Unusual association between scrotal swelling and abdominal pain

Abstract

A 54-year-old man experienced acute dull pain radiating from the left lower abdominal area for 3 days after binge drinking. He had an underlying condition of diabetes, hyperlipidemia, and alcohol abuse. The pain worsened following intake of food and water, and the pain was observed to progressively radiate toward the left inguinal area accompanied by swelling of the scrotum (Figure 1A). He visited the emergency department; the laboratory examination revealed leukocytosis (white blood cell count, 14 000 cells/mm3) and mild anemia (hemoglobin, 13.6 g/dL). Biochemical examination showed increased triglyceride levels (823 mg/dL) and increased lipase levels (104 U/L, normal range: 19-47). Ultrasound performed by a urologist suggested hydrocele without testicular torsion, epididymitis, or epididymo-orchitis (Figure 1B). This was followed by an abdominal computed tomography (CT) scan (Figure 2). What is the likely diagnosis of this patient? Based on the acute onset of symptoms and the progression of the clinical status, the differential diagnoses included testicular torsion, strangulated hernia, and epididymitis. The abdominal CT scan revealed pancreatic fat stranding with fluid accumulation in the left pararenal space along the left abdomen and extending into the left inguinal canal (Figure 2, arrows). Based on the clinical, laboratory, and imaging findings, a diagnosis of pancreatic hydrocele was established. The patient was placed on fluid supplement. The pain gradually improved, and he was discharged 5 days later. His scrotal swelling also gradually subsided during the 1-month follow-up period. Pancreatic hydrocele refers to scrotal swelling associated with acute pancreatitis.1-3 It is a rare complication of acute pancreatitis and is caused by the effusion of pancreatic juices into the inguinal canal along the retroperitoneal tract. This rare complication resembles other acute scrotal conditions such as testicular torsion, appendicular torsion, and epididymitis. Abdominal CT is useful for diagnosis, and ultrasound-guided aspiration of scrotal fluid showing high amylase and lipase levels can assist in confirming the presence of this condition. Treatment is generally conservative. Surgical drainage or debridement is rarely required.3 The authors declare no conflict of interest.