A 45-year-old man presented to the emergency room with abdominal pain and distention, dyspnea and a scrotal mass with absence of a visible penis as shown in the figure 1 below.

Abdominal circumference was 120 cm, scrotum circumference was 80 cm and the height of the scrotum was 35 cm. There were no signs of acute abdomen and preliminary routine laboratory labs were within normal except for minimally elevated transaminase levels.

Physical examination showed that the patient has ascites along with a compressible painful scrotum and he is known to have Hepatitis C. There were no signs of acute gastrointestinal bleeding or encephalopathy.

CT scan of the abdomen showed significant amount of free peritoneal fluid and a patent renal and splenic vein. EGD showed grade 3 esophageal varices.

Aspiration of the fluid was done and cytology showed SAAG>1.1 and did not reveal the presence of malignant cells. TSH and α-FP were negative.

The diagnosis was an abdominal ascites with an inguinal hernia. The presences of the hernia lead to the progressive enlargement of the scrotal sac, which was filled with fluid and intestines in this case. A splenorenal shunt and a repair of the hernia were done and the patient was discharged on the 4th post operative day.

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   Figure 1:

   Patient on the examination table with the abdominal distention and the scrotal mass visualized.