Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report

Abstract

Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.

Keywords: abdominal wall infection; debridement. fascitis; enterocutaneous fisulae; necrotizing appendicitis; necrotizing fascitis.

Figure 1. Large indurated tender lesion over 12 inches, purulent weeping with large ecchymosis, and extended edema and erythema

Figure 2. CT abdomen/pelvis with intravenous contrast showing extensive subcutaneous emphysema throughout the ventral abdominal/pelvic wall; a large cavity is seen within the subcutaneous tissues of the right lower quadrant with layering fluid and extravasation of oral contrast that appears to communicate with loops of small bowel in the right lower quadrant consistent with enteric fistula

Figure 3. Abdomen following first irrigation and debridement of the necrotic tissue and contents