Perforated diverticulitis presenting as necrotising fasciitis of the leg
© Underwood et al; licensee BioMed Central Ltd. 2008
Received: 11 January 2008
Accepted: 27 February 2008
Published: 27 February 2008
Diverticulosis of the colon is a common condition of increasing age. Complications of diverticulitis including stricture, perforation and fistula formation often require surgery. Perforated diverticulitis may rarely present with spreading superficial sepsis. We describe for the first time, to our knowledge, a case of retroperitoneal diverticula perforation presenting as necrotising fasciitis of the leg necessitating hind-quarter amputation.
Colonic diverticulosis is a common condition in the Western World and its incidence increases with advancing age . Diverticula of the large bowel are believed to occur at areas of weakness, commonly at the site of entry of blood vessels as a result of increased intraluminal pressure . Complications of diverticulosis include stricture, bleeding, perforation and fistula formation . Perforation as a result of infected diverticulitis often leads to intra-abdominal sepsis and peritonitis requiring emergency surgery . Uncommonly diverticulitis perforates into the anterior abdominal wall or retroperitoneum causing spreading infection that may require massive debridement [3, 4].
Intra-abdominal sepsis may rarely present as soft tissue infection of the thigh and this has been documented as a complication of appendicitis . In one case of appendicitis disarticulation of the hip was required to treat necrotising fasciitis. A literature search has shown there to be no previously documented cases of diverticula perforation presenting in this way. Here we present a case of diverticulitis with retroperitoneal perforation presenting as necrotising fasciitis of the left leg requiring disarticulation of the hip.
In the U.S an individual's risk of developing diverticulosis approaches 50% by the age of 60 . Diverticulitis, infection and inflammation as a consequence of diverticula, occurs in 20–30% of patients with diverticulosis . Perforation is a well recognised complication of diverticulitis often requiring emergency surgery. However, necrotising fasciitis as a consequence of perforated diverticulosis is an uncommon but potentially lethal condition requiring prompt surgical intervention . Previous reports have documented the presentation of inta-abdominal sepsis either as a consequence of diverticulitis or acute appendicitis in the retroperitoneal space [3, 5, 6]. We have described for the first time, to our knowledge, a case of perforated sigmoid diverticulitis that led to significant retroperitoneal infection and subsequent tracking of infection via the left psoas into the left thigh, necessitating hip disarticulation.
The patient had been assessed previously for diverticulosis but surgery was not considered at that time. The recent move away from resection for uncomplicated diverticular disease is supported by large series [7, 8] but such septic complications may become more common as a result of this change.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
All authors are funded by the National Health Service in the UK.
- Bordeianou L, Hodin R: Controversies in the surgical management of sigmoid diverticulitis. J Gastrointest Surg. 2007, 11 (4): 542-548. 10.1007/s11605-007-0126-y.PubMed CentralView ArticlePubMedGoogle Scholar
- Stollman NH, Raskin JB: Diverticular disease of the colon. J Clin Gastroenterol. 1999, 29 (3): 241-252. 10.1097/00004836-199910000-00004.View ArticlePubMedGoogle Scholar
- Secil M, Topacoglu H: Retroperitoneal necrotizing fasciitis secondary to colonic diverticulitis. J Emerg Med. 2007Google Scholar
- Mahler CW, Boermeester MA, Busch OR: Acute diverticulitis mimicking necrotizing fasciitis. J Am Coll Surg. 2003, 197 (3): 517-10.1016/S1072-7515(03)00536-2.View ArticlePubMedGoogle Scholar
- Penninga L, Wettergren A: Perforated appendicitis during near-term pregnancy causing necrotizing fasciitis of the lower extremity: a rare complication of a common disease. Acta Obstet Gynecol Scand. 2006, 85 (9): 1150-1151.View ArticlePubMedGoogle Scholar
- Jacobs PP, van der Sluis RF, Tack CJ, Wobbes T: Necrotising fasciitis of the lower limb caused by undiagnosed perforated appendicitis, which necessitated disarticulation of the hip. Eur J Surg. 1993, 159 (5): 307-308.PubMedGoogle Scholar
- Alexander J, Karl RC, Skinner DB: Results of changing trends in the surgical management of complications of diverticular disease. Surgery. 1983, 94 (4): 683-690.PubMedGoogle Scholar
- Makela J, Vuolio S, Kiviniemi H, Laitinen S: Natural history of diverticular disease: when to operate?. Dis Colon Rectum. 1998, 41 (12): 1523-1528. 10.1007/BF02237300.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.