Acute Perforated Appendicitis Complicated by Necrotizing Fasciitis and Bladder Perforation

Abstract

Acute uncomplicated appendicitis is a common surgical disease that has been well-studied, and its overall mortality has decreased over time. However, delay in treatment can be associated with rare complications such as necrotizing fasciitis, which carries a high mortality rate, and bladder perforation. We present such a case in an 81-year-old female with no significant surgical history who presented to the emergency department with four days of abdominal pain. A CT scan revealed extensive subcutaneous air in the abdominal wall, an inflamed appendix, and a periappendiceal abscess. During subsequent exploratory laparotomy, she was also found to have bladder perforation. She underwent debridement of necrotic tissue of the abdominal wall, appendectomy, drainage of periappendiceal abscess, and bladder perforation repair. She died of septic shock on post-operative day 19, due to gross spillage of urine into the abdomen and ongoing necrotizing fasciitis. Acute perforated appendicitis can lead to rare and fatal complications. Our case presents such a patient with a poor outcome. In approaching a patient with signs of peritonitis, differential diagnoses must remain broad to include late complications such as abscess formation, soft tissue infection, and perforation of surrounding structures.

Necrotizing fasciitis of the back originating from a perforated appendicitis: A case report

“…Similar to other reported cases [8] , [16] , [17] , [18] , [19] , this patient with appendicitis presented with non-specific or atypical symptoms and had even potentially been cooled off with initial antibiotics. Early diagnosis may be difficult since necrotizing fasciitis often presents with mild erythema in the skin as with common cellulitis ( Figs.…”

“…1 ) [15] , [18] . It spreads rapidly along fascial planes, resulting in overwhelming toxicity [6] , [17] , [19] , and devastating prognosis [8] , [19] . Without evident cutaneous cause of abdominal cellulitis, an intra-abdominal origin should be searched for [8] , [17] .…”

“…Cellulitis in the presence of an intraabdominal cause such as appendicitis in this case, should be a warning. When facing opportunistic infection to take over, time matters and there is no place for conservative treatment [3] , [15] , [19] . Here, prompt intervention and necessary reoperations, along with antibiotic treatment, prevented further flare up of infection or progression to shock, and resulted in a good prognosis.…”

“…They explain how infection may transgress the abdominal wall in an anatomical point of view, as in inguinal or femoral hernias [11] , [12] . However, despite its sporadic occurrence, necrotizing fasciitis in majority of the appendicitis cases, finds a way to reach the abdominal wall without a hernia [8] , [16] , [17] , [18] , [19] .…”

“…The mortality is very high, should necrotizing fasciitis occur [8] , [9] , [12] , [16] , [17] , [18] , [19] . Once diagnosis is done, there are no alternatives to immediate intervention, wide debridement of necrotic tissues, treatment of the underlying cause, and broad-spectrum antibiotics [6] .…”