Free Perforation

Large intestine perforation rarely takes place in Crohn's disease. The frequency of large-intestine perforation in patients with Crohn's disease has reached 1.8-2.4% [99,100], making up 20-50% of all digestive tract perforations in Crohn's disease. Typical symptoms of perforation may be hidden behind the effects of high dosages of steroids, thereby delaying early diagnosis. Perforation takes place most often during the course of toxic colitis (with or without toxic megacolon) or during a severe exacerbation of inflammation especially if accompanied by stenosis below the site of perforation. Iatrogenic damage of the inflamed colon during colonoscopy may also be the cause of perforation. Due to the frequent occurrence of intraperitoneal adhesions, some perforations are covered. Surgical treatment depends on the general condition of the patient, the site of the perforation, and the circumstances that caused it. In toxic colitis perforations, colectomy with ileostomy is a recommended surgical procedure. Proctocolec-tomy, which used to be a recommended procedure in the past, is no longer a preferred method in a toxic colitis accompanied by a toxic megacolon. This is because of the prolonged time of the surgery, which has a dramatic impact on the risk of perioperative mortality. In the case of perforation without active toxic colitis, the affected segment should be resected and a primary anastomosis created. When iatrogenic perforation resulting from colonoscopy takes place, the type of surgical procedure depends on the general condition of the patient, location of the perforation (is it located in an affected or in unaffected fragment?), and a level of intestinal preparation. When perforation is located in the affected part of the intestine, resection of the perforated segment should be performed, and depending on the state of the patient as well as other risk factors, Hartmann's procedure, or a resection with anastomosis should be done [26, 13]. If perforation is located in healthy part of the intestine the alternative treatment includes partial resection or a local suture of perforation.

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