Korean J Gastroenterol.  2013 Sep;62(3):169-173. 10.4166/kjg.2013.62.3.169.

A Rare Case of Free Bowel Perforation Associated with Infliximab Treatment for Stricturing Crohn's Disease

• Lim CS
• Moon W
• Park SJ
• Park MI
• Kim HH
• Kim JB
• Choi JM
• Chang HK
• Lee SH

• KMID: 1707200
• DOI: http://doi.org/10.4166/kjg.2013.62.3.169

Abstract

Crohn's disease is characterized by chronic transmural inflammation of the bowel and is associated with serious complications, such as bowel strictures, abscesses, fistula formation, and perforation. As neither medical nor surgical therapy provides a cure for Crohn's disease, the primary goals of therapy are to induce and maintain remission and prevent complications. As a biologic agent, infliximab, a monoclonal antibody to tumor necrosis factor, is indicated for refractory luminal and fistulizing Crohn's disease that does not respond to other medical therapies or surgery. Infliximab has proven to be very effective for inducing and maintaining remission in Crohn's disease; however, infliximab treatment has several potential complications. Here, we report a case of free perforation following a therapeutic response after an initial dose of infliximab for Crohn's disease. This is the first case report describing a free perforation in a Crohn's disease patient after an initial dose of infliximab.

Keyword

Crohn's disease; Stricture; Infliximab; Perforation

MeSH Terms

Adolescent
Anti-Inflammatory Agents, Non-Steroidal/adverse effects/*therapeutic use
Antibodies, Monoclonal/*adverse effects/*therapeutic use
Colonoscopy
Crohn Disease/*drug therapy
Dietary Fiber
Female
Fibrosis/pathology
Humans
Ileum/surgery
Intestinal Perforation/*chemically induced/surgery
Tomography, X-Ray Computed
Anti-Inflammatory Agents, Non-Steroidal
Antibodies, Monoclonal

Figure

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  Fig. 1. Colonoscopic findings. (A) Cobblestone appearance in the ascending colon consistent with Crohn's disease. (B) Longitudinal ulcers and luminal narrowing in the terminal ileum consistent with Crohn's disease.

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  Fig. 2. A small bowel follow-through at diagnosis demonstrating multiple strictures and pseudosacculations (arrowhead, stricture; arrow, pseudosacculation).

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  Fig. 3. Abdominal CT at the time of the emergency room presentation demonstrating a focal, asymmetric wall defect in the distal ileum with extraluminal free fecal density in the peritoneal space. A stricture is noted in the distal part of the perforation lesion. The wall is relatively thin at the level of the distal ileum perforation (arrow, wall defect of the distal ileum; arrowheads, extraluminal free fecal density in the peritoneal space; open arrows, stricture).

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  Fig. 4. Gross findings of the surgical specimen revealing a perforated lesion with a relatively thin ileal wall (arrows).

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  Fig. 5. Microscopic findings of the surgical specimen (H&E). (A) At the level of the perforation, only mild infiltration of inflammatory cells and fibrosis and a consequently thinned intestinal wall is noted (×40; arrows, perforated margin). (B) Noncaseating epithelioid granulomas are noted (×200; arrows, non-caseating epithelioid granulomas).

Reference

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