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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 147-149

Spontaneous enterocutaneous fistula due to colonic malignancy: A rare case report


Department of General Surgery, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India

Date of Web Publication13-Dec-2013

Correspondence Address:
Umesh Jethwani
Ward No. 26, Department Of General Surgery, Vardhman Mahaveer Medical College and Safdarjung Hospital, New Delhi -110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122940

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  Abstract 

Spontaneous colocutaneous fistula is a rare clinical entity usually associated with diseases like diverticulitis, crohn's disease and post radiotherapy treated malignancy. This case illustrates the challenges of diagnosis and management of such patients. We present a 60-year old lady who had a lump in left lumbar region which started discharging feculent material ten day prior to presentation. There was history of progressively worsening constipation and weight loss but no rectal bleeding or jaundice. There was a necrotic patch with feculent discharge from left lumbar region with underlying lump that was 5 Χ 4 cm, firm, non-tender and immobile. Following complete evaluation including abdomino-pelvic ultrasound that revealed an ill-defined mass arising from sigmoid colon, a diagnosis of colocutaneous fistula secondary to colonic malignancy was made. After resuscitation, the patient had exploration and Hartmann's procedure. Histopathology confirmed growth as adenocarcinoma and patient was placed on chemotherapy. We present this case to illustrate the challenges of diagnosis and management of such patients.

Keywords: Colonic malignancy, enterocutaneous fistula, left lumbar mass, sigmoid colon carcinoma


How to cite this article:
Jethwani U, Bansal AA, Kandwal VV. Spontaneous enterocutaneous fistula due to colonic malignancy: A rare case report. Arch Int Surg 2013;3:147-9

How to cite this URL:
Jethwani U, Bansal AA, Kandwal VV. Spontaneous enterocutaneous fistula due to colonic malignancy: A rare case report. Arch Int Surg [serial online] 2013 [cited 2024 Mar 1];3:147-9. Available from: https://www.archintsurg.org/text.asp?2013/3/2/147/122940


  Introduction Top


Spontaneous colocutaneous fistula is a rare clinical entity usually associated with diseases like diverticulitis, crohn's disease, and post radiotherapy treated malignancy. We present a case of colonic malignancy complicated with a rare clinical presentation of spontaneous enterocutaneous fistula and abdominal wall necrotizing fasciitis. This case illustrates the challenges of diagnosis and management of such patients.


  Case Report Top


A 60-year-old lady from poor socioeconomic background presented with history of lump in left lumbar region of two months duration. Ten days prior to the presentation, she developed spontaneous feculent discharge from the left lumbar region and later associated infection and cellulits of the abdominal wall with foul smelling fecopurulent discharge. There was history of progressively worsening constipation and weight loss. There was no history of rectal bleeding or jaundice. There was no history of surgery. On examination, her vital signs were stable. She was conscious alert and oriented. However, she was dehydrated and malnourished and had a Karnofsky performance score of 80. There was a necrotic patch with feculent smelling pus discharge from left lumbar and iliac region with underlying lump that was 5 Χ 4 cm, firm, non-tender and immobile [Figure 1]. There was no hepatomegaly or evidence of free fluid in the abdomen. Digital rectal examination was normal. A provisional diagnosis of colocutaneous fistula secondary to colonic malignancy was made. Laboratory investigations revealed-hemoglobin-10.4 gm%, total leucocyte count-11000 cells/mm 3 , serum urea-30 U/dl, serum creatinine-1.4 I/dl, serum sodium-136 meq/dl and potassium-3 meq/dl. Abdominal ultrasound revealed ill-defined mass arising from sigmoid colon but no ascites or liver metastasis. The patient was resuscitated with intravenous fluids, antibiotics, and analgesics coupled with commencement of nutritional rehabilitation.
Figure 1: Preoperative photograph

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She was prepared for emergency debridement of the necrotizing fasciitis wound and exploratory laprotomy for suspected colonic malignancy. Intraoperative findings confirmed communication of abdominal wound with sigmoid colon with associated inflammatory changes [Figure 2]. There was no ascites and no liver metastasis. The sigmoid colon growth of size 7 cm by 5 cm was resected to 5 cm distal margin with creation of distal Hartmann's pouch and proximal end taken out as end colostomy [Figure 3] and [Figure 4]. Histopathology confirmed growth as adenocarcinoma with margins free of tumor. The resected mesenteric lymph nodes did not contain tumor. Postoperative period was uneventful. The patient was referred to medical oncology department where he received chemotherapy. Follow-up at 6 months was uneventful. Now patient is planned for closure of colostomy.
Figure 2: Intraoperative findings confirmed communication of abdominal wound with sigmoid colon with associated infl ammatory changes

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Figure 3: The sigmoid colon growth of size about 7 cm was resected with wide local excision of 5 cm margin with creation of distal Hartmann's pouch and proximal end taken out as end colostomy

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Figure 4: Creation of Hartmann's pouch

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  Discussion Top


Colon cancers presenting as colocutaneous fistula and necrotizing fasciitis is rare and signifies the delayed presentation of this disease seen in people with poor socioeconomic status. Such fistulas are more commonly seen with diverticulitis. Of 93 patients with colocutaneous fistulas associated with diverticulitis, reported by Fazio et al., [1] 88 patients developed fistulas after operation, and in only 5 did the fistulas develop spontaneously.

There are only few case reports with such primary malignancy presenting as fistulas and abdominal wall cellulitis. [2],[3] Colorectal cancers often present with abdominal pain or change in bowel habits. Barely 5% of colorectal cancers perforate the colon, whereas 0.35% of them are associated with abscess. [4] There are sparse case reports of colorectal cancer affecting the abdominal wall at the time of diagnosis. [4],[5],[6] In a review of 16,000 patients, treated for colon cancer at Massachussetes General Hospital between 1938 and 1970, only nine patients had a presenting complaint of abdominal wall abscess. [7] In the series reported by Zera et al., [8] of 68 enterocutaneous fistulas, none was from carcinoma of the colon. Spontaneous enterocutaneous fistula have also been reported following radiotherapy. [9],[10],[11]

Development of fistula in a cancer patient indicates the advanced stage of the disease and increases morbidity and mortality. It can also prohibit any definitive surgical treatment and attempts at closure of the fistula. [9]

Enterocutaneous fistula are classified into four types based on modified Sitges-Serra classification proposed by Shein and Decker. [10],[11]

Type I-fistula are esophageal, gastric or duodenal fistula

Type II-involve small bowel

Type III-involve large bowel

Type IV-fistula where all the aforementioned drains through a large abdominal wall defect.

Raghavendra et al., [2] have also reported a case of spontaneous colocutaneous fistula secondary to colon carcinoma, which was managed with left hemicolectomy and excision of rim of abdominal wall at the site of the fistula. Such cases also present management dilemmas. During surgery the aim was curative resection with en bloc resection of tumor along with fistula tract and any other structure invaded by the tumor or the fistula tract.

In our case with the availability of limited resources in emergency setting, we performed debridement and exploratory laparotomy with definitive surgery. No guidelines have been specified for management and prognostic significance with such kind of presentation.

In conclusion, enterocutaneous fistula is most commonly seen after anastomotic breakdown, crohn's disease, or diverticular abscess. Colonic malignancy presenting as spontaneous entercuteous fistula is a rare presentation. Surgery is the treatment of choice in such cases. In patients with malignant enterocutaneous fistula not amenable to resection either a palliative bypass or diverting ostomy may be considered.

 
  References Top

1.Fazio VW, Church JM, Jagelman DG, Weakley FL, Lavery IC, Tarazi R, et al. Colocutaneous fistulas complicating diverticulitis. Dis Colon Rectum 2007;30:89-94.  Back to cited text no. 1
    
2.Nagaraja R, Kudva A, Prasad NN. Spontaneous colocutaneous fistula: A rare presentation of colon carcinoma. Internet J Surg 2008;15:1.  Back to cited text no. 2
    
3.Bischoff K, López C, Shaffer K, Schwaitzberg S. Colorectal adenocarcinoma presenting as abdominal wall cellulitis. Radiol Case Rep 2008;3:204.  Back to cited text no. 3
    
4.Speights VO, Johnson MW, Stoltenberg PH, Rappaport ES, Helbert B, Riggs M. Colorectal cancer: Current trends in initial clinical manifestations. South Med J 1991;84:575-8.  Back to cited text no. 4
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5.Hulnick DH, Megibow AJ, Balthazar EJ, Gordon RB, Surapenini R, Bosniak MA. Perforated colorectal neoplasms: Correlation of clinical, contrast enema, and CT examinations. Radiology 1987;164:611-5.  Back to cited text no. 5
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6.Okita A, Kubo Y, Tanada M, Kurita A, Takashima S. Unusual abscesses associated with colon cancer: Report of three cases. Acta Med Okayama 2007;61:107-13.  Back to cited text no. 6
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7.White AM, Haskin BJ, Jenkins CK, Pfister RC. Abscess of the abdominal wall as the presenting sign in carcinoma of the colon. Cancer 1973;32:142-6.   Back to cited text no. 7
    
8.Zera RT, Bubrick MP, Sternquist JC, Hitchcock CR. Enterocutaneous fistulas. Effects of total parentral nutrition and surgery. Dis Colon Rectum 1983;26:109-12.   Back to cited text no. 8
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9.Chamberlain RS, Kaufman HL, Danforth DN. Enterocutaneous fistulae in cancer patients: Etiology, management, outcome and impact on further treatment. Am Surg 1998;64:1204-11.  Back to cited text no. 9
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10.Sitges-Serra A, Jaurrieta E, Sitges-Creus A. Management of postoperative enterocutaneous fistulas: The role of parenteral nutrition and surgery. Br J Surg 1982;69:147-50.  Back to cited text no. 10
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11.Chintamani, Badran R, Rk D, Singhal V, Bhatnagar D. Spontaneous enterocutaneous fistula 27-years following radiotherapy in a patient of carcinoma penis. World J Surg Oncol 3;1:23.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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