Figure 1
Teaching Case
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsR. Thiagarajah, N. Menezes
Connected authors
89 years, male
With a
previous history of a TURBT 14 days ago, presented with a 10 days history of lower abdominal pain without fever and a tender palpable mass. An ultrasound scan and subsequent CT scan were
performed.
Duke’s C adenocarcinoma of the colon
An 89-year old male with a previous history of a TURBT 14 days ago, which later showed histology of grade 1 papillary transitional cell carcinoma with no
evidence of metaplasia, presented with a 10 days history of lower abdominal pain without fever and a tender palpable mass. His clinical history included ischaemic heart disease, hyperthyroidism,
hypertension, atrial fibrillation and DVTs.
An ultrasound scan showed a 7.0 x 6.7 x 6.3cm area of thickened bowel loops. CT scan of the abdomen was performed. There was marked thickening of the proximal
sigmoid colon with a walled off collection of fluid immediately adjacent to it. The appearances were likely to represent a paracolic collection. There was no evidence of metastatic disease.
The patient subsequently underwent a Hartmann’s procedure. Intra-operatively, a localized perforation of the sigmoid colon with a large abscess cavity
adherent to the posterior abdominal wall and the superior aspect of the bladder was seen. The sigmoid colon was thickened and inflamed – a likely diverticular perforation.
Histology revealed a Duke’s C adenocarcinoma of the colon.
There have been previous reports of adenocarcinoma of the colon presenting primarily as a liver abscess in the West Indies [1], as an abdominal wall
and thigh abscess in Japan [2] , as an abscess during pregnancy in Greece [3] and a psoas abscess in Spain [4]. There was also a rare account in the UK of an
adenocarcinoma of the transverse colon presenting as an abdominal wall abscess [5].
We present an adenocarcinoma of the sigmoid colon presenting as a paracolic abscess, which is an unusual primary presentation. The most common causes of intra-abdominal abscess are peptic ulcer
disease, appendicitis, diverticulitis, cholecystitis and mesenteric ischemia, and pancreatitis [6].
The most frequently used investigation of diverticulitis and intra-abdominal abscess, other than plain radiograph, is the water-soluble contrast enema.
Ultrasonography is also valuable in a patient with a suspected abdominal-pelvic mass. Colonoscopy and barium enema are usually contra-indicated in the acute setting of diverticulitis due to
potential hazards. CT is recommended when an abscess in suspected [7]. Another modality that has been used to investigate intra-abdominal abscess is a 111In-labeled white blood cell
scan, which has been used to demonstrate a sigmoid carcinoma mimicking an intra-abdominal abscess by Gouzi et al. [8].
In our case, the initial aetiology was assumed to be diverticulitis but the histology revealed a diagnosis of adenocarcinoma of the sigmoid colon. This rarely
presents as a paracolic abscess.
References
[1] Millichap JJ, McKendrick AI, Drelichman VS. (2005) Streptococcus intermedius liver abscesses and colon cancer: a case report. 54(5):341-2. (PMID: 16459520)
[2] Tsukuda K, Ikeda E, Miyake T, Ishihara Y, Watatani H, Nogami T, Masuda H, Takagi S, Hirai R, Moriyama S, Tsuji H, Furutani S, Kunitomo T, Nawa S. (2005) Abdominal wall and thigh abscess resulting from the penetration of ascending colon cancer. Acta Med Okayama. 59(6):281-3. (PMID: 16418772)
[3] Papathanasiou K, Tolikas A, Savvidis A, Traianos V, Tzafettas J. (2004) Advanced sigmoid colon cancer in pregnancy presented as an abscess. J Obstet Gynaecol. 24(3):319-20. (PMID: 15203644)
[4] Merino Munoz D, Perez Ruiz JM, Creagh Cerquera R, Galvez Acebal J, Pujol de la Llave E. (2001) Psoas abscess as first manifestation of a sigmoid adenocarcinoma. An Med Interna. 18(9):500-1. (PMID: 11715142)
[5] Andaz S, Heald RJ. (1993) Abdominal wall abscess--an unusual primary presentation of a transverse colonic carcinoma. Postgrad Med J. 69(816):826-8. (PMID: 8290422)
[6] Saber, A.A. LaRaja, R.D. Abdominal abscess. http://www.emedicine.com/med/topic2702.htm.
[7] Gouzi JL, Bloom E. (1995) Radiological and endoscopic diagnosis of sigmoid diverticulitis. Rev Prat. 15; 45(8):978-81. (PMID: 7761782)
[8] Becker W, Schaffer R, Borner W. (1885) Sigmoid carcinoma mimicking an intra-abdominal abscess in an 111In-labeled white blood cell scan. Eur J Nucl Med. 11(6-7):283-4. (PMID: 3935448)
Case information
| URL: | https://www.eurorad.org/case/5424 |
| DOI: | 10.1594/EURORAD/CASE.5424 |
| ISSN: | 1563-4086 |
