An Elderly with Concurrent Colonic Cancer
Babiker Ali Babiker Mohammed* and Miadah Difiaa Awad Jiber
Department of Surgery, Dallah Hospital, Saudi Arabia
Submission: December 11, 2017; Published: January 11, 2018
*Corresponding author: Babiker Ali Babiker Mohammed, Department of Surgery, Dallah Hospital, 7049 Abdul Rahman Ibn Nami-Al Muruj Unit No: 2 Ar Riyadh, 12281-3178, Kingdom of Saudi Arabia, Tel: +966 532880246; Email: [email protected]
How to cite this article: Babiker A B M, Miadah D A J. An Elderly with Concurrent Colonic Cancer and Ischaemia. J Tumor Med Prev. 2018; 2(4): 555595.
A case of acute bowel ischaemia in a 72-year-old female presented to our institution necessitated an emergency surgery. The surgery revealed ischaemic transverse colon and incidentally an adenocarcinoma in the transverse colon just proximal to the splenic flexure. The ischaemic bowel together with the cancer was resected in the same setting. This case emphasizes that a thorough laparotomy is essential because it may reveal another pathology, when treated would improve survival. This operation was performed as a damage control surgery which is important in critically ill patients.
Keywords: Colonic malignancy; Bowel ischaemia
Abbrevations: CVA: Cerebro Vascular Accident; PUH: Paraumblical Hernia; GCS: Glasgow Coma Scale; ECG: Electrocardiogram; CT: AT. ICU: Intensive Care Unit; TPN: Total Parenteral Nutrition; IBS: Irritable Bowel Syndrome; COPD: Chronic Obstructive Airway Disease; HDU: High Dependency Unit
Bowel malignancy is increasing in Saudi Arabia. Now it is the commonest cancer in male and third in females . Despite the high prevalence, still there is not much awareness about colorectal cancer neither among physicians nor among the public. Considerable numbers present late especially with obstruction, up to 45% . Bowel ischaemia is an uncommon surgical emergency which poses a high morbidity and mortality if not properly addressed . Arterial emboli are the most frequent cause of acute ischaemia. Most emboli are from the heart . Our case presented with these two pathologies, her acute presentation with bowel ischaemia brought her bowel cancer to attention. Moreover, she had a paraumblical hernia which was repaired and diverticular disease which manifested itself as a complication postoperatively with rectal bleeding.
This case report describes a 72-year-old female who presented with upper abdominal pain radiating to the back for one day. It was associated with repeated vomiting. She had a history of constipation on and off for one year. She was known to have IBS but has never had a colonoscopy. She also reported to having palpitations. Past medical history revealed diabetes mellitus, COPD, hypertension, old CVA and was also known to have PUH. Her pulse was irregularly irregular at a rate of 150
beats per minute and the ECG confirmed atrial fibrillation. Her Blood pressure was 145/71, respiratory rate was 25 cycles per minute, and oxygen saturation was 88% on room air. Abdominal examination revealed an irreducible PUH which was not tender. Bowel sounds were present. Laboratory values showed a hemoglobin of 12g/dl, white blood cell count elevated at 20.400/L, and a platelet count of 320/L. Her renal and liver functions tests were within normal limits. Her pancreatic enzymes showed Amylase of 31U/L and Lipase of 21U/L. Her arterial blood gases showed no evidence of acidosis. Abdominal X-ray showed no significant abnormalities.
The patient was admitted as a case of query bowel ischaemia. From the emergency room her atrial fibrillation was controlled and was started on anticoagulation. The CT scan with contrast was performed before the lady became hypotensive and was shifted to ICU where she was resuscitated and prepared for the emergency laparotomy. The result of the CT scan showed diffuse bowel thickening of the transverse colon and gas in the stomach wall suggesting ischaemia, PUH containing omentum only (Figure 1 & 2).
Intraoperatively the lady was hypotensive and hence a damage controlled laparotomy was performed. During the assessment of the ischaemic segment of bowel a cancer-looking lesion just proximal to the splenic flexure was discovered. The ischaemic transverse segment of the colon together with the
carcinoma looking lesion near the splenic flexure were resected
with stapled closed ends and no anastomosis was attempted.
The necrotic omentum was excised as well. The irreducible
hernia was reduced by the opening midline laparotomy incision
and was found to contain omentum. The fascia was not closed,
only skin was closed with clips. The patient was shifted to ICU
for a second look laparotomy. In ICU patient was stabilized on
inotropes. The heparin was continued and was started on TPN.
Two days later the patient was taken to operating room where
a second-look laparotomy took place. It revealed no evidence
of ischaemia, therefore anastomosis was fashioned, and the
abdomen was closed.
The next day of surgery she was extubated and was doing
very well. Three days post-surgery inotropes were stopped. One
week postoperatively her bowels opened and enteral feeding was
started. Nine days postoperatively she was transferred to HDU for
one day and subsequently transferred back to her room. There
she developed severe rectal bleeding and needed 4 units of blood
transfusion. The upper and lower gastrointestinal endoscopies
revealed gastritis and diverticular disease as the most likely cause
of the bleeding which stopped spontaneously within a couple of
days. She was already on proton pump inhibitors. Two weeks
postoperatively mobilization started but it was difficult for her to
maintain her oxygen saturation due to her COPD. She developed
superficial wound infection which settled with removal of clips,
frequent dressings and later secondary suturing. The histology
confirmed moderately differentiated adenocarcinoma of the
colon. The size of the tumour was 3.5X2.5cm. Total of 8 lymph
nodes were identified in the specimen, one of them was involved
with tumour cells. Both resection margins of the bowel specimen
were free from tumour. No perineural or lymphovascular
invasion was detected. The pathological staging was pT3, N1, MX.
She was reviewed in the oncology department and the consensus
was not to offer her chemotherapy treatment. Three weeks
postoperatively she was discharged home with oxygen therapy
and continued physiotherapy. She was reviewed in the hospital
two weeks following her discharge. She was asymptomatic and
clinically doing very well. A follow up telephone call, a year later
with her son, confirmed that she was alive and doing well, as she
lost to follow up.
Bowel ischaemia is a rare condition that present a major
diagnostic and therapeutic challenge to the treating surgeon.
Acute ischaemia remains a surgical emergency that should
be treated by laparotomy and resection of dead bowel in most
cases. Acute ischaemia can either be occlusive or nonocclusive.
Occlusion can either be due to embolism, thrombosis or
iatrogenic. The commonest cause is embolic (50% of all cases)
. Such emboli are usually cardiac in origin, but may arise from
atherosclerotic plaques or from arterial aneurysm. The presence
of abdominal pain together with atrial fibrillation should alert
the physician to the possibility of bowel ischaemia due to emboli
as in our case. Colorectal cancer is among the leading cancers
in Saudi Arabia . The incidence was rising, almost doubling
between 1994 and 2003. In Saudi Arabia, the rising rate of cancer
can be attributed to exposure to risk factors, lack of screening
program along with aging population 
This case is unique in having not only ischaemic bowel
and colon cancer but also a hernia and diverticular disease. In addition to her multiple pathologies, also the way her operation
was conducted underline an important principle in surgery which
namely the damage control. This patient had a damage control
laparotomy because she was hypotensive. In such scenario if
the operation is carried for long time, acidosis, hypothermia
or coagulopathy, the lethal triad, will develop. Repeat ‘secondlook’
laparotomy is an important principle in the management
of acute mesenteric ischaemia. The guidelines of the world
society of emergency surgery recommend the use of damage
control techniques when appropriate to allow for re-assessment
of bowel viability prior to definitive anastomosis and abdominal
closure . In our case the ischaemia is the reason to bring the
patient to hospital and allow cancer treatment.
Early diagnosis of colorectal cancer may be delayed by the
wide prevalence of gastrointestinal symptoms in the general
population, consequently many physicians underestimate
symptoms of abdominal pain, change of bowel habits especially
in areas where infectious diseases are still prevalent. Coexistence
of colorectal cancer with pathology may lead to an early
presentation, as was the case presented. There are many cases
in the literature with colorectal cancer and other concurrence
in different scenarios. Co-existence of colorectal malignancy
and aorto-iliac aneurysmal disease is uncommon, but may be
increasing. There is no consensus on the management whether
to do the operation for the two conditions synchronously or not
. Ischaemic colitis may be associated with partial or complete
bowel malignant obstruction. In one reported series, 10% of
patients with colonic ischaemia had an associated colorectal
carcinoma, the ischaemic area is proximal to the tumour and
may or may not be associated with the obstruction . The
speculation is that the colonic blood flow could be decreased as
a consequence of increased intraluminal pressure .
Colon cancer is seen less where sigmoid volvulus is common,
so it is rare for colon cancer to be synchronous with sigmoid
volvulus . Some studies have reported that the carcinoma
may be a rare predisposing factor for the volvulus. The
relationship between sigmoid diverticulitis and colon cancer
remain controversial. However, Steffansson et al reported that
diverticulitis in the sigmoid colon increase the risk of cancer in
the left colon compared with patients with diverticular disease
without any clinical signs of diverticulitis . Foreign bodies
ingestion has had resulted in the colonic cancer narrow area
to obstruct. Dentures had been ingested by elderly patient and
caused obstruction . Chicken bone is another example which
has caused not only obstruction but rather perforation . This
presentation brought a tumour earlier to diagnosis which will
otherwise present at a later stage possibly with obstruction and
the outcome would be worse.
In conclusion, due to the increased prevalence of bowel
malignancy, checking the entire digestive system in any
laparotomy considering the possibility of coexisting malignant
tumours is recommended. Change of bowel habits in an elderly
shouldn’t be labelled as IBS, rather colonoscopy is needed which
may reveal colon cancer. Damage control laparotomy saves
lives in critically ill patients and should always be utilized when
The authors would like to express their deep thanks to Dr.
Hani Dimassi who reviewed this manuscript. We would like to
thank Dr. Jamal Yaqoob for selecting the CT pictures. Authors
would like to thank Dr. Nadia Omer, anaesthetist for the
competent job she has done.