Ileal Perforation in a Patient with Ulcerative Colitis after Proctocolectomy

Ulcerative colitis (UC) is a form of inflammatory bowel disease that typically involves the colorectum; it has been reported that a certain proportion of patients with UC also develop ileitis, leading to ileal perforation in very extreme cases. We report a 66-year-old male with UC who presented with ileal perforation eight days after proctocolectomy. Although this situation is very rare, differential diagnoses for small bowel perforation after UC surgery could include backwash ileitis, cytomegalovirus (CMV) infection, Crohn’s disease, diffuse enteritis, ischemic enteritis, Behçet’s disease, medication adverse effect, and iatrogenic injury. Of these, backwash ileitis or diffuse enteritis is the most probable diagnosis in our case. Granulomas and transmural lymphoid aggregates with associated mucosal ulceration were absent. In addition, no signs or symptoms suggestive of Crohn’s disease were seen postoperatively. Thus, the original diagnosis was likely fulminant UC. Infectious enteritis (including CMV), ischemic enteritis, and Behçet’s diseases were clinically ruled out. Stool cultures and CMV antigen testing were negative. Moreover, histopathology revealed no evidence of CMV infection. Only a few cases of ileal perforation after UC surgery have been reported thus far. Surgeons should evaluate for perforation of the small bowel intraoperatively. Resection of the affected ileum is still a matter of debate. Although the inflammation is usually reversible and preservation of the distal ileum is vital for the creation of an ileal pouch and the avoidance of high output, the rare possibility of ileal perforation should be kept in mind in extreme cases of fulminant UC.