Anterior Abdominal Wall Abscess: An unusual presentation of Carcinoma of the Colon

Background:Colorectal cancer progresses without any symptoms early on, or those clinical symptoms are very discrete and so are undetected for long periods of time. The case reported is an unusual presentation of colorectal cancer.

案例报告：一个60岁的男子出现右侧腹部肿胀。经检查，注意到一个明确的，坚固，嫩的肿胀。计算机断层扫描证实，右侧腹壁和邻近收集的右结肠存在质量。进行了探索性剖腹手术，并进行了皮下脓肿，切除结肠的切除和回肠坦率结肠吻合术。

Conclusion:A differential diagnosis of carcinoma colon should be considered when an elderly patient presents with abdominal wall abscess accompanied by altered bowel habits or per rectal bleeding, even if there are no other significant clinical symptoms and a thorough investigative work up is required to confirm the diagnosis, to avoid untimely delay in treatment, and reduce mortality.

Carcinoma colon is the tenth leading cancer in India [1] and the fourth most common cause of death [2]. Perforation of colorectal cancer is rare as its incidence is 2.6-7.8% [3,4]. There can be either direct perforation into the peritoneal cavity or local perforation forming an abscess or fistula. Rare presentations of perforated colorectal carcinomas are subcutaneous thigh abscess, retroperitoneal abscess, abdominal wall abscess, subcutaneous emphysema [5].

报道的病例是癌结肠的不寻常表现。它显示出由于恶性质量穿孔以及随后的菌血症和败血症而形成的脓肿。该报告强调需要早期发现和将这种异常发现作为差异诊断的这种异常发现，以降低败血症的患者死亡率。

A 60 year old man presented with an 8 months history of intermittent constipation with occasional bleeding PR, abdominal discomfort and sense of incomplete evacuation after defecation. On initial evaluation, colonoscopy done showed ascending colon stricture with surrounding nodularity and biopsy suggestive of granulomatous colitis - possibility of tuberculosis or Cohn’s disease.

Patient was hence started on mesalazine, and advised to follow up. Patient was then lost to follow up for 4 months, when he presented again to the emergency department with fever with chills, right abdominal mass and had features of sepsis with tachycardia, elevated total counts and deranged liver & renal function tests. On examination, a well-defined firm, tender mass in the right hypochondrium and lumbar region extending up to right iliac fossa (Figure 1c).

对比度增强了腹部完成的计算机断层扫描，显示出上升结肠近端部分的异质壁增厚，壁分层损失并导致腔狭窄，尺寸为5.56 x 4.28 x 4 cm，周围炎症变化，邻近定义良好的收集10.45 x 3.8 x 9.43 x 9.43 x 9.43 x 9.43CMS和很少的空气口袋，渗入右侧腹壁（图1A，B）。腹部肿胀的细针吸入细胞学没有显示出恶性细胞的迹象。脓液被送去培养，长大了大肠杆菌。由于白细胞增多症并在完全血液的情况下进行左转，因此根据培养敏感性给予患者抗生素。

Patient was taken up for diagnostic laparoscopy and proceeded to exploratory laparotomy, abscess drained and an ileo-transverse colon anastomosis done. Intraoperatively omental deposits, and enlarged lymph nodes were noted (Figure 1c,d), FNAC done from these lesions were positive for malignancy, and histopathologcal examination was suggestive of metastatic mucin secreting adenocarcinoma.

患者术后患败血症。患者患有持续性低血压并最终在术后第四天到期。

结直肠癌是一种常见的致命疾病，如果未早期检测到延迟治疗。该疾病可能会在早期就没有任何症状而进展，并且由于其异常表现或出现离散症状而臭名昭著。它通常表现出直肠出血，腹痛，肠习惯的改变或贫血和隐匿性出血[6,7]。

Unusual presentations include local invasion or a contained perforation leading to formation of a malignant fistula into adjacent organs (bladder or small bowel), pyrexia of unknown origin, intra-abdominal, retroperitoneal, abdominal wall or intrahepatic abscesses; Streptococcus bovis bacteremia and Clostridium septicum sepsis are associated with underlying colonic malignancies in approximately 10 to 25 percent of patients [8].

结肠镜检查等传统研究可能不足，因为它不能证明超出结肠腔以外的异常。重复活检显示了良性病变，非特异性病理报告。因此，通常需要使用计算机断层扫描（CT）进行结构化评估。可以在CT上划定外生生长，局部脓肿形成的癌症，并浸润成相邻结构，腹壁的参与及其程度和淋巴结受累。在我们案例中，CT扫描显示出恶性和脓肿的存在，但没有显示两者之间的关系。

在我们的情况下，有时可能需要进行诊断性腹腔镜或探索性剖腹手术来确定诊断，并获得确定的病理学和微生物样本进行诊断。

败血症的控制以及对主要恶性肿瘤的治疗是通常的治疗方法。

我们的案例强调了迅速诊断和早期管理的重要性，因为3个月的延迟导致疾病的局部扩散并传播败血症，最终导致患者死亡。如果伴有肠症状，则应在鉴别诊断中考虑结肠癌。如果不排水和切除，它可能会导致败血症等并发症，这可能危害生命。

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