Peritonitis and Small Bowel Obstruction in a Colorectal Cancer Patient

Abstract

Background: Colorectal carcinoma is one of the most common types of cancer and the second leading cause of cancer related deaths. Age is a significant risk factor, peaking at over 80 years of age. Over 90% of these cancers are colorectal adenocarcinomas and are diagnosed mainly by an endoscopic biopsy or polypectomy. Although early detection significantly improves the prognosis, the disease often doesn’t present with typical clinical manifestations, leading to late or false diagnosis, tumor proliferation and systemic symptoms, such as cachexia and anemia. However, fecal occultation test and abdominal palpation can be helpful in detecting the cancer earlier. Intestinal obstruction usually occurs in the late stages of the disease and can present with abdominal pain, nausea, vomiting, exhaustion and sometimes spurious diarrhea. The following is a case report of a colorectal cancer patient which was initially mistaken for an infection. Case report: An 83 year old female patient with history of Parkinson’s, hypertension with heart failure, stage 3 chronic kidney failure and progressive cerebral ischemia arrived at the Emergency Department complaining of vomiting and yellow diarrhea that started a week prior. An infection was suspected and an elective endoscopy was recommended due to slight anemia. The patient returned two weeks later with constipation lasting for a week and general weakness. The patient had also lost 10 kilograms during the previous month. After performing abdominal ultrasound and esophagogastroduodenoscopy (EGD) the patient was sent to the Department of Surgery with suspicion of colorectal cancer. Ultrasound showed 200 ml pleural effusion as well as fluid in the peritoneal cavity, signs of intestinal obstruction. EGD showed external small bowel compression, however biopsy of intestinal wall was negative. Abdominal x-ray showed small intestine dilation to 4.3 cm and air-fluid levels. Colon was not dilated. C-reactive protein was 43, Ca 125 - 73.40, Ca 19-9 - 27.80, carcinoembryonic antigen - 11.70. Computed tomography scan showed signs of intestinal obstruction, air and fluid in the peritoneal cavity, small bowel dilation due to tumor near ileocecal valve with paracolic 1.1 cm nodes and another tumor at rectosigmoid segment. Right dome of diaphragm was relaxed and there was 2.8 cm liquid in the right pleura with signs of right lung compression Peritonitis was suspected and the patient was scheduled for an emergency surgery. Laparotomy, peritoneal drainage, decompression, right hemicolectomy and sigmoid colon resection with anastomosis were performed. Histology showed intestinal type colorectal adenocarcinoma. The patient was treated with intravenous cefuroxime and metronidazole, o2 therapy, infusions, low molecular weight heparin and increased nutritional protein for hypoalbuminemia. After three weeks the patient was sent home to continue outpatient treatment with an oncologist. Conclusions: Colorectal cancer is often missed or misdiagnosed, leading to treatment delay and tumor and symptom progression, highlighting the need for screening in some patients presenting with gastrointestinal symptoms, especially those above 80 years of age. In this case a missed diagnosis led to small bowel obstruction, peritonitis and emergency surgery.