CASE 17649 Published on 08.03.2022

Cecal diastatic perforation due to descending colon adenocarcinoma

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Mohamed Rafi Kathar Hussain, Rintu George

Sri Manukulavinyagar Medical College, Puducherry, India

Patient

72 years, male

Categories
Area of Interest Abdomen, Gastrointestinal tract ; Imaging Technique Abdomen, Gastrointestinal tract
Clinical History

A 72-year-old male patient came to outpatient department with complains of abdominal pain, vomiting and constipation for the past 4 days. Clinical examination revealed moderate abdominal distension with mild guarding and tenderness in the right iliac fossa region. Laboratory investigation showed elevated white blood cell count with neutrophilia.

Imaging Findings

Plain radiography revealed multiple air-fluid levels in small and large bowel loops extending up to the left colonic flexure, suggestive of large bowel obstruction(Fig. 1). The following day, emergency non-contrast CT scan (NCCT) of the abdomen was done, which showed midline distended cecum with luminal diameter measuring 9.6cm with associated dilatation of ascending and transverse colon and collapsed recto-sigmoid bowel loops. (Fig.2a). NCCT was done because patient had deranged renal function. Signs of small gaseous collection were noted within the caecal wall, leading to the diagnosis of pneumatosis coli. There was not any abnormal ceacal wall thickening or gas in the intestinal vessels (Fig. 2b). Heterogeneousirregular intraluminal soft tissue density mass lesion of size 3.7 x 3.9 cm was noted in the mid descending colon with associated mild peri-colonic fat stranding (Fig.3a, 3b). Gross pneumoperitoneum (Fig 4a, 4b)was noted inperi-hepatic, perisplenic and peri-colic region with minimal fluid collection in right iliac fossa.The patient underwent emergency laparotomy which confirmed a mass in the descending colon (Fig5a, 5b) associated with cecal perforation (Fig 5a). Left hemicolectomy, transverse colon to rectum end to side anastomosis, cecal closure and loop ileostomy was done. Histopathology report confirmed well-differentiated adenocarcinoma of descending colon (Fig 6).

Discussion

Gastrointestinal tract perforation is one of the most common surgical emergencies with a reported mortality ranging from 30 to 50% [1]. About 15–30% of colorectal cancer (CRC) patients can present with acute abdominal symptoms due to perforation, bleeding and obstruction [2]. The perforation incidence in case of CRC ranges from 2.6% to 10% [3]. Bowel perforation usually occurs at the maximal site of bowel distension, in certain conditions perforated bowel loop may be so distant from the underlying cause of the bowel obstruction. Perforation occurring at the site of tumour is seen in 70% of cases and colonic perforation occurring proximal to the tumour site is seen in around 30% of cases [4]. Perforation occurring proximal to the colonic mass is called as diastatic perforation. It is due to overdistension and blow out of cecal wall [5]. The typical radiologic triad is massive pneumoperitoneum, marked cecal dilatation and large bowel obstruction. In spite of perforation, cecum is dilated which is astonishing [6]. According to the Laplace law, the tube which has the largest diameter requires the least amount of pressure for distension. So, in case of distal large bowel obstruction, with competent ileocecal valve, the cecum is the most common site of perforation [7]. Peritoneal contamination is usually localized in case of tumour site perforation. While in case of proximal perforation, there will be faecal spread resulting in diffuse peritonitis and septic shock [4]. During this scenario, sepsis control is the important priority according to World Society of Emergency Surgery guidelines [4].

CRC is the third leading cause of cancer in men worldwide (10%) and the second cause in women (9.2%). It is the most common form of cancer of the gastrointestinal tract in both male and female [8]. Patients with CRC usually present with wasting syndrome before the bowel lumen is completely obstructed. Ceacal rupture associated with colorectal cancer is rarely described in the literature [8]. The surgical treatment of colonic perforation with cancer still remains controversial. No standardized protocol for the patient management with colonic perforation and the treatment mainly depends on patient’s general condition and experience of the treating surgeon [9]. Emergency colonic resection followed by primary ileocolic anastomosis is generally accepted strategy for perforated cancers of the right-sided with or without peritonitis, whereas discontinuity resection like Hartmann’s procedure is performed in cases of left-sided colon cancers [9]. Perforation itself not associated with poor survival rate, only higher immediate postoperative mortality was the concern.

 

Conclusion

The cecal perforation associated with colorectal cancer is very rare presentation. It is an important surgical emergency; therefore both radiologist and surgeon should be aware this condition for the ideal management.

Differential Diagnosis List
Well-differentiated adenocarcinoma of descending colon with cecal perforation
Colonic diverticular perforation
Ceacal volvulus
Bowel ischemia
Final Diagnosis
Well-differentiated adenocarcinoma of descending colon with cecal perforation
Case information
URL: https://www.eurorad.org/case/17649
DOI: 10.35100/eurorad/case.17649
ISSN: 1563-4086
License