Free perforation in regional enteritis.
Authors: K Nasr, D A Morowitz, J G Anderson, J B Kirsner
Journal: Gut (1969)

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 REPORTSCASE 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 wor- sening of her symptoms, a laparotomy was performed, revealing diffuse peritonitis (mixed Gram-negative or- ganisms).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 per- foration 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 Jejunum Jejunum Ileum Ileum Ileum Bypassed ileum No information Died, information incomplete No Resection, no follow up Unknown Incomplete information No First operation closure of perforation, 2nd operation resection six weeks; well No Closure of perforation and decompression, within six months recurrent symptoms No Closure of perforation, died six days postoperatively with second perforation No Closure of perforation, five days postoperatively, second perforation, second operation bypass; died 12 hr postoperatively No Resection eight years; well No Closure of perforation, six months; well Yes Resection; died one hour postoperatively 3 weeks No Resection one month; well No Closure of perforation; died three days postopera- tively No Resection; well postoperatively No First operation resection, second operation resection and ileostomy, four years; well No First operation closure of perforation and proximal ileostomy, second operation bypass three months; well No Closure of perforation; died 42 hours postopera- tively No Closure of perforation three months; weli No Closure of perforation; no follow up No Resection several months; well No First operation decompression, second operation bypass one year No First operation drainage, second operation resection; no follow up No Closure of perforation and bypass one month; well No First operation resection with double enterostomy; second operation ileostomy; no follow up No Resection; no follow up No Exteriorization of ileum; died No Resection and bypass; died No Resection 14 months; weol No Resection five months; well No First operation drainage, second operation resection; died eight days postoperatively No Resection six months; well Yes Resectioni, died, leakage at suture line A ithor