Pancreatitis is a common medical problem frequently encountered by hospitalists among alcohol abuse patients. It usually presents with abdominal pain with nausea with or without diarrhea. In severe cases, pancreatitis may be complicated by necrotizing process.

Pancreatitis is a common medical problem frequently encountered by hospitalists among alcohol abuse patients. It usually presents with abdominal pain with nausea with or without diarrhea. In severe cases, pancreatitis may be complicated by necrotizing process.

Cullen's sign of pancreatitis is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. The sign takes 24–48 hours to appear and can predict increased mortality. In more severe cases, it may be accompanied by Grey Turner's sign (bruising of the flank)indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding. Our case have an interesting presentation from which we can learn a new sign.

This is a 31 yo man of thin body habitus who presented to ED with complaints of abdominal pain, back pain and left hip pain. The patient has been complaining of pain "for a long time." Denies fever, chest pain, or shortness of breath. He has h/o alcohol abuse and chronic pancreatitis and recently spent 3 weeks at a bigger hospital in a nearby town then moved back to Fond du Lac. Patient also smokes. Walks with a cane. During interview he reported brown semen. Denies change in urine color or urinary discomfort. Last HIV test 2 years ago. Patient said he is heterosexual, lives with parents, unemployed, smokes >1 pack a day, drinks vodka, and denies illicit drugs. His home meds are mirtazapine, sertraline, lorazepam, oxycodone and potassium supplement. On arrival, vitals showed accelerated heart rate 143 bpm and normal other parameters: blood pressure 111/78, temperature 98.6 F, and respiratory rate 20 bpm. On physical exam, lungs clear to auscultation, no abdominal tenderness, and no scrotal swelling but there is limitation in ROM of 

left hip. CT abdomen and pelvis showed necrotizing pancreatitis with extension from the pancreatic tail inferiorly along the Gerota's fascia contacting the left psoas and iliacus muscles (see pictures). EKG is sinus tachycardia. Labs show increased white count and ketones as well as decreased hemoglobin, potassium, and albumin. Lipase mildly elevated. Bacteriological studies showed he was MRSA carrier and was positive for C. Diff. in stool.

Table 1

Figure 1: Compare the thickness of iliac muscles on both sides

Pancreas

There is moderate inflammatory changes surrounding the pancreas. There is ill-defined hypoattenuation within the pancreatic head and uncinate process may indicate areas of pancreatic necrosis. There are peripancreatic fluid collections some containing air which raises concern of superimposed infection. There is a very small focus of air and fluid just below the medial aspect the left hemidiaphragm near the medial and superior splenic pole which measures 14 x 7 mm which extends inferiorly is a thin fluid collection towards the pancreatic tail. This very small collection is separate from the largest collection. This largest collection extends from the pancreatic tail where the fluid and air loculation measures approximately 2.7 x 3.2 cm axially and 3.2cm craniocaudally. This is contiguous with a fluid collection extending inferiorly immediately anteriorto Gerota's fascia which measures 1.8 x

4.5 cm axially at its largest margin and extends approximately 13 cm craniocaudally. This fluid collection and associated surrounding inflammation extends onto the left psoas muscle and left iliacus muscles which are enlarged consistent with myositis. There is no definite intramuscular fluid collection at this time.

Figure:2 The seminal vesicles looked normal.

This youngman was admittedas inpatient to the MedSurgFloor for the following reasons:

• Possible acute on chronic necrotizing pancreatitis
• Possible sepsis
• Possible STD with ronoccoal left hip arthritis
• MRSA carrier
• Hypokalemia
• Anemia of chronicdisease
• Hypoalbuminemia
• Smoker
• Asthenia

The patient was treated with nothing by mouth, IV fluids, IV PPI, IV fluids and IV antibiotics. The surgeon evaluated the patient and thought the patient might have a smoldering process from the recent acute pancreatitis for which he was treated 3 weeks in hospital. HIV and tests for STDs came negative.

Comment: Disease is an aberration of physiological process. Each patient may have his/her own presentation of disease based on age, gender, race, genetics, and comorbidities. Our case presents a new sign, the sign of brown semen and left hip pain. I suggest to call it the Valid’s sign. This sign would be helpful in paying attention to the possible diagnosis of necrotizing pancreatitis on a background of alcohol abuse. The sign points to a pancreatitis-induced fluid accumulation spreading inferiorly from the tail of the pancreas down to the pelvis floor. The brown semen is a manifestation of reactive inflammatory process by vicinity affecting the seminal vesicle, probably on the left side, the same side of left hip pain coinciding with the side of the tail of the pancreas from which the pancreatic juice accumulated and spread down. There is no mention in the literature of brown semen as a sign of smoldering necrotizing pancreatitis. I am calling on researchers to do an epidemiological study, prospective or retrospective, to measure the predictive value of this sign for the above diagnosis.

ED: Emergency Department H/O: History Of

HIV: Human immunodeficiency virus ROM: Range of motion

CT: Computedtomography EKG: Electrocardiography

MRSA: Methicillin-resistant staphylococcus aureus

C. Diff.: Clostridium Difficile STDs: Sexuallytransmitted diseases IV: Intravenous

PPI: Proton pump inhibitor