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Abdominal necrotizing fasciitis due to perforated colon cancer
The Journal of Emergency Medicine, Vol. 30, No. 1, pp. 95–96, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $–see front matter
doi:10.1016/j.jemermed.2005.03.014
Visual Diagnosis in Emergency Medicine
ABDOMINAL NECROTIZING FASCIITIS DUE TO PERFORATED COLON CANCER Hsiao-Wen Ku,* Kuang-Jui Chang,* Tung-Yen Chen,† Ching-Wen Hsu,† and Shyr-Chyr Chen‡ *Department of Emergency Medicine and †Department of Surgery, Military Kaohsiung General Hospital, Taiwan, and ‡Department of Emergency Medicine, National Taiwan University Hospital, Taiwan Reprint Address: Shyr-Chyr Chen, MD, Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
CASE REPORT
Necrotizing fasciitis of the abdominal wall following perforated transverse colon carcinoma was suspected. A perforated transverse colon carcinoma with invasion to the rectus abdominis fascia and ileum was found during laparotomy. A Hartman’s procedure, debridement of the left abdominal wall with unroofing and resection of an ileum adhesion and end-to-end anastomosis were performed without complications. Histological examination proved colonic adenocarcinoma invading the rectus abdominis fascia and ileum. Postoperatively, the patient received antibiotic treatment (cefoxitin plus amikacin and metronidazole) and intensive care for 7 days. Abdominal wound cultures revealed Klebsiella pneumonia. The patient was discharged in stable condition 1 month later.
A 77-year-old woman presented to our Emergency Department with a chief complaint of severe pain over the left abdomen for 3 days. She felt abdominal pain, fullness, nausea and poor appetite for 1 week, but she did not have any fever, vomiting, recent weight loss, bowel habit change or rectal bleeding. Her past history revealed mild congestive heart failure controlled with medications for several years. Physical examination showed an acutely ill-appearing woman with normal consciousness, pale conjunctiva, a body temperature of 37.6°C, a heart rate of 114 beats/ min, and a blood pressure of 147/68 mm Hg. Examination revealed a wide spreading erythematous and tender abdomen with palpable crepitus, muscle guarding, and rebound tenderness over the left middle and lower quadrants (Figure 1). Bowel sounds were decreased and tympany was found during percussion. No palpable mass was noted during digital examination. Laboratory findings revealed a white blood cell count of 12500/mm3 with 92% polymorphonuclear cells. Plain X-rays of the abdomen showed generalized dilatated small bowel loops with ileus pattern. Contrast-enhanced computed tomography (CT) scan of the abdomen was arranged for suspected necrotizing fasciitis. It demonstrated scattered abnormal air accumulation in the subcutaneous layer of the abdominal wall, and a heterogeneous mass deep in the middle of the abdominal cavity (Figure 2).
RECEIVED: 6 April 2004; FINAL ACCEPTED: 30 March 2005
SUBMISSION RECEIVED:
DISCUSSION Necrotizing fasciitis can occur in any region of the body, but most commonly occurs in the abdominal wall, extremities, and perineum (1,2). Abdominal necrotizing fasciitis most commonly develops after minor trauma, skin infection, or insect bites. Other less common causes include ischiorectal abscess, perforated diverticulitis, ruptured appendix, perforated duodenal ulcer, and inflammatory bowel disease (3). Rare cases have been reported of perforated carcinoma of the colon presenting as necrotizing fasciitis (4). The disease occurs more frequently in immunocompro-
16 February 2005; 95
96
mised, malnourished, postoperative, paraplegic, and elderly patients (4 – 6). Necrotizing fasciitis usually has an acute, rapidly progressive course. Clinical features include high fever with chills, tenderness over the affected area with skin color changes and palpable crepitus. Although subcutaneous tissues are often severely damaged, the skin may present with mild erythema. This disease may be mistaken as cellulitis, and sepsis develops quickly without aggressive treatment (7). Laboratory examination may reveal leukocytosis with massive polymorphonuclear cell infiltration. Anemia and hyperbilirubinemia may also occur due to hemolytic reaction of the bacteria (8). CT scan is more accurate in detecting soft-tissue gas than plain radiography, and also is helpful in delineating the extent of spread of the infection (9). Ultrasonography is limited to examining the superficial structures and fluid accumulations. Magnetic resonance imaging (MRI) also can demonstrate good tissue contrast and soft-tissue fluid. However, MRI had not been shown to be cost-effective compared to CT scan and is reserved for special cases (10). CT scan still is the best choice for diagnosing abdominal necrotizing fasciitis. The treatment for necrotizing fasciitis includes prompt surgery, and broad-spectrum antibiotics should be given early pending the results of wound cultures. One option is triple antibiotic therapy including penicillin, aminoglycoside or a third-generation cephalosporin, and either clindamycin or metronidazole (6,7,11). Empiric antibiotics can be changed when the results of wound cultures are available. Other adjuvant
Figure 1. Wide spreading erythmatous (black arrow) protruding mass (white arrow) with palpable crepitus over the abdomen (lower chest is marked with arrow head).
H.-W. Ku et al.
Figure 2. Abnormal air (white arrow) accumulation in the abdominal subcutaneous space with a heterogeneous mass density (black arrow) deeply into the middle abdominal cavity.
therapies include hyperbaric oxygen and intravenous immunoglobulin (7,11). In uncertain cases, surgical exploration should be performed until necrotizing fasciitis is ruled out (11,12). The most important factors in successful treatment of necrotizing fasciitis are early diagnosis and early, aggressive surgical intervention. REFERENCES 1. Weinbren MJ, Perinpanayagam RM. Streptococcal necrotizing fasciitis. J Infect 1992;25:299 –302. 2. Canoso JJ, Barza M. Soft tissue infections. Rheum Dis Clin North Am 1993;19:293–309. 3. Groth D, Henderson SO. Necrotizing fasciitis due to appendicitis. Am J Emerg Med 1999;17:594 – 6. 4. Dewire DM, Bergstein JM. Carcinoma of the sigmoid colon: an unusual case of Fournier’s gangrene. J Urol 1992;147:711–2. 5. Lam TP, Maffulli N, Chen EH, Cheng JC. Carcinomatous perforation of the sigmoid colon presenting as a thigh mass. Bull Hosp Jt Dis 1996;55:83–5. 6. Campbell WJ, Humphries WG. Thigh infection: a rare complication of colonic perforation. Ulster Med J 1991;60:96 –100. 7. Green R, Dafoe D, Raffin T. Necrotizing fasciitis. Chest 1996;110: 219 –28. 8. Janevicius R, Hann S, Batt M. Necrotizing fasciitis. Surg Gynecol Obstet 1982;154:97–102. 9. Yamaoka M, Furusawa K, Uematsu T, et al. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg 1994;22:268 –71. 10. Rahmouni A, Chosidow O, Mathieu D, et al. MR imaging in acute infectious cellulitis. Radiology 1994;192:493– 6. 11. Kavitha SK, Radhey SB, Navin MA. Necrotizing fasciitis. Am Fam Physician 1996;53:1691– 6. 12. Conly J. Soft tissue infections. In: Hall JB, Schmidt GA, Wood LDH, et al., eds. Principles of critical care. New York: McGrawHill; 1992;1325–34.
doi:10.1016/j.jemermed.2005.03.014
Visual Diagnosis in Emergency Medicine
ABDOMINAL NECROTIZING FASCIITIS DUE TO PERFORATED COLON CANCER Hsiao-Wen Ku,* Kuang-Jui Chang,* Tung-Yen Chen,† Ching-Wen Hsu,† and Shyr-Chyr Chen‡ *Department of Emergency Medicine and †Department of Surgery, Military Kaohsiung General Hospital, Taiwan, and ‡Department of Emergency Medicine, National Taiwan University Hospital, Taiwan Reprint Address: Shyr-Chyr Chen, MD, Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
CASE REPORT
Necrotizing fasciitis of the abdominal wall following perforated transverse colon carcinoma was suspected. A perforated transverse colon carcinoma with invasion to the rectus abdominis fascia and ileum was found during laparotomy. A Hartman’s procedure, debridement of the left abdominal wall with unroofing and resection of an ileum adhesion and end-to-end anastomosis were performed without complications. Histological examination proved colonic adenocarcinoma invading the rectus abdominis fascia and ileum. Postoperatively, the patient received antibiotic treatment (cefoxitin plus amikacin and metronidazole) and intensive care for 7 days. Abdominal wound cultures revealed Klebsiella pneumonia. The patient was discharged in stable condition 1 month later.
A 77-year-old woman presented to our Emergency Department with a chief complaint of severe pain over the left abdomen for 3 days. She felt abdominal pain, fullness, nausea and poor appetite for 1 week, but she did not have any fever, vomiting, recent weight loss, bowel habit change or rectal bleeding. Her past history revealed mild congestive heart failure controlled with medications for several years. Physical examination showed an acutely ill-appearing woman with normal consciousness, pale conjunctiva, a body temperature of 37.6°C, a heart rate of 114 beats/ min, and a blood pressure of 147/68 mm Hg. Examination revealed a wide spreading erythematous and tender abdomen with palpable crepitus, muscle guarding, and rebound tenderness over the left middle and lower quadrants (Figure 1). Bowel sounds were decreased and tympany was found during percussion. No palpable mass was noted during digital examination. Laboratory findings revealed a white blood cell count of 12500/mm3 with 92% polymorphonuclear cells. Plain X-rays of the abdomen showed generalized dilatated small bowel loops with ileus pattern. Contrast-enhanced computed tomography (CT) scan of the abdomen was arranged for suspected necrotizing fasciitis. It demonstrated scattered abnormal air accumulation in the subcutaneous layer of the abdominal wall, and a heterogeneous mass deep in the middle of the abdominal cavity (Figure 2).
RECEIVED: 6 April 2004; FINAL ACCEPTED: 30 March 2005
SUBMISSION RECEIVED:
DISCUSSION Necrotizing fasciitis can occur in any region of the body, but most commonly occurs in the abdominal wall, extremities, and perineum (1,2). Abdominal necrotizing fasciitis most commonly develops after minor trauma, skin infection, or insect bites. Other less common causes include ischiorectal abscess, perforated diverticulitis, ruptured appendix, perforated duodenal ulcer, and inflammatory bowel disease (3). Rare cases have been reported of perforated carcinoma of the colon presenting as necrotizing fasciitis (4). The disease occurs more frequently in immunocompro-
16 February 2005; 95
96
mised, malnourished, postoperative, paraplegic, and elderly patients (4 – 6). Necrotizing fasciitis usually has an acute, rapidly progressive course. Clinical features include high fever with chills, tenderness over the affected area with skin color changes and palpable crepitus. Although subcutaneous tissues are often severely damaged, the skin may present with mild erythema. This disease may be mistaken as cellulitis, and sepsis develops quickly without aggressive treatment (7). Laboratory examination may reveal leukocytosis with massive polymorphonuclear cell infiltration. Anemia and hyperbilirubinemia may also occur due to hemolytic reaction of the bacteria (8). CT scan is more accurate in detecting soft-tissue gas than plain radiography, and also is helpful in delineating the extent of spread of the infection (9). Ultrasonography is limited to examining the superficial structures and fluid accumulations. Magnetic resonance imaging (MRI) also can demonstrate good tissue contrast and soft-tissue fluid. However, MRI had not been shown to be cost-effective compared to CT scan and is reserved for special cases (10). CT scan still is the best choice for diagnosing abdominal necrotizing fasciitis. The treatment for necrotizing fasciitis includes prompt surgery, and broad-spectrum antibiotics should be given early pending the results of wound cultures. One option is triple antibiotic therapy including penicillin, aminoglycoside or a third-generation cephalosporin, and either clindamycin or metronidazole (6,7,11). Empiric antibiotics can be changed when the results of wound cultures are available. Other adjuvant
Figure 1. Wide spreading erythmatous (black arrow) protruding mass (white arrow) with palpable crepitus over the abdomen (lower chest is marked with arrow head).
H.-W. Ku et al.
Figure 2. Abnormal air (white arrow) accumulation in the abdominal subcutaneous space with a heterogeneous mass density (black arrow) deeply into the middle abdominal cavity.
therapies include hyperbaric oxygen and intravenous immunoglobulin (7,11). In uncertain cases, surgical exploration should be performed until necrotizing fasciitis is ruled out (11,12). The most important factors in successful treatment of necrotizing fasciitis are early diagnosis and early, aggressive surgical intervention. REFERENCES 1. Weinbren MJ, Perinpanayagam RM. Streptococcal necrotizing fasciitis. J Infect 1992;25:299 –302. 2. Canoso JJ, Barza M. Soft tissue infections. Rheum Dis Clin North Am 1993;19:293–309. 3. Groth D, Henderson SO. Necrotizing fasciitis due to appendicitis. Am J Emerg Med 1999;17:594 – 6. 4. Dewire DM, Bergstein JM. Carcinoma of the sigmoid colon: an unusual case of Fournier’s gangrene. J Urol 1992;147:711–2. 5. Lam TP, Maffulli N, Chen EH, Cheng JC. Carcinomatous perforation of the sigmoid colon presenting as a thigh mass. Bull Hosp Jt Dis 1996;55:83–5. 6. Campbell WJ, Humphries WG. Thigh infection: a rare complication of colonic perforation. Ulster Med J 1991;60:96 –100. 7. Green R, Dafoe D, Raffin T. Necrotizing fasciitis. Chest 1996;110: 219 –28. 8. Janevicius R, Hann S, Batt M. Necrotizing fasciitis. Surg Gynecol Obstet 1982;154:97–102. 9. Yamaoka M, Furusawa K, Uematsu T, et al. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg 1994;22:268 –71. 10. Rahmouni A, Chosidow O, Mathieu D, et al. MR imaging in acute infectious cellulitis. Radiology 1994;192:493– 6. 11. Kavitha SK, Radhey SB, Navin MA. Necrotizing fasciitis. Am Fam Physician 1996;53:1691– 6. 12. Conly J. Soft tissue infections. In: Hall JB, Schmidt GA, Wood LDH, et al., eds. Principles of critical care. New York: McGrawHill; 1992;1325–34.