Retroperitoneal Necrotizing Fasciitis Secondary to Perforated Colonic Diverticulitis-Case Report

穿孔性大腸憩室炎引起之後腹腔壞死性筋膜炎－病例報告

尹睿慈(Jui-Tzu Yin) ； 陳仁隆(Jen-Lung Chen) ； 謝式洲(Shyh-Jou Shieh)

《臺灣整形外科醫學會雜誌》 28卷4期 (2019/12) Pp. 296-304

摘要

Background: Retroperitoneal necrotizing fasciitis is a rare, fulminant gangrene that commonly develops in patients with immunosuppressed, cancer, or diabetes. Diverticulitis is a relatively common inflammatory disease; however, it rarely appears with an atypical extra-abdominal presentation, such as necrotizing fasciitis. Aim and Objectives: Here, we presented a case of a patient with perforated diverticulitis who initially presented with retroperitoneal necrotizing fasciitis. Physicians should consider the presence of intra-abdominal disease in patients with this diagnosis. Materials and Methods: A 74-year-old woman with underlying rheumatic arthritis under chronic steroid treatment was transferred to the emergency department with left flank pain and erythematous swelling for three days. Physical examination revealed local heat with marked erythema over the left lumbar area without abdominal tenderness. A presumed diagnosis of necrotizing fasciitis was made, and fasciotomy was performed with debridement on the day of admission to the emergency room. On postoperative day 7, stool spillage from the open wound was noted. Exploratory laparotomy showed descending colon perforation. She then underwent left hemicolectomy, end T-colostomy, and repeated debridement of retroperitoneal abscess. Results: The patient was managed in the intensive care unit and had a poor prognosis. On the 51st day of admission, she died because of uncontrollable sepsis. Conclusion: It is crucial to differentiate retroperitoneal, intra- or extra- abdominal diseases for necrotizing fasciitis of the flank region. Computed tomography scan is a useful assessment tool; however, overlapping image study and atypical clinical symptom presentation might delay the diagnosis in an immunosuppressed patient and lead to a poor outcome. For retroperitoneal necrotizing fasciitis, we should consider the possibility of a condition secondary to intra-abdominal disease, such as perforated colonic diverticulitis.

關鍵字

necrotizing fasciitis ； retroperitoneal ； diverticulitis

並列摘要

背景：後腹腔壞死性筋膜炎是一罕見卻病程進展快速之疾病，尤其於免疫力低下，癌症及糖尿病之病人。大腸憩室炎相較來說是較為常見之發炎症，卻極少以非典型之腹腔外症狀作為表現，如後腹腔之壞死性筋膜炎。目的及目標：此病例報告發表一例罕見由大腸憩室穿孔造成之後腹腔壞死性筋膜炎之不良預後，除病例報告外，亦整理相關之危險因子，鑑別診斷及治療方法。材料及方法：此病例為一74歲之女性病患有類風濕性關節炎之病史，並長期服用類固醇藥物，她因左側腰部紅腫及疼痛被送至急診，經過理學及實驗室檢查初步診斷為壞死性筋膜炎並接受緊急之左腰部筋膜切開術。病患於接受初次筋膜切開術後第七日，於開放性傷口處見糞便樣滲液滲出，並於同日接受緊急剖腹探查手術。結果：術中發現降結腸穿孔，並實行左側結腸切除手術及大腸造口，病理報告證實為憩室炎造成之穿孔，之後並多次反覆實行清創手術，病患於加護病房接受重症照護，於術後第51天死於重度敗血性休克及心肺衰竭。結論：腰部之壞死性筋膜炎需排除腹內外其他疾病之可能性。腹部電腦斷層是一有用的診斷工具，但重疊的影像學表現及不典型的臨床症狀表現可能造成延後診斷及無可避免之不良預後。對於後腹腔之壞死性筋膜炎，我們必須想到腹內疾病造成的可能性，例如結腸穿孔性憩室炎。