Free Colonic Perforation in a Patient With Crohn's Disease and Loop Ileostomy: Report of a Case
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Abstract Free bowel perforation in Crohn's disease is a relatively rare complication. In this report, we present a case of free colonic perforation in a Crohn's disease patient with loop ileostomy previously constructed for intractable perianal abscess. Normally, fecal diversion by ileostomy results in an improvement in Crohn's colitis. However, in some cases, fecal diversion is reported to adversely affect the inflammation of the diverted bowel, and it is this unusual complication of Crohn's disease that we discuss here.Keywords:
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Abstract Free bowel perforation in Crohn's disease is a relatively rare complication. In this report, we present a case of free colonic perforation in a Crohn's disease patient with loop ileostomy previously constructed for intractable perianal abscess. Normally, fecal diversion by ileostomy results in an improvement in Crohn's colitis. However, in some cases, fecal diversion is reported to adversely affect the inflammation of the diverted bowel, and it is this unusual complication of Crohn's disease that we discuss here.
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During recent years much progress has been made in creating well functioning ileostomies in paients after panproctocolectomy. The development of the adherent ileostomy bag has to a great extent facilitated the care of these patients. In spite of all the progress in management of the ileostomy and in spite of the fact that most of the patients are very pleased with the ileostomy after a long disabling disease, there are still many drawbacks of even as well functioning unit. The flow of intestinal content through the ileostomy is more or less continuous and not voluntarily controlled except to a small extent by the diet. Consequently the ileostomy bag contains more or less intestinal discharge most of the time and the possibility for leakage is present. Even with a proper ileostomy, leakage of intestinal discharge around the stoma can at least occasionally occur and this may initiate troublesome skin irritation. Some
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The authors present a patient with a presumed diagnosis of Crohn's disease for 6 years turning out to be an unusual inflammatory mass caused by ileal perforation due to a foreign body. When surgical intervention became necessary for admissions with recurrent obstruction, laparoscopy revealed an inflammatory mass in the terminal ileum, exposing two pieces of plastic bearing the word ‘Heinz’. Resection of the inflammatory mass led to the complete resolution of symptoms. Histology from the operative specimen showed no features of Crohn's disease. There were no granulomas and no fissuring ulcers. This case highlights that an inflammatory mass in the small intestine caused by the perforation of ingested foreign body can mimic Crohn's disease. To our knowledge, this is the first report of a synthetic plastic packaging causing ileo-caecal junctional perforation mimicking Crohn’s disease.
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A new diverting ileostomy is described which avoids the attendant problems associated with the previously described "loop ileostomy," and other described-ileostomies used in conjunction with ileoanal pull-through procedures. The ileostomy result is a functionally superior stoma, similar to that of the standard Brooke ileostomy, and requires only a local exploration for takedown. Initial experience with the procedure has been uniformly excellent and would support wider use of the "close loop" double barreled ileostomy.
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Grüner, O. P. N., Naas, R., Fiatmark, A., Fretheim, B. & Gjone, E. Ileostomy in ulcerative colitis. Results in 149 patients. Scand. J. Gastroent. 1976, 11, 777-784The operative mortality among 144 patients treated with protocolectomy and ileostomy for ulcerative colitis was 7.6%. Half the patients had fulminating colitis. Only 4 patients died during the follow-up period. Intestinal obstruction needing laparatomy occurred in 8.6%. Ileostomy revisions have been carried out in 13%, and significantly more often in females than males owing to a higher frequency of stoma retraction. Other ileostomy problems (leakage, skin soreness, excoriation) were experienced by nearly half the patients. These problems were episodic in the majority and could usually be remedied by instruction and new devices. Less than 7% used colostomy bags. In the remainder the changing interval appeared to be a measure of ileostomy success. The average length of the ileostomy spout was significantly longer in males without ileostomy problems (5.8 cm) than in males having leakage (3.7 cm). This difference was not apparent in females. Working and sexual impairment was rare. The success of an ileostomy depends on proper management, i.e. access to expert advice, instruction, training, follow-up, and adequate supplies of appliances. A stoma therapist on the staff is therefore extremely valuable.
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Among the considerations in making the decision for proctocolectomy in ulcerative colitis is the hazard of ileostomy. Since our current techniques for constructing an ileostomy were developed less than 20 years ago, the long-term risks associated with a permanent ileal stoma cannot yet be assessed. Nevertheless, periodic follow-up information on ileostomy patients is of value when operation is being considered for a patient with chronic ulcerative colitis. In this report attention has been focused on the frequency and type of ileostomy complications which require a corrective operation.
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The case histories of all patients who had a permanent ileostomy established during the 20-year period ending Dec 31, 1967, were reviewed. Patients in whom the ileal stoma was constructed because of chronic ulcerative colitis were selected for study. Cases in which the ileal stoma was made because of granulomatous colitis were excluded. Using these criteria a total of 88 cases wereIleostomy
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The operative mortality among 144 patients treated with proctocolectomy and ileostomy for ulcerative colitis was 7.6%. Half the patients had fulminating colitis. Only 4 patients died during the follow-up period. Intestinal obstruction needing laparatomy occurred in 8.6%. Ileostomy revisions have been carried out in 13%, and significantly more often in females than males owing to a higher frequency of stoma retraction. Other ileostomy problems (leakage, skin soreness, excoriation) were experienced by nearly half the patients. These problems were episodic in the majority and could usually be remedied by instruction and new devices. Less than 7% used colostomy bags. In the remainder the changing interval appeared to be a measure of ileostomy success. The average length of the ileostomy spout was significantly longer in males without ileostomy problems (5.8 cm) than in males having leakage (3.7 cm). This difference was not apparent in females. Working and sexual impairment was rare. The success of an ileostomy depends on proper management, i.e., access to expert advice, instruction, training, follow-up, and adequate supplies of appliances. A stoma therapist on the staff is therefore extremely valuable.
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