Case of the Month 2016-05, Page 3

Homogeneous, well circumscribed right scrotal lesion.

Sagittal and coronal images reveal there to be a very large varix in the right scrotum. Following the course of this vessel demonstrates communication with the superior mesenteric vein.

The scrotal mass was seen to be a large herniated varix into the scrotum.

Note the diminutive liver measuring 10cm craniocaudal and the enlarged spleen measuring 19cm (Image #12), commonly seen in cirrhotic patients. Additionally, note the multiple mesenteric varices in addition to the one seen herniating into the right scrotum (last image).

For larger images, please click on CT 3 , CT 4 , CT 5 , CT 6 , CT 7 , CT 8   and CT 9 .

Hepatic cirrhosis is characterized by chronic liver injury resulting in loss of hepatocytes, followed by inflammation and fibrosis. This fibrosis results in increased pressure within the portal venous system. The most common causes of cirrhosis are alcohol abuse and viral hepatitis, including hepatitis C. Complications of hepatic cirrhosis are related to loss of function from hepatocyte death and portal venous congestion[1].

Complications due to loss of function include protein deficiency from failure to synthesize albumin, clotting disorder due to coagulation factor deficiency, and hyperbilirubinemia.

Portal venous congestion results in increased intrahepatic resistance to blood flow and increased splanchnic blood flow due to vasodilation in the splanchnic vascular bed. This leads to portal hypertension, which is defined as the elevation of hepatic venous pressure gradient above 5 mmHg[2].

Complications due to portal venous congestion and portal hypertension include:

  • Thrombocytopenia secondary to splenic congestion and sequestration of platelets
  • Ascites, which may progress to spontaneous bacterial peritonitis.
  • Varices secondary to engorged portal vein tributaries and dilated collateral vessels.

Hepatic encepalopathy is a complex pathologic process involving the failure of the liver to metabolize toxic compounds generated by gastrointestinal bacteria such as ammonia, mercaptans, and phenols. This, together with venous congestion, results in these non-metabolized toxic compounds traveling to the brain through portosystemic collateral vessels and subsequent neurotoxicity [1].

Varices form as a necessary alternative route for blood to pass from the portal to systemic circulation. Common sites of varices in cirrhotic patients include esophageal, paraesophageal, omental, retroperitoneal-paravertebral, and mesenteric[3, 4]. Splenorenal and gastrorenal shunts may also form.

Mesenteric varices, as seen in this patient, occur in approximately 10% patients with portal hypertension[3]. They are commonly seen as unusually dilated and tortuous branches of the superior mesenteric vein (SMV).

Herniated varices have been reported in the literature and are quite rare. The most common hernias described in the literature are umbilical hernias containing umbilical vein, left gastroepiploic vein, and mesenteric varices [5-8]. Our literature search could not identify any previous report of an inguinal hernia containing a varix.

In patients with cirrhosis and an inguinal mass, ultrasound with color doppler should be performed to evaluate for a vascular lesion. Among patients with a history of cirrhosis and a vascular scrotal mass on color doppler, a herniated varix should be considered. Clinicians should be careful in attempting to drain a scrotal lesion in a cirrhotic patient prior to evaluating the lesion's vascularity.


1. Starr SP, Raines D: Cirrhosis: diagnosis, management, and prevention.Am Fam Physician 2011, 84:1353-1359.
2. Shah NL, Banaei YP, Hojnowski KL, Cornella SL: Management options in decompensated cirrhosis.Hepat Med 2015, 7:43-50.
3. Cho KC, Patel YD, Wachsberg RH, Seeff J: Varices in portal hypertension: evaluation with CT.Radiographics 1995, 15:609-622.
4. Wani ZA, Bhat RA, Bhadoria AS, Maiwall R, Choudhury A: Gastric varices: Classification, endoscopic and ultrasonographic management.J Res Med Sci 2015, 20:1200-1207.
5. Tahir A, Kakani N, O'Riordan D, Godwin R: Umbilical varix presenting as an incarcerated umbilical hernia--a costly mistake if not recognised.Ann R Coll Surg Engl 2004, 86:W47-48.
6. Hammad HT, Chennamaneni V, Ahmad DS, Esmadi M: Strangulated umbilical hernia after esophagogastroduodenoscopy in a patient with liver cirrhosis and ascites.Endoscopy 2014, 46 Suppl 1 UCTN:E247.
7. Sze DY, Magsamen KE, McClenathan JH, Keeffe EB, Dake MD: Portal hypertensive hemorrhage from a left gastroepiploic vein caput medusa in an adhesed umbilical hernia.J Vasc Interv Radiol 2005, 16:281-285.
8. Lim LG, Lee YM, Tan L, Chang S, Lim SG: Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices.World J Gastroenterol 2009, 15:3823-3826.

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