The Journal of Emergency Medicine, Vol. 50, No. 4, pp. 670–671, 2016 Copyright Ó 2016 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.09.016
Visual Diagnosis in Emergency Medicine
AN UNEXPECTED MIMICKER OF APPENDICITIS Seigo Urushidani, MD* and Akira Kuriyama, MD, MPH† *Department of Emergency Medicine and †Department of General Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan Reprint Address: Akira Kuriyama, MD, MPH, Department of General Medicine, Kurashiki Central Hospital, Miwa Kurashiki, Okayama 710-8602, Japan
CASE REPORT
DISCUSSION
A previously healthy 44-year-old man presented with fainting. He reported a 2-day history of right lower abdominal pain, which migrated from his epigastric area, and recent appetite loss and weight loss. On arrival, his vital signs were: temperature 38.3 C, pulse rate 130 beats/min, respiratory rate 25 breaths/min, and blood pressure 145/97 mm Hg. Physical examination revealed a diffuse abdominal tenderness, with the right lower abdomen most tender with rebound tenderness. Laboratory tests showed white blood cell count of 12,200/mm3, with neutrophils of 92.0%, and hemoglobin of 14.9 g/dL. The Alvarado score for acute appendicitis was 10 out of 10, and we suspected that this patient had appendicitis. Contrast-enhanced computed tomography showed a well-demarcated tumor, 10 cm in diameter, the content of which was heterogeneously enhanced, along with ascites in the abdominal cavity (Figure 1). A rupture of colon cancer or gastrointestinal tumor was suspected, and an emergency right hemicolectomy was performed. Hemorrhagic ascites was confirmed during surgery, and the pathology of the resected tumor proved to be adenocarcinoma of the colon and intratumoral hemorrhage.
Colorectal cancer is one of the leading causes of cancer deaths in developed countries, and the proportion of proximal colon cancer is increasing (1,2). Thus, complications of proximal colon cancer will be more important for differential diagnosis of appendicitis. Our patient showed a migration of stomachache as seen in cases with appendicitis. We hypothesized that the first epigastric pain was due to the visceral innervation of the midgut, and localized right lower abdominal pain was due to the extension of the serous membrane with rapidly enlarging tumor and the increased pressure toward the cecum (3). We also suspected that his rebound tenderness was due to the peritoneal irritation with blood from the ruptured tumor, and his fainting resulted from the acute circulatory collapse due to acute hemorrhage within and subsequently from the colon cancer. Although 7–40% of patients with colorectal cancer present with large bowel obstruction or perforation, bleeding occurs in 2% of them, and intratumoral hemorrhage and rupture of colon cancer is rarely reported (4). Given that it could present with shock and could be life-threatening, physicians need to include this entity in the differential diagnosis of right lower abdominal pain.
Written consent to publish the article and figures were obtained from the patient.
Acknowledgment—The authors would like to thank Ms. Ryoko Yoshida for editing the pictures.
RECEIVED: 29 July 2015; ACCEPTED: 16 September 2015 670
An Unexpected Mimicker of Appendicitis
671
Figure 1. (A) Intratumoral hemorrhage within colon cancer (asterisk) and blood around the cancer (arrow) in the sagittal view. (B) Intratumoral hemorrhage within colon cancer (asterisk) and blood around the cecum (arrow) in the coronal view.
REFERENCES 1. Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014;64:104–17. 2. Cheng L, Eng C, Nieman LZ, Kapadia AS, Du XL. Trends in colorectal cancer incidence by anatomic site and disease stage
in the United States from 1976 to 2005. Am J Clin Oncol 2011; 34:573–80. 3. Petroianu A. Diagnosis of acute appendicitis. Int J Surg 2012;10: 115–9. 4. Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 2000;127:370–6.
http://dx.doi.org/10.1016/j.jemermed.2015.09.016
Visual Diagnosis in Emergency Medicine
AN UNEXPECTED MIMICKER OF APPENDICITIS Seigo Urushidani, MD* and Akira Kuriyama, MD, MPH† *Department of Emergency Medicine and †Department of General Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan Reprint Address: Akira Kuriyama, MD, MPH, Department of General Medicine, Kurashiki Central Hospital, Miwa Kurashiki, Okayama 710-8602, Japan
CASE REPORT
DISCUSSION
A previously healthy 44-year-old man presented with fainting. He reported a 2-day history of right lower abdominal pain, which migrated from his epigastric area, and recent appetite loss and weight loss. On arrival, his vital signs were: temperature 38.3 C, pulse rate 130 beats/min, respiratory rate 25 breaths/min, and blood pressure 145/97 mm Hg. Physical examination revealed a diffuse abdominal tenderness, with the right lower abdomen most tender with rebound tenderness. Laboratory tests showed white blood cell count of 12,200/mm3, with neutrophils of 92.0%, and hemoglobin of 14.9 g/dL. The Alvarado score for acute appendicitis was 10 out of 10, and we suspected that this patient had appendicitis. Contrast-enhanced computed tomography showed a well-demarcated tumor, 10 cm in diameter, the content of which was heterogeneously enhanced, along with ascites in the abdominal cavity (Figure 1). A rupture of colon cancer or gastrointestinal tumor was suspected, and an emergency right hemicolectomy was performed. Hemorrhagic ascites was confirmed during surgery, and the pathology of the resected tumor proved to be adenocarcinoma of the colon and intratumoral hemorrhage.
Colorectal cancer is one of the leading causes of cancer deaths in developed countries, and the proportion of proximal colon cancer is increasing (1,2). Thus, complications of proximal colon cancer will be more important for differential diagnosis of appendicitis. Our patient showed a migration of stomachache as seen in cases with appendicitis. We hypothesized that the first epigastric pain was due to the visceral innervation of the midgut, and localized right lower abdominal pain was due to the extension of the serous membrane with rapidly enlarging tumor and the increased pressure toward the cecum (3). We also suspected that his rebound tenderness was due to the peritoneal irritation with blood from the ruptured tumor, and his fainting resulted from the acute circulatory collapse due to acute hemorrhage within and subsequently from the colon cancer. Although 7–40% of patients with colorectal cancer present with large bowel obstruction or perforation, bleeding occurs in 2% of them, and intratumoral hemorrhage and rupture of colon cancer is rarely reported (4). Given that it could present with shock and could be life-threatening, physicians need to include this entity in the differential diagnosis of right lower abdominal pain.
Written consent to publish the article and figures were obtained from the patient.
Acknowledgment—The authors would like to thank Ms. Ryoko Yoshida for editing the pictures.
RECEIVED: 29 July 2015; ACCEPTED: 16 September 2015 670
An Unexpected Mimicker of Appendicitis
671
Figure 1. (A) Intratumoral hemorrhage within colon cancer (asterisk) and blood around the cancer (arrow) in the sagittal view. (B) Intratumoral hemorrhage within colon cancer (asterisk) and blood around the cecum (arrow) in the coronal view.
REFERENCES 1. Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014;64:104–17. 2. Cheng L, Eng C, Nieman LZ, Kapadia AS, Du XL. Trends in colorectal cancer incidence by anatomic site and disease stage
in the United States from 1976 to 2005. Am J Clin Oncol 2011; 34:573–80. 3. Petroianu A. Diagnosis of acute appendicitis. Int J Surg 2012;10: 115–9. 4. Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 2000;127:370–6.
