Free perforation in regional enteritis.

Abstract

The inflammatory reaction in regional enteritis is characteristically transmural, with affected loops of intestine frequently becoming attached to adjacent structures. As a result, deep ulcerations and fissures commonly lead to fistula formation rather than to free perforation into the peritoneal cavity. Over the past three years, we have encountered five cases of regional enteritis with free perforation. These cases and a review of the literature are presented in an attempt to clarify the pertinent factors leading to this complication. CASE REPORTS CASE 1 (89-26-98) This 11-year-old white girl was admitted to the University of Chicago Hospital with a two-year history of lower abdominal cramps and bloody diarrhoea. Barium x-ray studies revealed regional enteritis involving the distal ileum, sigmoid colon, and rectum. While on intravenous fluids, antibiotics, and corticosteroids, she experienced recurrent episodes of partial small intestinal obstruction. With sudden worsening of her symptoms, a laparotomy was performed, revealing diffuse peritonitis (mixed Gram-negative organisms). She underwent a resection of 29 cm of terminal ileum and adjacent 5 cm of ascending colon, creating a diverting ileocolostomy. Pathological examination revealed severe regional enteritis with superficial and deep ulcerations of the entire terminal ileum. A small perforation was found in the diseased ileum, proximal to a markedly thickened distal segment and 8 cm from the ileocaecal valve. Two months after the resection, the ileocolostomy was closed. Six months later, there was radiological evidence of disease in the distal 15 cm of ileum. Over the next two years, she has continued to present evidence of disease in both the distal ileum, the sigmoid, and the rectum. Though she has remained asymptomatic, she has failed to grow. CASE 2 (79-82-58) This 23-year-old white man was seen at the University of Chicago Hospital with a two-year history of abdominal pain and diarrhoea. Barium x-ray studies revealed regional enteritis involving the terminal ileum. Treatment included a bland diet, phenobarbital, belladonna, and azulphidine. Symptoms continued and the patient subsequently was admitted to hospital on two occasions with partial small intestinal obstruction. On the second admission to hospital, attempts at intestinal decompression were unsuccessful; previously active bowel sounds disappeared and a plain film of the abdomen revealed free air under both diaphragms. Laparotomy revealed diffuse peritonitis (E. coli). Resection of 48 cm of terminal ileum and 9 cm of ascending colon was accompanied by an ileocolostomy. Though the pathological examination confirmed the diagnosis of regional enteritis with moderate constriction of the lumen, no overt perforation could be found. During the five months following resection, the patient has continued well.CASE 3 (96-70-94) This 50-year-old white woman was admitted to the University of Chicago Hospital with a one-year history of abdominal pain, diarrhoea, and weight loss increasing in severity and ac...

Free perforation of the small bowel in Crohn's disease

“…There was no free gas on plain abdominal X-ray of this case and this also accords with the majority of reports (Waye and Lithgow, 1967). Although the pathology usually reveals active on chronic disease (Steinberg et al, 1973), perforation has been reported in acute ileitis (Nasr et al, 1969). The commonest site of perforation is the ileum (Nasr et al, 1969), but perforations have been described in the jejunum (Homb, 1946), Meckel's diverticulum (Horn and Rhoads, 1944), caecum (Midgley, Thompson and Arbor, 1968), and colon, Javett and Brooke, 1970).…”

“…Although the pathology usually reveals active on chronic disease (Steinberg et al, 1973), perforation has been reported in acute ileitis (Nasr et al, 1969). The commonest site of perforation is the ileum (Nasr et al, 1969), but perforations have been described in the jejunum (Homb, 1946), Meckel's diverticulum (Horn and Rhoads, 1944), caecum (Midgley, Thompson and Arbor, 1968), and colon, Javett and Brooke, 1970). These perforations have been single or not identified and only four cases of multiple ileal (Harjola, Appelqvist and Lilius, 1965;Crohn, 1965;Nasr et al, 1969;Menguy, 1972), and one multiple jejunal perforation (Harjola et al, 1965), can be found in the literature.…”

“…The commonest site of perforation is the ileum (Nasr et al, 1969), but perforations have been described in the jejunum (Homb, 1946), Meckel's diverticulum (Horn and Rhoads, 1944), caecum (Midgley, Thompson and Arbor, 1968), and colon, Javett and Brooke, 1970). These perforations have been single or not identified and only four cases of multiple ileal (Harjola, Appelqvist and Lilius, 1965;Crohn, 1965;Nasr et al, 1969;Menguy, 1972), and one multiple jejunal perforation (Harjola et al, 1965), can be found in the literature. Perforation appears most commonly to occur proximal to lumenal narrowing (Waye and Lithgow, 1967;Robinson and Craft, 1967;Steinberg et al, 1973), as was the case in the present patient.…”

“…Steroids are not considered an important aetiological factor in the causation of perforation in Crohn's disease (Nasr et al, 1969;Steinberg et al, 1973), but the high incidence of anastomotic leakage following elective surgery for Crohn's disease has been attributed to steroids (Menguy, 1972).…”

Gastrocnemius Myositis in a Patient with Inflammatory Bowel Disease

“…Small intestinal involvement was reported on the small bowel follow-through in 1970 and spontaneous mid-ileal perforation occurred 13 years later. This latter complication is a rare, but well-documented occurrence in ileal Crohn's disease [11] with granulomata being less frequently found [12] and sometimes very little inflammatory reaction [13]. Simi larly the development of a perianal abscess and rectovaginal fistula were more in keeping with a diagnosis of Crohn's disease [14].…”