Unorthodox Presentation of Colorectal Cancer With Multiple Fistulas and Multiple Abscesses

Abstract

Colorectal cancer is the third most lethal cancer in the United States and is the third most common type of cancer. In 2016, 134,490 cases of colorectal cancer were diagnosed in the United States. The diagnosis is usually made with screening colonoscopy on asymptomatic patients, while other patients are diagnosed after presenting symptoms such as hematochezia, iron deficiency anemia, changes in bowel movements, and abdominal pain. Also on emergency surgical procedures, a tumor may be found. We present a case of a 50-year-old Hispanic woman, G3P3AO, with a past medical history of hypertension, major depressive disorder and hysterectomy in 2003 without any toxic habits or family history of colon cancer or inflammatory bowel disease. Patient arrived with left lower quadrant pain, fever, and loss of appetite and was treated with IV antibiotics for an acute diverticulitis. Patient had multiple visits to urgency room for fecal material that discharged from the vaginal area and multiple intraabdominal abscesses in addition to obstruction. On imaging studies, patient had rectovaginal fistula and multiple abscesses. The patient's clinical condition became more complicated with enterocutaneous fistula and enterocolonic fistula 4 months later, suggesting inflammatory bowel disease. Sigmoid adenocarcinoma was diagnosed on the second colonoscopy. The clinical presentations of this patient with multiple abscesses and fistulas are commonly found on inflammatory bowel disease and can also be found in complicated intraabdominal infections. Rectovaginal fistulas which were the first fistula more commonly are caused by obstetric complications. Other common causes associated include surgery, inflammatory bowel disease, radiation therapy, and malignancy. These findings can mask the diagnosis of colorectal cancer and make the diagnosis challenging.