A 63 year old buissinessman Mr.Basheer,

from Pudunagaram, came to surgery OPD

on 2/1/2013 with H/O right sided

abdominal pain of 3 days duration .

There was no H/O nausea, vomiting,

anorexia, fever or weight loss.

Bowel & bladder was normal

He is neither a smoker nor an alcoholic

1. He is a known hypertensive on treatment

2. He has H/O tuberculosis 30 years back completed Antituberculartreatment under category 1

3. Morbid obesity +

On examination

Vitals stable, afebrile

abdomen was distended ,

umbilical hernia + ,

dialated veins + on the right flank, flow from below

upwards.

Diffuse tenderness + involving the right hypochondrium & RIF

No organomegaly

No free fluid

Bowel sounds heard

External genitalia appeared normal

Hernial orifices free except for umbilical hernia

Clinical diagnosis of Subhepatic appendicitis was suspected & was worked up.

T.C-14800

ESR-40 mm/hr

USG abdomen – mild fatty changes in

liver, umbilical hernia ,subhepatic

appendicitis

His Alvarado [MANTRELS] score was 4

Tenderness in the RIF 2

Leucocytosis 2

He was advised conservative management with oral antibiotics & analgesics and was sent home.

The abdominal pain did not subside with

the oral antibiotics and antiinflammatory

drugs . 2 days later, on 4/1/13 he got

admitted in MSW

TREATMENT

IVF & parenteral broad spectrum antibiotics

Catheterised

Kept in NPO

Abdominal girth charting

On the next day on 5/2/13 patient developed

difficulty in breathing

O/E basal crepts heard bilaterally

Chest X ray –bilateral basal pneumonia

Patient was given inhalational & intravenous

bronchodilators and steroids.

Sputum AFB & gramstaining was not done

since the patient could not produce sputum

2 days later, on 7/1/13 , a swelling was observed in the right inguinal region, cord was thickened .

USG scrotum- bilateral acute epididymitis R > L & bilateral minimal hydrocele

On 8/1/13 ,His breathing difficulty persisted ,O/E coarse inspiratory crepts heard in the left infrascapular area,

Chest X-ray - nonhomogenous opacity on left lower zones

Diagnosis – left lower lobe pneumonia

He was given I.V antibiotics .

C.T. ABDOMEN - liver normal size with fatty

changes and calcified focus,umbilical hernia ,

minimal fluid collection in RIF,right cord

appear thickened with minimal surrounding

fluid,minimal gaseous distention of small bowel

loops.

C.T.THORAX – consolidation seen in posterior

segment of left upper lobe,trace of left pleural

effusion seen

WORKING DIAGNOSIS –

1) Left pneumonia

2) Right epididymitis

3) Subhepatic appendicitis

4) Chronic liver disease

His total count & abdominal girth was

progressively increasing over 8 days.

On 12/1/13 screening USG showed focal

collection in RIF & USG guided aspiration

was done which yielded 5ml of frank pus &

was sent for culture & sensitivity.

D/D 1.R epididymitis

2.appendicular abscess

Patient was planned for exploratory

laparotomy.

EXPLORATORY LAPAROTOMY WITH RIGHT HIGH INGUINAL ORCHIDECTOMY was done on 12/1/13 under epidural anaesthesiathrough low right paramedian incision.

FINDINGS – Dilatation of bowel + RIF explored ,PUS COLLECTION + ,APPENDIX NORMAL, ASCENDING INFLAMMATION OF CORD STRUCTURES WITH NECROSIS & ABSCESS FORMATION found

PROCEDURE - RIF explored , Pus evacuated , peritoneal wash given ,R orchidectomy done

Pus c/s-organism isolated was E.coli

sensitive to amikacin, ceftazidime, ofloxacin

& pipiracillin/tazobactum

HPE reports –

1) Epididymis – Non specific epididymitis with

duct obstruction ,Epididymal cyst

2) Testes – No significant pathology

3) Spermatic cord - funiculitis

ASCENDING INFECTION OF RIGHT CORD STRUCTURES RESULTING IN RIF ABSCESS

Post operative period was uneventful except for oozing from drain tube site

Pus c/s from drain tube site : organism isolated was E.coli sensitive to amikacin,ampicillin,sulbactum,ofloxacin,pipiracillin,tazobactum,imipenam

On 28/1/13 USG Abdomen showed 8 *2.1 cm , 25 cc collection seen in the abdominal wall in the right lower abdomen, a diagnosis of anterior abdominal wall abscess was made for which USG guided wound debridement done under L/A on 9/2/13 &

the patient was discharged on the 30 th post -operative day on 11/2/13 after check USG.

Inflammation confined to epididymis -EPIDIDYMITIS

Infection spreading to testes - EPIDIDYMO-ORCHITIS

Mode of infection

1. Primary infection of urethra, prostate or seminal vesicles → via vas → epididymis

2. In men with BOO – high pressure in the prostatic urethra→reflux of infected urine up the vasa

3. Young men – STD –Chlamydia & gonococci – asso . With urethritis

4. Bloodborne - if E.coli,streptococci,proteus without evidence of urinary infection

Acute epididymitis can follow any form of urethral instrumentation or catheterisation

Acute tuberculous epididymitis - if vas is thickened & there is little response to antibiotics

Mumps – at any age

Infections with other enteroviruses, brucellosis,lymphogranuloma venerum also can cause epididymitis

initial symptoms of urinary infection

Ache in groin

Fever

Epididymis &testes swell and become painful

Scrotal wall – first red edematous & shiny & may become adherent to epididymis

Occasionally an abscess can form & discharge pus through scrotal skin

Resolution may take 6-8 weeks

Urine analysis & urine culture & sensitivity should be obtained in all cases

Need aggressive treatment with parenteralantibiotics

Doxycycline – DOC- for chlamydial infection

Broad spectrum antibiotic against urinary tract pathogens

Analgesics

Plenty of oral fluids

SCROTAL ELEVATION

If suppuration + - drainage is necessary

reactive hydrocoele,

ABSCESS FORMATION

infarction of the testicle,

testicular atrophy,

reduced fertility.

Due to retrograde infection from a tuberculous focus in seminal vesicles –so lower pole of epididymis is involved first

Clinical features – fiirm discrete swelling of lower pole of epididymis which aches a little ,the disease progresses until the whole epididymis is firm & craggy behind a normal feeling testes

Lax secondary hydrocele Beading of vas Seminal vesicles indurated & swollen Cold abscess formation & discharge

Investigations – examination of urine & semen for tubercle bacilli ,IVU & chest X ray

TREATMENT

ATT

If no resolution within 2 months - epididymectomyor orchidectomy