BACKGROUND: Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. CASE PRESENTATION: We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall. CONCLUSION: This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed

A Giuliano

Conor D Marron

DC Elliott

E Chaib

G Singh

Gerarde T McArdle

H Kobayashi

HA El-Khatib

John Moorehead

Milind Rao

MS Fayman

MS Matthews

N Jallali

S Hasham

Stephen Sinclair

TP Lam

TS Burge

V Descamps

English

PubMed

Abstract Background Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. Case presentation We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall. Conclusion This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed.</p

Sinclair Stephen

Rao Milind

McArdle Gerarde T

Marron Conor D

Moorehead John

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BMC Surgery

Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management

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BioMed CentralBMC Surgery
ssOpen AcceCase report
Perforated carcinoma of the caecum presenting as necrotising 
fasciitis of the abdominal wall, the key to early diagnosis and 
management
Conor D Marron*1,3, Gerarde T McArdle1, Milind Rao1, Stephen Sinclair2 and 
John Moorehead1
Address: 1Department of Surgery, Ulster Hospital Dundonald, Upper Newtownards Road, Belfast, BT16 1RH, Northern Ireland, UK, 2Department 
of Plastic Surgery, Ulster Hospital Dundonald, Upper Newtownards Road, Belfast, BT16 1RH, Northern Ireland, UK and 3Department of Surgery, 
ICS, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
Email: Conor D Marron* - cdmarron@mac.com; Gerarde T McArdle - gerrymcardle@hotmail.com; Milind Rao - rmilind@hotmail.com; 
Stephen Sinclair - stephen.sinclair@ucht.n-i.nhs.uk; John Moorehead - john.moorehead@ucht.n-i.nhs.uk
* Corresponding author    
Abstract
Background: Necrotising Fasciitis is a life threatening soft tissue infection which requires
aggressive, early surgical management.
Case presentation: We present a rare case of a retroperitoneal perforation of a carcinoma of
the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.
Conclusion: This case highlights the importance of early aggressive debridement to healthy tissue
limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction
in order that aggressive initial surgery can be adequately performed.
Background
Necrotising Fasciitis is a life threatening soft tissue infec-
tion which requires aggressive, early surgical manage-
ment. The precise aetiology of necrotising fasciitis is
unclear in many cases. We present a rare case of a retro-
peritoneal perforation of a carcinoma of the caecum pre-
senting as a necrotising fasciitis of the anterior abdominal
wall.
Case presentation
A 52 year old male presented with a one week history of
discomfort and swelling in the right iliac fossa, and 12
hours of skin erythema which was rapidly progressing.
Within 2 hours of assessment, the cellulitis was noted to
have spread outside the boundaries marked on admis-
sion. He was hypotensive, tachycardic, febrile and noted
to have an elevated white cell count.
On examination of the area there was diffuse oedema of
the skin with marked erythema and heat in the area of
skin from the right loin to groin across to midline. Subcu-
taneous crepitus was present. A lateral abdominal X-Ray
revealed free gas within the subcutaneous tissues (Fig. 1).
A presumed diagnosis of necrotising fasciitis was made
and the patient commenced on intravenous antibiotics,
resuscitated with intravenous fluids, and taken immedi-
ately to the operating theatre.
Published: 29 September 2006
BMC Surgery 2006, 6:11 doi:10.1186/1471-2482-6-11
Received: 21 February 2006
Accepted: 29 September 2006
This article is available from: http://www.biomedcentral.com/1471-2482/6/11
© 2006 Marron et al; licensee 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.Page 1 of 5
(page number not for citation purposes)
BMC Surgery 2006, 6:11 http://www.biomedcentral.com/1471-2482/6/11Extensive debridement of the affected cutaneous, subcuta-
neous tissue, and muscle was performed and pus noted to
extend to the right loin area. Histology and bacteriology
confirmed a diagnosis of necrotising fasciitis, with a β-
haemolytic group streptococcus cultured. Exploration
revealed a retroperitoneal abscess arising as a result of a
perforation of a caecal carcinoma. The caecum was
resected and a right hemicolectomy performed, with a
large defect resulting in the anterior abdominal wall from
the extensive debridement (Fig. 2).
The patient was admitted to the intensive care unit for
inotropic support and management of sepsis, and 2 days
later proceeded to have a rectus femoris myocutaneous
flap fashioned to close the defect in the abdominal wall.
He made a good post-operative recovery, with adequate
skin closure on the abdominal wall (Fig. 3), and was dis-
charged from hospital 8 weeks post-operatively. The
patient subsequently died at home, from a myocardial inf-
arction, five months after surgery. Informed consent for
publication and use of images had been received from the
patient and his family.
Discussion
Retroperitoneal, or psoas, abscess is an unusual problem,
which has insidious and occult characteristic[1]. There are
often delays in the diagnosis of retroperitoneal abscess
due to its insidious nature, and it frequently extends
beyond the peritoneum before being identified. Even in
those cases with contamination from the gastro-intestinal
tract, the course appears relatively benign. Retroperitoneal
abscess rarely results from perforation of the colon as
most perforations occur into the peritoneal cavity[1].
Those that perforate into the retroperitoneum rarely result
in formation of a psoas abscess[1].
Conversely, necrotising fasciitis is a soft tissue infection
associated with high morbidity and mortality[2]. Necro-
tising soft tissue infections have been recognised and
reported for centuries the earliest dating back to Hippoc-
rates in the 5th century BC[3]. A rapidly progressive soft tis-
sue infection (synergistic undermining gangrene) caused
by the synergistic action of a β-haemolytic group strepto-
coccus +/- staphylococcus, was described in 1924 by
Meleney[4]. Wilson subsequently re-termed this observed
phenomenon as necrotising fasciitis, in 1952[5].
Necrotising fasciitis is rare within the UK with an esti-
mated at 500 new cases each year, however this is difficult
to confirm, as different eponyms are given to describe the
same condition, as outlined above[6]. The aetiology of
necrotising fasciitis is not fully understood, with patients
often having a history of trauma, including insect bites,
scratches, or abrasions[7]. However in some cases no pri-
mary cause can be found. Patients that have pre existing
conditions which increase susceptibility to infection seem
to be at an increased risk of developing necrotising fascii-
tis these conditions include diabetes mellitus, peripheral
vascular disease, chronic renal failure, drug misuse, and
advanced age[8].
The cornerstone of management of necrotising fasciitis is
recognised as being aggressive surgical debridement and
intensive support, whilst other severe soft tissue infections
do not necessarily require the same amount of aggressive
debridement. Therefore it is important that clinicians are
able to differentiate between the two.
Necrotising fasciitis should be considered in those
patients who have rapidly progressing cellulitis, and pal-
pable subcutaneous crepitus, in association with tachycar-
Lateral Abdominal X-Ray demonstrating subcutaneous gas wi hin the abdominal wallFigure 1
Lateral Abdominal X-Ray demonstrating subcutaneous gas 
within the abdominal wall.Page 2 of 5
(page number not for citation purposes)
BMC Surgery 2006, 6:11 http://www.biomedcentral.com/1471-2482/6/11dia, hypotension, neutropenia or neutrophilia, and
hyponatraemia[6].
Adjuvant diagnostic tools for necrotising fasciitis include
CT scanning and plain radiography[8]. In this case the
clinical finding of crepitus, and soft tissue air on plain
radiograph were both present, however these signs are
only seen in 37% and 57% of patients respectively[6].
The finding of necrotising fasciitis of the anterior abdom-
inal wall associated with a carcinomatous perforation of
the colon is rare, having only previously been described
with perforation of a sigmoid colon carcinoma directly
adherent to the anterior abdominal wall[9]. In addition,
this case is unusual in that retroperitoneal abscesses have
been described to track along psoas, or through the obtu-
rator foramen to give swellings in the thigh or gluteal
region, but not to give rise to infection of the anterior
abdominal wall[1,9].
This case illustrates that the principles of management
should be two-fold; 1) To rapidly and unequivocally con-
trol infection and sepsis through extensive radical debri-
dement of necrotic tissue and; 2) Identify and treat any
underlying condition giving rise to the infection, in this
case removing the caecal tumour.
Intravenous antibiotics should be started promptly and
modified when sensitivities return. However, it is essential
to ensure that adequate necrotic material is removed at
the first opportunity to reduce the risk of further progres-
sion, regardless of the defect that will remain. Defects may
be closed using a variety of techniques, including split
skin grafts, Vacuum Assisted Closure (VAC) therapy[6],
and flap procedures, including myocutaneous flaps [10-
12]. Hyperbaric oxygen therapy in the treatment of necro-
tising fasciitis remains controversial, conflicting studies
have reported contradicting results as to potential bene-
fits[13].
Extensive debridement of abdominal wall leaving small bowel and kidney exposedFigure 2
Extensive debridement of abdominal wall leaving small bowel and kidney exposed.Page 3 of 5
(page number not for citation purposes)
BMC Surgery 2006, 6:11 http://www.biomedcentral.com/1471-2482/6/11Conclusion
Early recognition of important signs of necrotising fascii-
tis is essential to effective management of this condition,
and clinicians assessing patients with rapidly progressive
cellulitis should be aware of these vital features.
In cases presenting with necrotising fasciitis there should
be consideration given to an underlying cause for the
infection.
Aggressive surgical management is the cornerstone to
management of this condition, and is the key to survival
for these patients. This case demonstrates that extensive
debridement can be performed with resulting large
defects, which can be adequately closed at a later time,
and therefore this should not be thought of as a barrier to
adequate surgical debridement and definitive treatment.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
All authors have read and approved the final version of
the manuscript.
CM was involved in the conception for the idea for the
report, and was involved with the diagnosis, operative,
and post-operative management of the patient. He is
responsible for preparation of the manuscript for submis-
sion
GMcA was responsible for up to date literature review, re-
writing of manuscript prior to submission, gaining of con-
sent for use of images, and management of the patient.
MR was responsible for ward care of the patient, review,
and re-writing of manuscript prior to submission.
SS was the senior consultant Plastic Surgeon responsible
for the patients operative management and post-operative
care and was involved in review and alteration of the man-
uscript prior to submission.
Defect in abdominal wall closed using rectus femoris myocutaneous flapFigure 3
Defect in abdominal wall closed using rectus femoris myocutaneous flap.Page 4 of 5
(page number not for citation purposes)
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RM was the Senior Consultant General Surgeon involved
with operative and post-operative management of the
patient and was responsible for critical review of the man-
uscript prior to submission.
References
1. Kobayashi H, Sakurai Y, Shoji M, Nakamura Y, Suganuma M, Imazu H,
Hasegawa S, Matsubara T, Ochiai M, Funabiki T: Psoas abscess and
cellulitis of the right gluteal region resulting from carcinoma
of the cecum.  J Gastroenterol 2001, 36:623-628.
2. Lam TP, Maffulli N, Chen EH, Cheng JC: Carcinomatous perfora-
tion of the sigmoid colon presenting as a thigh mass.  Bull Hosp
Jt Dis 1996, 55:83-85.
3. Descamps V, Aitken J, Lee MG: Hippocrates on necrotising fasci-
itis.  Lancet 1994, 344:556.
4. Giuliano A, Lewis FJ, Hadley K, Blaisdell FW: Bacteriology of
necrotizing fasciitis.  Am J Surg 1977, 134:52-57.
5. Burge TS: Necrotizing fasciitis--the hazards of delay.  J R Soc
Med 1995, 88:342P-343P.
6. Hasham S, Matteucci P, Stanley PR, Hart NB: Necrotising fasciitis.
Bmj 2005, 330:830-833.
7. Singh G, Sinha SK, Adhikary S, Babu KS, Ray P, Khanna SK: Necrotis-
ing infections of soft tissues--a clinical profile.  Eur J Surg 2002,
168:366-371.
8. Elliott DC, Kufera JA, Myers RA: Necrotizing soft tissue infec-
tions. Risk factors for mortality and strategies for manage-
ment.  Ann Surg 1996, 224:672-683.
9. Chaib E, Leal MC, Onofrio PL, Nahas P, de Mello JB: [Crepitant
abdominal cellulitis: a rare clinical presentation of sigmoid
tumor].  Arq Gastroenterol 1990, 27:80-82.
10. Matthews MS: Abdominal wall reconstruction with an
expanded rectus femoris flap.  Plast Reconstr Surg 1999,
104:183-186.
11. Fayman MS, Schein M, Saadia R: Abdominal wall reconstruction
after open management of the septic abdomen.  S Afr J Surg
1990, 28:62-65.
12. El-Khatib HA: V-Y fasciocutaneous pudendal thigh flap for
repair of perineum and genital region after necrotizing fasci-
itis: modification and new indication.  Ann Plast Surg 2002,
48:370-375.
13. Jallali N, Withey S, Butler PE: Hyperbaric oxygen as adjuvant
therapy in the management of necrotizing fasciitis.  Am J Surg
2005, 189:462-466.
Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2482/6/11/prepubPage 5 of 5
(page number not for citation purposes)


Abdominal wall reconstruction after open management of the septic abdomen.

Abdominal wall reconstruction with an expanded rectus femoris flap. Plast Reconstr Surg

Cheng JC: Carcinomatous perforation of the sigmoid colon presenting as a thigh mass. Bull Hosp Jt Dis

de Mello JB: [Crepitant abdominal cellulitis: a rare clinical presentation of sigmoid tumor]. Arq Gastroenterol

Funabiki T: Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum.

FW: Bacteriology of necrotizing fasciitis.

MG: Hippocrates on necrotising fasciitis. Lancet

NB: Necrotising fasciitis. Bmj

Necrotizing fasciitis--the hazards of delay.

Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg

PE: Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis.

SK: Necrotising infections of soft tissues--a clinical profile.

V-Y fasciocutaneous pudendal thigh flap for repair of perineum and genital region after necrotizing fasciitis: modification and new indication. Ann Plast Surg

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Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management

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