In November 2014, a 33-year-old man presented to the Chiba University Hospital with a sudden onset of right lower abdominal pain spreading to the right lower back, developing 10 hours after gross bleeding. He had been receiving anti-tumor necrosis factor therapy for 10 years for mild to moderate Crohn’s disease with no fever. On examination, his temperature was 38.9°C and other vital signs were normal. The patient limped on the right leg to avoid worsening of the pain in the right lower back. The pain was relieved by lying on his back with the right knee bent and raised. The right lower abdomen was tender with involuntary guarding and rigidity. The psoas sign was positive on the right. Contrast-enhanced computed tomography revealed thickening of the intestinal wall and an abscess involving the iliopsoas containing free air in an area ranging from the terminal ileum to the transverse colon. Computed tomography also revealed retention of contents containing hemorrhagic components and a resulting marked dilatation of the intestinal tract in the proximal part of the ascending colon. The patient was diagnosed as having gastrointestinal perforation associated with gastrointestinal bleeding and a retroperitoneal abscess.
He responded to treatment with intravenous antibiotics that provided empiric coverage for gram-negative and anaerobic pathogens (doripenem, 500 mg every 8 hours), and an extended right hemicolectomy with end-to-end anastomosis was performed. As of October 2015, he was well without relapse.
It is generally accepted that 1.0% to 2.0% of patients with Crohn’s disease will present with a free perforation. Progressive intestinal stenosis produces a rapid increase in intra-intestinal pressure, resulting in gastrointestinal perforation. However, as in the present case, gastrointestinal bleeding also causes a rapid increase in intra-intestinal pressure. In addition, patients with Crohn’s disease receiving anti-tumor necrosis factor treatment are reported to frequently experience gastrointestinal perforation (odds ratio, 2.7). The time to the development of gastrointestinal perforation varies from patient to patient. Some patients experience gastrointestinal perforation several years after the onset of Crohn’s disease, whereas others experience it as an initial manifestation of Crohn’s disease. Acute exacerbation of Crohn’s disease is usually associated with crampy abdominal pain, whereas gastrointestinal perforation presents with sudden, severe abdominal pain accompanied by peritoneal irritation; therefore, the nature, mode of onset, and time course of abdominal pain can be clues for differentiating both types of abdominal pain. As in the present case, patients with mild to moderate disease activity experience fever less frequently. Therefore, new-onset fever is a notable finding suggesting gastrointestinal perforation or abscess formation.
Approximately 10% of patients with Crohn’s disease have intra-abdominal abscesses, which occur in the abdominal wall, peritoneal cavity, retroperitoneal space, iliopsoas, or subphrenic space. In the present case, a retroperitoneal abscess was formed after gastrointestinal perforation and then inflammation involved the iliopsoas, resulting in progressive pain in the right lower back. In addition, a positive psoas sign was helpful in diagnosing iliopsoas involvement with inflammation.
Gastrointestinal perforation in Crohn’s disease is rare, but it is a life-threatening complication. It is important to rapidly diagnose and treat gastrointestinal perforation on the basis of the presence of sudden, severe abdominal pain rather than crampy abdominal pain, new-onset fever, and associated symptoms indicating the extension of an abscess and the known risks of anti-tumor necrosis factor treatment.
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-Kiyoshi Shikino, MD, PhD, Shingo Suzuki, MD, PhD, Yuta Hirose, MD, Yoshiyuki Ohira, MD, PhD, Masatomi Ikusaka, MD, PhD
This article originally appeared in the April 2016 issue of The American Journal of Medicine.
