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Free perforation in Crohn's disease: I. A survey of 99 cases
Abstract:
A review of more than 181 reported cases of free perforation in Crohn's disease yielded 84 cases that fulfilled rigorous criteria for classification as spontaneous free perforation with generalized peritonitis. An additional 15 cases from The Mount Sinai Hospital, derived from a population of 1010 patients with Crohn's disease, bring the total number to 99. Separately tabulated are 116 other cases either occurring in bypassed segments, developing after surgery, presenting with ruptured abscesses, or not definitively documented. Most reported perforations in the literature occurred in the distal small bowel. Among the Crohn's disease patients in our hospital, however, the incidence of colonic and small bowel perforation were 1.6 and 0.7%, respectively, with the highest frequency actually occurring in diseased segments of jejunum (2/50 = 4%). Free perforation was the presenting manifestation of the disease in 25 of the 84 reported cases. In our 15 patients, although perforation was never the presenting manifestation, it tended to occur early in the course of the disease (mean 3.5 years from onset of symptoms). Ninety-six of the 99 cases were operated on. The three patients treated without surgery all died. Mortality was most frequent following simple suture in the earliest reported case (39%), but considerably less frequent after resection and anastomosis (3.7%). All 18 patients treated by resection and diversion survived. Immediate surgery with resection and/or diversion therefore appears to be appropriate treatment for free perforation in Crohn's disease.
Insights
Spontaneous free perforation in Crohn's disease is a serious complication. Early surgical intervention with resection and/or diversion significantly improves survival rates, while non-surgical management is associated with high mortality.
Area of Science:
- Gastroenterology
- Surgical Gastroenterology
- Inflammatory Bowel Disease Research
Background:
- Crohn's disease can lead to spontaneous free perforation, a rare but life-threatening complication.
- Understanding the incidence, location, and outcomes of free perforation in Crohn's disease is crucial for effective management.
Purpose of the Study:
- To review and classify cases of spontaneous free perforation in Crohn's disease.
- To analyze the incidence and location of perforation within a specific patient cohort.
- To evaluate the outcomes of different surgical and non-surgical treatment strategies.
Main Methods:
- Systematic review of 181 reported cases of free perforation in Crohn's disease.
- Inclusion of 15 additional cases from The Mount Sinai Hospital patient population.
- Analysis of perforation location, presentation, and treatment outcomes.
Main Results:
- 84 cases met criteria for spontaneous free perforation with generalized peritonitis, totaling 99 cases with additional data.
- While distal small bowel is common, jejunal perforation occurred at a higher rate (4%) in the hospital cohort.
- Free perforation presented the disease in 25% of reviewed cases; in the hospital cohort, it occurred early in the disease course.
- Surgery was performed in 96 of 99 cases; mortality was 39% with simple suture, 3.7% with resection and anastomosis, and 0% with resection and diversion.
Conclusions:
- Spontaneous free perforation is a significant complication of Crohn's disease requiring prompt surgical management.
- Resection and/or diversion are associated with the best survival outcomes.
- Non-surgical management of free perforation in Crohn's disease carries a high mortality risk.
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