Grey Soup

Necrotising fasciitis! Two words that instantly twist the guts of any surgeon with an icy squeeze. 

It’s bad enough when the back of your mind whisperingly flirts with the possibility of this dreaded diagnosis whilst reviewing a patient with a perfectly innocent, garden-variety cellulitis in the light of day. It’s a little more troubling when, later that night at 3am, you suddenly sit bolt upright clutching at the damp bedsheets, utterly convinced that somehow you missed the first subtle signs. It is of course worse by far to peek under the bedsheets and instantly just know.

For a disease that is supposedly vanishingly rare according to the textbooks, I feel that in my short career I have already encountered more than my fair share. Four cases of barbaric, destructive, ruthless dissection are seared into my memory. The overpowering smell. The sensation of human flesh liquified to a grey soup. The putrefaction of normal anatomy to the point where a deluge of stinking liquid leaks out of the body the moment your scalpel opens the overlying tissue layers.

In a previous encounter this condition, before rushing to scrub, the patient had laid momentarily exposed on the operating table. In that moment of calm, it had felt  absurdly difficult to comprehend what all of the rushing and fuss was about. A few hours earlier, this middle aged lady had presented to A&E conspicuously unwell, with a discharging Batholin’s Abscess. In the noise and bustle of A&E she had looked anxious and sick - panting, flushed and in pain. Now she looked serenely peaceful as she laid exposed and spreadeagled on the operating table. 

The abscess was still discharging stinking pus that dripped onto the Inco Sheets on the floor. There was necrotic tissue overlying the abscess, and associated erythema extending over the perineum, bilateral medial thighs and up over the abdomen to the level of the umbilicus. A CT scan, which had been arranged by A&E, suggested that the involvement was even more extensive than these external appearances would suggest. Air could be seen infiltrating tissues up as far as that overlying the ribs! Indeed the seriousness of the situation was sadly confirmed once the dissection had begun. There was necrosis of the paravaginal tissues extending under the pubic arch, crepitus on palpating the urethra, involvement of the fascia of the medial thighs and extensive necrosis of the abdominal wall muscles. We excised the necrotic anterior rectus fascia and external oblique muscles, but this unfortunately this revealed that the underlying internal oblique muscle was also extensively necrotic. Obviously further debridement would compromise abdominal wall integrity. Furthermore, likely involvement of the bladder would have necessitated cystectomy and urinary diversion. At this point, it was decided by all in attendance - general surgeons, plastic surgeons, urologists, gynaecologists and anaesthetists - that complete dissection of all involved tissues would result in unacceptable morbidity, and anyway was not ultimately survivable. She was moved back to ITU still ventilated and passed away later that night.

Necrotising fasciitis is scary for a whole number of reasons. Emergency General Surgeons are well accustomed to dealing with sick patients who will die very quickly if they are not taken rapidly to the operating theatre, but as the surgical truism goes, time really is tissue with necrotising fasciitis. In the case described above, the decision to scan this lady or any other series of small delays may have ultimately cost her her life. In addition to needing to move lightningly fast, it is also a clinical diagnosis, and the external appearances will sometimes be extremely difficult to differentiate from regular cellulitis or a simple abscess. Clinicians are left without the crutch of imaging, scores or blood tests that are reliably diagnostic. Equally, what are thought of as classical signs, such as crepitus, bullae, necrosis and gangrene, are not necessarily reliably present, but may well also be seen in non-necrotising fasciitis infections. Patients will however, generally have a disproportionate amount of pain, dramatic speed of progression, fever, severe toxicity, renal failure, hypovolaemia and cardiovascular collapse caused by septic shock. Basically, they will be sick as a dog! Lastly, the horrendously high mortality and life-destroying morbidity for those who ultimately do make it really does pile on the pressure for the unfortunate Surgical Reg who receives that call in the middle of their night shift.

I hope that I don’t have any more clinical encounters like this anytime soon. What are your experiences of flesh eating bacteria? Do you have any words of wisdom about how to recognise and manage this surgical nightmare?