Necrotizing fasciitis (NF) is a deadly soft tissue infection causing a significant morbidity and mortality. Abdominal and chest wall NF are unusual. We describe a 49-year-old male with anterior abdominal wall NF secondary to per- forated gastric ulcer (PGU). He was admitted in septic shock presenting an abdominal wall NF with severe metabolic acidosis requiring dialysis and admission to the intensive care unit. There was a patch of gangrene with surrounding skin discoloration at lower quadrant of the abdominal wall. Local debridement was done without a preoperative computed tomography that was performed after surgery. Adequate source control was not achieved after the second surgery and the patient had worsened resulting to death. We describe this rare presentation of NF and discuss the issues learnt from this unfortunate event.
As general population of obese patients in Malaysia rapidly increases, more obese patients are requiring anaesthesia for various operative procedures. Obesity is associated with anatomical and physiological differences and co-morbidities that influence on the choices of anaesthesia care. A surgical case with general anaesthesia is used as a basis of discussion. A 37-year-old female, history of untreated hypertension and gastrooesophageal reflux disease (GORD), BMI of 41 admitted for laparoscopic cholecystectomy for symptomatic cholelithiasis under general anaesthesia. She presented with pain at the upper right abdomen and associated with bloated abdomen, nausea and vomiting after intake of meals. General anaesthesia and right ultrasound-guided transversus abdominis plane (TAP) block for abdominal wall blocks via subcostal approach was performed. Operation was removal gallstones in the common bile duct via laparoscopic approach. Post-operation patient was extubated successfully. She was prescribed paracetamol 1g 4 hourly and started on fentanyl patient-controlled analgesia (PCA) for next 2 days. In this case report, there is the description of the application of TAP block which when used in obese abdominal surgical procedure, can provide excellent postoperative pain relief, early mobilization and recovery.
Percutaneous Endoscopic Gastrostomy (PEG) tubes were often offered to patients requiring long term enteral feeding. Even though the procedure is relatively safe, it is associated with various complications such as peritonitis or even death.1 We presented a case of a 54-year-old gentleman with underlying ischemic stroke and pus discharges from a recently inserted PEG tube. Computed Topography (CT) scan confirmed abdominal wall necrotising fasciitis complicated with hyperosmolar hyperglycaemia state (HHS) and later succumbed after 48 hours of admission. Our case illustrated the rare complication related to the insertion of PEG tube; abdominal wall necrotising fasciitis that was associated with mortality.
Fournier's gangrene is a severe life-threatening infection involving the perianal area, perineum, and external genitalia. It demands prompt recognition, critical care therapy, surgical therapy, and a combination of antibiotics. The infection commonly spreads via the fascial planes and causes superficial vascular thrombosis within the Colles' fascia around the external genitalia. It can extend cephalad to involve the Scarpa's fascia and Camper's fascia in the abdominal wall. The treatment would include multiple debridements, which would result in disfiguring scars of the perineum and might lead to significant physical and psychological complications. We describe a case of a 58-years-old man presenting with Fournier's gangrene resulting from an infection of an impacted urethral stone. The patient previously had obstructive voiding symptoms for 1 month but chose to neglect them. The resultant infection was severe and caused penile and right testicular gangrene. He underwent multiple wound debridements, which included a total penectomy and right orchiectomy. Psychological and rehabilitative support was necessary for him to overcome his loss and disfigurement.
Traumatic diaphragmatic rupture and traumatic abdominal wall hernia are two well-described but rare clinical entities associated with blunt thoracoabdominal injuries. To the best of our knowledge, the combination of these two clinical entities as a result of a motor vehicle accident has not been previously reported.