Endoscopic Perforation in Inflammatory Bowel Diseases

Abstract

Ileocolonoscopy represents the cornerstone for diagnosis, assessment of disease extent and activity, prediction of prognosis, monitoring of therapeutic effects and neoplastic surveillance in patients with chronic inflammatory bowel diseases (IBD). The thickened, non-compliant inflamed bowel wall and the presence of strictures increase the risk of endoscopic perforation up to 0.52–1 % (approximately doubled compared to control patients) in both Crohn’s disease (CD) and ulcerative colitis (UC). However, whether IBD patients really are at increased risk of iatrogenic perforation remains debated: a large study revealed a much lower incidence (0.168 %) attributed to the higher expertise in performing IBD endoscopy procedures. Borrowing from experience in the general population, plain radiographs may reveal post-endoscopy pneumoperitoneum with moderate (below 50–70 %) sensitivity. Multidetector CT provides a comprehensive assessment of colonoscopic perforations including quantification of extraluminal air, detection of the perforation site and signs of peritonitis. Alternatively, CT may depict findings consistent with post-polypectomy electrocoagulation syndrome. As shown by the presented case, in the IBD population, the treatment decision between surgery and nonoperative strategy relies not only on clinical and imaging findings but should consider other factors such as the underlying colonic disease, presence or absence of peritonitis and postoperative bowel anatomy.