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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 20-21

Carcinoma of the ascending colon presenting as a retroperitoneal abscess


Department of General Surgery, Goa Medical College, Bambolim, Goa, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Shantata Kudchadkar
Goa Medical College, Bambolim, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_8_18

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  Abstract 


Patients with the right side of colonic malignancy commonly present with obstruction and bleeding. At times, in 4% of cases, they may present with perforation. Presentation with symptoms other than these is rare. Besides atypical presentations of colonic malignancy are associated with poor prognosis. We present a case report of a retroperitoneal abscess following a perforated ascending colon malignancy as a primary presentation of carcinoma of ascending colon.

Keywords: Ascending colon carcinoma, perforation, retroperitoneal abscess


How to cite this article:
Kudchadkar S, Chodankar S, Amonkar D. Carcinoma of the ascending colon presenting as a retroperitoneal abscess. Indian J Colo-Rectal Surg 2018;1:20-1

How to cite this URL:
Kudchadkar S, Chodankar S, Amonkar D. Carcinoma of the ascending colon presenting as a retroperitoneal abscess. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2018 Dec 9];1:20-1. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/1/20/241302




  Introduction Top


The malignancy of caecum and ascending colon commonly presents as a lump or obstruction. Presentation as an abscess is very rare. We present a case report where the patient presented with a retroperitoneal abscess following perforation of the malignant caecum, ascending colon.


  Case Report Top


A 70-year-old lean female was referred to us from a primary health center with complaints of fullness in the right lumbar region for 1 month with pain and fever for 10 days. On clinical examination, a tender and fluctuant swelling measuring 10 cm × 15 cm were noted in the right lumbar region. Clinical examination did not reveal psoas rigidity sign and costolumbar sensitivity. The patient had no underlying diabetes and was not immunocompromised. On further evaluation, blood investigations revealed hemoglobin of 9.9 g/dl, with raised white blood cell counts of 21,300. Her biochemical investigations were normal. A clinical diagnosis of psoas abscess of tuberculous etiology was made. Ultrasound sonography abdomen was done, which showed evidence of a large collection measuring 12 cm × 10 cm × 14.5 cm in the right posterolateral abdominal wall. The collection extended up to the retroperitoneal space on the right side, displacing the right kidney and hepatic flexure of the colon medially with dense internal echoes within. There was no evidence of pneumoperitoneum. After working up the patient, the patient was operated through a retroperitoneal approach. A pus collection of 500 ml was drained. A tube drain was placed, and closure was done. On the postoperative day 8, there were feces seen in the drain. Contrast-enhanced computed tomography (CT) was done which showed a mass causing circumferential thickening of the ascending colon extending to a length of 6 cm, with wall thickness of 1.5 cm with pericolic stranding and lymphadenopathy suggestive of neoplastic etiology. There was a peripherally enhancing retroperitoneal collection measuring 8.1 cm × 5.5 cm × 3.6 cm on the posterior aspect of the ascending colon. Carcinoembryonic antigen level done was 307.99 ng/ml. Hence, the patient was taken to laparotomy. Intraoperatively, an irregular, hard mass in the ascending colon with omentum adhered to the mass with posterior perforation of the ascending colon was a found. A thorough lavage was given, followed by right hemicolectomy with ileostomy. Histopathology of the resected specimen revealed poorly differentiated adenocarcinoma.


  Discussion Top


Colonic carcinoma is the third most common cancer in men (663,000 cases, 10% of all cancer cases) and the second most common in women (571,000 cases, 9.4% of all cancer cases).[1],[2] In India, the annual incidence rates (AARs) for colon cancer and rectal cancer in men are 4.4 and 4.1/100,000, respectively. The AAR for colon cancer in women is 3.9/100,000. Colon cancer ranks the 8th and rectal cancer ranks the 9th among men. Among women, colon cancer ranks 9th.[3]

The right-sided colon adenocarcinomas comprise approximately 20% of large bowel cancers. It commonly presents with anemia, mass, and weight loss.[3],[4] Presentation of abscess following perforation in a patient of the right-sided colon is an uncommon presentation. Cecal and ascending colon perforation most commonly occurs due to sepsis. Posterior perforations are usually sealed and do not manifest overtly. At times, it leads to an abscess on the psoas muscle in the retroperitoneal space, as in our case.[5] At times, peritonitis may occur due to a free perforation of the cecum.[6],[7] Clinical signs (e.g., psoas rigidity sign and costolumbar sensitivity) play a significant role in the diagnosis [8],[9] of a retroperitoneal abscess. These clinical signs were absent in our case.

Retroperitoneal abscess may be of the multifactorial origin. It can be either primary with no definite etiology or can be secondary to gastrointestinal, genitourinary infections, and other adjacent infected organs. Important predisposing factors are considered to the diabetes mellitus, muscle trauma, and immunocompromised states as in HIV-positive individuals.

Ultrasound examination is the investigation of choice for the diagnosis of the retroperitoneal abscess.[10] CT has a greater sensitivity. The abscess can be treated with CT-guided drainage of the abscess with broad-spectrum antibiotic coverage which is the main treatment. Sometimes, surgical intervention may be needed to explore the abdomen and/or even excise any primary neoplastic lesion causing the abscess. When surgery is performed early in the course of the disease, the prognosis may be quite good, otherwise, mortality is high (2.5%–20%) due to lethal sepsis.[11] Treatment of choice for cecal carcinoma is right hemicolectomy, which is performed as soon as the diagnosis has been made.


  Conclusion Top


Right-sided colon carcinomas are one of the common cancers. Although bowel perforation is a well-recognized complication of colon carcinoma, symptoms and physical findings may be misleading, mainly in older adults, leading to delay in the diagnosis and prompt treatment with increase in the morbidity and mortality. Perforated colonic carcinoma may mimic many other diseases and should always be kept in mind during the differential diagnosis of retroperitoneal abscesses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rovito PF, Verazin G, Prorok JJ. Obstructing carcinoma of the cecum. J Surg Oncol 1990;45:177-9.  Back to cited text no. 1
    
2.
Morris PJ, Malt RA. Oxford Textbook of Surgery. The Netherlands: Oxford University Press; 1995.  Back to cited text no. 2
    
3.
Foss JF. Cecal carcinoma presenting as acute appendicitis. Postgrad Med 1989;86:123, 126.  Back to cited text no. 3
    
4.
Fabri PJ, Carey LC. Cecal carcinoma presenting as acute appendicitis: A reappraisal. J Clin Gastroenterol 1980;2:173-4.  Back to cited text no. 4
    
5.
Kuo DY, Smith HO, Runowicz CD, Goldberg GL. Cecal cancer in a teenager presenting with a pelvic mass: A case report and review of the literature. Gynecol Oncol 1994;55:149-51.  Back to cited text no. 5
    
6.
Panwalker AP. Unusual infections associated with colorectal cancer. Rev Infect Dis 1988;10:347-64.  Back to cited text no. 6
    
7.
Bohrer SP, Bodine J. Perforated cecal carcinoma presenting as thigh emphysema. Ann Emerg Med 1983;12:42-4.  Back to cited text no. 7
    
8.
Mann GN, Scoggins CR, Adkins B. Perforated cecal adenocarcinoma presenting as a thigh abscess. South Med J 1997;90:949-51.  Back to cited text no. 8
    
9.
Kelley WE Jr., Brown PW, Lawrence W Jr., Terz JJ. Penetrating, obstructing, and perforating carcinomas of the colon and rectum. Arch Surg 1981;116:381-4.  Back to cited text no. 9
    
10.
Jakab F, Egri G, Faller J. Clinical aspects and management of a retroperitoneal abscess. Orv Hetil 1992;133:2335-9.  Back to cited text no. 10
    
11.
Zielinski M D, Merchea A, Heller S F, You Y N. Emergency management of perforated colon cancers: how aggressive should we be? J Gastrointest Surg 2011;15:2232-8.  Back to cited text no. 11
    




 

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Abstract
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Case Report
Discussion
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