Case 18673

Case 18673
A scrotal egg – Peritoneal loose

body in the inguinal hernia
Published on 28.08.2024
DOI: 10.35100/eurorad/case.18673
ISSN: 1563-4086
Section: Uroradiology & genital male imaging
Area of Interest: Genital / Reproductive system male
Imaging Technique: CT
Imaging Technique: Ultrasound
Imaging Technique: Ultrasound-Colour Doppler
Case Type: Clinical Case
Authors: Padma Badhe 1, Ajith Varrior 1, Swaksh
Nemani 1, Jui Nigudkar 1, Moinuddin Sultan 2
Patient: 54 years, male
Clinical History:
A 54-year-old man presented with complaints of gradually increasing swelling in the right inguinal region for one
year. There was no pain. The swelling was non-reducible with no signs of bowel obstruction on clinical examination.
A routine preoperative ultrasound was performed.
Imaging Findings:
Ultrasound of the inguinoscrotal region shows herniation of bowel loops and omentum into the right scrotal sac with
normal bowel vascularity. There was a well-defined round lamellated hypoechoic lesion with central calcification in
the tunica vaginalis sac adjacent to the bowel loops measuring approximately 2.8 x 2.4 cm (Figure 1a). There was
no vascularity on colour Doppler (Figure 1b). Both the testes were separate from the lesion. A radiograph of the
pelvis (Figure 2) showed a soft tissue swelling in the scrotal region with lucencies suggestive of a hernia with bowel
loops as the content. There was a well-defined abnormal round calcification within the soft tissue on the left side. An
unenhanced computed tomography of the pelvis confirmed the findings on ultrasound and the radiograph. The
lesion was isodense to the bowel with central calcification (Figures 3a and 3b). The lesion was removed surgically
with a reduction of the hernia followed by hernioplasty (Figure 4).
Discussion:
Peritoneal loose bodies or peritoneal mice are necrotic tissue with central calcification found within the peritoneal
cavity [1]. They occur secondary to torsion of the epiploic appendage with necrosis of its pedicle and detachment.
There is sequential saponification and calcification. They grow in size due to continuous protein deposition derived
from the peritoneal serum [2]. They range in size from tiny lesions (0.5 to 2.5 cm) to large masses (5–10 cm) [1].
They may even occur in patients with pancreatitis (mesenteric fat necrosis). They are more common in men (ratio of
18:4) and seen in the age group of 50–70 years [2]. They are usually solitary; however, they may be multiple in a
few cases [3].
Due to the insidious nature of its pathogenesis, they are usually asymptomatic and detected incidentally on imaging
or during laparoscopy/laparotomy. When symptomatic, the usual presentation is chronic vague abdominal pain, and
when large enough, they produce symptoms due to extrinsic compression over the bladder (increased frequency of
micturition) and bowel (obstruction).
They are mobile and frequently seen in the dependent region of the abdomen, such as the pelvis, pouch of Douglas,
and rectovesical pouch [4]. Rarely, they may herniate along the abdominal contents forming a content of hernial sac
in the inguinal region [1].
Due to the central calcification, they can be detected on radiographs. On ultrasound, these lesions are
homogeneously hypoechoic with a lamellated appearance and a central calcification. There is no vascularity on
colour Doppler. On computed tomography (CT) there is soft tissue attenuation (isodense to the muscle) with a
central calcification. On magnetic resonance imaging (MRI), it is hypointense on both T1 and T2-weighted
sequences [5]. The central area might be hyperintense on T1-weighted sequences due to the proteinaceous content
[4]. There is no enhancement that helps in ruling out other differentials, such as leiomyoma and teratoma [6]
. A change in position can be demonstrated on dynamic ultrasound with a change in patient decubitus. Similarly, on
CT and MRI, the location of the lesion varies on imaging in the prone position [4].
The common differentials include benign pathologies such as leiomyoma, teratoma, adnexal pathologies, a foreign
body with adjacent granulation tissue, and a calcified fibrous pseudotumour.
At surgery, they are free-floating with a smooth egg-shaped white hard glistening appearance [3].
They are usually managed conservatively when detected incidentally; however, they are removed surgically when
detected incidentally during surgery or when they cause symptoms.
Differential Diagnosis List: Peritoneal loose body in the scrotum, Inguinal hernia consisting of a peritoneal loose
body, Foreign body, Leiomyoma, Calcified fibrous pseudotumour, Teratoma
Final Diagnosis: Inguinal hernia consisting of a peritoneal loose body
References:
Patel DN, Patel RR, Desai HK, Patel RK (2020) A Rare Case of Peritoneal Loose Body (Mice) in Left Sided Inguinal
Hernial Sac. Annal Urol & Nephrol 2(4):2020. doi: 10.33552/AUN.2020.02.000542.
Silva AA, Reis RA, Rocha CC, Pinto-de-Sousa J (2024). Giant peritoneal loose body: a challenging diagnosis in an
asymptomatic patient. Int Surg J 11(1):126–8. doi: 10.18203/2349-2902.isj20233932.
Gayer G, Petrovitch I (2011) CT diagnosis of a large peritoneal loose body: a case report and review of the
literature. Br J Radiol 84(1000):e83-5. doi: 10.1259/bjr/98708052. (PMID: 21415299)
Makineni H, Thejeswi P, Prabhu S, Bhat RR (2014) Giant peritoneal loose body: a case report and review of
literature. J Clin Diagn Res 8(1):187-8. doi: 10.7860/JCDR/2014/7352.3925. (PMID: 24596768)
Kumar BGJ, Balol S, Manohar V, Naik Y, Ravate Patil SS (2024) Intra-abdominal “boiled-egg”: A rare case of giant
peritoneal loose body. Eurorad 18523. doi: 10.35100/eurorad/case.18523
Kim K, Sapundzieski M, Gaikstas G (2018) Mobile intra-abdominal mass: A case of large peritoneal loose body.
Eurorad 15388. doi: 10.1594/eurorad/case.15388
Figure 1
a
Description: Ultrasound of the inguinoscrotal region shows herniation of the bowel loops with omentum
into the right scrotal sac (yellow arrow). A well-defined round lamellated hypoechoic lesion (white arrow)
with central calcification was noted in the tunica vaginalis sac (a). It measures 2.8 x 2.4 cm. There was
no vascularity on colour Doppler (b). Origin: © Department of Radiology, Seth GS Medical College and
KEM Hospital, Mumbai, India
b
Description: Ultrasound of the inguinoscrotal region shows herniation of the bowel loops with omentum
into the right scrotal sac (yellow arrow). A well-defined round lamellated hypoechoic lesion (white arrow)
with central calcification was noted in the tunica vaginalis sac (a). It measures 2.8 x 2.4 cm. There was
no vascularity on colour Doppler (b). Origin: © Department of Radiology, Seth GS Medical College and
KEM Hospital, Mumbai, India
Figure 2
a
Description: A plain radiograph of the pelvis shows a soft tissue opacity in the scrotal region with
lucencies (yellow arrow) suggestive of inguinal hernia. There is a well-defined round calcification within
the soft tissue on the left side (white arrow). Origin: © Department of Radiology, Seth GS Medical
College and KEM Hospital, Mumbai, India
Figure 3
a
Description: Unenhanced computed tomography of the pelvis in the sagittal (a) and axial sections (b)
shows a well-defined lesion isodense to the bowel loops within the scrotal sac (white arrows). Note the
bowel loops and omentum in the scrotal sac are suggestive of inguinal hernia. Origin: © Department of
Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India
b
Description: Unenhanced computed tomography of the pelvis in the sagittal (a) and axial sections (b)
shows a well-defined lesion isodense to the bowel loops within the scrotal sac (white arrows). Note the
bowel loops and omentum in the scrotal sac are suggestive of inguinal hernia. Origin: © Department of
Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India
Figure 4
a
Description: Post-surgical gross specimen showing a well-defined round smooth white lesion
measuring approximately 3.0 x 2.5 cm. Origin: © Department of Radiology, Seth GS Medical College
and KEM Hospital, Mumbai, India

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Case 18673

A scrotal egg – Peritoneal loose

Final Diagnosis: Inguinal hernia consisting of a peritoneal loose body

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