Sharique Nazir, MD, Timothy S Kuwada, MD FACS FASMBS. Division Gastrointestinal and Minimally Invasive Surgery,Carolinas Medical Center,Charlotte
Acute appendicitis is relatively common and can present with a myriad of abdominal and systemic symptoms. If diagnosed early, surgery is an effective treatment and most patients have a rapid recovery. However, once appendicitis progresses to perforation of the appendix, treatment and recovery becomes more complex. Complications of perforated appendicitis include phlegmon, abscess, and bowel obstruction. However necrotizing fasciitis is an extremely rare complication of advanced perforation.
We present a case of abdominal wall necrotizing fasciitis secondary to a perforated appendix. A 72 year old African American, immunocompetent female presented to our emergency department with a 4 day history of dull, diffuse right sided abdominal pain associated with nausea and diarrhea. She denied any fevers. Her medical history was significant for chronic atrial fibrillation for which she took Coumadin. She had a remote abdominal procedure after a motor vehicle accident (right lower quadrant scar). She had undergone a normal, uncomplicated colonoscopy the week prior at an outside hospital. On exam she was afebrile with a heart rate of 110 and a systolic pressure in the 90’s. She was alert, in no distress and did not appear “toxic”. She was focally tender in the right lower quadrant and flank with no subcutaneous crepitus. WBC was 9,000. CT scan revealed air throughout the right retroperitoneum extending through the lateral side wall into the subcutaneous tissue.
The patient was taken to the OR for a diagnostic laparoscopy with a presumptive diagnosis of a perforated viscus vs. appendicitis. Intraoperative findings were notable for a gangrenous, retrocecal appendix. The retroperitoneum had copious amounts of purulent fluid with obvious erosion into the right side wall. There was no intra-peritoneal contamination. There was extensive peri-cecal inflammation that precluded a simple appendectomy. A laparoscopic hand assisted ileocecectomy with end ileostomy was performed in less than an hour. The ileostomy was positioned in the left abdomen. Incision of the right flank revealed necrotic deep fascia. The patient was then placed in the lateral decubitus position and an extensive right abdominal wall and flank myofascial debridement (100 x 80cm) was undertaken.
The patient was hemodynamically unstable for 48 hours, requiring three pressors. Wound exploration 48 hours after surgery revealed viable tissue with no evidence of progression of the necrotizing process. She rapidly improved and was extubated one week after surgery. Wound cultures grew out Streptococcus constellatus and two different strains of E.coli. She was treated with Piperacillin-Tazobactam and Ciprofloxacin. Her large wound is currently being managed with a VAC with plans for a skin graft in the near future.
Necrotizing fasciitis is a serious soft tissue infection that is lethal if it is not treated early with aggressive debridement and hemodynamic support. Although rare, intra-abdominal infections such as appendicitis can progress to abdominal wall necrotizing faciitis. Immunosuppressed and elderly patients with appendicitis are particularly susceptible to complicated appendicitis due to their often atypical presentation which can delay diagnosis and treatment.
Session Number: Poster – Poster Presentations
Program Number: P114