Cecal adenocarcinoma causing perforated appendicitis and ileal obstruction
Presentation
One week of generalized abdominal pain, worse in the last 24 hours with pain more in right iliac fossa. Nausea and vomiting. Peritonism. Raised white cell count.
Patient Data
Irregular mass-like enhancement of the cecum with abnormal wall thickening causing obstruction of the appendiceal orifice. The appendix is dilated and fluid-filled measuring 19 mm in maximal diameter. The appendix extends from the cecum inferiorly and courses across the midline to the left. The appendiceal tip demonstrates decreased mural enhancement. Significant mesenteric stranding is seen throughout the right iliac fossa with a small volume of free fluid tracking into the pelvis. The adjacent terminal ileum demonstrates mural edema and fecalisation of contents proximally.
Enlarged right lower mesenteric lymph nodes. Some of these are mildly hyperdense and show contrast enhancement. Diffuse small para-aortic and retrocrural lymph nodes.
Dependent calcified gallbladder sludge within the gallbladder fundus. No CT features of cholecystitis. The liver, spleen, pancreas, and adrenal glands are normal. Small bilateral midpolar renal cysts.
Small enostoses in the left inferior ileum adjacent to the left sacroiliac joint. No concerning osseous lesion identified. Mild dependent hypostatic changes in the lung bases bilaterally.
Impression
cecal mass causing appendiceal obstruction. Reduced enhancement of the appendiceal tip is suspicious for necrosis. No features of perforation at this stage. The cecal mass is cancer until proven otherwise. Surgical opinion is advised
terminal ileitis with small bowel feces sign which indicates slow transit, which could be secondary to inflammatory change or partial ileal obstruction from the cecal mass
multiple enlarged right mesenteric lymph nodes are larger than expected for simple inflammation of the appendix and are suspicious for neoplastic involvement. Given some of these are hyperdense, DDx should include neuroendocrine neoplastic disease of the cecum
Operative report:
Findings:
localized perforation of the necrotic appendix with abscess cavity in the pelvis. A loop of sigmoid colon was adherent to the abscess cavity but separated easily from the perforation. Pus from the cavity was sent for microscopy, culture, and sensitivity (MCS)
firm cecal mass with highly adherent small bowel loop approximately 100 cm from the ileocecal valve. The small bowel loop would not separate and was likely involved with the malignancy and resected en bloc
multiple firm lymph nodes along the ileocolic pedicle. All were swept to specimen and no palpable major lymph nodes remained
free serous peritoneal fluid has been sent for cytology and MCS
no palpable liver metastases or obvious peritoneal disease
Procedure:
midline laparotomy
fluid was sent for cytology and MCS
abscess cavity washed out and pus was sent for MCS
sigmoid colon peeled off abscess cavity, grossly intact. Right colon mobilized from inferior to superior, lateral to medial, exposing duodenum. Hepatic flexure taken down. Some troublesome venous bleeding from near the head of pancreas oversewn with 3-0 PDS (polydioxanone). Flowseal high ileocolic double ligation
All suspicious lymph nodes were swept to the specimen side
small bowel adherent to cecum resected en-block with the specimen. A side-to-side stapled anastomosis with 80 mm linear stapler was used 100 cm proximal to the IC valve. Approximately 10 cm of small bowel resected
a side-to-side stapled coloenteric anastomosis was fashioned with an 80 mm linear stapler. This was oversewn with running PDS
both mesenteric defects closed with PDS
Case Discussion
The patient underwent post-operative chemotherapy and is disease-free after 2 years. A few benign polyps have been removed on follow-up colonoscopy.
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