Unexpected Cause of Abdominal Pain and Genitourinary Symptoms.

Abstract

Question: A 40-year-old Vietnamese man with a past medical history significant for tobacco and alcohol use presented the emergency room with a 4-week history of an inability to ejaculate and left lower abdominal pain that started suddenly after hearing a "pop" in the mid-left abdomen while sitting at rest. Pain was associated with a 15- to 20-pound weight loss, nausea, cibophobia, and night sweats. A computed tomography scan of the abdomen and pelvis demonstrated a huge complex fluid collection in the left abdomen that displaces the stomach, colon, urinary bladder, left kidney, and left psoas muscle (Figure A). His laboratory values revealed hemoglobin 7.9 g/dL, white cell count of 5.1 k/μL, and C-reactive protein of 11.3 mg/L (reference range, <5 mg/L). Renal function, liver enzymes, and lipase levels were normal. His carcinoembryonic antigen was elevated at 30.54 μg/L. He underwent endoscopic ultrasound examination for cystgastrostomy and nasocystic tube placement and started on antibiotics because Escherichia coli species were detected in the culture of cystic fluid (Figure B). The patient left the hospital against medical advice and presented 1 month later with necrotic left inguinal sinus draining purulent fluid. Repeat abdominal imaging demonstrated abscess extending from pancreatic tail traversing to below pelvic brim (Figure C). He was taken to the operating room for debridement and retroperitoneal abscess drainage (Figure D). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Nonpancreatic retroperitoneal pseudocysts are rare and could arise, in the absence of acute pancreatitis, from the mesentery or omentum as a sequela of an abscess that was not resorbed.1Ahn J. Chandrasegaram M.D. Alsaleh K. et al.Large retroperitoneal isolated fibrous cyst in absence of preceding trauma or acute pancreatitis.BMC Surg. 2015; 15: 25Crossref PubMed Scopus (4) Google Scholar It is very uncommon with an incidence of 1 in 5750 to 1 in 250,000.2Alzaraa A. Mousa H. Dickens P. et al.Idiopathic benign retroperitoneal cyst: a case report.J Med Case Rep. 2008; 2: 43Crossref PubMed Scopus (21) Google Scholar It grows slowly and gives nonspecific symptoms when compress adjacent structures. These cysts usually contain serous fluid and do not have any epithelial lining. Unlike pancreatic pseudocysts, these cysts are not associated with high levels of amylase or lipase in the cystic fluid.3Yang D.M. Jung D.H. Kim H. et al.Retroperitoneal cystic masses: CT, clinical, and pathologic findings and literature review.Radiographics. 2004; 24: 1353-1365Crossref PubMed Scopus (281) Google Scholar Infection, mass effects, and hemorrhage could complicate these lesions. Treatment options include drainage or surgical excision. The latter is preferred to avoid complications and potential recurrence.1Ahn J. Chandrasegaram M.D. Alsaleh K. et al.Large retroperitoneal isolated fibrous cyst in absence of preceding trauma or acute pancreatitis.BMC Surg. 2015; 15: 25Crossref PubMed Scopus (4) Google Scholar