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CASE REPORT
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 126-128

Anterior abdominal wall abscess: A rare presentation of advanced carcinoma of the stomach


1 Department of General Surgery, Unit 1, Christian Medical College, Vellore; Department of General Surgery, Gudalur Adivasi Hospital, Nilgiris, Tamil Nadu, India
2 Department of General Surgery, Unit 1, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission02-Jan-2021
Date of Decision25-Jan-2021
Date of Acceptance04-Feb-2021
Date of Web Publication15-Apr-2021

Correspondence Address:
Dr. Royson Jerome Dsouza
Gudalur Adivasi Hospital, Nilgiris - 643 212, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_1_21

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  Abstract 


Surgeons often encounter patients with advanced carcinoma of the stomach that necessitate urgent operative interventions. The presentations include perforation-peritonitis, bleeding, and gastric outlet obstruction. Carcinoma of the stomach is known to invade surrounding organs such as the transverse colon, pancreas, spleen, liver, and rarely, the anterior abdominal wall. In this case report, we describe an elderly diabetic male patient who presented with a large anterior abdominal wall abscess. The contrast-enhanced computed tomography scan of the abdomen showed a communication from the pylorus of the stomach to the abscess cavity. He underwent drainage of the abscess, and the wound was transiently managed with a vacuum-assisted closure. On gastroscopy, a fistulous opening was noted in the pylorus with surrounding erythema. The biopsy from the lesion was reported as a poorly differentiated adenocarcinoma with signet-ring cells. Anterior abdominal wall abscess is a rare presentation of carcinoma stomach and when identified, the primary aim of the treatment should be the sepsis control and wound healing followed by definitive management.

Keywords: Abdominal wall abscess, carcinoma stomach, carcinoma stomach infiltrating abdominal wall


How to cite this article:
Dsouza RJ, Samuel VM, Thomas CT, Gaikwad P. Anterior abdominal wall abscess: A rare presentation of advanced carcinoma of the stomach. Curr Med Issues 2021;19:126-8

How to cite this URL:
Dsouza RJ, Samuel VM, Thomas CT, Gaikwad P. Anterior abdominal wall abscess: A rare presentation of advanced carcinoma of the stomach. Curr Med Issues [serial online] 2021 [cited 2021 Jun 19];19:126-8. Available from: https://www.cmijournal.org/text.asp?2021/19/2/126/313806




  Introduction Top


Carcinoma of the stomach is a high-risk malignancy that can have nonspecific symptoms even in advanced stages.[1] Involvement of the anterior abdominal wall is a rare manifestation of a perforated carcinoma of the stomach. Since the clinical features can be misleading, the diagnosis of underlying malignancy becomes difficult.[1],[2] In the current report, we present an elderly male patient with an acute history of anterior abdominal wall abscess. The patient had no specific symptoms attributable to carcinoma of the stomach, and the diagnosis was made midway during the treatment of the abscess and its subsequent evaluation for the etiology. The clinical features, relevant investigations, diagnostic challenges, and management have been discussed with a review of the literature.


  Case Report Top


A 68-year-old male patient with diabetes mellitus presented to the emergency department with the complaints of a painful swelling over the right-hand side of the upper abdomen for 5 days. It was insidious in onset and was associated with fever, nausea, and reduced appetite. He did not have jaundice, hematemesis, or melena. His bowel and bladder habits were normal. He had undergone an open subtotal cholecystectomy 4 years ago for acute cholecystitis and his postoperative period was uneventful.

On examination, he was tachycardia and tachypnea and in acute distress due to pain. On examination of the abdomen, there was a tender swelling over the right hypochondrium, predominantly in the subcutaneous and muscular plane under the previous cholecystectomy scar. It measured 10 cm × 8 cm with the erythema of the skin and surrounding induration. There was no sinus or discharge from the skin. The rest of the abdomen was soft and nontender.

His relevant blood investigations are shown in [Table 1]. After resuscitation with intravenous fluids and administration of broad-spectrum intravenous antibiotics, a contrast-enhanced computed tomography (CT) scan was done to further characterize the lesion [Figure 1]. The CT showed a large abscess extending from the subcutaneous and intermuscular planes over the right hypochondrium and breaching the peritoneum. There was no intra-abdominal collection. There was also suspicion of a fistulous communication noted from the antropyloric segment of the stomach into the abscess cavity. There were no other features to suggest malignancy such as asymmetric thickening of the stomach wall or perigastric lymphadenopathy.
Figure 1: Axial and coronal sections of contrast-enhanced computed tomography of the abdomen postoral and intravenous contrast showing an ill-defined abscess along the right anterior abdominal wall with multiple air foci and adjacent inflammatory changes (yellow arrowheads). The abscess has an intraperitoneal extension and is seen communicating with the pyloric region of the stomach (red arrowheads) with associated thickening of the pylorus (green arrowheads).

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Table 1: Relevant blood investigations

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He underwent drainage of the abscess with debridement of the necrotic skin under general anesthesia. Intraoperatively, the abscess wall contained purulent material mixed with partially digested food particles. There was a small opening in the peritoneum through which the gastric contents were entering the abscess cavity. As the fistula was contained, without a major breach in the peritoneum or intra-abdominal sepsis, the intent of the surgery was primarily sepsis control by adequate drainage of the abscess. The wound cavity was packed and left open for healing by secondary intention.

Postoperatively, the patient improved symptomatically and the wound was managed by vacuum-assisted closure (VAC) dressing. A gastroscopy was performed once the patient stabilized, which showed a fistulous opening in the antropyloric region measuring 1 cm × 1 cm with surrounding induration. The biopsy was consistent with poorly differentiated adenocarcinoma with signet-ring cell morphology. The case was discussed in a multidisciplinary tumor board meeting with a recommendation for neoadjuvant chemotherapy followed by a radical subtotal gastrectomy. The patient was discharged on the 10th postoperative day with a healthy wound. However, the patient deferred further treatment and was lost to follow-up. Consent was obtained from the patient for his case to be reported.


  Discussion Top


Anterior abdominal wall abscesses are infrequently encountered in surgical emergencies and are mostly limited to postoperative laparotomy wounds.[3],[4] The various etiologies include the breakdown of a gastroenteric anastomosis, iatrogenic injury, failure of gastrostomy tract healing, chronic inflammatory diseases, pancreatitis, radiation, and malignancy.[4] The diagnosis of the specific etiology is essential for curative treatment. Since the clinical features of the underlying disease can be often nonspecific, higher imaging modalities such as contrast-enhanced CT scan of the abdomen must be promptly used.[5],[6],[7]

The use of a multidetector CT scan has improved the accuracy of the diagnosis of carcinoma of the stomach to 80%–89%.[8] An ideal CT imaging requires the patient to be nil orally for 4–6 h, with good gastric distention achieved using negative endoluminal contrast agents.[8] This is, however, not possible in an emergency setting when the patient is in sepsis, thus decreasing the sensitivity and specificity. Gastroscopy cannot be performed solely for diagnostic purposes in patients with abdominal wall abscess until sepsis control is achieved.

There is a common consensus regarding the primary aim of treatment being drainage of the abscess with initiation of appropriate antibiotics to control sepsis.[4],[5],[9] However, whether the first operation should also include radical resection of the malignancy is debatable.[10] As the patient is often septic, curative resection may result in increased morbidity.[1],[2],[5] Wound management following drainage of the abscess should be a priority. The risk of tumor infiltration into the wound and abdominal wall should be anticipated. Hence, the first operation should focus on sepsis control without breaching the planes that could potentially lead to seeding of the tumor.[5],[11] In our patient, as there was no suspicion of malignancy preoperatively, the operative intervention only focused on sepsis control. Following this, the wound healed well with VAC.

In perforated tumors, with an abdominal wall or intra-abdominal abscess, the option of neoadjuvant therapy can still be explored following sepsis control and wound management. The major limitation in our report is that the patient was lost to follow-up, and the effects of neoadjuvant therapy on wound healing and outcome following definitive surgery could not be assessed.


  Conclusion Top


Anterior abdominal wall abscess is a rare manifestation of perforated carcinoma of the stomach, and the use of a multidetector CT scan can aid in the diagnosis of the same. The primary aim of treatment should be sepsis control by draining the abscess followed by wound management. The definitive surgical resection should be planned only after wound healing and neoadjuvant chemotherapy in selected patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Melloni M, Bernardi D, Asti E, Bonavina L. Perforated gastric cancer: A systematic review. J Laparoendosc Adv Surg Tech A 2020;30:156-62.  Back to cited text no. 1
    
2.
Jwo SC, Chien RN, Chao TC, Chen HY, Lin CY. Clinicopathological features, surgical management, and disease outcome of perforated gastric cancer. J Surg Oncol 2005;91:219-25.  Back to cited text no. 2
    
3.
Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014;51:344-62.  Back to cited text no. 3
    
4.
Papavramidis TS, Mantzoukis K, Michalopoulos N. Confronting gastrocutaneous fistulas. Ann Gastroenterol 2011;24:16-9.  Back to cited text no. 4
    
5.
Cho J, Park I, Lee D, Sung K, Baek J, Lee J. Advanced gastric cancer perforation mimicking abdominal wall abscess. J Gastric Cancer 2015;15:214-7.  Back to cited text no. 5
    
6.
Guang TN, Ci-An TG, Goh BK. An unusual cause of anterior abdominal wall abscess. Left anterior abdominal wall abscess secondary to fish bone migration from the gastrointestinal tract. Gastroenterology 2015;149:e8-9.  Back to cited text no. 6
    
7.
Gandhi J, Gandhi N. Abdominal wall abscess: more than meets the eye. BMJ Case Rep. 2010;2010:bcr08.2009.2151. doi: 10.1136/bcr.08.2009.2151. Epub 2010 Feb 8. PMID: 22315645; PMCID: PMC3029540.  Back to cited text no. 7
    
8.
Hallinan JT, Venkatesh SK. Gastric carcinoma: Imaging diagnosis, staging and assessment of treatment response. Cancer Imaging 2013;13:212-27.  Back to cited text no. 8
    
9.
Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20.  Back to cited text no. 9
    
10.
Heimlich HJ. The treatment of perforated cancer of the stomach. Am J Gastroenterol 1963;39:243-51.  Back to cited text no. 10
    
11.
Carlomagno N, Schonauer F, Tammaro V, Di Martino A, Criscitiello C, Santangelo ML. A multidisciplinary approach to an unusual medical case of locally advanced gastric cancer: A case report. J Med Case Rep 2015;9:13.  Back to cited text no. 11
    


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