Unexpected Crohn’s Disease after a Free Gastrointestinal Perforation

Abstract

A 46-year-old male with history of chronic intermittent diarrhea and chronic lower-back pain was presented to our clinic with sudden diffuse abdominal pain irradiated to both shoulders. He had been on nonsteroidal antiinflammatory drugs (NSAIDs) and prednisone (5–20 mg POq24h) for three years with partial back pain relief. Physical examination revealed diffuse tenderness and rigid abdomen with no bowel sounds. X-ray of chest showed a pneumoperitoneum (Figure 1). A diagnosis of a possible peptic ulcer perforation was made. He was immediately managed with intravenous volume, nasogastric tube, intravenous proton-pump inhibitor (PPI), broadspectrum antibiotics, and urgent laparotomy. During surgery a 3–4 mm perforation 50 cm before the ileocecal valve was found along with multiple focal mucosal ulcerations (Figure 2). Partial bowel resection with an ileostomy was made. Erythrocyte sedimentation rate and C-reactive protein were elevated and a macrocytic anemia with low levels of serum B12 was documented. The ileum biopsy revealed focal ulcerations across the ileum wall with acute/chronic inflammation and no sign