CASE REPORT Pelvic abscess formation in perforated carcinoma of the jejunum Abstract A 76 year old Chinese woman presented with a pelvic abscess, secondary to perlorated carcinoma of the jejunum. Plain abdominal radiograph showed a mottled lesion which corresponded to the site of the perlorated tumour seen on CT and confirmed during laparotomy. The clinical and imaging features of carcinoma of the jejunum are briefly reviewed. Wilfred CG Peh DMRD, FRCR, FAMS Associate Professor "JudyWC Ho MBSS, FRCS Senior Medical Officer Departments of Diagnostic Radiology and 'Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong Introduction Carcinoma of the jejunum is a rarely encountered lesion which usually mani- fests clinically with non-specific signs and symptorns.Abscess formation from its per- foration as a presenting feature has, to our knowledge, not been described previously. We report the clinical and radiological find- ings in such a case. This article. is a reprint ol a case report from the Diagnostic CliniCS Senes of the Singapore Medical Journal. Case report A 76 year old Chinese woman first pre- sented to our hospital with a one day his- tory of abdominal pain, most severe over the left lower quadrant. There was no sig- nificant past history except for a rather vague history of constipation for one year. Examination revealed an obese and febrile woman. Vital signs were stable. There was generalised abdominal tenderness, mostse- vere over the left lower quadrant, but no 21 SA JOURNAL OF RADIOLOGY- November 1996 palpable mass. Rectal examination was negative. Her temperature spiked soon af- ter admission. The white cell count was raised at 20.2 g/dL with predominant neutrophilia (18.5 g/dL). Liver and renal function tests were normal, as were serum amylase levels. She was started on intrave- nous antibiotics with a presumptive diag- nosis of diverticulitis. Plain abdominal radiograph on admis- sion (Figure 1) showed a large rounded Figure 1: Plain radiograph shows a rounded mottled area (arrows) in the left abdomen. mottled area in the left upper quadrant, with no evidence ofbowel obstruction. CT done three days later confirmed the pres- ence of a large mass of soft tissue density at this site (Figure 2a). This mass contained oral contrast indicating communication with the bowel lumen. Air and debris-like material within the mass correlated with topage22 Pelvic abscess in jejunal carcinoma Ultrasound also con- finned the presence of a large pelvic fluid col- lection. At laparotomy, a polypoidal tumour, measuring 8 cm in di- ameter; was present in the proximal jejunum. Its base was perforated and sealed with omentum. Loculated abscesses were present at the left iliacfossaand the pelvis,each containing about 50 ml of pus. There was exten- sive lymphadenopathy along the course of the superior mesenteric artery Small bowel resection with end-to-end anastomosis and abscess drainage was done. On histopatho- logicalexamination, the tumour had infiltrated through the full thick- ness of the bowel wall into the surrounding subserosal adipose tissue. The lesion was extensively ulcerated, and the serosa showed changes of peritonitis. The diagnosis was undifferentiated carcinoma of the Figure 3: Contrast instilled via a Ry/e's tube shows extrinsic compression and obstruction of the duodena/loop. Figure 2(a): CT of upper abdomen shows a large soft tissue mass with irregular borders (arrowheads). It contains barium, debris and air (arrows). the mottled appearance on plain radiographs. The outer margins of this mass were irregu- lar with ill-definition of the adjacent intra-, peritoneal fat and muscle layers of the left abdominal flank (Figure 2b). This was con- tinuous with a large fluid collection in the left lower abdomen and pelvis (Figure 2c). Figure 4: CT of the upper abdomen shows massive lymph nodes (arrows) compressing the distal duodenum (arrowheads). Discussion Primary tumours of the small bowel constitute a mere 1-2% of allgastrointestinal malignancies. Carcinoma of the jejunum is rarer still, comprising 0.22% oflI 438 cases of gastrointestinal tumours in one series', The rarity of jejunal carcinoma issupported in other large studies of small bowel tu- mours+" Signs and symptoms of small bowel malignancy are vague and non-spe- cific, often being present for months or years before the diagnosis is made. 1,5,7,8 The more frequent presentations of this tumour are pain, anorexia, weight loss,bleeding or small bowel obstruction.v" Perforation is a rare presenting feature of adenocarcinoma of the jejunum, occurring in only one patient in a series oBI cases'There were no instances of perforation in two other large series, jenunum. Her postoperative recoverywas complicated initially by wound in- fection. She then developed bile- stained vomiting about four weeks later. Water soluble contrast meal showed complete obstruction at the third part of the duodenum (Figure 3), which was shown to be due to massive lymphadenopathy on CT (Figure 4).The rapid progression of lymphadenopathy subsequently produced bilateral ureteric obstruc- tion. She finally died seven weeks afterthe operation. Figure 2(c): CT at level of the pelvic brim shows large fluid col/ections (arrows). to page 23 22 SAJOURNAL OF RADIOLOGY- November 1996 Pelvic abscess in jejunal carcinoma from page 22 comprising 16 and 32 patients, respee- tively.3,4It was interesting to note that in a pathological study of IOcases of jejunal adenocarcinoma, all I 0 cases showed trans- gression through the bowel wall, with di- rect extension of tumour into the mesenteryin 4 cases? It is thereforesurpris- ing that perforation and its sequelae are not manifested more frequently, as in our pa- tient where perforation was followed by infection and abscess formation. The plain abdominal radiograph is usu- ally unhelpful for the diagnosis of jejunal carcinoma unless a complication such as obstruction or perforation had occurred. The unusual plain film appearance of a large mottled area was probably produced by debris and air within an abscess cavity adjacent to the site of perforation. This fea- ture was not recognised at the time the ra- diograph was taken as it was thought to be due to faecal material. In retrospect how- ever, this was unlikely as its shape was too circular and no other adjacent faecal-filled bowel loops were evident radiologically. The large soft tissue mass seen on cr was produced by a combination of the tu- mour mass, abscess cavity and surround- ing adherent omentum. The cr appear- ance of jejunal carcinoma has previously been recognised as a polypoidal or annular mass causing luminal narrowing. 10, II Al- though extra-luminal growth andinfiltra- tion of the surrounding fat have been described in tumours, the irregularity of the mass outline and streaky ill-definition of the adjacent fat in our case was due to an infec- tive process.The path of spread of infection was clearly demonstrated on CT by fuzziness of both the inner and outer walls of the left abdominal wallmuscuIature, lead- ing to fluid coUections in the left iliac fossa and pelvis.These findings oflocalised peri- tonitis and pus were subsequently con- firmed at surgery. Initial cr failed to detect mesenteric lymph node invasion in our patient, reflect- ing the experience of other investigators. I I Moreover, lymph node enlargement in jejunal carcinoma is unusually not as bulky asthat characteristicallyseen in lymphoma." A remarkable feature of our case was the rapid onset and progression of massive lymphadenopathy; which eventually lead to her unexpectedly quick demise. We are unable to explain the aggressive behaviour of this tumour. CT in combination with small bowel enema has been advocated for the detection and preoperative staging of thistumour'!" Small bowel enema is more sensitive than conventional small bowel fol- low-through examination in detecting jejunal carcinomas, manifest as polypoidal intra-luminal masses, annular strictures or ulcerated masses. Indirect evidence of tu- mour includes dilated bowel loops and fis- tulas," In our case, cr also illustrated the unusual presentation of pelvic abscess for- mation in jejunal carcinoma. 23 SAJOURNAL OF RADIOLOGY. November 1996 References 1. Martin RG. Malignant tumours of the small intes- tine. Surgical Clinics ofN071hAmerica 1986;66:779-85. 2. Ebert PA, Zuidema GD. Primary tumours of the small intestinc.An:hivesofSuTgery 1965;91 :452-5. 3. 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