Journal of Case Reports in Practice (JCRP) 2017; 5(1): 4-6

CASE REPORT

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Atypical presentation of sigmoid colon carcinoma as right lower quad-rant abdominal wall abscess: the visible part of icebergSaeed Kargar1, Ehsan Arjmandzadeh2, Fatemeh Ehsani1, Fatemeh sadat Alavizadeh1, Sara Talebi2

1Department of surgery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran2Department of medicine, International Campus, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

ABSTRACTColorectal cancer (CRC) is the most common cancer of gastrointestinal (GI) tract, third most common cancer with a prevalence of 13% and the second most frequent cause of cancer mortality among men and women worldwide. Locally advanced colorectal cancers account for 5% - 22% of all colorectal carcinomas (CRCs) and are a subgroup of colorectal tumors that invade adjacent organs without distant metastases. Although anterior abdominal wall ab-scesses due to direct invasion of colonic tumors are very rare but have been described and according to the largest review by White et al consists of nine cases collected over a 32-year, have an overall incidence of approximately 1 per 1700 colorecal carcinoma cases. Here we describe a case of sigmoid carcinoma with abnormal presentation due to tumor perforation and right lower quadrant abdominal wall abscess formation. Our purpose is to draw atten-tion to this rare presentation and to indicate that such patients are potentially curable especially under purposeful screening programs.

Key words: colorectal carcinoma, anterior abdominal wall abscesses, rare presentation, potentially curable

INTRODUCTIONColorectal cancer (CRC) is the most common cancer of gastrointestinal (GI) tract1 , third most common cancer with a prevalence of 13% and the second most frequent cause of cancer mortality among men and women worldwide.2 Fortunately in recent years the incidence of CRC is decreasing due to more general population awareness and early diagnosis based on screening programs, considering this fact that more than 95% of all CRCs arise from adenomatous pol-yps.3 Locally advanced colorectal cancers account for 5% - 22% of all CRCs and are a subgroup of colorec-tal tumors that invade adjacent organs without distant metastases. Intra-abdominal abscess formation is rare and only 0.3% - 0.4% of CRCs are associated with abscess. Perforative colonic carcinomas account for 2.6 - 7.8% of CRCs and rarely present as extra-ab-dominal abscess including retroperitoneal abscess, abdominal wall abscess and subcutaneous thigh ab-scess.4 Although abscesses of the anterior abdominal wall due to direct invasion of colonic tumors are very rare too, but have been described5 and according to the largest review by White et al. consists of nine cas-es collected over a 32-year, have an overall incidence

of approximately 1 per 1700 colorecal carcinoma cas-es.6 Here we describe a case of sigmoid carcinoma with abnormal presentation due to tumor perforation and then adherence to the abdominal wall leading to bacterial fecal contamination and abscess formation.

CASE REPORTA 51-year-old man admitted to our hospital with the complaint of abdominal pain and swelling of the abdominal wall in the right lower quadrant (RLQ) (Fig.1). Patient’s abdominal pain was started about 2 months ago and at first it was a generalized and occasional pain with a colicky pattern without any

Correspondence:Ehsan ArjmandzadehDepartment of medicine, International campus, Shahid Sadoughi University of Medical Sciences, Yazd, IranE-mail: ehsanarj69@yahoo.com

Figure 1, Right lower quadrant tender and erythematous swelling, the chief complaint of the patient.

Saeed Kargar et al.

5Journal of Case Reports in Practice (JCRP) 2017; 5(1): 4-6

migration or radiation, aggravated during Valsalva maneuvers and improved after defecation. From 20 days before admission the pain was localized in the RLQ and he noticed a local abdominal wall swelling and skin reddening. On examination the swelling di-mensions were 8×6cm, erythematous and tender, he was systemically well without fever (T: 37.2), obvi-ous weight loss or reduction in appetite but with a neglected bowel habit change and a history of 1 year constipation and about 3 months tarry and smelly stool (melena) discharge. There were no radiological features indicating bowel obstruction. Looking for the source of the abscess and due to melena discharge that raised malignancy suspicious a computed tomog-raphy (CT) scan was performed. CT revealed a solid mass that was not separable from sigmoid and with an evident fistulous tract spreading into the abdomi-nal wall forming an abscess (Fig. 2). The abscess was drained under general anesthesia with about 200 ml non-feculent pus drainage. Patient underwent a mid-line laparotomy. Sigmoid was attached to the abdom-inal wall from the anti-mesenteric side and from the site of the tumor. The mass dimensions were about

10 × 5cm. The adhesions were released and sigmoidal resection with safe border and anastomosis was done (Fig. 3) There were no distant metastases with normal liver, spleen and para-aortic lymph nodes and the le-sion was completely excised. Pathological examina-tion of the tumor specimen showed adenocarcinoma of the sigmoid colon. Our case is unique firstly be-cause of the tumor presenting as abscess, secondly because of an abdominal wall abscess not just an in-tra-abdominal one and thirdly due to the site of the abscess which is located in the RLQ, the opposite side of the anatomical position of the sigmoid colon.

DISCUSSIONTypical clinical manifestations related to colorec-tal carcinoma depends on the site of the tumor and include change in bowel habit as increasing consti-pation or spurious diarrhea, pencil like stool, hema-tochezia and weight loss. CRC is one of the great imitators in medicine and it has a variety of clinical manifestations that are well documented. One of the rare clinical manifestations is perforation and abscess formation.6 Although we have some reports on in-tra-abdominal abscess formation in the presence of CRCs but abdominal wall abscesses are very rare in colorectal carcinoma although have been seen as a presentation of gallstone spillage during laparo-scopic cholecystectomy, tuberculosis, Crohn disease, cholangiocarcinoma and intra-abdominal sepsis.7,8,9

Colonic carcinoma presenting as a subcutaneous ab-scess without acute bowel symptoms is a fact that emphasizes the difficulty of CRC diagnosis which is based on a high index of suspicion.6 The prognosis of CRC mostly depends on the presence or absence of nodal and adjacent tissues involvement although some reports show abdominal wall direct involve-ment due to tumor adherence does not necessarily mean these tumors are non-resectable as many of them who thought to be inoperable benefit from sur-gical approach and on the other side according to the literature such patients are potentially curable.6,10,11

Although the chief complaint of our patient was ab-dominal pain and swelling but there was a neglected

Figure 2, Left cut showing the sigmoid colon (Arrow A) and the tumor (Arrow B) attached to the anterior abdominal wall and sigmoid colon. Right cut showing air in the soft tissues indicating an abscess within the anterior abdominal wall.

Figure 3, RLQ abscess drainage and necrotizing perforated sigmoid colon tumor.

Atypical presentation of Sigmoid colon carcinoma as right lower quadrant abdominal wall abscess

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3-month history of melena discharge emphasizing the importance of accurate history taking and the necessi-ty of CRC screening programs that should be adopted at the age of 45 years old due to the mean age of CRC diagnosis in Iran especially in men who consist about 73% of the colorectal carcinoma cases.12

CONCLUSIONAccording to the importance of early diagnosis in CRC and due to the variety of clinical manifestations of colonic cancers all of the abdominal wall abscess-es without any known origin especially in men need further investigations for ruling out colorectal carci-noma.

CONFLICT OF INTERESTNone.

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Journal of Case Reports in Practice (JCRP) 2017; 5(1): 4-6