Introduction
Pyogenic liver abscess is a common intra-abdominal infection, but it is rarely reported in association with locally advanced colon cancer. When found together, diagnosis and treatment are challenging. A 76-year-old male was admitted to the First Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, with right upper quadrant abdominal pain, high fever, and chills. Ultrasonography (US) and computed tomography (CT) scans supported a diagnosis of liver abscess. Colon cancer complicated with liver, gallbladder, and duodenal invasion was discovered during laparotomy.
Materials and methods
A 76-year-old male, with chief complaints of right upper quadrant abdominal pain, high fever, chills, and weight loss for two months, was admitted to our hospital in September 2009; he presented no other digestive symptoms. Physical examination revealed right upper quadrant abdominal tenderness, percussion tenderness over the hepatic region, and no rebound tenderness. Routine blood tests showed a hemoglobin (Hb) level of 54 g/L, increased white blood cell count, and a neutrophil percentage of 87%. Other relevant laboratory values included the following: serum carcinoembryonic antigen, 3.53ng/ml (N: 0–3.4); alpha fetoprotein, 2.66 ng/ml (N: 0–7.02); alanine aminotransferase, 32U/L (N: 0–40); aspartate aminotransferase 19U/L , (N: 0–40). Occult blood was positive in the routine stool test. Abdominal US and CT showed a liver abscess with gas, 7.4 cm × 8.9 cm × 9.0 cm in size (Fig. 1). Considering the anatomical relationship between the liver lesion and the hepatic flexure of the colon, colography was performed, revealing a fistula connecting the hepatic flexure of the colon to the cavity of the liver abscess (Fig. 2).
Results
The diaphragmatic surface of the liver was smooth and soft with tenderness. However, the outlines of the hepatic flexure of the colon, duodenum, and gallbladder were unclear, forming a solid mass in the visceral surface, the diameter of which was 9 cm. Dissection along the hepatic visceral surface revealed the abscess. After dissecting, the boundaries of the abscess were as follows: the roof of the abscess was the lobe V of the liver, the median wall was the ampulla of the gallbladder and duodenum wall, and the floor was the colon wall (Fig. 3). Two fistulas were found connecting the duodenum to the colon cavity via the liver abscess, the diameters of which were 1 and 5 cm, respectively. Abscess drainage revealed black pus containing white pills, which was sent to the laboratory for bacterial culture.
Tissue and lymph node resection of the duodenum, gallbladder, and colon was performed for biopsy. Histology of the colon tissue resection showed poorly differentiated adenocarcinoma (Fig. 4). Carcinoma tissue invaded the whole colon wall, and parts of the liver, gallbladder, and duodenum. However, metastasis of the lymph nodes was not observed (all eight lymph nodes). Bacterial culture showed Escherichia coli and Enterococcus faecom (type D).
After right-hemicolectomy, cholecystectomy and partial hepatectomy, a partial duodenal resection of the invasive carcinoma was performed. The margins of the duodenal wall were negative-detected by frozen pathological examination, which was repeated twice. The duodenal defect was 3 cm in diameter; the defect was repaired with a pedicled flap of the terminal ileum. Considering the lesion close to the duodenal papilla, which may influence the flow of bile and pancreatic juice, T-tube drainage was performed and a decompression drainage tube was applied in the duodenal cavity. Then, digestive tract reconstruction was performed, including gastrojejunostomy, ileostomy, and mucous fistula (Fig. 5). Effective anti-infection treatment and nutritional support were performed in the early postoperative period. Adjuvant chemotherapy (FOLFOX4) was administered for eight cycles from the 14th day after operation. The patient had no postoperative complications and survived for 16 months after the operation.
Discussion
Colorectal cancer is the fourth most common cancer in men and the third most common cancer in women worldwide. Previous studies have reported rapid increases in colorectal cancer incidence rates, particularly in economically transitioning countries [
1,
2]. In China, approximately 172 000 cases of colorectal cancer occur per year, accounting for about 99 000 deaths annually [
3]. According to the natural history of colorectal cancer, approximately 60% of all patients develop distant organic metastasis [
4]. In contrast, in approximately 5%-15% of patients, the primary cancer directly invades adjacent organ structures, and distant metastasis does not occur [
5]. When this happens, the term “locally advanced colorectal cancer” is used. Generally, the most vulnerable organs are the duodenum or the head of the pancreas [
6]. In our patient, a right colon cancer invaded adjacent multi-organs, including the liver, duodenum, and gallbladder (Fig. 5A). A large abscess formed in this area, secondary to the destruction of the mucosal barrier of the colon and bacterial translocation. Liver abscess was the main clinical manifestation. Such a case has rarely been reported. In the past, pyogenic liver abscess was usually related to hepatobiliary tract diseases or intra-abdominal infections, but gastrointestinal pathology (occult malignancy, in particular) should always be considered [
7].
Colorectal adenocarcinoma grows slowly, and a long period of time elapses before it is large enough to cause symptoms. Common manifestations of colon cancer include alterations in bowel habits, rectal bleeding, and abdominal pain. Bowel symptoms occur commonly in the community and are often self-limiting. Little information is available regarding why or when people seek medical attention for such symptoms. Adelstein
et al. [
8] analyzed 62 eligible papers from 14 121 articles and found that most bowel cancer symptoms do not indicate colorectal cancer and polyps. Furthermore, the clinical manifestation of locally advanced colon cancer is much more complicated under the condition of local organic invasion. When this happens, colon cancer is easily masked by atypical clinical manifestations (such as liver abscess) and misdiagnosed. In anemic elderly with right upper quadrant abdominal pain, weight loss, and pyogenic liver abscess, colonoscopy is suggested and required to avoid misdiagnosis.
Because colon cancers invading adjacent organs are often missed before operation, solving adjacent invasive lesions is the focus in surgical procedures. Previous research has shown that the mean survival period of patients who undergo palliative bypass is 9 months, and, in cases of incomplete resection (R1-2), the mean length of survival is 11 months [
9]. In contrast, following R0 multivisceral resection, the mean survival was found to be around 40 months [
10,
11]. This long-term survival following multivisceral resection may be explained by the fact that 45% of all cases of locally advanced colorectal cancer do not present compromised lymph nodes (N0), and spreading is solitary and local [
10,
12], as in the present case. Curley
et al. [
6] considered such cancers to be a specific subgroup of locally aggressive right colon cancers. According to their biological characteristics, complete resections are recommended, and some surgeons consider it to be the greatest survival predictor of local advanced colon cancers [
13,
14]. Thus, in the present case,
en bloc resection was performed, including right-hemicolectomy, cholecystectomy, partial duodental resection, and hepatectomy. Although at a poorly differentiated stage, with three invaded organs (liver, gallbladder, and duodenum) and intra-abdominal infections, the patient survived for a relatively long time.
In conclusion, locally advanced colon cancer, even when associated with confined perforation, may require resection with removal of local organs to control acute complications. The procedure offers a chance of recovery to a state in which the patient can be offered adjuvant therapy and achieve a reasonably long period of palliation.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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