大肠埃希菌引起阑尾炎所致腹壁坏死性筋膜炎CT影像学分析:附1例报告

目的对大肠埃希菌引起阑尾炎所致腹壁坏死性筋膜炎案例进行探讨。方法采用回顾性研究,总结1例由盲肠癌侵犯阑尾,由大肠埃希菌感染引起腹壁坏死性筋膜炎的影像学、组织细胞学、及病理学综合分析。结果该病例CT平扫表现为全腹壁弥漫性水肿,皮下广泛性积气,腰大肌脓肿,增强后呈环形强化,盲肠管壁不规则增厚,阑尾包绕其中,阑尾远端增粗、短缩,增强后明显强化,阑尾周围炎性渗出,取腹壁脓液细菌培养为大肠埃希菌,经肠镜及病理检查,证实盲肠腺癌,阑尾开口闭塞,经临床有效治疗后复查,腹壁脓肿、皮下积气明显减少。结论对于大肠埃希菌继发引起阑尾炎所致腹壁坏死性筋膜炎,应根据腹壁坏死性筋膜炎症状、体征及特点早期做出诊断,采取正确的检查方法,了解病变的范围及病因,为临床治疗提供及时、准备的信息。      

Necrotizing fasciitis due to appendicitis.

Necrotizing fasciitis, although rare, is one of the more serious, life-threatening complications of missed acute appendicitis. Patients who are predisposed to developing necrotizing fasciitis, regardless of the cause, are typically immunocompromised. We present a case of a 49-year-old immunocompetent female whose diagnosis of acute appendicitis was missed and who subsequently developed necrotizing fasciitis of the abdominal wall and flank. She recovered 1 month after admission due to aggressive surgical and medical therapy.     

Necrotizing fasciitis: a rare complication of appendicitis

The mortality of acute appendicitis increases sixfold if perforation occurs. We have reported a case of perforated appendix complicated by necrotizing fasciitis of the abdominal wall and retroperitoneum. We believe this complication has not been previously described in the English literature.     

Retroperitoneal and Cutaneous Necrotizing Fasciitis Secondary to Necrotizing Pancreatitis

Background

Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10–25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess.

Case Report

We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome.

Why Should An Emergency Physician Be Aware of This?

Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course.     

Comparison of men and women presenting to an ED with acute appendicitis

Appendicitis is a common problem presenting to the Emergency Department (ED). Missed or delayed diagnosis can result in increased morbidity and is a common cause of malpractice claims. Diagnosis in women is more difficult because of additional clinical considerations. The study hypothesis is that women with appendicitis presenting to an ED experience a longer delay to operative intervention resulting in an increased rate of perforated appendix. A retrospective chart review of 196 male and female patients between twelve and fifty years of age presenting to the ED with final discharge diagnosis of appendicitis was performed. Mean time from ED presentation to operative intervention was 477 minutes for men and 709 minutes for women (P = .02). Perforated appendix was present in 38.7% of men and 23.5% of women (P = .002). Women with appendicitis presenting to an ED experience significant delay to surgery, however, this is not associated with an increased rate of perforation.     

Severe cellulitis and abdominal wall emphysema following laparoscopic colonic surgery: A case report

Abdominal wall emphysema is a common complication of laparoscopic surgery. This condition is usually harmless; however, if an infection occurs, it can develop into a serious condition such as necrotizing fasciitis. We report a case of a 51‐year‐old woman suffering from severe cellulitis that spread from an area of abdominal wall emphysema after laparoscopic surgery for sigmoid colon cancer. Recognizing this complication, early diagnosis, and prompt treatment are cornerstones for successful management of this potentially fatal disease.     

Case report of open appendectomy in treating acute perforated appendicitis with necrotizing fasciitis of the abdominal wall: A rare complication of a common disease

Acute appendicitis can be associated with uncommon complications such as necrotizing fasciitis. We present a case of a 37‐year‐old woman referred to our hospital with a 1‐week history of significant weakness, anorexia, and mild abdominal pain. According to laboratory and radiographic data, the patient was diagnosed with perforated appendicitis and gangrene.     

Treatment and management of acute appendicitis

Acute appendicitis is one of the most common surgical conditions, and affects about seven per cent of the population. Perforation of the appendix and associated peritonitis is the most common complication. This guided reflection article discusses the signs, pre and postoperative treatment and nursing management of patients presenting with acute appendicitis.     

Recognizing the various presentations of appendicitis.

Appendicitis is one of the most common causes of acute abdominal pain in the industrialized world. Appendicitis must be considered in the differential diagnosis of any patient presenting with abdominal pain. Workup may include blood tests, abdominal radiographs, abdominal ultrasound, and focused appendix computed tomography. Unfortunately, none of these provides definitive results. Although several signs and symptoms are associated with appendicitis, their inconsistent presentation, especially among the young and the elderly, can lead to an erroneous diagnosis. The classic sequence of symptoms includes the onset of vague epigastric or periumbilical pain; associated nausea, anorexia, or unsustained vomiting; and pain migrating to the right lower quadrant. In uncomplicated cases, the treatment of appendicitis is appendectomy. However, less definitive presentations merit further diagnostic testing and close follow-up.     

Sonography and computed tomography of the mimics of appendicitis

There are numerous entities that can mimic acute appendicitis. Ultrasound and computed tomography are the most common first-line, cross-sectional imaging modalities in the acute care setting. Ideally, imaging will either confirm appendicitis or exclude it by identifying a normal appendix. In the latter scenario, an alternate diagnosis can frequently be established that range from genitourinary, gastrointestinal, to even abdominal wall processes. Imaging is especially helpful in cases of patients presenting with atypical signs/symptoms for acute appendicitis and those presenting with a classic presentation where an alternative diagnosis is determined. The correct diagnosis will allow the most appropriate clinical management and therapy; specifically, avoiding nonindicated surgery is essential. Common and uncommon mimics of acute appendicitis are discussed with specific attention to their sonographic and computed tomographic appearances.     

An unusual complication of missed appendicitis

A case of necrotizing fasciitis complicating missed appendicitis with perforation and abscess formation in a 63-year-old diabetic is presented. The case emphasizes the importance of thorough, conservative evaluation and management in elderly diabetic patients. The ED management of patients with necrotizing fasciitis is also briefly reviewed.     

History of appendectomy? An atypical case of recurrent abdominal pain

Acute appendicitis is a common condition emergency physician encounter during pediatric emergency visits. With a reported incidence of 1 in 50,000 appendectomies, stump appendicitis, an acute inflammation of the residual appendicular tissue, is a rare post-operative complication. The diagnosis of stump appendicitis is time-critical to prevent associated morbidities of abscess formation, perforation and sepsis. Another atypical presentation of appendicitis includes recurrent appendicitis, which is recognized as one or more previous episodes of similar clinical presentation as acute appendicitis, but symptoms subside within 24 to 48 hours. Intervals between attacks may vary from weeks to years during which the patient may be asymptomatic. Although recurrent appendicitis is rare, emergency physicians should be aware of this possibility and to not assume that previous appendectomy precludes recurrent appendicitis. This case highlights the importance of considering such unusual condition in a patient presenting with recurrent right-sided abdominal pain.     

Early diagnosis of retroperitoneal necrotizing fasciitis

OBJECTIVE: To report survival of retroperitoneal necrotizing fasciitis in an inmunocompromised patient and to demonstrate early clinical signs that may help in the prompt diagnosis and treatment of this severe infection. DESIGN: Case report and literature review. SETTING: An adult, 18-bed intensive care unit within a university hospital. PATIENT: A 38-yr-old man who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 5 for erythema around the hemorrhoidectomy and a dirty brown discharge from the wound. INTERVENTIONS: Early diagnosis of retroperitoneal necrotizing fasciitis, wide and repeated debridement, broad-spectrum antibiotics, and eventual abdominal wall reconstruction. MEASUREMENTS AND MAIN RESULTS: This patient manifested periumbilical and bilateral flank erythema, reminiscent of the pattern of ecchymosis seen in cases of retroperitoneal hemorrhage. The findings demonstrate a variation of Cullen's and Grey Turner's sign, most often found in patients with hemorrhagic pancreatitis. An abdominal radiograph revealed a ground glass appearance with radiolucency outlining the bladder, consistent with retroperitoneal air. The chest radiograph showed mediastinal air extending into the neck. Sharp debridement of the retroperitoneal fat, the right anterior rectus sheath, and the right anterior thigh fascia was required to gain control of the infection. Operative cultures grew a mixed flora with Eschericha coli, beta-hemolytic streptococcus, and Bacteroides fragilis predominating. The hospital course was complicated by hemodynamic instability, renal failure, pneumonia, and a pelvic abscess. The patient ultimately survived and underwent abdominal wall reconstruction with mesh. CONCLUSION: Retroperitoneal necrotizing fasciitis is an uncommon soft tissue infection that is often fatal. Early diagnosis in this case was facilitated by the unique clinical findings of a modified Cullen's and Grey Turner's sign. A review of the limited available literature suggests that survival of retroperitoneal fasciitis is possible with prompt debridement and antibiotic therapy.     

新生儿阑尾炎临床及超声图像特点分析

目的总结新生儿阑尾的临床及超声图像特点。 方法选取2007年1月至2017年10月在首都医科大学附属北京儿童医院经手术或临床诊断的新生儿阑尾炎28例,总结其临床及超声图像特点。 结果28例新生儿阑尾炎患儿中超声可显示阑尾9例,其中3例阑尾外径<0.4 cm,6例阑尾外径≥0.4 cm;2例阑尾壁厚<0.2 cm,7例阑尾壁厚≥0.2 cm。19例新生儿阑尾显示困难,则重点观察阑尾周围改变。超声扫查提示：28例右下腹可见阑尾周围系膜肿胀,26例可见阑尾周围积脓或炎性包块;超声提示诊断新生儿阑尾炎22例,新生儿坏死性小肠结肠炎4例,消化道穿孔1例;1例因腹胀明显,初诊超声无异常发现,腹胀缓解后超声诊断新生儿阑尾炎。28例患儿中2例继发近端小肠粘连梗阻,2例阴囊内混浊积液。超声随访观察28例新生儿治疗后改变,其中保守治疗21例,18例1个月内超声复查可见周围炎症范围较上次检查缩小（4例5~10个月复发,2例再次手术,2例保守治疗后均好转）。7例手术治疗的患儿中,4例术后1周行超声复查,原病变区局部仅可见少许粘连。 结论新生儿阑尾炎临床症状多样,超声图像表现为阑尾周围系膜肿胀,阑尾外径增大（≥0.4 cm）和（或）阑尾壁增厚（≥0.2 cm）,可合并积脓和（或）炎性包块,超声检查可对患儿的诊断及治疗提供依据。     

Appendix vermiformis duplex – An unexpected surprise

Duplication of the vermiform appendix is extremely rare. It is found in only 1/25.000 patients (0.004%) operated on for acute appendicitis. A 60-year-old male patient was hospitalized for a peridiverticular sigmoid abscess without signs of a free abdominal perforation and an abscess cavity in the small pelvis. A Hartmann's resection and an appendectomy (the vermiform appendix was part of the abscess wall) were performed. The pathology report described an external appendicitis. After 3 months, the intestine was successfully reanastomosed. During mobilisation of the coecum, a second retrocoecal vermiform appendix was surprisingly found. Because of signs of a chronic appendicitis a second resection was performed. Although the diagnosis of an appendix duplex is a rarity, surgeons should be aware of the possibility, especially when clinical signs and symptoms point to appendicitis, although at laparotomy the appendix looks normal. A routine exploration for a second appendix is definitely not indicated because of the rarity and the increased complication rate.     

Necrotizing fasciitis as the clinical presentation of a retroperitoneal abscess

Infections of the retroperitoneal space may present with insidiously vague symptoms and non-specific clinical signs. We report a case of a retroperitoneal abscess presenting as necrotizing fasciitis of the thigh from direct spread over the iliac crest. In cases of necrotizing fasciitis of the thigh with no obvious source, an intra-abdominal nidus of infection may be considered.     

Left-sided Acute Appendicitis: A Pitfall in the Emergency Department

Background

Acute appendicitis continues to be a condition at high risk for missed and delayed diagnosis. It characteristically presents with right lower quadrant pain after vague epigastric or periumbilical discomfort. Left-sided appendicitis is an atypical presentation and has been reported rarely. The majority of these cases have been described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix. We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon.

Objectives

To alert emergency physicians to an anatomical anomaly that could delay the diagnosis of appendicitis.

Case Report

A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant. Abdominal computed tomography scan revealed a redundant, floating, ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. Exploratory laparotomy was performed and perforated appendicitis with turbid ascites was found during the surgery. Appendectomy was performed and the patient recovered uneventfully.

Conclusion

This case is presented to increase awareness among emergency physicians of this anatomical variant and atypical presentation of appendicitis.     

Perihepatic abscess caused by dropped appendicoliths following laparoscopic appendectomy: Sonographic findings

We report the case of a 6‐year‐old girl presenting with acute appendicitis complicated by perforated appendix, followed by perihepatic abscess associated with ectopic appendicoliths. CT findings were initially suspicious for an intrahepatic abscess with internal calcifications. However, on sonography the abscess appeared to be in a perihepatic location. Perihepatic abscess associated with a dropped or retained appendicolith has been rarely reported. Awareness of the possibility of a perihepatic abscess as a complication of laparoscopic appendectomy and use of sonography should result in optimal management of this rare complication. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :366–369, 2013     

MDCT of acute appendicitis: value of coronal reformations

Acute appendicitis is the most common cause of abdominal pain requiring urgent surgery in the United States. The clinical diagnosis can be difficult in patients with atypical presentations and, over the past several decades, computed tomography (CT) has been increasingly utilized to improve diagnostic accuracy. Helical CT has proven to be an excellent tool in the work-up of acute abdominal pain with a diagnostic accuracy for acute appendicitis of 93–99%. However, occasionally there are equivocal or false positive or negative cases, often due to non-visualization of the appendix. The development of multi-detector row CT and recent advancements in reconstruction software has allowed rapid, high-resolution imaging of the entire abdomen and pelvis resulting in multiplanar reformations (MPR) with a spatial resolution similar to that of the axial plane. This article reviews the utility of CT in suspected acute appendicitis and the potential added diagnostic value of coronal reformations in confirming or excluding the diagnosis.     

Use of drotrecogin alfa in necrotizing fasciitis: a case report and pharmacologic review

Necrotizing fasciitis (NF) is a devastating subset of necrotizing soft tissue infections that requires prompt diagnosis and treatment. Although often occurring in patients with impaired host defense mechanisms (diabetes mellitus, systemic immunosuppression, malignancy, etc.), NF may also present in the immunocompetent following a cutaneous lesion or break. Patients with NF often progress to a systemic inflammatory response syndrome or multiorgan system failure that demands advanced critical care practices. We present a case of NF in an immunocompetent patient and the subsequent use of drotrecogin alfa (Xigris). A review of the pharmacologic treatment of streptococcal NF is included. The addition of drotrecogin alfa to operative debridement and penicillin G/clindamycin therapy may be a useful adjunct in the treatment of necrotizing fasciitis due to group A streptococcus.