Unexpected Crohn’s Disease after a Free Gastrointestinal Perforation

Crohn’s disease is a chronic illness of uncertain etiology that is characterized by a transmural inflammation of the entire gastrointestinal tract. Crohn’s complications are fistulae, localized peritonitis, abscesses, bowel obstructions, gastrointestinal perforation, and hemorrhage. Of them free gastrointestinal perforation, which is a life-threatening complication, is the most rare and described only in 1–2% of these patients. It is more common as the initial manifestation of the illness, but has also been described during the course of the disease. Most of the patients present instead with an intra-abdominal abscesses or fistulae. The most common site of free perforation is the ileum or jejunum and chronic steroid use has been proposed as risk factor for perforation. Pneumoperitoneum, as found in this case, is an uncommon feature of small intestine perforation. Diagnosis is made by the characteristic clinical presentation of acute abdominal pain along with acute systemic inflammatory response syndrome or sepsis and the characteristic findings on the chest and abdominal X-rays or computed tomography. Immediate management to achieve hemodynamic stability with high-volume intravenous fluids and sometimes catecholamines along with broad-spectrum antibiotics is essential. Nevertheless, urgent surgical management with exploratory laparotomy is the cornerstone of the treatment. Prognosis compared to ulcerative colitis perforation is formidable with a mortality rate of less than 5% if managed promptly. In this case, the steroids that could have treated and “masked” the illness for a long time could have also been the triggering cause of the gastrointestinal perforation.