Management challenges of advanced colorectal cancer in a young adult from a low-resource setting: A case report.

1
Introduction
Colorectal cancer (CRC) has traditionally been considered a disease of older adults; however, recent evidence indicates a concerning rise in cases among individuals under 50 years, a group classified as young-onset colorectal cancer (YOCRC) [1,2]. Over the past two decades, epidemiological data have shown a steady global increase in CRC incidence among adolescents and young adults, with particularly notable growth in those aged 20–24 [3].
In Africa, although data remain limited, available studies suggest a similar upward trend. In 2022, the continent recorded an estimated 70,428 new CRC cases and 46,087 related deaths, with rising incidence observed in both North Africa and Sub-Saharan Africa [4].
This trend is worrisome because younger patients often present with advanced disease and nonspecific symptoms such as altered bowel habits, abdominal pain, rectal bleeding, and iron-deficiency anemia, which are frequently overlooked or misattributed, leading to diagnostic delays [1,3]. The etiology of YOCRC is multifactorial, involving hereditary syndromes such as Lynch syndrome and other genetic predispositions, as well as environmental and lifestyle factors including obesity, alcohol consumption, tobacco use, dietary habits, sedentary behavior, and potential alterations in gut microbiota [1,3,5]. Despite these risks, screening programs have historically targeted older populations, contributing to under-detection and late-stage diagnosis in younger individuals [1,2,5].
Although CRC in adolescents and young adults remains relatively uncommon compared with older groups, its increasing incidence demands greater clinical vigilance and consideration of tailored diagnostic and therapeutic strategies [2,5].
Importantly, there is limited literature describing YOCRC from low-resource settings, where diagnostic and treatment infrastructures are often constrained. Presenting such a case provides unique insights into the intersection of biological disease behavior and systemic healthcare limitations, which may differ markedly from high-income contexts. Highlighting these challenges is crucial for understanding global disparities in CRC outcomes and informing context-specific interventions [4].
Here, we present the case of a 26-year-old male with a colonic tumor, illustrating the clinical presentation, diagnostic challenges, and management considerations of YOCRC. This case is particularly notable as it originates from a resource-limited environment, emphasizing how infrastructural, economic, and sociocultural factors can shape patient pathways and outcomes. This case report has been prepared in accordance with the SCARE 2025 criteria [6].
Here, we present the case of a 26-year-old male with a colonic tumor, illustrating the clinical presentation, diagnostic challenges, and management considerations of YOCRC. This case report has been prepared in accordance with the SCARE 2025 criteria [6].

2
Case presentation
A 26-year-old male presented to our facility with a three-year history of intermittent, colicky, non-radiating generalized abdominal pain. The episodes were associated with reduced appetite and progressively difficult bowel movements. One week prior to admission, he developed complete inability to pass stool, abdominal distension, and multiple episodes of projectile vomiting.
There was no history of fever, night sweats, significant weight loss, cough, chest pain, dyspnea, or bone pain. Throughout the course of illness, he had visited several peripheral health facilities, where he was repeatedly treated for presumed urinary tract infections with oral analgesics and antibiotics, but his symptoms persisted. He subsequently used traditional herbal remedies, which also failed to provide relief. With progressive worsening, he sought further evaluation at our center.
He had no prior history of abdominal surgeries, blood transfusions, or chronic illnesses. However, he reported a five-year history of regular alcohol consumption, including traditional brews, but no history of smoking. On general examination, he appeared acutely ill and cachectic but was neither pale nor jaundiced, with no peripheral edema. Vital signs were within normal limits: blood pressure 124/68 mmHg, pulse 91 bpm, temperature 36.5 °C, and oxygen saturation 98 % on room air.
Abdominal examination revealed a distended abdomen that moved with respiration. The umbilicus was everted, and traditional scarification marks were noted on both flanks. There was generalized tenderness, with percussion eliciting a dull note and bowel sounds diminished on auscultation. The provisional diagnosis was intestinal obstruction secondary to an intra-abdominal mass, with inflammatory bowel disease considered as a differential diagnosis.
Investigations included: full blood count (WBC 7.34 × 109/L, Hb 15 g/dL, platelets 325 × 109/L), serum creatinine 0.72 mg/dL (reference 0.7–1.8), serum urea 14.5 mg/dL (reference 18–55), random blood glucose 4.5 mmol/L, sodium 137 mmol/L, potassium 3.9 mmol/L, and chloride 99 mmol/L. Plain abdominal radiographs revealed dilated loops of small bowel, ascending and transverse colon, with collapsed descending and sigmoid colon on the supine view, and multiple air–fluid levels on the erect film (Fig. 1, Fig. 2). CT scan was not performed due to unavailability at our facility and the patient's clinical instability precluding transfer.
An emergency exploratory laparotomy was undertaken. Intraoperatively, there was gross distension of both small and large bowel up to the splenic flexure, with collapse of the descending and sigmoid colon. A constricting mass was identified at the colonic flexure, raising suspicion of malignancy with possible pelvic seeding (Fig. 3). Resection of the tumor was performed; the distal segment was buried, and the transverse colon exteriorized as a colostomy. A drain was placed, and the patient was transferred to the High Dependency Unit (HDU) for monitoring.
The patient was started on intravenous (IV) metronidazole 500 mg three times daily (TDS) for 5 days, IV ceftriaxone 1 g twice daily (BD) for 5 days, and intramuscular (IM) diclofenac 75 mg three times daily (TDS) for 5 days. He also received daily wound and colostomy care. His condition improved, and he was later transferred to the surgical ward.
He was discharged home with a follow-up appointment one week later. At review, the wound was healing well, with no discharge or signs of infection. Histopathological analysis of the resected tumor revealed a moderately differentiated invasive mucinous adenocarcinoma (pT3N2Mx) (Fig. 4A) using Hematoxylin and Eosin (H&E) staining at 10× original magnifications. Tumor cells demonstrated immunoreactivity with CDX2 (Fig. 4B) and β-catenin at 10× original magnification. He was referred to a regional oncology center for further evaluation and initiation of chemotherapy.

3
Timeline (per SCARE 2025)

4
Discussion
This case illustrates the convergence of clinical and systemic barriers in the management of colorectal cancer in young adults within low-resource settings. The presentation of a 26-year-old male with advanced colonic adenocarcinoma reflects the growing global challenge of young-onset colorectal cancer (YOCRC). Although still uncommon, YOCRC is increasingly recognized and often manifests more aggressively, with epidemiological data showing a marked rise in incidence since the mid-1990s and projections suggesting it may become a leading cause of cancer-related death in adults under 50 by 2030 [[7], [8], [9], [10]]. The patient's stage at diagnosis (pT3N2Mx) mirrors findings from larger cohorts where most young patients present with regional or metastatic disease [11,12], underscoring diagnostic delays and systemic gaps.
The three-year history of vague abdominal symptoms in this patient exemplifies the diagnostic challenges common in a resource-constrained setting. Nonspecific complaints such as abdominal pain, altered bowel habits, and bloating are often misattributed to benign conditions, leading to prolonged delays before definitive evaluation. Studies indicate that up to half of YOCRC patients experience diagnostic delays due to low clinical suspicion [10,13], a problem exacerbated by limited access to advanced imaging. In Sub-Saharan Africa, as many as 79 % of patients present at stage III/IV [13], consistent with this case's intraoperative findings.
In addition to healthcare infrastructure limitations, several contextual factors contribute to delayed diagnosis among young patients in low-resource environments. These include restricted access to specialized diagnostic services, high out-of-pocket healthcare costs, and reliance on traditional medicine prior to hospital presentation. Cultural perceptions that cancer is a disease of older adults can further reduce early health-seeking behavior. Moreover, YOCRC may exhibit inherently more aggressive biological behavior, characterized by mucinous or signet-ring histology, which can lead to rapid progression even within short symptomatic intervals [10,13,14]. Addressing these multifactorial contributors is essential for improving outcomes.
The absence of a family history in this patient contrasts with reports that one-third of YOCRC cases involve a first-degree relative with CRC [14], emphasizing the multifactorial nature of disease causation. Environmental factors such as alcohol consumption, processed meat intake, and sedentary lifestyles combine with potential contributors like altered gut microbiota and hereditary syndromes including Lynch syndrome [2,10,14]. Genetic testing was not feasible in this setting, although 20–27 % of YOCRC tumors demonstrate microsatellite instability [14].
Management in this case was shaped by local resource constraints. Emergency laparotomy with resection and colostomy remains an accepted standard in acute obstruction, yet the lack of multidisciplinary input and access to neoadjuvant therapy illustrates the compromises clinicians face in low-income contexts. In high-resource settings, more than half of non-metastatic YOCRC patients benefit from neoadjuvant regimens that improve outcomes [12]. Referral for chemotherapy post-resection was therefore critical, since stage III disease achieves 5-year survival rates approaching 70 % with adjuvant therapy but much lower without it [14]. Unfortunately, survival falls sharply in regions where oncology infrastructure is limited, with reports as low as 17 % [13].
Beyond clinical management, this case underscores pressing public health implications. The patient's prolonged reliance on traditional remedies highlights the role of health literacy, cultural practices, and stigma in delaying access to care. Such patterns are common across low-resource settings, where fear of cancer diagnosis, mistrust of biomedical systems, and competing socioeconomic priorities often discourage timely medical consultation [13,15]. These barriers, combined with long treatment courses, contribute to socioeconomic burdens including financial strain, travel difficulties, and income loss. Furthermore, fertility preservation is often overlooked in young patients undergoing chemotherapy, despite its relevance to this age group [10]. Calls to lower CRC screening thresholds are particularly important in Africa, where incidence is rising faster than in high-income countries [13]. Integrating culturally appropriate awareness campaigns and cost-effective screening modalities could play a pivotal role in overcoming diagnostic delays and improving survival outcomes in such settings. Increased awareness among both providers and patients, coupled with feasible screening approaches such as flexible sigmoidoscopy, could improve early detection.

5
Conclusion
This case underscores that young-onset colorectal cancer may present with prolonged, nonspecific symptoms that are easily overlooked, leading to delays in recognition and treatment. It also demonstrates how resource limitations in low-income settings contribute to late diagnosis and restrict access to standard multidisciplinary care. Finally, it highlights the urgent need for age-appropriate screening strategies and strengthened oncology infrastructure to improve outcomes and inform public health policies in regions where the burden of this disease is rising.

List of abbreviations

CT Scan – Computed Tomography scanWBC – white blood cellsHb – hemoglobin

Author contribution
AAK and AK did Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing and all authors validated the study and approved the final version of the manuscript.

Consent
Written informed consent was obtained from the patient both for the clinical procedure described and for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval
Ethical approval was not required for this case report in accordance with institutional policy, as single-patient case reports are exempt from formal review board approval. This case has not been presented at any conference or regional meeting and is not under consideration for publication in any other journal.

Guarantor
AAK and AK are the guarantors of the study.

Research registration number
Not applicable.

Funding
Not applicable.

Conflict of interest statement
The authors declare that they have no conflicts of interest.