An unusual complication of missed appendicitis

Necrotizing fasciitis caused by a primary appendicocutaneous fistula

We report a case of necrotizing fasciitis in the loin of a 76-year old man with several coexisting or past health issues, including diabetes mellitus, hypertension, alcohol-related liver cirrhosis, gastrectomy for gastric cancer, subarachnoid hemorrhage, normal pressure hydrocephalus, and cerebral infarction. Incision of the necrotizing fasciitis was successful, but it revealed an appendicocutaneous fistula; thus, we performed appendectomy and fistulectomy. We think that the necrotizing fasciitis was caused by appendicitis perforation involving the retroperitoneum, inducing the formation of an appendicocutaneous fistula. Necrotizing fasciitis and appendicocutaneous fistulae are rare complications of appendicitis. Moreover, to our knowledge, this is the first report of fluoroscopic examination demonstrating that a primary appendicocutaneous fistula had caused necrotizing fasciitis. Our search of the literature found 12 cases of necrotizing fasciitis caused by preoperative appendicitis. We discuss the characteristics and findings of these cases.

Fasciitis and septic shock complicating retrocecal appendicitis

INTRODUCTION

A case of fasciitis and septic shock complicating retrocecal appendicitis is presented.

CASE REPORT

A 52-year-old man presented to the Emergency Department with lumbar pain, fever of recent onset and subsequently developed septic shock attributed to fasciitis of abdominal, flank and groin region. On intensive care unit, he was managed with broad-spectrum intravenous antibiotics and surgical debridement. An abdominal computed tomography scan confirmed the findings of fasciitis and was negative for intra-abdominal pathology. In the following days, an enterocutaneous fistula with foul smelling fluid was noted. A new surgical exploration revealed the presence of a ruptured retrocecal appendix, and right hemicolectomy was performed. The postoperative period was long but uneventful.

CONCLUSION

Retrocecal appendicitis can rarely be presented as deteriorating cellulitis-fasciitis in the right abdominal, flank or groin region, with or without abdominal symptoms.

Necrotizing fasciitis due to acute perforated appendicitis: case report

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in treatment increases the likelihood of complications such as perforation, which is associated with an increase in morbidity and mortality rates. We herein present the case of a 76-year-old woman presenting with necrotizing fasciitis of the abdominal wall and right flank regions due to a perforated appendix. Such complication is extremely rare but life-threatening. It may be confused with cellulitis, causing a delay in aggressive treatment. This case represents an unusual complication of a common disease. Also, acute appendicitis or intra-abdominal pathologies should be taken into consideration in determining the cause of necrotizing fasciitis presenting over abdominal, flank, or perineal regions.

Retroperitoneal abscess resulting from perforated acute appendicitis: analysis of its management and outcome

BACKGROUND

Acute appendicitis may become life threatening if it is complicated by retroperitoneal abscess. To the best of our knowledge, only case reports have been documented; thus, we analyzed the published experiences and reviewed this issue.

MATERIALS AND METHODS

In addition to two patients treated at our institution, a PubMed search identified 22 cases of acute appendicitis, complicated by retroperitoneal abscess, reported by 18 authors between 1955 and 2005. The patients' characteristics, onset of symptoms, timing and methods of diagnosis and management, and outcome are reviewed and analyzed.

RESULTS

Most of the patients were adults (21/24, 87.5%), of whom seven were older than 65 years. None of the patients presented with the classical symptoms of acute appendicitis at the onset of the disease, and less than half (9/24) reported abdominal pain. The average interval between the onset of symptoms and diagnosis was 16 days, and the most effective diagnostic tool was computed tomography. Pathogens were usually polymicrobial, and appendectomy followed by adequate drainage of the abscess was the best treatment. The mortality rate was 16.7% (4/24), and all deaths were caused by profound sepsis. According to the available data, the average hospital stay was 27.3 days for the survivors.

CONCLUSION

The formation of complicated retroperitoneal abscesses involving thigh, psoas muscle, perinephric space, or even the lateral abdominal wall is a serious complication of perforated acute appendicitis. An intra-abdominal pathological abnormality cannot be excluded in a patient presenting without abdominal symptoms. The mortality rate can only be reduced by a high index of suspicion, accurate diagnosis, and appropriate treatment.

Gas-forming abdominal wall abscess: unusual manifestation of perforated retroperitoneal appendicitis extending through the superior lumbar triangle

We present a case of an extensive gas-forming abdominal wall abscess secondary to ruptured retroperitoneal appendicitis in a diabetic patient. Computed tomography (CT) demonstrated a retroperitoneal abscess extending to the abdominal subcutaneous tissue through the superior lumbar triangle pathway, a known anatomical defect of the lumbar musculature. This case not only represents an unusual manifestation of acute appendicitis, but also alerts us to the importance of anatomical considerations in the imaging interpretation of disease extent. The applied anatomy of the lumbar triangle as a conduit of intra-abdominal and retroperitoneal processes into the abdominal wall is reviewed.