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Key points

Retroperitoneal fasciitis

  • Retroperitoneal fasciitis is an infection that spreads along the fascial planes within the retroperitoneal cavity.
  • It is a rare, often fatal condition.
  • The etiology can be due to a primary source, including appendicitis, diverticulitis, pyelonephritis, perianal abscess, perforation, postsurgical complications, or from a secondary source, such as an infection.
  • The most common secondary etiology of retroperitoneal fasciitis may be due to a lower extremity necrotizing fasciitis, particularly if it involves the thigh.
  • Disease range: Simple fasciitis or infection of the fascial planes to a fulminant necrotizing form.

Pathophysiology

  • Diseases of the retroperitoneal space can involve a variety of conditions, including infectious, inflammatory, and neoplastic etiologies.
  • Indirect tracking or transgression of fascial planes suggests the more severe form of retroperitoneal fasciitis.
  • The hallmark of retroperitoneal fasciitis is gas tracking (but this is not seen in all cases, particularly in the early stages).

Epidemiology

  • The incidence of retroperitoneal fasciitis remains unknown.
  • Mortality remains high, especially in the necrotizing form of retroperitoneal fasciitis.

Clinical presentation

  • Clinical symptoms are often challenging, since the symptoms of retroperitoneal fasciitis can easily mimic other etiologies of acute abdominal disorders.
  • Nonspecific but high clinical suspicion includes patients who present with disproportionate abdominal pain (secondary to intramuscular edema and inflammatory involvement of nerves, resulting in compartment syndrome), flank pain, and evidence of infection.
  • Labs are nonspecific but may include variable elevations of white blood cells, the erythrocyte sedimentation rate, and C-reactive protein.

Imaging features (CT and MRI)

  • CT is the first-line imaging modality
  • Emergency CT can aid in early diagnosis and provide a further evaluation of the extent and severity of the disease
  • MRI can also guide in distinguishing the non-necrotizing form from the necrotizing form
  • Asymmetric fascial thickening and enhancement
  • Muscular edema
  • Fat stranding
  • Gas tracking along fascial planes in the retroperitoneum
  • Transgression of fascial planes
  • Fluid collection
  • Abscess formation

Treatment and prognosis

  • Urgent surgical intervention is indicated in more severe cases, but it can also be treated with conservative measurements, including broad-spectrum IV antibiotics.
  • A delay in diagnosis due to a lack of specific clinical signs of retroperitoneal fasciitis can lead to sequela of septic shock, hypotension, and death.
  • Anticipation of retroperitoneal fasciitis along with early life-saving measures is crucial.

References

  1. Chingkoe CM, Jahed A, Loreto MP, et al. Retroperitoneal fasciitis: Spectrum of CT findings in the abdomen and pelvis. Radiographics. 2015;35(4):1095-1107. doi:10.1148/rg.201514007
  2. Tirkes T, Sandrasegaran K, Patel AA, et al. Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging [published correction appears in Radiographics. 2019 May-Jun;39(3):912].Radiographics. 2012;32(2):437-451. doi:10.1148/rg.322115032
  3. Ünal E, Onur MR, Akpinar E, Karcaaltincaba M. Primary retroperitoneal fasciitis: A rare cause of acute abdominal pain. Am J Emerg Med. 2017;35(7):1040.e1-1040.e4. doi:10.1016/j.ajem.2017.02.050

Our appreciation is extended to Adrian A. Torres Arana, Florida State University College of Medicine in Tallahassee, Florida, U.S., and Drs. Andrew Dakkak and Zachary Ballenger, AdventHealth Orlando in Orlando, Florida, U.S., for contributing to this case.