Lin 2019

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IMAGES IN RADIOLOGY

Robert G. Stern, MD, Section Editor

A Man with Right Lower Quadrant Abdominal Pain


Shum-Shin Lin, MD a, Ching-Yu Han, MD a,b, Chun-Yu Chen, PhD c, Yu-Jang Su, MD d,e
a
Department of Emergency Medicine, Tao-Yuan General Hospital, Ministry of Health and Welfare, Tao-Yuan, Taiwan; b Department of Emer-
gency Medicine, Hsinchu Mackay Memorial Hospital Hospital, Hsinchu City, Taiwan; c Department of Neurology, Neurological Institute, Taipei
Veterans General Hospital, Taiwan; d Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan; e Department of Med-
icine, Mackay Medical College, New Taipei City, Taiwan.

PRESENTATION DIAGNOSIS
A 35-year-old Vietnamese male worker in Taiwan with a past A general surgeon was consulted for suspected mucocele of
history of gastric ulcer presented to our Emergency Department the appendix. Surgical exploration was performed, revealing a
with sudden, severe, continuous right lower abdominal pain for 10 × 15-cm2 retroperitoneal cystic mass with gangrene change
2 days. He had had several episodes of pain previously, but had (Figure 2), and excision was performed. The postoperative
not sought help. He denied having fever or changes in bladder course was uneventful, and the patient was discharged 3 days
or bowel habits. later. The pathology of the tumor revealed hyperchromatic neo-
plastic cells positive for placental alkaline phosphatase and
CD117, and negative for alpha-1-fetoprotein and CD30,
ASSESSMENT supporting the diagnosis of classic seminoma. The paratesticular
tissue and spermatic cord were also examined, showing conges-
Upon examination, his vital signs were as follows: body
tion and focal hemorrhage, compatible with torsion.
temperature, 37°C; pulse, 94 beats per minute; respiratory
rate, 20 breaths per minute; blood pressure, 142/80 mm Hg.
Physical examination showed right lower abdominal tender-
ness on palpation, without muscle guarding or any palpable
MANAGEMENT
mass. Chest and abdominal radiographs taken in an Cryptorchidism with at least one undescended testis occurs in
erect posture did not show free air in the subdiaphragmatic 3% of full-term and 30% of premature infant boys, but 80% of
area. The serum white blood cell count was 6700/μL, cryptorchid testes descend by the first year of life.1 Without
with a segmented neutrophil percentage of 74.5% and a intervention, undescended testes are often associated with
C-reactive protein level of 1.34 mg/L. The Rovsing sign reduced fertility, increased risk of testicular germ-cell tumors
and psoas signs were slightly positive. A provisional clinical (mostly seminoma), torsion, and psychological problems
diagnosis of acute appendicitis was made, and contrast- in adulthood.2 To reduce these risks, orchiopexy is usually
enhanced computed tomography of the abdomen was per- performed in infancy.
formed, which revealed a 10 × 13-cm2 lobulated mass without Testicular torsion is a urologic emergency needing surgery
obvious contrast enhancement in the right lower abdomen and is more common in neonates and postpubertal boys.
(Figures 1A, B). Torsion of undescended testis located within the abdomen is
rare and typically occurs in the perinatal period. There are
only a few studies in the English literature describing torsion
of the intra-abdominal undescended testis in adults. The
mechanism of testicular torsion in cryptorchidism remains
controversial. Two theories have been proposed. One states
that abnormal contractions or spasms of the cremasteric
muscles cause spermatic cord torsion. This theory is supported
Funding: None. by the high prevalence rate of cryptorchidism (53.8%) in
Conflict of Interest: None. cerebral palsy patients and some cases of undescended testes
Authorship: All authors had access to the data. SSL and CYH wrote the torsion in spastic neuromuscular disease patients.3 The second
draft, and CYC gathered data for the discussion. YJS revised the manuscript. theory states that the huge size of the undescended testis
Requests for reprints should be addressed to Yu-Jang Su, MD, Department
of Emergency Medicine, Mackay Memorial Hospital, No. 92, Sec 2, North increases the risk of testicular torsion. Some reports and our
Chung Shan Rd., Taipei 10449, Taiwan. case have revealed that increased weight and distortion of
E-mail address: yjsu.5885@mmh.org.tw the normal dimensions of the developmental tumor can lead

0002-9343/© 2019 Elsevier Inc. All rights reserved.


https://doi.org/10.1016/j.amjmed.2019.02.014
Lin et al Right Lower Quadrant Abdominal Pain 831

Figure 1 (A, B, the black arrow keys) A 10 × 13 cm2 lobulated mass without obvious contrast
enhancement in the right lower abdomen.

to testicular torsion. A case series between 1978 and 2013 tomography, and technetium Tc-99m scrotal scintigraphy
reviewing 35 patients with testicular torsion in cryptorchidism can offer more details but do not suffice for making a diagno-
reports about 96% (27 of 28) of children without testicular sis. The European Society for Pediatric Urology guidelines on
tumor and 50% (2 of 4) of adults with malignant testicular pediatric urology and cryptorchidism state that “there is no re-
tumors.4 This finding supports the fact that an undescended liable examination to confirm or exclude an intra-abdominal,
testis develops into a tumor in adults and makes torsion easier. inguinal, or vanished testis except for diagnostic
The clinical presentations of intra-abdominal testicular laparoscopy.”6 Orchiectomy is suggested in most cases be-
torsion are nonspecific and include abdominal pain, poor cause of the low salvage rate in the torsional cryptorchid testi-
oral intake, nausea with vomiting, inguinal region pain, and cle of approximately 10%, compared with
restlessness.5 It also can mimic several clinical conditions, approximately 70% for torsion of the normally descended
such as acute abdomen, acute appendicitis, urethral stone, testis within 12 hours of treatment.7
incarcerated inguinal hernia, and inguinal lymphadenitis. Its Our case emphasizes that intra-abdominal testicular torsion
diagnosis is often difficult because of frequent neglect in exam- should be considered in the scenario of acute abdominal
ining the external genitalia during abdominal examination and pain. Genital examination should be performed in all cases
unawareness of the absence of testes within the hemi-scrotum. of acute groin pain, especially in patients with impaired verbal
Imaging studies such as Doppler ultrasonography, computed communication.

Figure 2 A retroperitoneal 10 × 15 cm2 cystic mass with gangrene change.


832 The American Journal of Medicine, Vol 132, No 7, July 2019

References 4. Geng JH, Huang CN. Torsion of undescended testis: clinical, imaging, and
surgical findings. Urol Sci 2014;25:31-4.
1. Man DW, Li AK. Cryptorchidism: an approach to management. 5. Papparella A, Nino F, Coppola S. An unusual case of intra-abdominal
Hong Kong Pract 1987;9:2813-6. testicular torsion: role of laparoscopy. Afr J Pediatr Surg 2013;10:29-31.
2. Cortes D, Thorup J, Petersen BL. Testicular neoplasia in undescended 6. Cisek LJ, Peters CA, Atala A, Bauer SB, Diamond DA, Retik AB. Current
testes of cryptorchid boys-does surgical strategy have an impact on the findings in diagnostic laparoscopic evaluation of the nonpalpable testis.
risk of invasive testicular neoplasia? Turk J Pediatr 2004;46(Suppl):35-42. J Urol 1998;160:1145-9.
3. Candocia FJ, Sack-Solomon K. An infant with testicular torsion in the 7. Moore CP, Marr JK, Huang CJ. Cryptorchid testicular torsion. Pediatr
inguinal canal. Pediatr Radiol 2003;33:722-4. Emerg Care 2011;27:121-3.

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