Fournier's Gangrene Secondary to Perforated Sigmoid Adenocarcinoma Within an Incarcerated Inguinal Hernia.

Colon cancer is the third most common cancer worldwide. Approximately one-fifth of colon cancers will present emergently due to obstruction or perforation. Necrotizing soft tissue infection is a rare presentation of perforated colon cancer and represents a surgical emergency due to high mortality rate.  A man in his 80s presented with several days of scrotal pain and weakness. On physical exam he was found to have scrotal edema and erythema and bilateral inguinal hernias. Imaging revealed a large scrotal abscess and concern for necrotizing soft tissue infection. He was taken to the operating room for surgical debridement and exploration and was discovered to have perforated colon within an incarcerated inguinal hernia. He underwent exploratory laparotomy with sigmoid resection and end colostomy creation. Pathology returned demonstrating invasive sigmoid adenocarcinoma. Fournier's gangrene requires a high index of suspicion. It is a rapidly progressing infection associated with high mortality. Early initiation of antibiotics and surgical debridement are mainstays of treatment. When associated with perforated colonic malignancy, workup must include imaging of the chest, abdomen, and pelvis as well as carcinoembryonic antigen (CEA) level to complete staging. Fournier's gangrene secondary to perforated sigmoid adenocarcinoma is a unique presentation. Treatment first involves antibiotics and aggressive surgical debridement. Once the patient is stabilized, further oncologic workup should be completed to determine treatment course.

Pneumoperitoneum Secondary to Necrotic Intra-abdominal Lymph Node.

Pneumoperitoneum is often treated as a surgical emergency as the most common etiology is perforated hollow viscus. Here, we present the case of a man in his 70s who presented to the emergency department with fever and abdominal pain. On physical exam, he was diffusely tender in the bilateral lower quadrants with guarding. Imaging demonstrated moderate volume pneumoperitoneum. On review of his imaging, the pneumoperitoneum was centered around a 7 cm necrotic lymph node. Repeat CT scan with positive oral (PO) and rectal contrast demonstrated no extraluminal contrast extravasation, but air bubbles were seen extending from the necrotic lymph node into the lower abdominal cavity. He underwent CT-guided drain placement and was started on antibiotics, and improved without surgical intervention. In stable patients presenting with pneumoperitoneum and known intra-abdominal lymphadenopathy, perforated viscus should be ruled out prior to surgical intervention, and necrotic intra-abdominal lymph node should be considered as a differential diagnosis.