Unusual presentation of pancreatitis: Inguinoscrotal edema mimicking an incarcerated hernia - a case report.

INTRODUCTION: In rare instances, pancreatitis can manifest as inguinal edema without typical abdominal symptoms, posing diagnostic challenges. CASE PRESENTATION: We report a case of a man in his 40s, with alcohol addiction, who presented with left inguinal pain and swelling but no other abdominal complaints. Physical examination revealed inguinal tenderness and edema, with no hernia signs. Laboratory results showed leukocytosis and elevated C-reactive protein, inconsistent with the patient's symptoms. Abdominopelvic CT scan revealed peripancreatic fat densification and retroperitoneal fluid extending into the inguinal area. No hernia was evident. Extended analysis revealed elevated amylase and lipase levels, sustaining the diagnosis of pancreatitis. The patient responded well to supportive care and was discharged symptom-free. DISCUSSION: Acute pancreatitis emerging as an inguinoscrotal swelling, in the absence of any abdominal symptoms or signs, is extremely rare and can mimic more common causes of inguinoscrotal swellings, such as incarcerated hernias. This case highlights the ability of leaking pancreatic juice to track widely in the retroperitoneal tissues, particularly on the left side. A high level of suspicion, in combination with a CT scan, is essential for achieving an accurate diagnosis and determining the disease's extent. Failure to diagnose correctly could lead to unnecessary surgical procedures and inappropriate/delayed medical care. CONCLUSION: Inguinal edema as the sole presentation of acute pancreatitis is extremely rare. Therefore, it is essential to maintain a high index of suspicion, especially in patients with a history of alcohol consumption, in order to proceed with prompt treatment and avoid unnecessary surgery.

Pancreaticopleural fistula as the inaugural presentation of chronic pancreatitis: A case report.

INTRODUCTION: Pancreaticopleural fistula is a rare complication most associated with alcohol-induced chronic pancreatitis. This usually presents with chest symptoms instead of abdominal ones. Diagnosis requires a high index of suspicion in patients with pancreatitis and persistent pleural effusions. PRESENTATION OF CASE: We present a case of an 81-years-old man admitted in the emergency department with a one week complaints of productive cough, fever, dyspnea and left-side chest pain. The chest X-ray revealed a moderated-volume left-side pleural effusion. The pleural fluid analysis was consistent with an exsudative pleural effusion with high levels of amylase. The thoracoabdominal CT raised the suspicion of a pancreaticopleural fistula, confirmed by ERCP. A pancreatic main duct stenting was performed with good results. The patient was discharged asymptomatic after 18 days of hospitalization. DISCUSSION: Because of PPF insidious presentation it poses a great number of differential diagnosis, so pleural fluid analysis is of paramount importance with high levels of amylase confirming the diagnosis. MRCP and ERCP may establish the fistulous tract between the pancreatic duct and the pleural cavity, with the latter being also therapeutic. CONCLUSION: The rarity of this complication related to pancreatitis and the seldomly presence of abdominal pain in contrast with chest symptoms poses a diagnostic challenge.

Inflammatory parameters as predictive factors for complicated appendicitis: A retrospective cohort study.

INTRODUCTION: Acute appendicitis is a major cause of acute abdomen. Although its diagnosis is clinical, it is often supported by complementary diagnostic tests. Sometimes, delay in diagnosis can lead to worsening of the clinical picture, resulting in a complicated acute appendicitis. Some series have studied some clinical and analytical parameters as possible predictors of complicated acute appendicitis. STUDY DESIGN: A retrospective analysis of patients admitted for acute appendicitis and undergoing appendectomy between January 2014 and December 2017 was performed in order to assess the possible existence of preoperative analytical predictive factors for complicated acute appendicitis (such as leukocytosis, C-reactive protein and ratio between neutrophils and lymphocytes). RESULTS: 841 patients underwent emergency appendectomy during the analysed period. This initial sample was divided into two groups: Group 1 with patients with uncomplicated acute appendicitis and Group 2 with patients with complicated acute appendicitis. Group 2's presentation age, duration of symptoms and hospital stay was significantly higher than Group 1. Regarding analytical parameters, the measurement of leukocytes, C-reactive protein and ratio between neutrophils and lymphocytes was significantly higher in patients with complicated acute appendicitis. After a multivariate analysis, it was found that only C-reactive protein was a good predictor of complicated acute appendicitis. CONCLUSION: Several publications have studied and demonstrated the possible use of certain analytical parameters as predictors of complicated acute appendicitis. In our study, C-reactive protein proved to be a good independent predictor of complicated acute appendicitis and, therefore, when an assay of this protein exceeds 63.3 mg/L, faster surgical approach should be considered due to the high probability of the presence of a complicated picture of this clinical entity.

Dieulafoy's lesion in the cecum: A rare case report presentation.

INTRODUCTION AND IMPORTANCE: Dieulafoy's lesion is a rare entity, normally present in the stomach and more rarely in the colon, and it is responsible for 1% to 5% of acute gastrointestinal bleeding cases. Its true incidence may be underrated, since most cases are asymptomatic and difficult to diagnose despite endoscopic advances. We present a clinical case of acute gastrointestinal bleeding due to Dieulafoy's lesion in the cecum. CASE PRESENTATION: An 85-year-old woman presented with a clinical condition of haematochezia associated with anaemia and haemodynamic instability, needing blood transfusion. Colonoscopy demonstrated a Dieulafoy's lesion in the cecum with active bleeding, and haemostasis was performed successfully with localized adrenaline injection and haemostatic clip placement. Hospitalization occurred without further complications. DISCUSSION: The diagnosis of Dieulafoy's lesion is difficult because it is a rare condition and thus, usually not included in the differential diagnosis of gastrointestinal bleeding. Its endoscopic diagnostic and therapeutic approach is the standard method in the event of an acute gastrointestinal bleeding episode, with greater efficiency with the combined use of haemostatic techniques. Surgery is necessary in less than 5% of cases when bleeding is not effectively controlled by endoscopic or angiographic techniques. CONCLUSION: It is essential to be aware of this lesion as a possible cause of gastrointestinal bleeding and differentiate it from other causes. Advances in endoscopy have increased the rate of diagnosis of these lesions and reduced their associated mortality.