|Year : 2020 | Volume
| Issue : 1 | Page : 46-49
Malignant perforation of sigmoid colon in long-standing ulcerative colitis
GK Adithya, Varun Madaan, Rigved Gupta, Satya Prakash Jindal, Deepak Govil
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, Delhi, India
|Date of Submission||08-Jun-2019|
|Date of Acceptance||24-Jan-2019|
|Date of Web Publication||17-Mar-2020|
G K Adithya
Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, Delhi - 110 076
Source of Support: None, Conflict of Interest: None
Chronic ulcerative colitis (UC) is a risk factor for malignancy in long-term disease process. Obstruction, perforation, and hemorrhage are the possible emergency situations in colorectal malignancy. A 68-year-old male with chronic UC for 18 years with steroid-dependent disease (on 10 mg prednisolone daily) presented with acute pain abdomen with distention not passing stool or flatus for 2 days. The patient was diagnosed to have perforation of colon secondary to rectosigmoid malignancy. Following the adjuvant therapy, the patient denied any definitive surgery and opted to stay on a colorectal cancer surveillance program. At present, the patient's positron emission tomography/computed tomography shows pelvic, liver surface, and small bowel deposits, suggestive of recurrence or metastasis. This case report is discussed to emphasize the importance of aggressive surgical treatment in long-term steroid-dependent disease and poor prognosis of perforated malignancy irrespective of pathological staging.
Keywords: Chronic ulcerative colitis, perforated colonic malignancy, steroid-dependent ulcerative colitis
|How to cite this article:|
Adithya G K, Madaan V, Gupta R, Jindal SP, Govil D. Malignant perforation of sigmoid colon in long-standing ulcerative colitis. Apollo Med 2020;17:46-9
| Introduction|| |
Chronic ulcerative colitis (UC) is a risk factor for many catastrophic events. One among them is a malignancy of large bowel. Data quote a prevalence of 3.7%, and duration is one of the possible etiological factors in UC predisposing to malignancy; a systematic review states a cumulative risk of 3%–4.4% at 10 years, 5.9%–8.6% at 20 years, and 8.7%–12.7% at 30 years., Recent data indicate an incidence ratio of 2.17 and a 30-year risk of 2.1%–7.6%., Even though every complication of long-standing UC culminates in surgery, malignancy particularly affects the prognosis. Perforated tumor in its initial presentation itself portends poor prognosis. It increases the incidence of local recurrence significantly. The exact incidence of perforation of malignancy in UC is not known. Here, we present a case of long-standing UC presenting as perforated sigmoid malignancy in the emergency department.
| Case Report|| |
A 68-year-old male with chronic UC for 18 years with steroid-dependent disease (on 10 mg prednisolone daily) presented with acute pain abdomen with distention not passing stool or flatus for 2 days. The patient was also on mesalamine 1.2 g twice daily throughout. The presentation was associated with a low-grade fever for 2 days. Abdominal examination revealed distention with diffuse tenderness. Blood report showed leukocytosis with white blood cell count of 14.49 103/mm3. The patient had his last colonoscopy 8 years back. Contrast-enhanced computed tomography (CECT) abdomen done at presentation showed a short segment of heterogeneously enhancing mural thickening (16 mm) of the sigmoid colon with pericolic fat stranding, causing abrupt and near-complete luminal narrowing and shouldering suggestive of a stricture with proximal dilatation of large bowel. Mesenteric vasculature around the involved bowel segment looked prominent. Distal sigmoid colon and rectum and small bowel appeared normal. There was an evidence of loculated peripherally enhancing suprapubic collection with air foci within it measuring 5.8 cm × 3.7 cm, closely abutting the sigmoid stricture with a linear-enhancing tract, arising from it, and communicating with the collection pocket; however, no definite evidence of any extraluminal air or ascites was seen [Figure 1]. Suspecting tumor perforation, emergency exploratory laparotomy was planned. Intraoperatively, the following findings were noted: grossly dilated colon till the rectosigmoid junction with an abscess cavity attaching the anterior wall of sigmoid to the posterior bladder wall, with colonic wall breach when abscess pocket was cleared [Figure 2]. A 5 cm × 6 cm mass lesion in the distal sigmoid colon was noted with narrowing at that site. Pseudopolyps were seen at the cut end of the bowel [Figure 3]. The sigmoid colon containing the tumor was resected, and Hartmann's procedure was performed. The postoperative period was uneventful. The patient was managed in the intensive care unit with parenteral steroids. The final histopathological examination showed well-differentiated adenocarcinoma infiltrating deep into muscularis propria and focally invading the subserosa without lymphovascular and perineural invasion. Proximal and distal resection margins were free from tumor, and no lymph node metastasis was present (0/11). TNM staging was pT3N0Mx. The patient was offered restorative proctocolectomy after 12 cycles of adjuvant chemotherapy (FOLFOX). However, the patient refused to undergo any kind of definitive procedure and chose to be under surveillance even after detailed discussion about the pros and cons of both. Follow-up carcinoembryonic antigen was 3.3 ng/ml. The patient underwent Hartmann's reversal with ileostomy with ventral hernia repair after 10 months of primary surgery. Ileostomy was reversed after 5 months for various reasons. The patient was on surveillance imaging and colonoscopy till now and remained asymptomatic with complete disappearance of colonic lesions on colonoscopy. The patient could not be freed from steroids. He was on regular follow-up with a medical oncologist and being surveilled with regular CECT/positron emission tomography (PET)/CTs. At present, his PET/CT shows intensely fluorodeoxyglucose (FDG)-avid (maximum standardized uptake value [SUVmax]: 18.78) nodular wall thickening in the lateral and anterior wall of rectum with FDG-avid (SUVmax: 16.76) enhancing nodular lesion along the pelvic floor involving the superior and left lateral wall of urinary bladder continuing inferiorly with the prostate which also shows heterogeneous enhancement suggestive of pelvic peritoneal deposits. FDG-avid (SUVmax: 10.30) peritoneal deposits are seen on the liver surface and surface of bowel loops which are new findings along with FDG-avid (SUVmax: 8.80) nodular stranding at the lower anterior abdominal wall suggestive of deposits [Figure 4]. In view of these findings, transurethral resection of bladder tumor was done which revealed it to be a bladder tumor.
|Figure 3: Loculated collection around strictured sigmoid colon with wall thickening (arrows in the upper and lower picture, respectively) and proximal dilatation|
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|Figure 4: Positron emission tomography/computed tomography showing fluorodeoxyglucose-avid lesions at the rectum, anterior abdominal wall, and liver surface|
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| Discussion|| |
Malignancy is a well-known complication of chronic UC. Because of which, colonoscopic surveillance is a must in these patients after 8 years of disease onset. The American Society for Gastrointestinal Endoscopy, American College of Gastroenterology, American Gastroenterological Association, and Crohn's and Colitis Foundation of America guidelines recommend initiation of colonoscopic surveillance after 8–10 years of disease detection. This particular protocol does not guarantee the occurrence of malignancy before that period. Hence, a high level of clinical suspicion will need investigations to rule out malignancy. Colorectal malignancies can present in different ways, either obstruction with or without perforation or locally or distantly advanced disease. In our patient, it had presented with local catastrophe. Timely intervention was able to salvage the patient. However, those patients who do not follow the protocol for colorectal cancer (CRC) surveillance miss out on the opportunity for early detection.
It is shown that 5-aminosalicylic acid use is protective in preventing early colorectal malignancies suggesting its potential role as a chemoprevention tool in inflammatory bowel disease (IBD) patients. However, our patient was on mesalamine throughout his treatment period; still, compliance is a big game changer. Long-term steroid dependence is definitely an indication for surgery. However, its role in causation of malignancy individually is not known. Long-term steroid usage is an indirect marker of unfavorable disease process and definitely earns early surgery. In our patient, he was able to cope up with steroid usage and did not ask for definitive surgery. Long-standing disease (>8 years), extensive colitis (proximal to the splenic flexure), backwash ileitis, severe inflammation activity, colitis-associated primary sclerosing cholangitis, and family history of CRC seem to increase the risk of IBD-associated malignancy.
The long-term prognosis of patients with perforated colorectal tumors is dismal due to the advanced malignancy status and the possibility of tumor seedling through the perforation site. The extent of peritoneal contamination determines the prognosis. In our case, perforation was contained which may contribute to long-term survival, as he completed a full course of adjuvant chemotherapy. Tan et al. have published a 5-year experience of perforated colorectal malignancy. A total of 45 patients in 5 years were operated for CRC malignant perforation with sigmoid colon (n = 17, 37.8%) and cecum (n = 13, 28.9%) being the most common sites of perforation. Perforation proximal to the tumor (diastatic perforation) was seen in 11 (24.4%) patients, whereas perforation at the tumor was seen in the remaining 34 (75.6%) patients. Sixteen (35.6%) patients had Stage IV disease during surgery, and the rest had Stage II and III diseases. Hartmann's procedure and right hemicolectomy were most frequently performed in 17 (37.8%) and 15 (33.4%) patients, respectively. Eight (17.8%) patients died in the perioperative period and 12 (26.7%) required surgical intensive care unit care. The median length of stay was 10 (2–54) days. Thirty-seven (82.2%) patients survived overall. Defunctioning ileostomy was closed in all the patients (n = 4) and only four patients with Hartmann's procedure. A total of 10 (41.7%) patients had disease recurrence. The median time to recurrence was 13 months (6–48 months). Factors such as site of perforation, diastatic perforation, age, gender, American Society of Anesthesiologists score, and extent of peritonitis were all not associated with recurrence.
With these two factors in mind, long-term steroid-dependent disease and perforation of malignant lesion of the sigmoid, the patient should be offered restorative proctosigmoidectomy with ileal pouch–anal anastomosis (IPAA). Since the perforation was contained, IPAA can be contemplated in this patient. This case report is discussed to emphasize the importance of aggressive surgical treatment in long-term steroid-dependent disease and poor prognosis of perforated malignancy irrespective of pathological staging.
| Conclusion|| |
Strict adherence to surveillance protocol is a must, and an aggressive surgical approach should be the norm in long-term steroid-dependent patients. Tumor perforation is a potential risk factor for early and unfavorable recurrences.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]