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Clinical Case: Necrotizing Fasciitis of the Anterior Abdominal Wall - want to learn more about it?

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Clinical Case: Necrotizing Fasciitis of the Anterior Abdominal Wall

In this article, we describe a clinical case of a woman that developed necrotizing fasciitis of the anterior abdominal wall after a swallowed fish bone perforated her small bowel. You will find out the presentation of this emergency, as well as its management, and important relevant anatomical considerations.

Key facts
Necrotizing fasciitis Necrotizing fasciitis is a severe infection with anaerobic bacteria of the superficial fascia, resulting in thrombosis, ischemia, and edema. It is most commonly found in the lower limbs, abdominal wall, and perineum.
Pneumoperitoneum It refers to free air in the peritoneal cavity caused by a perforation. The air will be located inferiorly to the diaphragm on a radiograph, most commonly on the right side of the abdomen. 
Sepsis It is a life-threatening complication of an infection that occurs when defensive inflammatory mediators against the infection trigger the development of additional and abnormal system-wide inflammatory responses. 

After reviewing this case you should be able to describe the following:

  • What is necrotizing fasciitis and where is it most common?
  • What are all the biological processes that occurred in order for a swallowed fish bone to result in necrotizing fasciitis in the anterior abdominal wall?
  • How one would diagnose pneumoperitoneum on a PA standing chest radiograph, and why was this important to the treating physicians.  Also, why might a finding of pneumoperitoneum on a radiological image a few weeks after the laparoscopic surgery be misleading?
  • What is the meaning of sepsis and how did this condition likely resulted in cardiovascular complications.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case Description

History & Physical Examination

A 63-year-old female with no remarkable medical history presented to the ER department complaining of right-sided abdominal pain for three days. The physical examination revealed that she was afebrile with stable vital signs. The right side of her abdomen was characterized by patchy erythema in an area extending from her lower right ribs down to, and including, the vulva (Figure 1). Her right labium major was mildly edematous. Palpation indicated right abdominal tenderness, but no crepitus or subcutaneous emphysema. 

Figure 1. Photograph of the patient showing erythema on the right side of her abdominal wall extending to her labium major.

Laboratory Tests & Imaging

A standing chest radiograph failed to show a pneumoperitoneum. Labs revealed leukocytosis. A contrast CT scan indicated a large gas-containing mass in the right abdominal wall (Figure 2). There was no obvious intra-abdominal organ injury although the aorta had calcifications.

Figure 2.  Axial CT showing the fasciitis in the abdominal fascia and also the embedded fish bone.

Management

A laparoscopy suggested that a fish bone had perforated through the small bowel and become lodged in the anterior abdominal wall, causing the abscess to form; this fish bone was also visible on the CT (Figure 2). This fish bone was removed via laparoscopic surgery (Figure 3 &4).  

Figure 3.  Photograph of the laparoscopic procedure that removed the fish bone from the anterior abdominal wall.  

The small bowel perforation associated with the fishbone penetration had apparently sealed without treatment (no pneumoperitoneum), but a subcutaneous infection had developed and spread along Scarpa’s fascia in the anterior abdominal wall to the vulva.

Figure 4. Photograph of the removed fish bone.

 

Three separate debridements were done (Figure 5&6). Laparoscopy during each debridement confirmed that the patient did not suffer from peritonitis and that there was no bowel perforation. There was, however, a defect in the transversalis fascia, which was about 2 cm in size and was repaired.

Figure 5.  Intraoperative opening of the skin for initial debridement. Note the fasciitis.

The abdominal wall defect that resulted from the debridements was larger than 50 × 20 cm (Figure 6a).  The debridements removed necrotic sections of the skin, Camper’s and Scarpa’s fascial layers and the external oblique muscle (Figure 6a). 

Figure 6.  Photograph depicting the wide skin wound associated with the debridements on the left and a dissection image (to provide perspective) depicting some of the same anatomical structures (on right). 

Complications & Evolution

Between the debridements, the patient had persistent sepsis and developed cardiovascular complications presumably as a function of the systemic sepsis: takotsubo’s cardiomyopathy, supraventricular tachycardia, and pulseless ventricular tachycardia (VT) requiring defibrillation. 

Despite the sepsis and cardiovascular complications, the patient recovered remarkably well (Figure 7).  The wound was controlled with lavage and vacuum dressing.  The wound healed without the use of any synthetic mashes, skin grafts or tissue flaps to cover the gap.  The patient was discharged from the hospital on post-op day 32. The wound was almost completely healed after five months.

Figure 7.  Photographs showing the healing progression.  OT refers to the three debridements.

Anatomical Considerations

Scarpa's and Camper's Fascias

Scarpa’s and Camper’s are two relatively distinct layers of the superficial fascia of the lower anterior abdominal wall. Scarpa’s fascia is the deeper denser layer whereas Camper’s is the more superficial fatty layer (Figure 6). Camper’s fascia is continuous into the perineum and the thigh. Scarpa’s fascia continues into the perineum and becomes Colle’s fascia, but it fuses to the deep fascia of the thigh, thus forming a barrier to the spread of fluids and infection into the thigh (of course necrotizing fasciitis could eventually penetrate this fascia boundary but in this patient it may have impeded the spread of the infection into the thigh). 

Vulva

In this case report, the authors use the term “vulva.”  This is a somewhat of an ambiguous term but generally is meant to include the mons pubis, labia major and minor, clitoris, vestibular bulb, vestibule of the vagina, external urinary meatus and greater and lesser vestibular glands. Here, based on Figure 1, we believe the authors were primarily referring to the labium major.

Anterior Abdominal Wall Muscles

The external and internal oblique muscles, plus the transverse abdominis and rectus abdominis are the muscles of the anterior abdominal wall.  During the debridements necrotic sections of the external oblique muscle and the aponeuroses of the muscles were removed in order to thoroughly clean the wound of all the infectious debris.

Explanations to Objectives

Objectives

  • What is necrotizing fasciitis and where is it most common?
  • What are all the biological processes that occurred in order for a swallowed fish bone to result in necrotizing fasciitis in the anterior abdominal wall?
  • How one would diagnose pneumoperitoneum on a PA standing chest radiograph, and why was this important to the treating physicians.  Also, why might a finding of pneumoperitoneum on a radiological image a few weeks after the laparoscopic surgery be misleading?
  • What is the meaning of sepsis and how did this condition likely resulted in cardiovascular complications.

Necrotizing Fasciitis

Necrotizing fasciitis is a severe infection of the superficial fascia. Although it can develop in any part of the body, it is most commonly found in the lower limbs, followed by the abdominal wall and perineum. Without treatment, patients almost always die.

In necrotizing fasciitis, anaerobic bacteria multiply and produce enzymes that destroy the fascia and fat. Arteries supplying these tissues become thrombosed, leading to ischemia and edema.

The diagnosis of necrotizing fasciitis can be difficult because the early signs and symptoms are generalized: localized pain, erythema, and swelling. The “finger test”, which requires a two cm incision through the superficial fascia followed by gentle probing of a finger, may reveal “dishwater pus,” lack of hemorrhage and lack of tissue resistance to blunt finger pressure. CT and MRI can also help to establish the diagnosis. The pertinent radiologic images should show tissue infection, fascial swelling, and inflammation. As in this patient, these imaging modalities can also reveal gas that is released by the bacteria into the soft tissue. 

Figure 8.  Flowchart showing sequence of events that led to necrotising fasciitis. 

Diagnosis of Pneumoperitoneum

Pneumoperitoneum refers to free air in the peritoneal cavity. It is not normal to have free air and such air usually means a perforated viscus or trauma. Because air rises, free air in the peritoneum will locate directly inferior to the diaphragm as shown in Figure 9. Whereas visible air under the diaphragm on the right in an upright chest radiograph is diagnostic for “free air,” air visible in a similar position on the left has to be distinguished from normal air that is swallowed and in the fundus of the stomach or in the splenic flexure of the colon. In Figure 9, note that the air visible on the left follows the lower border of the diaphragm and the upper border of the fundus of the stomach.  Thus, this is “free air“, rather than a bubble of air in the fundus of the stomach.

Figure 9. Chest radiograph showing pneumoperitoneum (free air in the peritoneal cavity)

Laparoscopic abdominal procedures involve injection of carbon dioxide into the peritoneal cavity so that structures are displaced from each other. This gas is slowly absorbed by the peritoneum but remains visible on a chest radiograph for weeks after the procedure. Thus a finding of “pneumoperitoneum” shortly after a laparoscopic procedure may be misleading. 

Sepsis

Sepsis is a life-threatening complication of an infection. Sepsis occurs when inflammatory mediators, released into the vascular system from a localized infection to counter the infection, trigger the development of additional system-wide inflammatory responses.  This systemic response can result in inflammatory responses in various organs especially those related to the cardiovascular system. These responses may impede organ function such as heart function, as in this case. Without treatment, sepsis may progress to septic shock and death.  

Clinical Case: Necrotizing Fasciitis of the Anterior Abdominal Wall - want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 1,084,116 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

Reference:

  • Lo STW, Leung SL, Tang CN. Abdominal wall necrotising fasciitis secondary to fish bone ingestion.  Journal of Surgical Case Reports, 2015;7, 1–3. 
  • Modified by Joel A. Vilensky PhD , Carlos A. Suárez-Quian PhD , Aykut Üren, MD.

Authors:

  • Joel A. Vilensky 
  • Carlos A. Suárez-Quian
  • Aykut Üren

Layout:

  • Abdulmalek Albakkar
  • Adrian Rad
© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

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