Perforation is an acute surgical emergency in patients with ulcerative colitis. Perforation is rare in the absence of toxic megacolon and the risk of perforation is greatest at the time of the first attack. Perfo ration can be free or walled off and carries a high mortality rate of up to 40% [29]. Free perforation occurs in approximately 2% of patients with UC and is usually associated with toxic colitis or toxic mega-colon. If perforation occurs due the course of the disease, it is clear, but for a substantial proportion of patients, it is unfortunately an indication that is "too late" for urgent surgical treatment. The best prevention of this complication is proper, early surgical treatment in patients with fulminant colitis or toxic megacolon before perforation occurs. It should be emphasised that sometimes signs of perforation can be masked in patients receiving high-dose steroids. The patient with this complication is typically severely ill with increased abdominal or shoulder pain associated with tachycardia and fever [30]. Only early recognition of this complication can save the patient's life, necessitating multidisciplinary treatment and frequent monitoring (close cooperation between gastroenterologist, radiologist and surgeon). In the majority of patients, free perforation can easily be seen on upright films of the abdomen but evidence of confined, walled-off perforation may be more subtle. If a perforation is suspected, the patient should be transferred to the operating theatre without delay. The procedure of choice in these circumstances is subtotal colectomy with terminal ileostomy. The rectal stump should be closed in a usual manner or if there is a great risk of dehiscence, mucous fistula can be created.

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