A RARE CASE OF ADYNAMIC ACUTE

Dr. Ayana M. Dev, Junior Resident,

INTESTINAL OBSTRUCTION Dr. Nimisha C.R. Assistant
Professor,
Dr. Vinodh M. Professor,
Dr. Babu P. John, Professor,
• A 55-yr-old male, alcoholic, with no other known comorbidities
Dr. Ravindran C., Addl. Professor,
presented with features of acute intestinal obstruction.
Dept. of Gen Surgery GMC,
• Emergency laparotomy and colostomy was initially done suspecting a Thrissur
distal colonic obstruction, possibly neoplastic. But peritoneal cavity
was clean with grossly enlarged large bowel without a transition point
and approximately 200 ml of pus was evacuated from the
extraperitoneal plane through a rent in peritoneum.

• Over the next week– patient’s condition worsened – abdominal

symptoms persisted – MRI revealed large bilateral intermuscular plane
collection involving whole of abdominal wall extending to scrotum
diagnosed as Necrotizing Fascitis of Anterolateral Abdominal Wall.

• Proceeded with extraperitoneal drainage via bilateral flank incisions

and placement of tube drains in the plane between Internal Oblique and
Transversus Abdominis muscles.
 A RARE CASE OF ADYNAMIC ACUTE
INTESTINAL OBSTRUCTION Dr. Ayana M. Dev, Junior Resident,
• The abdominal wall is a continuous musculoaponeurotic structure which Dr. Nimisha C.R. Assistant
extends from thoracic cage to the pelvis arranged in a three ply manner similar Professor,
to that of thorax and extending to the scrotum over the cord structures. Dr. Vinodh M. Professor,
Dr. Babu P. John, Professor,
• Necrotizing Fascitis in itself is an uncommon disease, usually involving the
Dr. Ravindran C., Addl. Professor,
extremities
Dept. of Gen Surgery GMC,
• Involvement of the abdominal wall is a rare presentation of the disease. Thrissur
• The presentation of this case is rarer still in that it involved the deeper layers of
muscle and parietal peritoneum causing acute intestinal obstruction and
considerably sparing the major portion of subcutaneous tissue and skin as
opposed to the presentation of Meleney’s gangrene.

• The available literature have only numbered discussions on Necrotizing

Fascitis of abdominal wall, that too mainly on Meleney’s gangrene which has a
very high mortality rate(~67%).

• Common causes of adynamic intestinal obstruction include abdominal trauma,

surgeries, electrolyte abnormalities, infections, intestinal ischemia, skeletal
injury , uremia, pancreatitis and medications and it is usually a diagnosis of
exclusion.
 A RARE CASE OF ADYNAMIC ACUTE
INTESTINAL OBSTRUCTION Dr. Ayana M. Dev, Junior Resident,
Dr. Nimisha C.R. Assistant
• The pus culture and tissue culture yielded E.coli
unlike polymicrobial or Streptococcal infection in
Meleney’s gangrene, whereas blood culture remained
sterile which helped to guide the antibiotic regimen.
• Daily wound care with thorough saline wash,
nutritional support and physical rehabilitation were the
key postoperative management strategy.
• Early diagnosis and the timely intervention combined
with supportive care helped the patient survive.
• All the wounds were completely healed by the end of
3months and repeat imaging ruled out residual
collections
• Colostomy was reversed 6 months later.
• Patient is doing well at 1 year follow up
Professor,
References: Dr. Vinodh M. Professor,
• Ecker KW, Baars A, Töpfer J, Frank J. Necrotizing Dr. Babu P. John, Professor,
Fasciitis of the Perineum and the Abdominal Wall- Dr. Ravindran C., Addl. Professor,
Surgical Approach. Eur J Trauma Emerg Surg. 2008
Jun;34(3):219-28. doi: 10.1007/s00068-008-8072-2. Dept. of Gen Surgery GMC,
Epub 2008 May 30. PMID: 26815742. Thrissur
• DeMuro J, Hanna A, Chalas E, Cunha B. Polymicrobial
abdominal wall necrotizing fasciitis after cesarean
section. J Surg Case Rep. 2012;2012(9):10. Published
2012 Sep 1. doi:10.1093/jscr/2012.9.10
• Wong CH, Song C, Ong YS, Tan BK, Tan KC, Foo CL.
Abdominal wall necrotizing fasciitis: it is still "Meleney's
Minefield". Plast Reconstr Surg. 2006 Jun;117(7):147e-
150e. doi: 10.1097/01.prs.0000219079.65910.54. PMID:
16772902.
• Kaistha S, Kumar A, Ramakrishnan TS. Necrotizing
Fasciitis: A Rare Complication of Acute Necrotizing
Pancreatitis. J Clin Diagn Res. 2017 Jun;11(6):PD05-
PD06. doi: 10.7860/JCDR/2017/27032.10032. Epub
2017 Jun 1. PMID: 28764243; PMCID: PMC5535435.
• McConville, K., Dangleben, D. A., Sandhu, R. S. (2010,
November). A Severe Case of Necrotizing Fasciitis of the
Abdomen: A Survivor story