Fall 2021: Daunting Diagnosis
Question:
A 63 year-old female presents to the emergency department with diffuse abdominal pain and “black discoloration” on her abdominal wall. The patient has a history of ovarian cancer, which was treated in 2014, opiate abuse, and known abdominal hernia. Patient presents febrile and hypotensive.
A photograph of her abdomen is below, along with a CT of her abdomen and pelvis. What clinical condition does the patient have?
Image 1: Abdominal wall with necrotic tissue
Image 2: Abdominal/Pelvis CT showing extensive fluid collection and development of air-fluid level with extensive amount of gas pockets and severe diffuse subcutaneous edema
Image 3: Abdominal/Pelvis CT showing 6 cm ventral hernia with protrusion of omental fat
Answer:
The CT scan shows extensive inflammatory changes of the abdominal wall including an air-fluid level and subcutaneous gas concerning for superimposed infection with a gas-forming bacteria. The inflammatory changes are associated with a large, incarcerated ventral hernia and bowel perforation.
The patient was hemodynamically unstable, requiring sepsis protocol and emergent general surgery consultation.
The patient underwent an initial exploratory laparotomy for a necrotizing soft tissue infection, and multiple subsequent surgeries including resection of the transverse colon, multiple debridements of the anterior abdominal wall, open cholecystectomy, multiple wound wash-outs, and wound vac placement.
The patient additionally underwent hyperbaric treatment. Hematology was consulted for further treatment of her ovarian cancer. The patient’s prognosis is poor.
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