Subcutaneous Emphysema, Muscular Necrosis, and Necrotizing Fasciitis: An Unusual Presentation of Perforated Sigmoid Diverticulitis

INTRODUCTIONAlthough diverticular disease of the colon is frequent, perforated diverticulitis causing subcutaneous emphysema is a uncommon entity. We wish to present this extremely rare case of perforated colonic diverticulum in the subcutaneous tissue, which is the first one that we have encountered in our practice, along with the accompanying diagnostic and therapeutic issues and a review of the literature.PRESENTATION OF CASEWe report the case of an 83-year-old man who admitted to the emergency room due to an abdominal subcutaneous emphysema. Physical examination revealed a severe subcutaneous emphysema especially in the left iliac fossa and abdominal pain. An urgent contrast enhanced abdominal CT scan showed multiple diverticula in the sigmoid colon and multiple air bubbles in the subcutaneous tissue. The exploratory laparotomy identified a perforation of diverticular in subcutaneous tissue. Forty centimeters of colon were resected. The subcutaneous emphysema resolved without specific treatment. The postoperative period was uncomplicated.DISCUSSIONSubcutaneous emphysema of anterior abdomen wall is an obvious physical sign but its etiology is complex to determine and may be potentially lethal. The pathophysiological mechanism involved is the emergence of a pressure gradient between the peritoneum and surrounding structures, causing rupture of the anterior abdominal wall, allowing gas from a perforation to diffuse along tissue planes.CONCLUSIONThis physical sign may be of especial value in elderly patient groups amongst whom perforation may be less clinically obvious. General surgeons should bear in mind this rare complication of colonic diverticulosis.

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“…This rupture of the anterior abdominal wall allows gas from a perforation to diffuse along tissue planes. 8 …”

Section: Discussionmentioning

confidence: 99%

Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema

Kassir

Abboud

Dubois

et al. 2014

International Journal of Surgery Case Reports

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“…A review of the English literature reveals reports of six cases. 4,5,[7][8][9][10] However, only two of these involve a colocutaneous fistula, 4,5 as in our case.…”

Section: Discussionmentioning

confidence: 56%

“…In most of the previously documented cases, the patients were reported to have gastrointestinal symptoms preceding (or associated with) the skin manifestations. 4,5,7,8,10 Our patient had no signs or symptoms suggesting intra-abdominal pathology and was not known to have diverticular disease. On the other hand, she did not have any significant risk factors for the development of soft tissue infection and this prompted us to consider an underlying disease process.…”

Section: Discussionmentioning

confidence: 99%

Necrotising fasciitis secondary to a colocutaneous fistula

Husnoo

Patil

Jackson

et al. 2016

annals

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Colocutaneous fistulae secondary to diverticular disease are rare, especially spontaneous fistulae. We report a case of a 74-year-old lady, with no previous history of diverticular disease, presenting with necrotising fasciitis of the anterior abdominal wall in the left iliac fossa, without any other symptoms. Urgent surgery was performed. An initial diagnostic laparoscopy demonstrated a perforated sigmoid diverticulum forming a fistula to the anterior abdominal wall. Following soft tissue debridement, a sigmoid colectomy was performed through a midline laparotomy.Gastrointestinal pathology should be considered as a potential cause of abdominal wall necrotising fasciitis. Our approach of using laparoscopic visualisation to assess for intra-abdominal sources in this context (in the absence of preoperative imaging when imaging could delay treatment) has not been described before. To our knowledge, only two cases of abdominal wall necrotising fasciitis secondary to diverticular disease with a colocutaneous fistula have been reported in the English literature.

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“…In two of these patients, infection followed perforations of the rectum and sigma, while the other patients indicated previous injuries with existing hematomas of the gluteal region and the region of the front abdominal wall. The literature data on the existence of NSTI with different localizations, occurring through the perforation of the hollow organs of the abdominal cavity, have been mostly presented as rare case reports [1,[17][18][19][20][21][22][23]. In relation to the origin of NSTI,…”

Section: Discussionmentioning

confidence: 99%

Necrotizing soft tissue infections of perianal and perineal region - still lethal infection

et al. 2017

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Introduction/Objective Necrotizing soft tissue infection is a life-threatening condition, characterized by widely spread necrosis of the skin, subcutaneous adipose tissue, fascia, and muscle. This study aimed to determine the risk factors associated with lethality due to necrotizing soft tissue infection of perianal and perineal region, for all patients surgically treated at a tertiary referral hospital. Methods A retrospective review of 38 patients with necrotizing soft tissue infection of the perianal and perineal region, in the period between January 2007 and December 2014, was performed. We reviewed sex and age of the patients, the presence of known risk factors (diabetes mellitus, obesity, alcoholism), localization of necrotizing soft tissue infection, duration of symptoms, length of hospitalization, the number of necessary operations done, the performance of the stoma, and the outcome. We used logistic regression to identify the predictors of lethal outcome in a univariate analysis with estimated odds ratios and 95% confidence intervals. Results There was a significantly higher fatality rate in the group of patients over 60 years of age (p < 0.05), with more than 10 days from the onset of symptoms to the treatment (p < 0.05), with a perianal localization (p < 0.05), and stoma creation (p < 0.05). The overall fatality rate was 18.4%. Conclusion Patients' age, time passed between the onset of the symptoms and the initiation of the treatment, perianal localization, and stoma creation were related to higher lethality risk.

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Subcutaneous Emphysema, Muscular Necrosis, and Necrotizing Fasciitis: An Unusual Presentation of Perforated Sigmoid Diverticulitis

Cited by 10 publications

References 7 publications

Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema

Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema

Necrotising fasciitis secondary to a colocutaneous fistula

Necrotizing soft tissue infections of perianal and perineal region - still lethal infection

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