Acute Appendicitis with Abscess Formation As Complication of Carcinoma of the Cecum CLEO MILLER, M.D. Diplomate, American Board of Surgery, Nashville, B. F. WOOLDRIDGE,M.D., Boston, Massachusetts From tbe Department of Surgery, Hospital, Nasbville, Tennessee.
Mid-State
the right Iower quadrant. The peIvic examination confirmed this right Iower quadrant mass. Other physica findings were not abnormal. Laboratory examinations reveaIed the urine to be normaI. HematoIogy reveaIed an anemia consisting of 8.0 gm. per cent hemoglobin with 3.60 miIIion red blood ceIIs; the white bIood count was 14,500 with a shift to the left. BIood seroIogy was negative. X-ray examination of the coIon after barium enema reveaIed the folIowing: “The colon hIIs readiIy and there are no defects seen. During the IIuoroscopic examination there was a pressure deformity of the cecum, but when the cecum is compIeteIy fiIIed, this deformity disappears.” The diagnosis was somewhat in doubt after this evaIuation, it being thought that the patient had either an appendicea1 abscess or a right ovarian cyst. Due to the upper respiratory tract infection and the paucity of toxic symptoms it was thought advisabIe to postpone surgery unti1 a sIightIy Iater date. The patient was treated rather intensiveIy with antibiotics as an outpatient and was readmitted to the hospita1 three weeks Iater. Examination of the abdomen reveaIed considerabIe voluntary and invoIuntary muscIe rigidity in the right Iower quadrant and there was a suggestion of an iII-dehned mass in the right lower quadrant. There was slight rebound tenderness. PeIvic and recta1 examinations were within norma Iimits and the remainder of the physica examination was not remarkabIe. Hemogram on this admission was 8.0 gm. per cent hemogIobin with 3.51 miIIion red blood ceIIs. The white bIood count was I 1,050 with an essentiaIIy norma differential count. On examination the urine was normaI. Preoperative bIood transfusions were given, and two days Iater the abdomen was expIored through a McBurney incision under genera1 anesthesia. The previousIy noted mass was found to be retroperitonea1 and retroceca1, and
Baptist
CUTE appendicitis as a comphcation of carcinoma of the cecum is unusuaI and as a subject entity has received scant mention in the Iiterature. Robinson and ErnstlO in 1953 were able to coIIect onIy nineteen recorded cases and added one additiona case report. In the case reported herein the patient was operated upon for what was beIieved to be appendicitis with abscess formation. She was found to have a periceca1 abscess, the contents of which contained flaky material in which adenocarcinoma was found microscopicaIIy. Subsequent right hemicoIectomy reveaIed a smaI1 uIcerating carcinoma of the cecum which was beIieved to have instigated obstructive appendicitis with rupture and abscess formation.
A
CASE
Tennessee AND
REPORT
E. M. first entered the hospita1 on January 3, 1953, presenting herseIf as a fifty year old white married gravida II, para II. Her chief compIaint was pain in the right Iower abdomen. About ten days prior to this hospita1 admission she began to experience sharp and aching pain in the right Iower abdomina1 quadrant. The pain had remained IocaIized without radiation. Throughout the present iIIness she had continued to have this constant aching pain in the right Iower quadrant and had experienced some nausea and vomiting. There had been associated anorexia and some fever. Her Iast menstrua1 period was a norma one and had occurred two months prior to the onset of the present iIIness. She had had no bIeeding since that time. The past history, famiIy and socia1 history were irreIevant. PhysicaI examination reveaIed a bIood pressure of 135/80, temperature 99.8”~., puIse 90 and respirations 20. There was moderate injection of the nasopharynx. Examination of the abdomen reveaIed a tender, iII-defined mass in 500
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a
I
FIG. I. IIIustrates the microscopic
appearance
of the mutinous ffakes present within the abscess cavity.
IIIustrates the microscopic
appearance
at the region of dceration
FIG.
2.
with mobilization was found to be a pericecal abscess. The suppurative content, however, was found to contain an admixture of mucoid materia1, and severa Iarge ffakes of this aIong with a portion of the abscess waI1 were sent to the laboratory for microscopic study. The abscess cavity was evacuated and a rubber tissue drain inserted for externa1 drainage. No evidence of an appendix was found at this operation. The pathoIogic report read as foIIows: “The specimen consists of varied-sized masses of mucous and puruIent exudate and a singIe piece of fat removed from the region of the cecum. The tissue appears ragged and hemorrhagic. Microscopic pathoIogy shows a marked acute and chronic inffammatory reaction and one margin appears to have been the waI1 of an abscess. In this tissue, there is no evidence of any maIignancy. HistoIogic examination of the mucoid materia1 found in the region of the cecum reveaIs the presence of a mutinous carcinoma. Nowhere in this section is there evidence of any structure resembIing appendix. A simpIe mucoceIe of the appendix wouId not have the apparent neopIastic ceIIs in the
of the cecum.
mucoid materia1. With the finding at operation of norma ovaries, it is supposed that this represents a mutinous carcinoma of the cecum.” Figure I, iIIustrates this microscopic picture. Postoperatively the patient was treated with nasogastric suction for twenty-four hours. The tissue drain was progressiveIy removed, and foIIowing its remova the wound promptIy cIosed. Eight days Iater, under spina anesthesia, a right hemicoIectomy with iliotransverse coIostomy was carried out without incident. The pathoIogic report read as foIIows: “The specimen consists of a portion of the termina1 iIeum, the cecum and the ascending colon. The periceca1 fat is markedIy indurated and beIow the IeveI of the iIeoceca1 vaIve, there is a ragged perforation that extends into the cecum. The appendix is not found in this specimen. On opening the bowe1, the portion of the iIeum appears normaI. BeIow the region of the iIeoceca1 vaIve on the cecal side, there is a smaI1, ovaI, 2% X 145 cm. uIcerating tumor. The margins of the tumor are flattened and the base communicates with the perforation. The waI1 of the tumor is soft and mucoid. 501
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3,400 cases of acute appendicitis. Considering simpIy the mechanics invoIved of neopIastic obstruction, one would not expect the association of carcinoma of the cecum and appendicitis to be so unusua1. Another causa1 reIationship of the two conditions may be that the carcinoma becomes uIcerated and secondariIy infected, SubsequentIy contaminating the adjacent appendix. Uihlein and McDonaIdrr have discussed the probIem of primary carcinoma of the appendix and have pointed out that the cystic and colonic types, which are more frequentIy located near the appendiceal base, may first become manifest by the deveIopment of acute obstructive appendicitis. The absence of an appendix at either operation and the faiIure of the pathoIogist to demonstrate one as such Ied us to beIieve that in our case the neoplastic invasion of the ceca1 carcinoma had blocked the base of the appendix. Subsequent rupture of a retroceca1 appendix then Ied to the development of a retroceca1 abscess within which the appendix’ remains were compIeteIy necrotized. It is not aIways apparent from the case histories reported in the literature whether appendicitis had caused an abscess or whether the abscess had been caused by perforation of the carcinoma with subsequent infection of the adjacent appendix. In severa cases, as in our own, the appendix has not been found in the operative specimen, it having apparentIy been compIeteIy necrotized in the abscess.4p6*7*g In the usua1 case reported in the Iiterature the patient has been operated upon for SUSpetted acute appendicitis and the surgery uItimateIy performed in two stages.1*2*4~sTwo factors mitigate against the recognition of the presence of carcinoma of the cecum as an underIying process in acute appendicitis: (I) An underlying neopIasm may be mistaken for the varying degree of induration of the wal1 of the cecum that may be present in acute appendicitis. (2) It is not considered good surgica1 judgment to expIore adjacent organs in the presence of an acute inflammatory process. ConsequentIy, definitive surgery for the ceca1 neopIasm is usuaIIy performed at a subsequent operation folIowing microscopic diagnosis of the neoplasm.
The mesentery is free of Iymph nodes. The mucosa of the cecum and colon are not otherwise remarkabIe. Microscopicahy, at the site of the tumor, the muscuIaris and serosa are thickened and fibrous. On the serosal surface there are Fibrin and acute inflammatory ceIIs. In the muscuIaris at the area of uIceration, there are Iakes of mucin in which there are neopIastic, epithehat celIs and distorted gIands. There is an abscess in the periceca1 fat that is free of neopIastic ceIIs. Diagnosis-perforating, mutinous adenocarcinoma of the cecum.” Figure z represents a microscopic section taken from the region of the perforation. The patient did we11postoperativeIy and was discharged on the sixteenth postoperative day. She was admitted for the third time eight months Iater with a compIaint of a progressive increase in the size of the abdomen and an irreguIar, vague type of Iower abdominaI discomfort of three weeks’ duration. Under spinal anesthesia an expIoratory Iaparotomy was carried out, revealing Iarge biIatera1 Krukenberg tumors and carcinomatous impIants throughout the peritonea1 cavity. A biIatera1 salpingo-oophorectomy and a greater omentectomy were performed. The pathoIogic report read as foIIows: “The specimen consists of a Iarge amount of mucoid materia1 that weighs 2,650 grams. Incorporated within the mass are both ovaries and both oviducts. Attached to the surfaces of the ovaries and oviducts and in some areas invading the stroma, there is a mutinous carcinoma. The tumor is made up of Iarge Iakes of mucin, in which there are scattered cIumps and strands of onIy moderateIy pIeomorphic neopIastic ceIIs. The tumor is simiIar to that seen at the time of resection of the coIon. Diagnosis-secondary mutinous carcinoma of the peritoneum and pelvis.” The patient’s postoperative course was essentiaIIy uneventfu1 and she was asymptomatic when seen two months after her Iast operation. COMMENTS
Because of the earIy non-symptomatic growth of many carcinomas of the cecum, acute appendicitis or an abscess in the right Iower abdomina1 quadrant may be the first indication of this neopIasm. That obstruction of the appendicea1 Iumen may be the etioIogic factor in acute appendicitis is a well recognized fact.6 CoIIins3 found such obstruction as a causative factor in 50 per cent of a series of
SUMMARY
Acute appendicitis as a compIication of carcinoma of the cecum is unusua1. EtioIogic 502
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5. HELLSTEN, H. and RAMSTROM, S. Coexistent ceca1 cancer and appendicular abscess. Arch. Surg., 62: 112, 1951. 6. MAINGOT, R. AbdominaI Operations. New York, 1948. AppIeton-Century-Crofts, Inc. 7. MCLAUGHLIN, E. F. Carcinoma of the cecum in association with acute appendicitis. Am. J. Surg., 72: 585, ‘946. 8. PARKER, G. E. and ROSENTHAL, D. B. Carcinoma of large bowel as direct cause of acute appendicitis and simuItaneous acute intestinal obstruction. Lancet, 2: 1089, 1933. g. RICHTER, H. M., JR. Carcinoma of cecum with perforated appendicitis and empyema of the gaIlbladder. Quart. Bull., Northwestern Univ. M. School, 23: 375, 1949. IO. ROBINSON, E. K. and ERNST, R. W. Carcinoma of the cecum associated with acute appendicitis. Am. Surgeon, Ig: 1000, 1953. II. UIHLEIN, A. and MCDONALD, J. R. Primary carcinoma of the appendix resembling carcinoma of the coIon. Surg., Gynec. @ Obst., 76: 71 I, 1943.
factors and some of the probIems of recognition and therapy invoIved are briefly discussed. A case is presented in which an appendicular abscess was drained, the associated neopIastic process in the cecum becoming apparent onIy after microscopic study of the abscess contents. REFERENCES I. BANKS, A. G. and GREEN, R. D. Acute appendicitis
associated with carcinoma of the cecum. Brit. M. J., I: 926, 1935. 2. BARTLETT, M. K. and MILLER, R. H. Acute appendicitis as complication of carcinoma of the cecum. New England J. Med., 222: 783, 1940. 3. COLLINS, D. C. EtioIogicaI factors in acute appendicitis based upon study of 3,400 cases. Surgery, 5 : 267, 1939. 4. COOK, J. Acute appendicitis with carcinoma of the cecum. Brit. M. J., 2: 1083, 1936.
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