Occult small bowel perforation presenting as extensive subcutaneous emphysema without skin breach

A woman with ulcerative colitis status post total pan-proctocolectomy and ileal pouch-anal anastomosis 17 years prior presented with recurrent abdominal pain, vomiting, and weight loss. Following multiple admissions being managed for subacute bowel obstruction and anastomotic narrowing without functional obstruction, she was found to have extensive subcutaneous emphysema from the right inguinal canal to the thorax on imaging. The aetiology was fistulation between a small bowel loop and the anterior abdominal wall without any skin breach. Management involved drainage and control of sepsis with formation of a controlled enterocutaneous fistula to avoid a laparotomy in a nutritionally compromised patient. This case highlights that recurrent obstructive symptoms in patients with complex surgical histories may have evolving intra-abdominal pathology, including occult perforation and fistulation. In selected patients, controlled enterocutaneous fistula formation may offer an alternative to laparotomy.