ABDOMINAL WALL NECROTIZING FASCIITIS: A RARE COMPLICATION OF PERCUTANEOUS GASTROSTOMY

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Percutaneous gastrostomy is a commonly performed procedure for providing enteral nutrition in patients with head and neck cancers, stroke and bulbar palsy. A number of non-infectious and infectious complications of percutaneous gastrostomy have been reported previously. Abdominal wall necrotizing fasciitis is a rare but life-threatening complication of percutaneous gastrostomy [1]. Here, we report the case of an elderly lady, who developed gastrostomy-site necrotizing fasciitis and expired consequently. CASE PRESENTATION: An 81-year-old lady with past history of end-stage renal disease and anoxic brain injury (requiring tracheostomy and percutaneous gastrostomy placement) was transferred from a long-term facility with a 3-day history of fever. On physical examination, she was noted to have discoloration of skin around the gastrostomy site (Figure 1). Her laboratory investigations revealed leukocytosis (white cell count of 44,700/mm3) with a neutrophilic predominance (92%). Computed tomography of the abdomen (Figure 2 and Figure 3) demonstrated extensive subcutaneous emphysema (arrows in Figure 3) throughout the anterior abdominal wall along with infiltration of the subcutaneous fat (arrowheads in Figure 3). A diagnosis of necrotizing fasciitis of the gastrostomy site was made and broad-spectrum antibiotic therapy (vancomycin, meropenem and clindamycin) was started. Subsequently, two sets of blood culture grew carbapenem-resistant Klebsiella pneumoniae for which colistin (polymyxin E) and meropenem were instituted. Surgical debridement of the abdominal wall was discussed with the patient’s family. However, surgical intervention was not pursued in line with her goals of care and she expired subsequently. DISCUSSION: Abdominal wall necrotizing fasciitis is a rare complication of percutaneous gastrostomy with an estimated incidence of 1 in 129 gastrostomy procedures [2]. Dislodgement of the gastrostomy tube is implicated in most cases (as in this case) and allows infection by gas-producing organisms. Buried bumper syndrome (i.e. erosion of internal bumper of feeding tube into gastric wall due to pressure necrosis) is another factor that may be implicated in some cases [2]. Patient-related risk factors include old age, obesity, diabetes mellitus, immunocompromised status and chronically bedridden patients. Treatment consists of aggressive surgical debridement and broad-spectrum antibiotics. Mortality rates are reported to be as high as 30% despite surgical interventions [3]. CONCLUSIONS: Necrotizing fasciitis is a rare but potentially fatal complication of percutaneous gastrostomy. Prompt recognition and aggressive management with surgical debridement and broad-spectrum antibiotics may afford a favorable outcome for some patients [3]. As gastrostomy tubes are widely used in critically ill patients, intensivists and radiologists must be aware of this rare but life-threatening complication. Reference #1: Lockett MA, Templeton ML, Byrne TK, Norcross ED. Percutaneous endoscopic gastrostomy complications in a tertiary-care center. Am Surg. 2002;68:117-120. Reference #2: Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol. 2009;34:103-112. Reference #3: Artul S, Nseir W, Assaf V, Abboud N. Abdominal wall necrotising fasciitis due to dislodged percutaneous endoscopic gastrostomy tube. BMJ Case Rep. 2014;2014:bcr2013201346. DISCLOSURES: No relevant relationships by Hafiza Noor Ul Ain Baloch, source=Web Response No relevant relationships by Michael Silverberg, source=Web Response