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

Chang Sup Lim; Won Moon; Seun Ja Park; Moo In Park; Hyung Hun Kim; Jong Bin Kim; Jeong Moon Choi; Hee Kyung Chang; Seung Hyun Lee

doi:10.4166/kjg.2013.62.3.169

Journal List > Korean J Gastroenterol > v.62(3) > 1007136

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Lim, Moon, Park, Park, Kim, Kim, Choi, Chang, and Lee: A Rare Case of Free Bowel Perforation Associated with Infliximab Treatment for Stricturing Crohn's Disease

Case Report

Korean J Gastroenterol 2013;62(3):169-173.

Published online: 4 October 2013

DOI: https://doi.org/10.4166/kjg.2013.62.3.169

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

Chang Sup Lim¹, Won Moon^1,⁴, Seun Ja Park¹, Moo In Park¹, Hyung Hun Kim¹, Jong Bin Kim¹, Jeong Moon Choi¹, Hee Kyung Chang², Seung Hyun Lee³

¹Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea

²Department of Pathology, Kosin University College of Medicine, Busan, Korea

³Department of Surgery, Kosin University College of Medicine, Busan, Korea

⁴Institute for Medical Science, Kosin University College of Medicine, Busan, Korea

Correspondence to: Won Moon, Department of Internal Medicine and Institute for Medical Science, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 602-702, Korea. Tel: +82-51-990-5205, Fax: +82-51-990-3005, E-mail: moonone70@hanmail.net

Received 8 November 2012 Accepted 26 February 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Crohn's disease, Stricture, Infliximab, Perforation

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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.

Fig. 2.

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

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).

Fig. 4.

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

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).

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