Recurrent free perforation in gastroduodenal Crohn's disease

Three separate episodes of free perforation of the duodenum and stomach are described in a 47-year-old white man with histological evidence of gastroduodenal Crohn's disease, co-existing with peptic disease. His mother died of Crohn's disease after ostomy surgery and two brothers required ileostomy for inflammatory bowel disease. In 1972, the patient underwent a bypass gastroenterostomy for obstructing Crohn's disease of the descending duodenum. In 1977, 1978, and 1982, three free perforations occurred first in the duodenum and then twice at the gastrojejunostomy site. This occurred while on continuous Cimetidine therapy as well as steroids and after vagotomy. The basal and maximum acid outputs, secretin stimulation test, and serum gastrins were normal throughout his clinical course. This unique situation of acid peptic perforation in the presence of active Crohn's disease, poses an etiological dilemma and signals the vulnerability of the diseased stomach and duodenum in transmural disease.