A 50-year-old female presented to the emergency department with pain in the abdomen since 5 days, vomiting and constipation since 3 days. There was no history of fresh bleeding per rectum or malena. She had a history of abdominal hysterectomy 2 years back for multiple uterine fibroids. She had no other co-morbidities, and her family history was not significant.
On examination she was conscious, oriented with a regular low volume pulse of 98/min, blood pressure 98/66 mmHg, respiratory rate 22/min, and temperature of 98.8 F. Abdominal examination revealed mild distension with visible peristalsis. A lower midline irregular scar was seen; no lump was palpable. All the hernial orifices were intact. The patient had generalized tenderness, and the bowel sounds were exaggerated. Rectum was empty on per rectal examination, and there was no evidence of any growth. Clinical impression of acute intestinal obstruction was made, and the patient was subjected to blood and radiological investigations. Her blood investigations were - hemoglobin: 9.1 g/dl, total leucocyte count: 7000 cells/mm3, serum bilirubin 0.9 mg%, serum glutamic-oxaloacetic transaminase: 55 IU, serum glutamic pyruvic transaminase: 48 IU, blood urea: 29 mg%, serum creatinine: 1.4 mg%, potassium: 3.2 meq/l, sodium: 139 meq/l, random blood sugar: 98 mg%
Patient was subjected to X-ray abdomen and chest. X-ray abdomen showed multiple air fluid levels while chest X-ray was normal. Computerized tomography scan was not done as it was not available in emergency. Ultrasound Abdomen revealed distended bowel loops. Based on history, clinical examination and X-ray findings, an impression of acute intestinal obstruction secondary to postoperative adhesions was made.
Exploratory laparotomy was planned after adequate resuscitation. Exploration revealed distended small bowel and caecum with a circumferential growth at the hepatic flexure of size around 5 cm x 5 cm. Large bowel distal to the lesion was collapsed. The mesenteric lymph nodes were enlarged, and there were three liver lesions, two on the right lobe and one on the left ranging in size from 2 cm to 5 cm. There was no evidence of any free fluid or peritoneal deposits. An extended right-sided hemicolectomy with ileocolic, end-to-end anastomosis was done. Biopsy from the liver lesion of the largest size was taken. Mass closure of the abdomen was done with a single drain in the pelvis. Patient recovered well though she developed superficial surgical wound infection which was treated with irrigation and antibiotics as per the culture and sensitivity.
Post-operative contrast enhanced computerized tomography of the abdomen showed multiple hypodense lesions in both lobes of the liver suggestive of metastases [Figure 1a and b]. Histopathological examination of the resected bowel revealed well-differentiated mucin secreting adenocarcinoma invading the muscular layer [Figure 2c and d]. Twelve lymph nodes isolated were uninvolved by the tumor (Stage pT2N0). Biopsy from the liver nodules showed multiple confluent epithelioid granulomas with caseation necrosis suggestive of TB [Figure 2a and b]. No metastatic deposit was seen.
Based on the histopathology findings, patient was put on anti-tubercular treatment. Chemotherapy was not started as it was a T2 tumor and patient was put on regular follow-up. Ultrasound abdomen done after 2 months showed absence of any lesions in the liver. Carcinoembryonic antigen done after 3 months of surgery was 1.2 ng/ml. Thus, the patient responded well to anti-tubercular treatment and is still continuing with the treatment.