55

INFLAMMATORY COMPLICATIONS OF CANCEROF THE CAECUM AND ASCENDING COLON

By M. R. EWING, F.R.C.S. (Eng. and Ed.)From the Department of Surgery, Postgraduate Medical School of London

There occurs in the right lower abdomen a widevariety of pathological lesions many of whichpresent clinically as a lump. Chief among themare carcinoma and the 'appendix mass' or theappendix abscess. Recent experience has broughthome to me how confused the diagnosis may bebetween these two; for not only may they be verymuch alike when presenting alone, but still moreperplexing is the occurrence of the two together,as is so often the case. Clinicians of riper ex-perience than mine will doubtless number in re-collection many patients presenting, in theirmanagement, just the problems which I shallpresently describe. It is also true that there havebeen several contributions on this aspect of caecalcancer in the literature of the past 20 years or so(Wakeley and Rutherford, 1932; Bartlett andMiller, I940; Mayo, 1941; Brown, Colvert andBrush, I948). My only excuse in' rediscovering'what is already known to a few, is the somewhatdisturbing lack of awareness (or so at least it seemsto me) of the high incidence of the inflammatorycomplications of right colon cancer, a deficiencywhich many of the standard textbooks of surgerydo little or nothing to make good.Pathogenesis

Cancer in the proximal colon is often com-plicated by inflammatory disease, and this in avariety of ways:-

I. The tumour extends through the wholethickness of the bowel wall and breaks down toallow intestinal contents to leak out into thecellular tissues beyond (Fig. Ia).

This is probably the commonest happening andis especially a feature of the typical proliferatingtumours of the proximal colon.Even when the tuinour has not penetrated the

whole thickness of the bowel wall (either naked eyeor on microscopy) infection may still find its wayout into the surrounding connective tissue (Fig.ib). Microscopic evidence of such leakage iscommonly encountered by the pathologist either

in the form of an acute inflammatory reaction oreven more strikingly, by the presence of vegetablematerial surrounded by a foreign-body giant cellresponse. Even when the infection is more ad-vanced it may still be unsuspected clinically andoverlooked at operation. It may be first discoveredduring the gross dissection of the pathologicalspecimen as a small abscess cavity plastered upagainst the wall of the bowel at the site of thecancer.

If the abscess is bigger and more obvious it willbe encountered at operation as a disturbingcomplication:-

(a) Because it obscures the diagnosis.(b) Because it increases the technical difficulties

of the resection, e.g. in recognition and avoidanceof the ureter.

(c) Because it often makes it exceedingly diffi-cult to define and to recognize the limits of ex-tension of the malignant disease.

(d) It may lead to the death of the patient whenthe disease is still resectable and curable, andeven with survival its presence increases con-siderably the likelihood of post-operative mor-bidity.

(e) It may delay resection of the tumour and adda further stage to what may already be planned asa multi-stage procedure.As an offset to these very considerable dis-

advantages, the lucky warning signal of an acuteinfective complication may sometimes serve todraw attention early to a silent and previouslyunnoticed growth.

If the inflammatory process is still more inevidence it may obscure completely at operationthe associated underlying and causative newgrowth. Not only will the presence of the tumourreadily be overlooked at operation, but the in-flammatory complications will often dominate theclinical picture to confuse and confound theunwary and unexperienced.

2. Carcinoma of the caecum may co-exist withacute appendicitis, the relationship between the

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6 POSTGRADUATE MEDICAL JOURNAL October 195r

EXTENSION. OF TUMOURTHROU&H THICKNESS OFBOWEL WALL FOLLOWEDBY PERFORATION

.. FIG.

WHERE THE TUMOUR HAS NOrYET OBVIOUSLY PENETRATED THROUgHTHE ENTIRE THICKNESS OF THEBOWEL WALL THE INFECTION' IS PROBABLYLYMPH BORNE.

FIG. Ib

CARCINOMA BLOCKINCAPPENDICULAR OPENING:OBSTRUCTIVE APPENDICItISWITH OR WITHOUT. PERFORATION'AlOD ABSCESS FORMATION. . ..

FIG. IC

CARCINOMA WITHDIRECT EXTENSION TO WALL

OF IE'B-1E..F .WPPENDIX:oaTRICTIyl '*APPENDIICTIS.

FIG. Id

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October i 95 EWING: Inflammatory Complications of Cancer of the Caecum 517

two being apparently one of cause and effect. Theacute inflammation in the appendix can be pre-cipitated in one of two ways.

(a) Commonly there is blockage of the lumen,usually by a bulky proliferating tumour, whichgrows over and obscures completely the ap-pendicular orifice (Fig. ic). Less frequently thereis direct extension of the malignant tissue into thewall of the appendix at its base, with effectivenarrowing and final complete blockage of thelumen (Figs. id and 2).Whatever the mechanism of the obstruction,

the result is the same-as it almost invariably iswhenever the lumen of the appendix is blocked bywhatever cause-namely, the development of acuteobstructive appendicitis, which is no different inits behaviour from that due to more benign

FIG. 2.-Section through base of appendix to showdiffuse infiltration of its wall by growth (x I5).

causes. Gangrene and perforation occur early,with widespread peritonitis or local abscess forma-tion as common sequelae. It will be appreciatedthat, at this stage, the symptoms of the complicat-ing acute obstructive appendicitis must often over-shadow those of the less urgent caecal neoplasm.

(b) When a growth blocks the colon some waydistal to the ileo-caecal valve, the caecum becomesprogressively more distended. Under such con-ditions it seems highly probable that the appendixtoo will share in the distension and will find in-creasing difficulty in emptying its content into thecaecum. It may well be that under such conditionswhat we might reasonably call ' stercoral ap-pendicitis ' may result (Fig. 3a). I must, however,admit that this conception is largely hypotheticaland I can quote from my experience no singleinstance of such a happening.

OBSTRUCTI N CARCINOMAWITH "STERCORAL APPENDICITISWITH OR WITHOUT PERFORATIONAND ABSCESS FORMATION.

FIG. 3a

3. Complete intestinal obstruction in the largebowel at any level distal to the caecum leads todistension of the whole length of the colon proxi-mal to the obstruction; it is the caecum, however,which suffers most. Of the gross caecal distensionunder such conditions the surgeon is well aware;the risk at operation of rupturing the overstretched,paper-thin, necrotic caecal wall is always in hismind when he explores the abdomen in thepresence of a neglected large bowel obstruction.Spontaneous rupture of a stercoral caecal ulcer isa calamity of the first order, a rapidly spreadingand very lethal peritonitis being the almost in-variable sequel (Fig. 3b). Sometimes, happily, itsperforation may occur more insidiously to givetime for the development of an encapsulated peri-colic abscess, but this is not often the case.

FrequencyI was recently impressed by a succession of

patients with cancer of the right half of the colon,in each of whom the clinical picture was dominatedby a complicating infection. On going through therecords of Hammersmith Hospital for the years

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518 POSTGRADUATE MEDICAL JOURNAL October I951

DISTAL OBSTRUCTING CARCINOMAWITH PERFORATION OF STERCORAL ULCEROF CAECUM AND PERITONITISOR ABSCESS FORMATION.

FIG. 3b

1939 to I949, I have been able to collect 42 cases ofcarcinoma of the caecum, ascending colon, andhepatic flexure. In no less than 17 of the 42 therewas evidence of infection, and in the great majorityof these of sufficient seriousness to alter the clinicalpicture in varying degree.Effect on Clinical PictureThe presence of infection affects the symptoms

and signs in these patients in a variety of ways,some of which I propose now briefly to discusswith illustrations from my own experience andfrom our hospital records.

(a) The obvious case of cancer of the large bowel,where the incident of inflammation leads to someuncertainty in the diagnosis or requires the additionof a further step-that of drainage of a pericolicabscess-to what may already, in an obstructed case,be a time-consuming staged procedure.

Case i. A pale, worried old man was admittedwith a large lump in the right iliac fossa diagnosedas a carcinoma of the caecum. His temperature onthe evening of admission rose to 101° and con-tinued during the next few days to swing between99° and ioi°, while the abdominal tumour in-creased steadily in size and became acutely tender.On the fifth day after admission an ileo-transversecolostomy was fashioned and through a secondlateral muscle-cutting incision 500 ml. of foul puswere evacuated from a large abscess cavity lyinglateral to the caecum. When hemicolectomy wascarried out about one month later, a large cauli-

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FIG. 4.-Case IO. Clinical diagnosis acute appendicitis.Found at operation to have a perforated appendixwith abscess formation. Cancer of caecum over-looked until it erupted on to skin surface throughthe unhealed operation wound.

the sinus shown in Fig. 4. The extension of theadenocarcinoma to the skin is clearly shown ( x 39).

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EWING: Inflammatory Complications of Cancer of the Caecum

flower growth was found obstructing the ileo-caecal valve and the appendix. There was anassociated massive honeycomb abscess extendingwidely into the iliacus muscle.

(b) The patient in whom the shortness of thehistory and of the presenting symptoms suggests adiagnosis of acute appendicitis or of appendix abscess,but where, often as a comtlete surprise, a colon canceris discovered at laparotomy.At operation there may be found either acute

appendicitis or a pericaecal abscess or neither,which, matters not at all; what is really importantis the recognition at this stage of the primarypathology, which has been earlier overlooked at thebedside.

Case 2. A plethoric old gentleman of 71 yearswas admitted to hospital as an emergency. Forabout a week he had complained of spasms ofviolent umbilical colic and had vomited once.

His abdomen was uniformly distended and therewas tenderness and rigidity in the right iliac fossa.A lump rising out of the pelvis slightly to the rightof the midline was thought to be a distendedbladder, but it did not disappear after catheteriza-tion. His temperature was o11°. A diagnosis ofacute appendicitis was made and expectant treat-ment advised. By the following afternoon, how-ever, the distension had become much moreobvious and a 'scout' film of the abdomenshowed the presence of fluid levels in the gut.Exploration was undertaken forthwith.The appendix was found to be acutely inflamed

and perforated in several places. In the wall ofcaecum at its base was a small hard white lump.This was removed along with the appendix, arubber caecostomy tube being inserted to fill thegap. Section through the caecal wall at the base ofthe appendix showed diffuse infiltration of themuscular coat by trabeculae of carcinoma cells.

Case 3. A very frail old lady of 65 years wasadmitted with a vague recent history of recurringbouts of abdominal colic and of occasional diar-rhoea. For ten days or so she had been consciousof a tender lump in the right lower abdomen.Her temperature on admission was oo00 and

there was a smooth, rounded, very tender, fixedmass in the right iliac fossa-the size of a largeorange.A provisional diagnosis of appendicitis with

abscess formation was made and conservativetreatment advised. When, after six days, therebeing no improvement, the abdomen was opened,the hard lump was proved to be a caecal cancer.No obvious abscess was discovered but theappendix itself was not identified.

Case 4. A thin, pale boot repairer, aged 44,had complained of recurring spasms of abdominalcolic of three weeks' duration, and also of increas-

ing anorexia, tiredness and pallor. There was anobvious tender lump in the right lower abdomen;his leucocyte count was 24,500 per c.mm. and hishaemoglobin 44 per cent. A provisional diagnosisof' appendix abscess ' was made, and at operationan abscess cavity was found on the anterior aspectof the caecum, which was suspiciously induratedand fixed to tb posterior abdominal wall.The abscess was drained and later a staged and

difficult right hemi-colectomy was carried out,when the true diagnosis of caecal cancer was con-firmed.

(c) The patient in whom the presence of infectionconfuses and confounds the diagnosis.

Case 5. A thin and rather tired looking youngman of 37 years was admitted to hospital as anemergency, complaining of recurring spasms oflower abdominal colic of eight days' duration,accompanied by constipation and some vomiting.

His abdomen was uniformly distended but notumour could be felt and there was no localizedarea of tenderness.By the following morning his temperature was

99° and his pulse Ioo. There was now markedabdominal tenderness, especially on the right side.It was thought possible that he had acute ap-pendicitis, a new growth complicated by infectionor even a caecal amoeboma.At laparotomy a small collection of pus was

found lying close to the appendix, which was asthick as one's ring finger but not obviously per-forated. When traced upwards it could be seendisappearing into a hard irregular tumour in-volving the posterior wall of the caecum. This waslater proved to be an adenocarcinoma to whichcoils of ileum were bound by granulation tissuecontaining chronic inflammatory cells, foreignbody giant cells and many polymorphs.

Case 6. A housewife, aged 60 years, firstattended in April I938 complaining of occasionalattacks of abdominal pain, three only in the pre-vious five months. She was seen only once in theout-patient department when a hard, nodular andslightly tender lump was felt low down in the rightiliac fossa. She failed to attend again untilSeptember. In the meantime she had had threemore attacks of pain, but the abdominal tumourwas now no bigger than a pigeon's egg. It was,however, still tender and inguinal adenitis wassuggested as the most likely diagnosis. Surgicaladvice was now sought when the alternativediagnoses of tuberculous adenitis or of strangulatedomentocele were suggested.

In October the swelling was explored whenabout 15 ml. of thick pus was evacuated from anintraperitoneal abscess cavity, in the depths ofwhich a hard lump could be felt lying on theiliacus muscle, but its true nature was not estab-

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POSTGRADUATE MEDICAL JOURNAL

lished at this stage. Later, however, a bariumenema revealed a persisting filling defect in thecaecum and at a subsequent operation a caecalcancer was resected. A large pericaecal abscesswas discovered which was packed with iodoformgauze and the patient made an uninterrupted re-covery. Section of the tumour showed it to be awell-differentiated adenocarcinoma.

(d) The patient with acute appendicitis diagnosedclinically, confirmed at operation and later firmlyestablished by histological section, which turns outultimately to be no more than the clinically apparentinfective manifestation of an underlying cancer.The surgeon is content to find his pre-operative

diagnosis of acute appendicitis confirmed and if hehad any doubts about the diagnosis before, they arenow quite dispelled when he retrieves an obviouslyinflamed and often perforated appendix. He mayperchance find an area of induration in the caecumbut this, if he is unwary, he may confidently dis-miss as part and parcel of the acute appendicularlesion. Recovery may be without incident andhealing complete in the normal time. All is nowwell for months or maybe even years, until thereshow themselves, and often in an intractable form,the all too familiar symptoms such as anorexia,asthenia, anaemia and the like, which we havecome to associate with malignant disease of theproximal colon. The time relationship betweenthe two episodes may be so close as to leave littledoubt in the mind of the surgeon, or so long as toleave the connection between the two a matter ofspeculation alone.

This type of presentation is illustrated by thefollowing clinical records.

Case 7. An old man of 73 years was admitted tohospital complaining of recurring attacks of colicin the right lower abdomen during the previous 36hours. His general condition was good and histemperature was only 99°. Just medial to the rightanterior superior spine was a tender mass whichseemed to be lying close under the skin. A diag-nosis of acute appendicitis was made and on ex-ploration a grossly swollen appendix was foundlying doubled up immediately medial to thecaecum. It was perforated at its base. On palpa-tion of the caecum through its wall, near the baseof the appendix there could be felt what was takento be a hard malignant ulcer, the size of a three-penny piece. There were no obviously enlargedlymph glands nearby. The appendix was removedalong with a small cuff of the caecum containing thegrowth, but section of the specimen was reportedto show no cancerous tissue. He made a good re-covery and was discharged with a diagnosis ofacute appendicitis.Three months later he returned complaining of

lower abdominal pain and diarrhoea. There was

now an obvious hard fixed mass in the right iliacfossa, and visible peristalsis. A clinical diagnosisof caecal cancer was confirmed at laparotomy whenan abscess cavity was also encountered lyingmedial to the ascending colon.The first pre-operative diagnosis of acute ap-

pendicitis was here confirmed at operation. Afirm suspicion of associated malignant disease wasnot established histologically (the section hassince been re-examined) and the quick and ap-parently complete recovery was allowed to allayall suspicion.

Case 8. This patient first came into hospitalin June 1936 at the age of 55 years. She gave athree days' history of abdominal pain, first at theumbilicus and later settling into the right iliacfossa. Her temperature was I02° and a tenderlump, the size of an orange, could be felt justmedial to the right anterior superior spine. Adiagnosis of appendicitis with early abscessformation was made but operation was delayed fortwo days, when a perforated gangrenous appendixwas removed.

She was re-admitted in November I939 with atwo months' history of griping abdominal painand diarrhoea. She was now found to have a firmnodule in the appendix scar and a more deeplysituated mobile lump. At laparotomy an in-operable carcinoma of the caecum was found withextension intc the muscles of the abdominal wall.Although we have in this instance no exact proof

of the existence of the cancer already at the firstoperation 3 years before, the findings of a nodulein the appendix scar at the second certainlysuggested the likelihood of this being so.

(e) Not very dissimilar from those in the previousgroup, there are the patients in whom a pre-operativediagnosis of appendix mass or of appendix abscess ismade, a diagnosis which appears to be confirmed atoperation when the associated carcinoma is over-looked.

Case 9. This patient, who was described inher notes as a ' plump, jolly old woman of 71,' wasadmitted urgently to hospital with a two weeks'history of colicky lower abdominal pain andanorexia. Her temperature was Ioo0 and therewas a fixed tender mass in the right iliac fossa.A provisional diagnosis of appendicitis with abscessformation was made, with pericaecal abscess froma carcinoma as a less likely alternative. She wasfirst treated expectantly but seven days later, be-cause of persisting pain and a swinging tempera-ture, the abscess was incised and drained. Shewas discharged a month later with a diagnosis of'appendix abscess,' her operation incision beingat this date still unhealed.

She returned, however, two months later,wasted and unhappy.' There was no doubt now

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about the large tender fixed mass in the rightlower abdomen and there was a recent discharge ofpus and of blood clot from a sinus which had de-veloped in the operation scar. She died on thefollowing day and autopsy confirmed the presenceof a caecal cancer with pericaecal inflammation ex-tending distally into the muscles of the thigh.

It is easy enough to understand how the tumourin such cases can be missed at operation, and thatfor a variety of reasons:-

(I) The finding of an abscess cavity in the regionof the appendix seems to confirm the pre-operativediagnosis and makes one forget to search furtherfor some other explanation.

(2) The presence of any area of hardness in theregion of the caecum seems reasonably to be ex-plained by its close proximity to the abscess cavity.

(3) The presence of an abscess makes it bothdifficult and unwise to carry out a really wide andcareful exploration.The inflammatory appendix mass, consisting as

it does of the inflamed appendix concealed andbuttressed by adherent omentum and coils of smallgut, commonly resolves without incident underpurely conservative treatment. Even the earlyabscess may clear spontaneously, emptying itself,maybe, into the bowel or into the rectum. Whenthings go wrong, and this is especially so in an olderperson, when increasing symptoms and extend-ing signs point to a progressing infection, it is wisealways to consider the possibility of an under-lying cancer as the primary pathology. This isespecially so when confronted with a patient wholooks altogether too thin, too pale and too frail tobe explained away by what seems to be only ashort infective illness.

(f) Persisting discharge from an appendicectomywound may be due to a variety of causes. It maypoint to no more than a residual and inadequatelydrained abscess, or to an appendix stump whichhas been left behind or which harbours a faecolith.The discharge in either event tends after a time todry up without treatment, as will a faecal leakwhich follows the separation of a sloughing patchon the caecal wall. As time passes and there is stillno sign of healing and no revealing rejection of silkor cotton thread, we think of faulty swab counts,of tuberculosis, of actinomycosis, or of regionalileitis. It would be wise at this stage to bear inmind in the young, as in the old, the possibility of anunderlying ceacal cancer, especially if there is ahistory before the recent acute inflammatoryepisode of abdominal colic, diarrhoea, anorexia,anaemia and the like.

Careful palpation, if necessary under generalanaesthesia, may sometimes reveal an underlyinglump, but. this finding might equally supportalmost any of the alternative diagnoses. Indura-

tion of the sinus tracks, appreciated on probing,to the accompaniment of bleeding, is no morespecific. The really helpful investigations are abarium enema, which may show clearly a fillingdefect in the bowel at the site of the sinus, orbiopsy of the wound track, always provided it iscarefully taken from the depths of the wound. Itis as true of this condition as it is of any biopsytaken elsewhere, that it must be adequate in size,carefully selected and as representative as possible,and a negative answer must never be allowed toblunt the acuteness of the surgeon's criticalalertness.That a cancer may be unsuspected before

operation and overlooked even when the abdomenis opened and the appendix removed and, further,that this possibility may first be seriously enter-tained only when the tumour grimly erupts on thesurface-this is a happening of which I am pain-fully aware and that I am sure many honestsurgeons will admit to sharing just such an ex-perience.

In the following cases, both treated in ourhospital, the diagnosis was established when it hadbecome only clearly apparent as the tumour fun-gated out along the appendicectomy wound.

Case o1. The patient, a young man of 44 years,was admitted urgently to hospital with a recenthistory of recurring attacks of fairly generalizedabdominal colic. Two days prior to admission thishad become much more severe and had latersettled down in the right lower abdomen.A tender lump was felt in the right lower

abdomen. This was believed to be an appendixmass and expectant treatment was advised. Nextday, however, because of signs of spreading in-fection the abdomen was opened. The appendix,with a perforation at its base, was found lying inan abscess cavity. Its removal was tedious anddifficult, and during the dissection a portion ofthe rather necrotic caecal wall was torn. This wasdealt with by exteriorization of the caecum. Hisconvalescence was punctuated by recurring attacksof colic and prolonged by digestion of the skinedges. Almost three weeks later an extraperitonealclosure of the caecostomy was done, but difficultywas encountered in dealing with what wasdescribed as a hard, inflamed and oedematousbowel. Healing was eventually complete and hewas allowed home.He soon returned, however, complaining now of

the passage of blood and faeces from a re-openedcaecal fistula. In the middle of the old operationscar was a large irregular sinus ringed by an ex-tensive collar of hard, nodular growth raised alittle above the level of the surrounding skin(Fig. 4). This tissue bled on the slightest pressureand was found to be only the superficial limit of a

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522 POSTGRADUATE MEDICAL JOURNAL October 1951

hard, fixed mass which could be felt extendingbackwards and laiterally in the right iliac fossa. Itwas now clear that we had overlooked from thestart a malignant growth in the colon, a diagnosiswhich was at once confirmed when biopsy from theedge of the fistula revealed anaplastic spheroidalcell carcinoma extending up to and involving theskin (Fig. 5).

Case I. This 56-year-old clerk first began tocomplain of diarrhoea early in I941; this wasfollowed later that year by constant 'nagging'abdominal pain. In April 1942 he was admittedto hospital where drainage was undertaken forwhat was taken to be an appendix abscess. Fol-lowing the operation he developed a faecal fistulain the wound which refused to heal. Its marginswere cauterized on two occasions without benefit,and when in June a biopsy was taken it showed nomore than an inflammatory reaction.He first came to Hammersmith Hospital in

November 1942, by which time he had lost 3 stonein weight in the previous i8 months. He wasthin and pale and a large mass could be felt largelyfilling the right lower abdomen. It was tender,firm, irregular and fixed. Crossing its lateral one-third was an unhealed McBurney incision whichwas gaping and discharging. Biopsy taken fromthe somewhat everted medial margin showed thepresence of a mucus-secreting adenocarcinoma in-volving skin.How does the presence of pericaecal inflammation

or of a complicating appendicitis modif) treatment?Formal right hemicolectomy in the presence of

an acute episode of inflammation would be to

invite the risk of the gravest infection. It is wise tolimit the first operation to simple drainage of theabscess through a short muscle cutting incisionmade over the summit of the abscess and as farlaterally as its situation will allow. It may beallowable in some instances to do at the same time(and preferably as the first step in the operation)an ileo-transverse colostomy, through a para-median incision, especially if there is any evidenceof obstruction.

It is only necessary to wait until the acuteepisode has subsided-in the average case this willtake 10 to 15 days-and then to proceed with aformal resection. A long oblique muscle cuttingincision is now made passing on either side of thedrainage wound to include all of the infected tissueof the abdominal wall. Apart from the varyingdifficulty in the dissection, the rest of the resectionfollows the usual lines.

SummaryIn a high proportion of patients with cancer of

the caecum and ascending colon there are in-flammatory complications of which pericolicabscess and acute appendicitis are the most fre-quent. This accident often leads to errors inclinical diagnosis and even at operation the primarycancer may only too easily be overlooked. Someof the difficulties encountered in the diagnosisand management of these patients are underlinedby illustrative case records.The photographs are the work of Mr. J. V.

Willmott and his staff.

BIBLIOGRAPHY

BARTLETT, M. K., and MILLER, R. H. (1940), New EnglandJ.Med., 222, 783.

BROWN, C. H., COLVERT, J. R., and BRUSH, B. E. (1948),Ann. Int. Med., 28, 940.

MAYO, C. W, (I941), Proc. Staff MAeet. Mayo Clinic, x6, 67.WAKELEY, C. P. G., and RUTHERFORD, R. (1932), Brit. j.

Surg., 20, 91.

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