Journal Meeting

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Journal Meeting

• Reporter R1. ???
• Director Dr. ???
• 92-04-15

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Fourniers gangrene 

• Church Dis Colon Rectum, Volume 43(9).September
  2000.1300-1308

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Pathophysiology

• A synergistic polymicrobial necrotizing fasciitis
  of the perineal, perirectal or genital area ?
  leads to thrombosis of small subcutaneous vessels
  and with infection ?results in the development of
  gangrene of the overlying skin.

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Introduction

• Neonate to elderly, mean 50 y/o MF 101
• Rapid progressive with mortality of 480
• Identified infection sources in 95 of cases
• Portal of entry may be urogenital, anorectal or
  cutaneous

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Sources-portal of entry

• Urogenital (45)
• urethral strictures,
• indwelling catheters,
• traumatic catheterization,
• urethral calculi,
• prostatic massage
• prostate biopsy
• Anorectal (33)
• Abscesses
• s/o procedure rectal mucosal biopsy , anal
  dilatation, banding of haemorrhoids
• Carcinoma
• Appendicitis,diverticulitis
• Rectal perforation by foreign body

• cutaneous (21)
• Elective surgery vasectomy, insertion of a
  penile prosthesis and diathermy for genital
  warts
• Constriction ring for erectile dysfunction
• Cutaneous abscess, pressure sore
• Women
• Vulval or Bartholin's abscess
• Complicate episiotomy, hysterectomy, septic
  abortion, and cervical or pudendal nerve blocks

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From   Church Dis Colon Rectum, Volume
43(9).September 2000.1300-1308
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• Risk factors
• Immunosuppressed
• DM
• Alcoholism
• Liver cirrhosis
• Morbid obesity
• Advanced age
• Malignancy
• Prolonged hospitalization
• IV drug users

• Successful treatment depends
• Early diagnosis,
• Aggressive radical debridement
• Broad-spectrum intravenous antibiotics
• Underlying conditions

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Histologic Findings

• The pathognomonic findings on pathologic
  evaluation
• Necrosis of the superficial and deep fascial
  planes
• Fibrinoid coagulation of the nutrient arterioles
• Polymorphonuclear cell infiltration
• Microorganisms identified within the involved
  tissues

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Pathologic findings

• Necrosis of the superficial and deep fascial
  planes
• Fibrinoid coagulation of the nutrient arterioles
• Polymorphonuclear cell infiltration
• Microorganisms identified within the involved
  tissues

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Microbiology

• Polymicrobial infection
• Aerobes, anaerobes, fungus, parasites
• Normal flora of the lower GI tract and perineum
• Enterobacteria, particularly Escherichia coli,
  Bacteroides, streptococcal species,
  Staphylococci, Peptostreptococci andClostridia

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Clinical presentation

• A more indolent courses
• Fever, scrotal pain and swelling,
• Early physical symptoms not always indicate the
  severity
• Prodromal symptoms of fever or lethargy, which
  may be present 2-7 days
• Severe genital pain with tenderness and swelling
• Increasing genital pain and progressive erythema
  
• Dusky skin, subcutaneous crepitus (5060)
• Gangrene of genitalia purulent drainage from
  wounds
• Odor

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• An apparent cellulitis ? does not respond to
  appropriate antibiotic therapy ?should also raise
  suspicion for Fournier's gangrene
• In the early stages ?may present with minimal
  cutaneous manifestations of the underlying
  infection
• Pain sometimes diminishes as the disease
  progresses? Once gangrene is established, pain
  often diminishes

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Image study

• The diagnosis is made primarily on clinical
  grounds if suspected, surgical exploration is
  mandatory.
• Radiological evaluation can be helpful in cases
  of diagnostic doubt.
• Help to confirm the diagnosis,
• Evaluate extent of disease,
• Detect underlying cause,
• Follow response to therapy.

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Radiography

• Consider when clinical examination is suspected
• Presence of soft tissue gas / subcutaneous
  emphysema.
• Marked swelling of the scrotal tissues
• Absence of subcutaneous air ?does not exclude the
  diagnosis of Fournier's gangrene.
• Soft-tissue gas or subcutaneous crepitance ? an
  absolute indication for surgical exploration

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Sonography

• Thickened and oedematous scrotal wall,
  Subcutaneous gas within the scrotal wall , and
  unilateral or bilateral peritesticular fluid.
• US can assess the blood flow to the testis if
  testicular torsion is in the differential
  diagnosis.
• need for direct pressure on the involved tissue?
  patient with Fournier gangrene will not tolerate
  this procedure

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Sonography

• Showing air surrounding the testis, ?as a
  consequence of Fournier's gangrene

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CT

• can detect smaller amounts of soft tissue gas
• can demonstrate fluid collections that track
  along the deep fascial planes
• should be considered the diagnostic tool of
  choice

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MRI

• Gives greater soft tissue detail than a CT scan
• but creates greater logistical challenges, (esp.
  in patients with critical illness)

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Differential Diagnosis

• Cellulitis
• Strangulated hernia
• Scrotal abscess
• Testis torsion
• Streptococcal necrotizing fasciitis
• Vascular occlusion syndromes
• Herpes simplex
• Pyoderma gangrenosum

• Gonococcal balanitis and edema
• Allergic vasculitis
• Polyarteritis nodosa
• Necrolytic migratory erythema (Glucagonoma
  syndrome)
• Warfarin necrosis
• Ecthyma gangrenosum (due to Pseudomonas
  septicemia)

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Treatment

• Successful treatment depends on
• early diagnosis,
• aggressive radical debridement of all areas of
  subcutaneous necrosis,
• prompt institution of broad-spectrum intravenous
  antibiotics.
• HBO and honey are treatment modalities yet to be
  universally adopted

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Surgery

• Establishing the diagnosis
• In presumptive diagnosis, the definitive
  diagnosis ? established by examination under
  anesthesia (EUA) followed by incision into the
  area of greatest clinical concern.
• If frankly gangrenous tissue is found or
  purulence is drained, the diagnosis is
  established.
• Excising of necrotic tissue

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• Gangrenous tissue is found
• Purulence is drained

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• Aggressive radical debridement of all areas of
  subcutaneous necrosis

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Complications

• The main complication is unresolved sepsis, often
  caused by 1 of the following
• Unrecognized cause of the infection (eg, PUD,
  appendicitis, diverticulitis)
• Extension of the necrotizing process outside the
  obvious wound CT scan is helpful for
  investigation of the above 2 possibilities.
• Complication of severe acute illness (eg, line
  sepsis, bacterial endocarditis, pneumonia)
• Comorbid conditions or the bedrest conditions
  imposed on patients who are acutely ill

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Complications

• Large scrotal, perineal, penile, and abdominal
  wall skin defects ? require reconstructive
  procedures

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From   Church Dis Colon Rectum, Volume
43(9).September 2000.1300-1308
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Clinical Pearls

• Fournier's gangrene is a rare condition that
  requires emergency surgical treatment.
• The clinical presentation can be variable but may
  consist of genital swelling, erythema, and
  tenderness, frequently accompanied by fever.
  Presentation often occurs before the development
  of crepitus. The disease may be indolent with
  progression over several days.
• Suspect a systemic disease such as diabetes,
  alcoholism, or HIV infection in a patient
  diagnosed with Fournier's gangrene.
• Search for the portal of entry, which typically
  includes the urogenital, urorectal or cutaneous.
• Mortality is still almost 20 despite advances in
  modern medicine.