Nivolumab-induced small bowel obstruction and perforation: a rare but life-threatening side effect of immunotherapy

We present a case of a 58-year-old female with anti-PD-1 immunotherapy-related small bowel perforation. The patient was on long-term therapy with nivolumab for metastatic non-small cell lung cancer. She presented to the emergency department with acute abdominal pain, in which the CT revealed a short segment of dilated distal ileum proximal to a very short segment of bowel with mural thickening and a perforation near the transition point. The patient underwent subsequent laparotomy, which confirmed the CT findings and revealed a short-segment of friable and dilated loop of distal ileum proximal to a stricture and a small perforation at the transition point. Pathological analysis revealed mural thickening at the site of stricture without evidence of malignancy with focal necrosis and perforation at the transition point. Bowel perforation in the setting of anti-PD-1 immunotherapy is rare, but life-threatening complication, and should be considered in oncology patients on immunotherapy presenting with severe abdominal pain.