Crohn stated in a 1957 paper: "Free perforation of ileitis into the peritoneal cavity never occurs or at least I have not seen it" [47]. In 1965 however, he reported seven cases of free perforation [48]. Free perforation occurs in approximately 2% of patients with ulcerative colitis and is usually associated with toxic colitis or megacolon [28]. Its occurrence without megacolon is rare [49]. The diagnosis may be delayed, as high-dose steroids may mask the signs of peritonitis. In Crohn's disease, free perforation is a rare but severe complication occurring in 1-3% of cases [50,51]. Holzheimer et al. [52] reported an incidence of 13% in 1995. Such different incidence rates are due to the fact that in some reports, abscess formation is included and in others it is not. A large series of free perforation in Crohn's disease has been published by Greenstein et al. [53] in 1985 and by Ikeuchi et al. [54] in 2003; it seems that the incidence of free perforation in Japan is higher than in Western countries. The procedure of choice for a patient with ulcerative colitis and free perforation is a subtotal colectomy and end ileostomy. Gastroduodenal perforations in Crohn's patients are best managed with debridement and primary repair. Perforated Crohn's colitis, which is often in the setting of toxic colitis, requires subtotal colectomy with rectal preservation and end ileostomy [51]. If the perforation occurs in a diseased small-bowel segment, this segment along with the perforation is resected. In a recent study, Nissan et al. [55], who advocated a more liberal approach to surgical treatment, found free perforation in only 3.8% of their study group. Intensive medical treatment resulted in a 6.2-year delay from diagnosis until surgery, in contrast to 3.3 years in the study by Greenstein et al. [56]. It is possible that a serious complication such as free perforation resulted from a conservative medical approach. Perforative Crohn's disease is accompanied by more postoperative complications, anastomotic healing is poor, and recurrent disease is more frequent in the short-term (up to 5 years) follow-up than in obstructive Crohn's disease [57]. Based on the results of many authors [55, 56, 58], early surgery in Crohn's disease patients depending on the clinical presentation, intensity and duration of medical treatment, and life quality impairment, is recommended. It is generally accepted that 1-3 % of patients with CD will present with a free perforation—initially or eventually in the course of their disease [53, 58, 59]. Operative mortality in case of perforation is 20-40% [31, 60], whereas it is 4% in patients with toxic megacolon operated on before perforation has taken place. In half of patients, perforation is not associated with toxic megacolon. Free perforation of the bowel due to cancer in Crohn's disease is very rare [61].

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