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Fournier Gangrene from a Thirty-Two-Centimeter Rectosigmoid Foreign Body
The Journal of Emergency Medicine, Vol. 44, No. 2, pp. e247–e249, 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2012.09.018
Clinical Communications: Adults FOURNIER GANGRENE FROM A THIRTY-TWO-CENTIMETER RECTOSIGMOID FOREIGN BODY Getahun Abate, MD, PHD, Mazumder Shirin, MD, and Vivek Kandanati, MD Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri Reprint Address: Getahun Abate, MD, PHD, Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, Doisy Research Center, 8th floor, 1100 S. Grand Blvd., St. Louis, MO 63104
, Abstract—Background: Medical and surgical problems associated with rectal foreign bodies are rare. Although most rectal foreign bodies can be removed without subsequent sequelae, they pose significant risk of infection. Objectives: We report a patient with a 32-cm rectosigmoid foreign body and subsequent development of Fournier gangrene despite successful removal of the foreign body. Case Report: A 63-year-old Caucasian man with past medical history of diabetes mellitus and depression presented with a chief complaint of ‘‘something stuck in my intestine.’’ He admitted that he placed a foreign body in the rectum. Abdominal X-ray study and computed tomography of the abdomen/pelvis showed a conical-shaped 32-cm rectosigmoid foreign body. The foreign body was removed manually and followup colonoscopy was done. The patient’s condition deteriorated in the first 2 days of hospital stay and he was diagnosed with Fournier gangrene. He required multiple surgeries and received broad-spectrum antibiotic coverage for mixed bacterial flora grown from deep tissue. Conclusion: Rectal foreign bodies can cause Fournier gangrene. A close observation and follow-up is important after removal of rectal foreign bodies. Published by Elsevier Inc.
pose a substantial risk of infection. Because most cases of rectal foreign bodies seek medical care early, infection is rarely seen. Anorectal abscess from rectal foreign bodies have been reported (1–3). We report a patient with Fournier gangrene after the removal of a rectal foreign body. CASE REPORT A 63-year-old Caucasian man with past medical history of type 2 diabetes mellitus and depression presented with a chief complaint of ‘‘something stuck in my intestine.’’ He admitted that he was trying to place a foreign object in the rectum about 90 min before he arrived at the hospital. He could not give the specification of the foreign object. In the Emergency Department (ED), his vital signs were stable. Abdomen was soft and non-tender. The tip of the foreign body could be palpated with a rectal examination. Abdominal X-ray study (Figure 1A) showed a conical-shaped radiolucent rectal foreign body and gas collection in the right perirectal soft tissue. This was further confirmed by the computed tomography (CT) scan of the abdomen/pelvis that showed similar findings of a rectosigmoid foreign body and extraperitoneal pelvic soft tissue gas (Figure 1B). The patient was evaluated by a surgical team. A repeat digital rectal examination and a colonoscopy were performed under general anesthesia. The foreign body was removed manually, and colonoscopy showed a small subcentimeter perforation in
, Keywords—Fournier gangrene; foreign body; rectum
INTRODUCTION Rectal foreign bodies are rare and there are only limited case reports. Most rectal foreign bodies are removed without complication. The damage to rectal mucosa and sometimes anorectal wall perforation
RECEIVED: 16 August 2011; FINAL SUBMISSION RECEIVED: 6 March 2012; ACCEPTED: 5 September 2012 e247
e248
G. Abate et al.
Figure 1. Imaging studies on a patient with a rectosigmoid foreign body. (A) Abdominal X-ray study showing a radiolucent conical-shaped rectosigmoid foreign body and perirectal gas collection. (B) Computed tomography (CT) scan of abdomen/pelvis showing extraperitoneal pelvic soft tissue gas. (C) A follow-up CT scan showing expansion of gas collection in the right perirectal tissue and similar emphysematous changes in the scrotum.
the posterior anal mucosa. There was no hemorrhage or purulence around the perforation site. The small foreign body was found to be a ring-sizer 32 cm in length, with the widest diameter being 2.8 cm. Intravenous vancomycin and piperacillintazobactam were started. However, the patient’s general condition deteriorated in the subsequent 2 days. He developed worsening pain and increasing swelling of the scrotum and perineal tissue. A repeat CT scan showed diffuse soft-tissue emphysema in the perirectal soft tissue and scrotum (Figure 1C). This prompted an extensive surgery including diversion colostomy and incision and debridement of the scrotum and tissue between the scrotum and the right side of the rectum. There was purulent drainage and necrotic tissue between the scrotum and rectum. The testicles were found to be viable. The cultures from debrided tissues grew Enterococcus fecalis (vancomycin sensitive), Citrobacter freundii (piperacillin-tazobactam resistant), Pseudomonas aeruginosa, Escherichia coli, Bacteroides fargilis, and Bacteroides ovatus. Based on the antimicrobial drug-susceptibility results, vancomycin was continued and piperacillin-tazobactam was changed to imipenem. The patient received these antibiotics intravenously for a full 3 weeks of hospitalization. The surgical wounds continued to heal. At the time of discharge, the surgical wounds appeared clean, with complete resolution of scrotal and perineal swelling. The intravenous antibiotics were discontinued. He was started on oral amoxillin-clavulanate and ciprofloxacin for 2 more weeks. He was followed by a psychiatrist while in the hospital and scheduled to follow-up with a psychiatrist and a surgeon as an outpatient. DISCUSSION Fournier gangrene is a necrotizing fasciitis involving the scrotum and perineum. It is a rapidly spreading infection leading to shock, multi-organ dysfunction, and death, with mortality as high as 29% (4). Trauma to the urogenital or perineal area seems to be the port of entry of
pathogens, although a significant number of patients may not have a discernable port of entry (5,6). Therefore, one has to be vigilant in identifying patients despite absence of history of trauma or reluctance of patients to reveal self-inflicted trauma. Rectal foreign bodies are infrequent medical problems. Moreover, Fournier gangrene from a rectal foreign body is very rare. Patients may have a retained rectal foreign body either by deliberately inserting objects into the rectum or inadvertently swallowing foreign bodies (1–3,7,8). However, patients may not recall ingestion of foreign body and those with deliberate insertion may be reluctant to reveal a relevant history partly due to associated psychiatric problems (9). Most rectal foreign bodies are removed without requiring surgery, and most patients have only minor trauma to the rectum without serious infection (7,8). Infection associated with rectal foreign body is rare, probably due to early removal and absence of serious trauma to the rectal area (7). However, some patients with a rectal foreign body may present with local abscess requiring early surgical drainage (2,3,10). Therefore, in selected cases, appropriate antibiotic coverage is essential to decrease the risk of progression to Fournier gangrene. Fournier gangrene is usually caused by mixed aerobic and anaerobic flora with pathogens similar to those isolated from the patient reported here (6,11,12). Patients with diabetes, malnutrition, or poor socioeconomic status may have a higher risk of developing Fournier gangrene (6,13,14). Surgical debridement and prompt initiation of antibiotics are keys in the management of Fournier gangrene. Hyperbaric oxygen is used as an adjunct therapy in necrotizing fasciitis, but its particular use in Fournier is controversial (15,16). Most patients with rectal foreign bodies do not require hospital admission. Patients with a sharp foreign body, signs and symptoms of peritonitis, serious rectal mucosal injury, focal abscess, and difficulty removing the foreign body warrant hospital admission or longer observation in the ED (7,17).
Fournier Gangrene from a Rectal Foreign Body
CONCLUSION In conclusion, some patients with rectal foreign body warrant a close observation or hospital admission. Rectal foreign body is one possible cause of Fournier gangrene. The recovery of patients with Fournier gangrene depends mainly on early removal of the foreign body, debridement, targeted antibiotics, and other relevant resuscitative measures. REFERENCES 1. Davis DH. A chicken bone in the rectum. Arch Emerg Med 1991;8: 62–4. 2. Byrne CM, Lim JK, Stewart PJ. Ischiorectal abscess caused by ingested bones. ANZ J Surg 2004;74:818–9. 3. Bennetsen DT. Perirectal abscess after accidental toothpick ingestion. J Emerg Med 2008;34:203–4. 4. Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vicente E. Fournier’s syndrome of urogenital and anorectal origin. A retrospective, comparative study. Dis Colon Rectum 1987;30:33–7. 5. Efem SE. The features and aetiology of Fournier’s gangrene. Postgrad Med J 1994;70:568–71. 6. Atakan IH, Kaplan M, Kaya E, Aktoz T, Inci O. A life-threatening infection: Fournier’s gangrene. Int Urol Nephrol 2002;34:387–92.
e249 7. Rodrı´guez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farre´s R. Management of foreign bodies in the rectum. Colorectal Dis 2007;9:543–8. 8. Cash DJW, Sadat MM, Abu-Own AS. Anorectal abscess and fistula caused by an ingested chicken bone. Am J Gastroenterol 2004;99: 1617–8. 9. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract. Retrospective review of 542 cases. World J Surg 1996;20:1001–5. 10. Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am 2010;90:173–84. 11. Fichev G, Kostov V, Marina M, Tzankova M. Fournier’s Gangrene: a clinical and bacteriological study. Anaerobe 1997;3:195–7. 12. Kuo CF, Wang WS, Lee CM, Liu CP, Tseng HK. Fournier’s gangrene: ten-year experience in a medical center in northern Taiwan. J Microbiol Immunol Infect 2007;40:500–6. 13. Salvino C, Harford FJ, Dobrin PB. Necrotizing infections of the perineum. South Med J 1993;86:908–11. 14. Yanar H, Taviloglu K, Ertekin C, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg 2006;30:1750–4. 15. Risenman JA, Zamboni WA, Cutis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduced mortality and the need for debridement. Surgery 1990;108:847–50. 16. Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of Fournier’s gangrene. J Urol 2005;173:1975–7. 17. Rodrı´guez-Hermosa JI, Codina-Cazador A, Sirvent JM, Martı´n A, Girone`s J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008;10:701–7.
http://dx.doi.org/10.1016/j.jemermed.2012.09.018
Clinical Communications: Adults FOURNIER GANGRENE FROM A THIRTY-TWO-CENTIMETER RECTOSIGMOID FOREIGN BODY Getahun Abate, MD, PHD, Mazumder Shirin, MD, and Vivek Kandanati, MD Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri Reprint Address: Getahun Abate, MD, PHD, Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, Doisy Research Center, 8th floor, 1100 S. Grand Blvd., St. Louis, MO 63104
, Abstract—Background: Medical and surgical problems associated with rectal foreign bodies are rare. Although most rectal foreign bodies can be removed without subsequent sequelae, they pose significant risk of infection. Objectives: We report a patient with a 32-cm rectosigmoid foreign body and subsequent development of Fournier gangrene despite successful removal of the foreign body. Case Report: A 63-year-old Caucasian man with past medical history of diabetes mellitus and depression presented with a chief complaint of ‘‘something stuck in my intestine.’’ He admitted that he placed a foreign body in the rectum. Abdominal X-ray study and computed tomography of the abdomen/pelvis showed a conical-shaped 32-cm rectosigmoid foreign body. The foreign body was removed manually and followup colonoscopy was done. The patient’s condition deteriorated in the first 2 days of hospital stay and he was diagnosed with Fournier gangrene. He required multiple surgeries and received broad-spectrum antibiotic coverage for mixed bacterial flora grown from deep tissue. Conclusion: Rectal foreign bodies can cause Fournier gangrene. A close observation and follow-up is important after removal of rectal foreign bodies. Published by Elsevier Inc.
pose a substantial risk of infection. Because most cases of rectal foreign bodies seek medical care early, infection is rarely seen. Anorectal abscess from rectal foreign bodies have been reported (1–3). We report a patient with Fournier gangrene after the removal of a rectal foreign body. CASE REPORT A 63-year-old Caucasian man with past medical history of type 2 diabetes mellitus and depression presented with a chief complaint of ‘‘something stuck in my intestine.’’ He admitted that he was trying to place a foreign object in the rectum about 90 min before he arrived at the hospital. He could not give the specification of the foreign object. In the Emergency Department (ED), his vital signs were stable. Abdomen was soft and non-tender. The tip of the foreign body could be palpated with a rectal examination. Abdominal X-ray study (Figure 1A) showed a conical-shaped radiolucent rectal foreign body and gas collection in the right perirectal soft tissue. This was further confirmed by the computed tomography (CT) scan of the abdomen/pelvis that showed similar findings of a rectosigmoid foreign body and extraperitoneal pelvic soft tissue gas (Figure 1B). The patient was evaluated by a surgical team. A repeat digital rectal examination and a colonoscopy were performed under general anesthesia. The foreign body was removed manually, and colonoscopy showed a small subcentimeter perforation in
, Keywords—Fournier gangrene; foreign body; rectum
INTRODUCTION Rectal foreign bodies are rare and there are only limited case reports. Most rectal foreign bodies are removed without complication. The damage to rectal mucosa and sometimes anorectal wall perforation
RECEIVED: 16 August 2011; FINAL SUBMISSION RECEIVED: 6 March 2012; ACCEPTED: 5 September 2012 e247
e248
G. Abate et al.
Figure 1. Imaging studies on a patient with a rectosigmoid foreign body. (A) Abdominal X-ray study showing a radiolucent conical-shaped rectosigmoid foreign body and perirectal gas collection. (B) Computed tomography (CT) scan of abdomen/pelvis showing extraperitoneal pelvic soft tissue gas. (C) A follow-up CT scan showing expansion of gas collection in the right perirectal tissue and similar emphysematous changes in the scrotum.
the posterior anal mucosa. There was no hemorrhage or purulence around the perforation site. The small foreign body was found to be a ring-sizer 32 cm in length, with the widest diameter being 2.8 cm. Intravenous vancomycin and piperacillintazobactam were started. However, the patient’s general condition deteriorated in the subsequent 2 days. He developed worsening pain and increasing swelling of the scrotum and perineal tissue. A repeat CT scan showed diffuse soft-tissue emphysema in the perirectal soft tissue and scrotum (Figure 1C). This prompted an extensive surgery including diversion colostomy and incision and debridement of the scrotum and tissue between the scrotum and the right side of the rectum. There was purulent drainage and necrotic tissue between the scrotum and rectum. The testicles were found to be viable. The cultures from debrided tissues grew Enterococcus fecalis (vancomycin sensitive), Citrobacter freundii (piperacillin-tazobactam resistant), Pseudomonas aeruginosa, Escherichia coli, Bacteroides fargilis, and Bacteroides ovatus. Based on the antimicrobial drug-susceptibility results, vancomycin was continued and piperacillin-tazobactam was changed to imipenem. The patient received these antibiotics intravenously for a full 3 weeks of hospitalization. The surgical wounds continued to heal. At the time of discharge, the surgical wounds appeared clean, with complete resolution of scrotal and perineal swelling. The intravenous antibiotics were discontinued. He was started on oral amoxillin-clavulanate and ciprofloxacin for 2 more weeks. He was followed by a psychiatrist while in the hospital and scheduled to follow-up with a psychiatrist and a surgeon as an outpatient. DISCUSSION Fournier gangrene is a necrotizing fasciitis involving the scrotum and perineum. It is a rapidly spreading infection leading to shock, multi-organ dysfunction, and death, with mortality as high as 29% (4). Trauma to the urogenital or perineal area seems to be the port of entry of
pathogens, although a significant number of patients may not have a discernable port of entry (5,6). Therefore, one has to be vigilant in identifying patients despite absence of history of trauma or reluctance of patients to reveal self-inflicted trauma. Rectal foreign bodies are infrequent medical problems. Moreover, Fournier gangrene from a rectal foreign body is very rare. Patients may have a retained rectal foreign body either by deliberately inserting objects into the rectum or inadvertently swallowing foreign bodies (1–3,7,8). However, patients may not recall ingestion of foreign body and those with deliberate insertion may be reluctant to reveal a relevant history partly due to associated psychiatric problems (9). Most rectal foreign bodies are removed without requiring surgery, and most patients have only minor trauma to the rectum without serious infection (7,8). Infection associated with rectal foreign body is rare, probably due to early removal and absence of serious trauma to the rectal area (7). However, some patients with a rectal foreign body may present with local abscess requiring early surgical drainage (2,3,10). Therefore, in selected cases, appropriate antibiotic coverage is essential to decrease the risk of progression to Fournier gangrene. Fournier gangrene is usually caused by mixed aerobic and anaerobic flora with pathogens similar to those isolated from the patient reported here (6,11,12). Patients with diabetes, malnutrition, or poor socioeconomic status may have a higher risk of developing Fournier gangrene (6,13,14). Surgical debridement and prompt initiation of antibiotics are keys in the management of Fournier gangrene. Hyperbaric oxygen is used as an adjunct therapy in necrotizing fasciitis, but its particular use in Fournier is controversial (15,16). Most patients with rectal foreign bodies do not require hospital admission. Patients with a sharp foreign body, signs and symptoms of peritonitis, serious rectal mucosal injury, focal abscess, and difficulty removing the foreign body warrant hospital admission or longer observation in the ED (7,17).
Fournier Gangrene from a Rectal Foreign Body
CONCLUSION In conclusion, some patients with rectal foreign body warrant a close observation or hospital admission. Rectal foreign body is one possible cause of Fournier gangrene. The recovery of patients with Fournier gangrene depends mainly on early removal of the foreign body, debridement, targeted antibiotics, and other relevant resuscitative measures. REFERENCES 1. Davis DH. A chicken bone in the rectum. Arch Emerg Med 1991;8: 62–4. 2. Byrne CM, Lim JK, Stewart PJ. Ischiorectal abscess caused by ingested bones. ANZ J Surg 2004;74:818–9. 3. Bennetsen DT. Perirectal abscess after accidental toothpick ingestion. J Emerg Med 2008;34:203–4. 4. Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vicente E. Fournier’s syndrome of urogenital and anorectal origin. A retrospective, comparative study. Dis Colon Rectum 1987;30:33–7. 5. Efem SE. The features and aetiology of Fournier’s gangrene. Postgrad Med J 1994;70:568–71. 6. Atakan IH, Kaplan M, Kaya E, Aktoz T, Inci O. A life-threatening infection: Fournier’s gangrene. Int Urol Nephrol 2002;34:387–92.
e249 7. Rodrı´guez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farre´s R. Management of foreign bodies in the rectum. Colorectal Dis 2007;9:543–8. 8. Cash DJW, Sadat MM, Abu-Own AS. Anorectal abscess and fistula caused by an ingested chicken bone. Am J Gastroenterol 2004;99: 1617–8. 9. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract. Retrospective review of 542 cases. World J Surg 1996;20:1001–5. 10. Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am 2010;90:173–84. 11. Fichev G, Kostov V, Marina M, Tzankova M. Fournier’s Gangrene: a clinical and bacteriological study. Anaerobe 1997;3:195–7. 12. Kuo CF, Wang WS, Lee CM, Liu CP, Tseng HK. Fournier’s gangrene: ten-year experience in a medical center in northern Taiwan. J Microbiol Immunol Infect 2007;40:500–6. 13. Salvino C, Harford FJ, Dobrin PB. Necrotizing infections of the perineum. South Med J 1993;86:908–11. 14. Yanar H, Taviloglu K, Ertekin C, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg 2006;30:1750–4. 15. Risenman JA, Zamboni WA, Cutis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduced mortality and the need for debridement. Surgery 1990;108:847–50. 16. Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of Fournier’s gangrene. J Urol 2005;173:1975–7. 17. Rodrı´guez-Hermosa JI, Codina-Cazador A, Sirvent JM, Martı´n A, Girone`s J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008;10:701–7.