Inguinoscrotal region as an unusual site of extra-pancreatic collections in infected pancreatic necrosis

Abstract

Severe acute pancreatitis often leads to pancreatic and peripancreatic collections but, rarely, it can lead to collections at sites remote from the pancreas. Three male patients presented with abdominal pain and inguinoscrotal swelling. They were initially misdiagnosed with obstructed inguinal hernia, epididymo-orchitis and hydrocele, respectively. Later, their diagnosis of acute pancreatitis was revealed on laparotomy in one patient and on computed tomography (CT) in the remaining two patients. All these cases had extensive peripancreatic necrosis and paracolic collections tracking along the psoas muscle, downwards towards the pelvis. These collections were initially managed by percutaneous drainage and saline irrigation as a part of the ‘step-up’ approach. Two of these patients required open necrosectomy, while all required incision and drainage of inguinoscrotal collections. All the patients were discharged in satisfactory condition. Inguinoscrotal swelling is unusual as a first presentation of acute pancreatitis. A high index of suspicion, with careful study of patient's history and examination along with CT, may provide an accurate diagnosis. Local drainage may be required to control sepsis and also provide an egress route for intra-abdominal collections.

Acute pancreatitis presenting as acute scrotum

“…The pathophysiology of inguinoscrotal involvement in pancreatitis involves tracking of fluid from the pancreas into the retroperitoneum and into the scrotum via the inguinal canal as highlighted in figure 1B,C. Being rich in pancreatic enzymes, this fluid causes scrotal irritation, fat necrosis and sometimes secondary infection in the scrotum 2 10 11. Infertility as a result of scrotal extension of pancreatitis results from a direct inflammatory insult to the testis/epididymis and any secondary ascending infection 12–14.…”

“…Extension of inflammation to the inguinoscrotal region in acute pancreatitis is rare 1. Acute pancreatitis manifesting as an acute scrotum on first presentation in the absence of significant upper abdominal signs is even rarer, and can lead to misdiagnosis and potential unnecessary surgical intervention if the correct diagnosis is missed 2. We report a case of left scrotal swelling and inflammation caused by severe acute pancreatitis.…”

Incarcerated Inguinal Hernia or Acute Necrotizing Pancreatitis?

“…The leak of the fluid arising from the pancreas can also mimic and must be differentiated from incarcerated or strangulated femoral hernia, testicular torsion, acute Epididymo-orchitis, hydrocele, testicular tumor, Hodgkin's lymphoma, mononucleosis, iliopsoas bursitis, and tuberculosis [3], [4], [5].…”

Hydrocele in recurrent acute pancreatitis caused by testicular venous obstruction

“…We noted patients with pancreatic hydrocele were mostly alcohol-related among different etiologies of pancreatitis. [ 4 , 7 , 10 , 11 , 15 – 25 ] Alcohol may increase the production of digestive and lysosomal enzymes, and result in more fluid collections.…”