The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.105
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS VASITIS MISDIAGNOSED AS STRANGULATED INGUINAL HERNIA Sung Hye You, MD, Deuk Jae Sung, MD, Na Yeon Han, MD, Beom Jin Park, MD, and Min Ju Kim, MD Department of Radiology, Anam Hospital, Korea University, College of Medicine, Seoul, Korea Reprint Address: Deuk Jae Sung, MD, Department of Radiology, Anam Hospital, Korea University College of Medicine, #126-1, 5-Ka Anam-dong, Sungbukku, Seoul 136-705, Korea
CASE REPORT
enhanced computed tomography (CT) using a 64detector-row scanner. Axial CT images showed an air-filled and thickened tubular structure with surrounding infiltrations from the left lower pelvic cavity to the left upper scrotum through the inguinal region (Figure 1A 1C). Coronal reconstruction CT image demonstrated an air-filled, bowel-like lesion with poor contrast enhancement of the involved wall in the left inguinal region and the left upper scrotum (Figure 2). Such clinical and imaging findings suggested the diagnosis of strangulated inguinal hernia and emergency surgery was performed. Surgical exploration, however, demonstrated necrotizing infection along the left vas deferens and spermatic cord without evidence of an inguinal hernia. The left spermatic cord including the vas deferens, left testis, and left epididymis were then removed and debridement was performed. Histopathologic examination confirmed acute necrotizing gangrenous inflammation involving the vas deferens. Escherichia coli were cultured from the necrotizing tissue and urine. Retrospective review of the CT images showed an abscess in the prostate (Figure 1B). Antibiotic therapy was started after surgery and the patient’s postoperative course was uneventful. The 1-month follow-up CT showed complete resolution of the abscess in the prostate.
A 69-year-old man presented to the emergency department with a 1-week history of left lower abdominal and scrotal pain with mild fever. His body temperature was 37.9 C. His blood pressure was 120/80 mm Hg with a pulse rate of 85 beats/min and a respiratory rate of 20 breaths/min. The patient had a medical history of diabetes mellitus and was recently diagnosed with rectal cancer, which was treated by chemotherapy and stent insertion. His physical examination revealed a painful mass, which was not reducible, on the left groin and scrotum with tenderness in the left lower quadrant. Initial laboratory findings revealed a leukocytosis (leukocyte count 17.400 109/L) and pyuria (leukocyte count >60 cells/high-power field). The level of lactic acid was within the normal range. After physical examination and laboratory tests, the patient was diagnosed with an incarcerated inguinal hernia. To confirm the diagnosis and further evaluate the tender abdomen, the patient underwent a contrast-
Institutional Review Board approval was not necessary for review of patient images in this report.
RECEIVED: 28 July 2013; FINAL SUBMISSION RECEIVED: 27 October 2013; ACCEPTED: 17 November 2013 1
2
S. H. You et al.
Figure 2. Coronal reconstruction computed tomography image shows a blind-ending, bowel-like lesion (arrows) with poor contrast enhancement of the wall, which was misinterpreted as strangulated inguinal hernia, through the left inguinal region into the upper scrotum.
Figure 1. Contrast-enhanced axial computed tomography images from cranial (A) to caudal (C) levels show a tubular lesion (arrows) with wall thickening and intraluminal air from the pelvic cavity to the left upper scrotum through the inguinal canal. Note the inflammatory changes in the surrounding fat, as well as the abscess (curved arrow) in the prostate (B).
DISCUSSION Gas-producing infections of the urinary tract are well known, especially in elderly patients with diabetes, because of potential morbidity and mortality. However,
emphysematous infection of the genital tract is extremely rare and not easily detected clinically. In addition, to the best of our knowledge, there have been no reports describing emphysematous infection involving the vas deferens. The correct diagnosis for emphysematous infections can be reliably established by imaging methods. When the clinical diagnosis of an abdominal hernia is uncertain, especially when bowel complications are suspected, CT is regarded as the best imaging modality (1). Because most abdominal hernias are inguinal hernias and masses are often located in the inguinal canal, knowledge of the anatomy of the inguinal canal is important for accurate radiologic interpretation and diagnosis (2). In men, the spermatic cord, which contains the vas deferens, testicular artery and veins, and genital branch of the genitofemoral nerve, passes through the inguinal canal to the scrotum. Some pathologic conditions arising from the spermatic cord, such as vasitis, encysted hydrocele, and lipoma can mimic inguinal hernia (3 5). After exiting the spermatic cord at the deep inguinal canal, the vas deferens courses posteriorly and medially to the obliterated umbilical artery, the obturator nerve, and vessels, and then crosses the ureter in the pelvic cavity. The thickened vas deferens caused by inflammation can easily mimic a herniated bowel loop on CT. Inguinal hernia, testicular torsion, and vasitis can present with groin masses and pain, and the clinical findings in such conditions can be very difficult to distinguish. In
Emphysematous Vasitis
addition, an incarcerated inguinal hernia and vasitis can appear as masses in the spermatic cord area with normal testis and epididymis on ultrasound (3). Recently, three cases of infectious vasitis were confirmed by CT and successfully treated with antibiotics (3,6). In our case, the presence of air in the thickened and nonenhancing vas deferens caused the radiologist to misdiagnose the condition as a strangulated inguinal hernia. Strangulated inguinal hernia is one of the most common causes of bowel obstruction in all age groups (7). CT findings of bowel obstruction include dilated bowel proximal to the hernia and collapsed bowel distal to the obstruction. Strangulation refers to ischemia resulting from compromised blood flow, and CT findings of bowel ischemia include bowel wall thickening, mural hypo- or hyperattenuation, and abnormal or absent wall enhancement (8). In the retrospective review of this case, there was lack of considerable dilatation in bowel loops on CT, and the nonenhancing and thickened vas deferens was misread as ischemic bowel. In conclusion, we report the first case of emphysematous vasitis misdiagnosed as strangulated inguinal hernia. CT has inherent limitations in the evaluation of inguinal hernias because hernias can be reduced at supineposition imaging, and some patients may require surgical exploration, such as the patient in this case. Nonetheless, imaging studies, especially CT, play an important role in
3
the accurate diagnosis and differentiation between inguinal hernias and infectious or inflammatory conditions of the spermatic cord and those of the scrotum in patients who present with groin masses and pain. Careful tracing of the course of the groin lesion on CT images can help to prevent unnecessary surgical intervention.
REFERENCES 1. Delabrousse E, Denue PO, Aubry S, et al. The pubic tubercle: a CT landmark in groin hernia. Abdom Imaging 2007;32:803–6. 2. Bhosale PR, Patnana M, Viswanathan C, et al. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics 2008;28:819–35. 3. Eddy K, Piercy GB, Eddy R. Vasitis: clinical and ultrasound confusion with inguinal hernia clarified by computed tomography. Can Urol Assoc J 2011;5:E74–6. 4. Wani I, Rather M, Naikoo G, et al. Encysted hydrocele of cord in an adult misdiagnosed as irreducible hernia: a case report. Oman Med J 2009;24:218–9. 5. Chang YT, Huang CJ, Hsieh JS, et al. Giant lipoma of spermatic cord mimics irreducible inguinal hernia: a case report. Kaohsiung J Med Sci 2004;20:247–9. 6. Eddy K, Connell D, Goodacre B, et al. Imaging findings prevent unnecessary surgery in vasitis: an under-reported condition mimicking inguinal hernia. Clin Radiol 2011;66:475–7. 7. Foster NM, McGory ML, Zingmond DS, Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg 2006; 203:170–6. 8. Wiesner W, Khurana B, Ji H, Ros PR. CT of acute bowel ischemia. Radiology 2003;226:635–50.
http://dx.doi.org/10.1016/j.jemermed.2013.11.105
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS VASITIS MISDIAGNOSED AS STRANGULATED INGUINAL HERNIA Sung Hye You, MD, Deuk Jae Sung, MD, Na Yeon Han, MD, Beom Jin Park, MD, and Min Ju Kim, MD Department of Radiology, Anam Hospital, Korea University, College of Medicine, Seoul, Korea Reprint Address: Deuk Jae Sung, MD, Department of Radiology, Anam Hospital, Korea University College of Medicine, #126-1, 5-Ka Anam-dong, Sungbukku, Seoul 136-705, Korea
CASE REPORT
enhanced computed tomography (CT) using a 64detector-row scanner. Axial CT images showed an air-filled and thickened tubular structure with surrounding infiltrations from the left lower pelvic cavity to the left upper scrotum through the inguinal region (Figure 1A 1C). Coronal reconstruction CT image demonstrated an air-filled, bowel-like lesion with poor contrast enhancement of the involved wall in the left inguinal region and the left upper scrotum (Figure 2). Such clinical and imaging findings suggested the diagnosis of strangulated inguinal hernia and emergency surgery was performed. Surgical exploration, however, demonstrated necrotizing infection along the left vas deferens and spermatic cord without evidence of an inguinal hernia. The left spermatic cord including the vas deferens, left testis, and left epididymis were then removed and debridement was performed. Histopathologic examination confirmed acute necrotizing gangrenous inflammation involving the vas deferens. Escherichia coli were cultured from the necrotizing tissue and urine. Retrospective review of the CT images showed an abscess in the prostate (Figure 1B). Antibiotic therapy was started after surgery and the patient’s postoperative course was uneventful. The 1-month follow-up CT showed complete resolution of the abscess in the prostate.
A 69-year-old man presented to the emergency department with a 1-week history of left lower abdominal and scrotal pain with mild fever. His body temperature was 37.9 C. His blood pressure was 120/80 mm Hg with a pulse rate of 85 beats/min and a respiratory rate of 20 breaths/min. The patient had a medical history of diabetes mellitus and was recently diagnosed with rectal cancer, which was treated by chemotherapy and stent insertion. His physical examination revealed a painful mass, which was not reducible, on the left groin and scrotum with tenderness in the left lower quadrant. Initial laboratory findings revealed a leukocytosis (leukocyte count 17.400 109/L) and pyuria (leukocyte count >60 cells/high-power field). The level of lactic acid was within the normal range. After physical examination and laboratory tests, the patient was diagnosed with an incarcerated inguinal hernia. To confirm the diagnosis and further evaluate the tender abdomen, the patient underwent a contrast-
Institutional Review Board approval was not necessary for review of patient images in this report.
RECEIVED: 28 July 2013; FINAL SUBMISSION RECEIVED: 27 October 2013; ACCEPTED: 17 November 2013 1
2
S. H. You et al.
Figure 2. Coronal reconstruction computed tomography image shows a blind-ending, bowel-like lesion (arrows) with poor contrast enhancement of the wall, which was misinterpreted as strangulated inguinal hernia, through the left inguinal region into the upper scrotum.
Figure 1. Contrast-enhanced axial computed tomography images from cranial (A) to caudal (C) levels show a tubular lesion (arrows) with wall thickening and intraluminal air from the pelvic cavity to the left upper scrotum through the inguinal canal. Note the inflammatory changes in the surrounding fat, as well as the abscess (curved arrow) in the prostate (B).
DISCUSSION Gas-producing infections of the urinary tract are well known, especially in elderly patients with diabetes, because of potential morbidity and mortality. However,
emphysematous infection of the genital tract is extremely rare and not easily detected clinically. In addition, to the best of our knowledge, there have been no reports describing emphysematous infection involving the vas deferens. The correct diagnosis for emphysematous infections can be reliably established by imaging methods. When the clinical diagnosis of an abdominal hernia is uncertain, especially when bowel complications are suspected, CT is regarded as the best imaging modality (1). Because most abdominal hernias are inguinal hernias and masses are often located in the inguinal canal, knowledge of the anatomy of the inguinal canal is important for accurate radiologic interpretation and diagnosis (2). In men, the spermatic cord, which contains the vas deferens, testicular artery and veins, and genital branch of the genitofemoral nerve, passes through the inguinal canal to the scrotum. Some pathologic conditions arising from the spermatic cord, such as vasitis, encysted hydrocele, and lipoma can mimic inguinal hernia (3 5). After exiting the spermatic cord at the deep inguinal canal, the vas deferens courses posteriorly and medially to the obliterated umbilical artery, the obturator nerve, and vessels, and then crosses the ureter in the pelvic cavity. The thickened vas deferens caused by inflammation can easily mimic a herniated bowel loop on CT. Inguinal hernia, testicular torsion, and vasitis can present with groin masses and pain, and the clinical findings in such conditions can be very difficult to distinguish. In
Emphysematous Vasitis
addition, an incarcerated inguinal hernia and vasitis can appear as masses in the spermatic cord area with normal testis and epididymis on ultrasound (3). Recently, three cases of infectious vasitis were confirmed by CT and successfully treated with antibiotics (3,6). In our case, the presence of air in the thickened and nonenhancing vas deferens caused the radiologist to misdiagnose the condition as a strangulated inguinal hernia. Strangulated inguinal hernia is one of the most common causes of bowel obstruction in all age groups (7). CT findings of bowel obstruction include dilated bowel proximal to the hernia and collapsed bowel distal to the obstruction. Strangulation refers to ischemia resulting from compromised blood flow, and CT findings of bowel ischemia include bowel wall thickening, mural hypo- or hyperattenuation, and abnormal or absent wall enhancement (8). In the retrospective review of this case, there was lack of considerable dilatation in bowel loops on CT, and the nonenhancing and thickened vas deferens was misread as ischemic bowel. In conclusion, we report the first case of emphysematous vasitis misdiagnosed as strangulated inguinal hernia. CT has inherent limitations in the evaluation of inguinal hernias because hernias can be reduced at supineposition imaging, and some patients may require surgical exploration, such as the patient in this case. Nonetheless, imaging studies, especially CT, play an important role in
3
the accurate diagnosis and differentiation between inguinal hernias and infectious or inflammatory conditions of the spermatic cord and those of the scrotum in patients who present with groin masses and pain. Careful tracing of the course of the groin lesion on CT images can help to prevent unnecessary surgical intervention.
REFERENCES 1. Delabrousse E, Denue PO, Aubry S, et al. The pubic tubercle: a CT landmark in groin hernia. Abdom Imaging 2007;32:803–6. 2. Bhosale PR, Patnana M, Viswanathan C, et al. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics 2008;28:819–35. 3. Eddy K, Piercy GB, Eddy R. Vasitis: clinical and ultrasound confusion with inguinal hernia clarified by computed tomography. Can Urol Assoc J 2011;5:E74–6. 4. Wani I, Rather M, Naikoo G, et al. Encysted hydrocele of cord in an adult misdiagnosed as irreducible hernia: a case report. Oman Med J 2009;24:218–9. 5. Chang YT, Huang CJ, Hsieh JS, et al. Giant lipoma of spermatic cord mimics irreducible inguinal hernia: a case report. Kaohsiung J Med Sci 2004;20:247–9. 6. Eddy K, Connell D, Goodacre B, et al. Imaging findings prevent unnecessary surgery in vasitis: an under-reported condition mimicking inguinal hernia. Clin Radiol 2011;66:475–7. 7. Foster NM, McGory ML, Zingmond DS, Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg 2006; 203:170–6. 8. Wiesner W, Khurana B, Ji H, Ros PR. CT of acute bowel ischemia. Radiology 2003;226:635–50.
