develop as a complication due to an accu-

S.-B. Kim et al.: Scrotal swelling caused by acute necrotizing pancreatitis: CT diagnosis

pancreatitis, and thus, facilitate treatment and excluded the possibility of a surgical emergency. References 1. Balthazar EJ, Ranson JH, Naidich DP, et al. (1985) Acute pancreatitis: prognostic value of CT. Radiology 156:767–772 2. Meyers MA, Feldberg MA, Oliphant M (1989) Grey Turner’s sign and Cullen’s sign in acute pancreatitis. Gastrointest Radiol 14:31–37 3. Zimin AF, Satsukevich VN, Molchanov NP (1979) Acute pancreatitis with hemorrhagic flow into the scrotum. Vestn Khir Im I I Grek 122:47–48 4. Isgar B, Blunt RJ, Wolinski AP (1994) Pancreatitis presenting with unilateral scrotal pain and swelling. Br J Surg 81:101

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5. Wolfson K, Sudakoff GS (1994) Ultrasonography and color Doppler imaging of a scrotal phlegmon in acute necrotizing pancreatitis. J Ultrasound Med 13:565–568 6. Choong KK (1996) Acute penoscrotal edema due to acute necrotizing pancreatitis. J Ultrasound Med 15:247–248 7. Lin YL, Lin MT, Huang GT, et al. (1996) Acute pancreatitis masquerading as testicular torsion. Am J Emerg Med 14:654–655 8. Lee AD, Abraham DT, Agarwal S, et al. (2004) The scrotum in pancreatitis: a case report and literature review. JOP 5:357–359 9. Liu KL, Lee TC, Wang HP (2006) A tender scrotum and inguinal mass caused by pancreatitis. Clin Gastroenterol Hepatol 4:xxvi 10. Shadbolt CL, Heinze SB, Dietrich RB (2001) Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics 21 Spec No:S261–271.