Progressive Perianal Necrotising Soft Tissue Infection in Decompensated Chronic Liver Disease: A Case Report

Abstract

Necrotising soft tissue infection in diabetics is known to carry a significant risk of mortality, while if it is associated with chronic liver disease (CLD) Child C, the mortality further increases. CLD alone has a predicted 5-year survival of 50%. This case report selectively highlights the occurrence of perianal spreading cellulitis in the presence of liver disease and diabetes with stress on special considerations. A 50-year-old male, presented with decompensated Child’s C CLD in metabolic acidosis with reduced urine output, deranged renal function, ascites and elevated bilirubin levels along with perianal pathology that began as a seemingly innocuous painful swelling. He was found to have extensive necrotising infection extending beyond the perianal region to involve the gluteal skin, perineum and scrotum and had poor anal sphincter tone. MRI revealed an extensive collection of pus involving both ischiorectal fossae extending extra-peritoneally into the left side of the pelvis. Special preoperative considerations involved optimising hydration (while avoiding overload), correcting acidosis arranging adequate blood products in view of coagulopathy and anaemia. The necessity of debridement for source control carried with it the attendant risk of further decompensation of CLD besides major haemorrhage from porto-systemic collaterals. Diversion, though imperative, carried the risk continuous peri-stomal seepage of ascites We describe a case of diversion after physiological stabilisation and highlight graded damage control measures for optimal outcomes and preventing stoma related complications in such immunocompromised patients.