Perforated sigmoid colon adenocarcinoma within an irreducible inguinal hernia: A case report

Abstract

Inguinal hernia is a potentially occult common surgical condition. Its association with asymptomatic adenocarcinoma is uncommon. However, malignancy-associated perforation of the large bowel within an irreducible hernia is rare. We report a case of 78-year-old male presenting with a long-standing inguinal hernia with a 2-day history of irreducibility. Examination revealed a large left-sided irreducible inguinal hernia. Patient underwent urgent inguinal herniotomy, during which multiple perforations were noted in the sigmoid colon. Patient underwent Hartmann’s procedure following bowel resection. Histology revealed a mucinous adenocarcinoma with extensive metastasis involving the resection margins. Elderly patients with long-standing inguinal hernia presenting with acute symptoms should be evaluated further for this rare but sinister diagnosis.

Introduction

Inguinal hernia is the commonest type of abdominal hernia and commonly seen in males (male:female ratio 8:1). Most of the inguinal hernias are asymptomatic. In adult males, most (65%) inguinal hernias tend to be indirect. Indirect inguinal hernias have a higher chance of complications such as incarceration and irreducibility as it protrudes through the narrow deep inguinal ring. Of the inguinal hernias, 10% become incarcerated. ¹ Hernia repair is one of the commonest surgeries; however, depending on the hernial contents, the hernia repair could pose challenges. It is quite rarely less than 0.4% of the cases that an adenocarcinoma of the colon presents in the contents of an inguinal hernia.^2,3 We report a case of adenocarcinoma of the colon with multiple bowel perforations in an irreducible inguinal hernia.

Case report

A 78-year-old previously unscreened male, with a history of asymptomatic left-sided inguinal hernia, presented to the emergency department with an irreducible inguinal lump for 1 day duration. On further inquiry, he did not complain of a colicky-type abdominal pain or a history of altered bowel habits. There was no per rectal bleeding, loss of weight, or related constitutional symptoms. His general physical examination was unremarkable, and he was hemodynamically stable. The abdominal examination revealed a large irreducible inguino-scrotal hernia containing bowel. The digital rectal examination revealed an empty rectum. His basic biochemical tests were unremarkable. Further investigation with imaging revealed a dilated transverse colon in the abdominal X-ray, without features suggestive of perforation of a hollow viscus on erect chest X-ray.

As there was no preoperative evidence to suggest visceral perforation, the patient underwent emergency left inguinal herniotomy with a standard inguinal incision. The hernia sac was opened into, which contained a dilated sigmoid colon. Further survey of bowel revealed multiple non-leaking perforations at proximal sigmoid colon covered in thick whitish mucoid material. No strangulation of bowel was noticed. Thickened inflamed bowel wall was noticed 3–4 cm proximal and distal to the perforations. The involved segment was resected, and Hartmann’s procedure was carried out.

Histological examination of the specimen revealed a mucinous adenocarcinoma T4N2Mx with the involvement of the resection margins. The perforations were located at the tumour site, possibly due to the necrotic tumour mass. The patient was investigated further with cross-sectional imaging. The contrast-enhanced computed tomography (CECT) of the abdomen showed segmental bowel wall thickening with nodular appearance distal to the colostomy with extensive tumour metastasis in the inguinal lymph nodes. However, there were no distant metastatic lesions.

The patient was informed of the diagnosis although further treatment was offered, the patient denied surgical or chemoradiotherapy interventions. Thus, a conservative approach was adopted in further management.

Discussion

Both inguinal hernia and colorectal carcinoma are common in elderly. Literature shows evidence to the fact that they can coexist especially when the carcinoma is asymptomatic. The tumour can be classified in relation to hernia sac as saccular and intrasaccular. Intrasaccular tumour arises from a left-sided abdominal organ commonly the sigmoid colon. ⁴ A preoperative diagnosis of a carcinoma in the context of an inguinal hernia is challenging, but some sinister details in the history may raise suspicion. Slater et al. ³ revealed that the clinician should have a high index of suspicion in elderly males, patients with long-standing hernia with recent onset pain or incarceration, patients with a history of intra-abdominal malignancy presenting with a new onset hernia, and other common sinister features such as unexplained weight loss, altered bowel habits, and per rectal bleeding should indicate the possibility of underlying carcinoma.

Similar to the index case, most previous literature reported cases presenting with painful inguinal lump which was diagnosed as strangulated inguinal hernia.^4,5 However, some were asymptomatic on presentation. Although perforation of a carcinoma is rare within a hernia sac, the symptoms may resemble Fournier’s gangrene which warrants immediate operative exploration. Delay in therapy may pose serious sequelae such as rapidly progressive necrotizing fasciitis of the perineum associated with a high rate of morbidity and mortality. ⁵ Furthermore, if the infection is contained in the hernia sac, the prognosis is good as it limits the spread to the peritoneum. However, if there is contamination of the peritoneum it affects prognosis negatively. ⁵ In the present case, urgent intervention and emergency exploration prevented progression towards fatal sequelae. Colorectal carcinoma once perforated deems a poorer prognosis due to inherent high mortality owing to peritoneal sepsis. Diao and Ghosh ⁶ recommend an inguinal approach in such cases as opposed to laparotomy in order to minimise contamination and peritoneal sepsis. In the index case, our initial approach was through an inguinal incision; however, after discovering the extent of perforations in the bowel, a Hartmann’s procedure was performed with resection of the involved bowel segment.

Mucinous adenocarcinoma usually occurs in a younger age. It is related to poorer prognostic factors such as higher lymph node metastasis (46.15%) and a 5-year survival rate as low as 39% compared to the non-mucinous type (60.3%). ⁷ In contrary to this finding, our patient was diagnosed at an age of 78 years with extensive nodal involvement. With regard to diagnostics, cross-sectional imaging is the gold standard used in a majority of previous literature. Ko et al. recommends CECT in inguinal hernias that are progressively enlarging, irreducible, associated with anaemia, sepsis, loss of weight, or bowel obstruction. Similarly, in the present case, the principal diagnosis was reached with CECT imaging. ⁸ Preoperative colonic evaluation is preferred in elective cases due to the possibility of colonic resection intraoperatively, especially in patients older than 40 years. Barium enema is preferred due to the associated risk of colonic perforation with colonoscopy in a colon within a hernia sac. ⁹

Most intrasaccular tumours in the sigmoid colon are discovered on table, during surgery. This highlights the importance of having a high index of suspicion when patients present with predisposing factors and highlights the necessity of further investigation even in those presenting with seemingly benign symptoms. ²

There are a few limitations in this case report. As this case was performed in an emergency setting, there was an inability of obtaining any intraoperative images. Furthermore, due to the limitation of resources during an economic crisis in the country, digital images of radiology investigations were not available. However, despite the limitations, the case depicts the management of such acute presentations in a resource-limited setting.

Conclusion

Both inguinal hernia and colonic adenocarcinoma are common presentations in elderly patients. However, both these conditions are rarely found in coexistence. Although patient presents with seemingly benign symptoms, a high index of suspicion should be kept in elderly patients with long-standing hernias which become suddenly symptomatic. Further evaluation is deemed essential as diagnosis is challenging purely based on clinical history and examination. The case also highlights the importance of cross-sectional imaging and the place for endoscopy in the management of these patients.