Free peritoneal perforation is a rare complication of Crohn's disease with a report of only 100 cases in the literature. It needs an emergency exploration and an unaware general surgeon is confounded in intraoperative decision-making. We present our experience when this rarity struck us in a district hospital and briefly review the guidelines of optimal management of this complication of Crohn's disease

Bhat, Sriram M

J, Madhusudhanan

K, Balu

M, Ashfaque

RK, Sendhil

English

Bhat M, Sriram

Cognitive Sciences ePrint Archive

Peer Reviewed, Open Access, Free
Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 6, Issue 4; Oct-Dec 2007
A Rare Presentation of Crohn's Disease
Authors
Sriram Bhat M,
Ashfaque M,
Balu K,
Madhusudhanan J,
Sendhil RK,
Department of Surgery, Kasturba Medical College, Mangalore, Karnataka, India
Address For Correspondence
Dr. Sriram Bhat M,
Department of Surgery,
Kasturba Medical College,
Mangalore,
Karnataka, India
E-mail: meera_sriram2003@yahoo.com
Citation
Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's 
Disease. Online J Health Allied Scs. 2007;4:6
URL
http://www.ojhas.org/issue24/2007-4-6.htm
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
http://ojhas.org 1
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
 Case Report
Submitted Dec 27, 2007; Suggested revision: Jan 4, 2008; Revised paper resubmitted: Jan 9, 2008; Suggested 
revision: Jan 11, 2008; Resubmitted: Jan 17, 2008; Accepted: Jan 18, 2008; Published: Jan 24, 2008
Abstract:
Free  peritoneal  perforation  is  a  rare  complication  of 
Crohn's disease with a report of only 100 cases in the 
literature.  It  needs an emergency  exploration and an 
unaware  general  surgeon  is  confounded  in 
intraoperative  decision-making.  We  present  our 
experience  when  this  rarity  struck  us  in  a  district 
hospital  and briefly  review the  guidelines  of  optimal 
management  of  this  complication of Crohn's  disease.
Key  Words:  Free  perforation,  Crohn's  disease,  Ileal 
perforation
Case Report:
A  19-year  old  girl  was  referred  to  our  hospital  for 
management of acute abdomen. She had a history of 
colicky pain abdomen with distension and vomiting for 
four months. All these complaints became more severe 
for the past 3 days. Vomiting was bilious and associated 
with  decreased  urine  output.  Her  past  and  personal 
histories  were  not  contributory.  Family  history  was 
positive  for  tuberculosis.  On  examination,  she  was 
malnourished, dehydrated and pale. BP was 100/70 and 
pulse  rate  was  110  per  minute.  Abdomen  was 
distended and warm with loss of bowel sounds.
An erect x-ray abdomen was taken which showed gas 
under diaphragm with dilated bowel loops. She under-
went exploratory laparotomy under general anesthesia. 
Peritoneal fluid was feculent. Entire length of the bowel 
was inspected and findings accurately recorded. Multi-
ple strictures and 3 perforations (Figure 1 and Figure 2) 
were present in the distal ileum all within 60 cm from 
ileocecal junction. Ileal mesentery was thick and friable 
with no palpable adenopathy. Large bowel and rest of 
the small bowel was grossly normal. Around 70 cm of 
ileum was resected and a hand-sewn ileo-ileal anasto-
mosis was performed in two layers. Patient had an un-
eventful postoperative recovery.
Fig. 1: Perforations in the terminal ileum (arrows)
Histopathological examination of the resected ileum 
showed Crohn's disease. After postoperative recov-
ery,  the medical  gastroenterology department  was 
involved  in  her  care.  Immunosuppression  (6-Mer-
captopurine,  1.5mg/kg)  was  started.  The patient is 
currently on follow-up with no clinical evidence of 
disease recurrence.
Fig. 2: Stricture (arrowhead) and perforations 
(arrows) in the terminal ileum
Discussion:
Crohn’s  disease  (CD)  is  a  chronic  relapsing  and 
remitting inflammation of the bowel involving all its 
layers  and  characterized  by  noncaseating 
granulomas.  It  has  an  unpredictable  course  and 
surgical  management  is  challenging.  Majority  of 
patients with CD require surgery as time progresses, 
such  that  78%  and  90% undergo  surgery  after  20 
years and 30 years of symptoms, respectively.(1) The 
most common indication for surgery in case of small 
bowel  CD  is  obstruction  due  to  a  terminal  ileal 
stricture  while  perforation,  fistulae  and  abscess 
formation  account  for  the  remaining.  The 
indications  for  surgery  in  Crohn's  colitis  include 
abscesses  (25%),  perianal  disease  (23%),  failure  to 
thrive  (21%),  toxic  megacolon (19%)  and  intestinal 
obstruction  (12%).(2)  Failure  of  medical 
management  in  the  form  of  persisting  symptoms 
despite aggressive therapy,  recurring symptoms on 
tapering and worsening symptoms during therapy is 
another indication for surgical intervention.
Though contained ileal perforation with septic fea-
tures and inflammatory abdominal mass is common, 
free perforation into the peritoneal cavity with gen-
eralized  peritonitis  is  a  rare  presenting  feature  of 
Crohn's disease with an incidence of 1-3% in West-
ern countries.(3) Only 100 cases have been reported 
in literature.(4) In patients with intra-abdominal sep-
http://ojhas.org 2
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
sis,  a  delay  in  surgery  for  presurgical  nutritional 
restoration may be detrimental,  especially  because 
the benefit  of presurgical  nutrition is  unproven in 
prospective  studies.(5)  Therefore  an  emergency 
surgery is warranted.
Resection  is  the  procedure  of  choice  for  Crohn's 
ileitis. Most commonly, the disease involves the ter-
minal ileum and caecum requiring ileocecal resec-
tion. When caecum is spared and adequate length of 
healthy  ileum,  approximately  7-10cm  proximal  to 
ileocecal valve remains, an ileal resection with end- 
to-end ileal anastamosis can be performed. This pre-
serves the ileocecal valve and helps to minimize di-
arrhea post-surgically.(6)
A study by Fazio et al (7) resolved the controversy 
regarding  optimal  margin  width  at  resection  of 
Crohn's  disease.  It  showed that  large  margins  are 
not beneficial and there was no statistically signifi-
cant difference in recurrence rates between patients 
with histologically involved and uninvolved margins. 
However, the surgeon has to choose the line of re-
section based on intraoperative  assessment  of  ex-
tent of disease. Proximal level of involvement is de-
termined by palpation of mesenteric border of the 
bowel.  In involved areas,  the phenomenon of fat-
wrapping (or fat hypertrophy), a feature peculiar to 
Crohn's  disease  (8)  will  obscure  the  bowel  wall, 
which becomes palpable  when normal  intestine is 
reached. A few centimeters away from this point will 
be an appropriate line of resection and small apht-
hous ulcers seen inside the bowel lumen shall not 
require further extension of resection.(6)
The technique of intestinal anastomosis in Crohn's 
disease has been a matter of debate for quite some-
time. A longer side-to-side anastomosis may be ben-
eficial  over an end-to-end anastomosis as it  is  be-
lieved that a large caliber anastomosis will take long 
time  to  produce  stenosing  obstruction.  However, 
published data to date does not show superiority of 
one  particular  type  of  intestinal  anastomosis.(9) 
Anastomosis can be hand-sewn or performed with a 
stapler.  Under appropriate  conditions  like  minimal 
peritoneal contamination in a patient with hemody-
namic stability and good nutrition, resection and pri-
mary anastomosis  is  a  safe procedure with  a  leak 
rate of less than 1 percent.(10) Nevertheless, in high 
surgical  risk  candidates  and  patients  with  free 
colonic  perforation or  fulminant  peritonitis,  resec-
tion  with  proximal  ileostomy  is  the  treatment  of 
choice.(11) Primary closure of the perforation is ab-
solutely contraindicated under any circumstances.
As no single surgery for Crohn's disease is curative, 
these patients always have a very high risk of recur-
rence,  the  prevention  of  which  should  be  in  the 
mind of every surgeon operating on Crohn's disease. 
Young age,  short  disease duration and perforating 
disease are risk factors for early postoperative recur-
rence.(12) Unfortunately, our patient had all  these 
risk factors. There is evidence to suggest the use of 
some types of medical therapy to prevent both en-
doscopic  and  symptomatic  recurrence  of  Crohn's 
disease  after  surgery.  Besides  being  inappropriate 
for maintenance therapy in nonsurgical Crohn's pa-
tients, steroids have proved inefficient for prophy-
laxis  against  disease  recurrence.  Although there is 
evidence and support  for  the efficacy of other  5-
acetylsalicylate preparations in the maintenance of 
postsurgical  remission,  the overall  beneficial  effect 
of mesalamine is small. Only a modest benefit has 
been  shown  with  azathioprine  and  6-Mercaptop-
urine.  But  since  there  is  much  stronger  evidence 
supporting their  use  in  maintenance therapy  after 
medically-induced  remission,  their  use  is  probably 
justified in high-risk post-operative patients.(13) Fi-
nally, smoking cessation is strongly advocated in all 
post-operative  patients  as  it  has  been  found  that 
smokers have double the rate of recurrence.(13)
We  wish  that  the  above-mentioned  facts  will  be 
helpful for surgeons in intraoperative decision mak-
ing when such a rare cause of ileal perforation is en-
countered. We conclude by stating that a team with 
a conservative surgeon and an aggressive physician 
will be ideal for optimal management of Crohn's dis-
ease.
References:
1. Mekhijan HS, Sweitz DM, Watts HD et al. Nation-
al cooperative Crohn's disease study: Factors de-
termining  recurrence  of  Crohn's  disease  after 
surgery. Gasteroenterology 1979;77:907-913.
2. Fazio  VW,  Wu JS.  Surgical  therapy  for  Crohn's 
disease  of  the  colon  and  rectum.  Surg  Clin  
North Am 1997;77:197-210.
3. Tomaszczyk M, Zwemer DA.  Int Surg 2005;90(3 
Suppl):S45-7.
4. Veroux M, Angriman I, Ruffolo C et al.  Minerva  
Chir 2003;58(3):351-4.
http://ojhas.org 3
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
5. Ellis LM, Copeland EM, Souba WW. Perioperative 
nutritional  support.  Surg  Clin  North  Am 
1991;71:493-507.
6. Delaney  CP,  FazioVW.  Crohn's  disease  of  the 
small  bowel.  Surg  Clin  North  Am 
2001;81:137-158.
7. Fazio VW, Marchetti F, Church JM et al. Effect of 
resection margins on the recurrence of Crohn's 
disease  in  the  small  bowel.  Ann  Surg 
1996;224:563-573.
8. Sheehan AL, Warren BF,  Gear MWL, et al.  Fat-
wrapping  in  Crohn's  disease:  Pathological  basis 
and  rrelevance  to  surgical  practice.  Br  J  Surg 
1992;79:955-958.
9. Scarpa M, Angriman I et al. Role of stapled and 
hand-sewn anastomosis in recurrence of Crohn's 
disease.  Hepatogastroenterology 
2004;51:1053-57.
10. Hurst RD, Molinari M, Chung TP et al. Prospec-
tive study of the features, indications and surgi-
cal treatment in513 consecutive patients affect-
ed by Crohn's disease. Surgery 1997;122:661-7.
11. Wexner SD et al. Surgery of Crohn's disease in-
cluding stricturoplasty. In: Robert J Baker, Josef E 
Fischer,  eds.  Mastery  of  Surgery,  4th  edition. 
2001. Philadelphia: Lippincott Williams & Wilkins. 
Pp. 1446-7.
12. Assche GV, Rutgeerts P. Medical management of 
postoperative  recurrence  in  Crohn's  disease. 
Gastroenterol Clin N Am 2004;33:347-360.
13. Yamamoto T. Factors  affecting recurrence after 
surgery  for  Crohn's  disease.  World  J  Gastroen-
terol 2005;11:3971-3979.
http://ojhas.org 4
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.


Crohn's disease of the small bowel.

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. Ann Surg

Factors affecting recurrence after surgery for Crohn's disease.

Fatwrapping in Crohn's disease: Pathological basis and rrelevance to surgical practice.

Medical management of postoperative recurrence in Crohn's disease.

Minerva Chir 2003;58(3):351-4. http://ojhas.org 3

National cooperative Crohn's disease study: Factors determining recurrence of Crohn's disease after surgery.

Perioperative nutritional support. Surg Clin North Am

Prospective study of the features, indications and surgical treatment in513 consecutive patients affected by Crohn's disease.

Role of stapled and hand-sewn anastomosis in recurrence of Crohn's disease.

Surgery of Crohn's disease including stricturoplasty.

Surgical therapy for Crohn's disease of the colon and rectum. Surg Clin North Am

A Rare Presentation of Crohn's Disease

Peer Reviewed, Open Access, Free
Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 6, Issue 4; Oct-Dec 2007
A Rare Presentation of Crohn's Disease
Authors
Sriram Bhat M,
Ashfaque M,
Balu K,
Madhusudhanan J,
Sendhil RK,
Department of Surgery, Kasturba Medical College, Mangalore, Karnataka, India
Address For Correspondence
Dr. Sriram Bhat M,
Department of Surgery,
Kasturba Medical College,
Mangalore,
Karnataka, India
E-mail: meera_sriram2003@yahoo.com
Citation
Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's 
Disease. Online J Health Allied Scs. 2007;4:6
URL
http://www.ojhas.org/issue24/2007-4-6.htm
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
http://ojhas.org 1
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
 Case Report
Submitted Dec 27, 2007; Suggested revision: Jan 4, 2008; Revised paper resubmitted: Jan 9, 2008; Suggested 
revision: Jan 11, 2008; Resubmitted: Jan 17, 2008; Accepted: Jan 18, 2008; Published: Jan 24, 2008
Abstract:
Free  peritoneal  perforation  is  a  rare  complication  of 
Crohn's disease with a report of only 100 cases in the 
literature.  It  needs an emergency  exploration and an 
unaware  general  surgeon  is  confounded  in 
intraoperative  decision-making.  We  present  our 
experience  when  this  rarity  struck  us  in  a  district 
hospital  and briefly  review the  guidelines  of  optimal 
management  of  this  complication of Crohn's  disease.
Key  Words:  Free  perforation,  Crohn's  disease,  Ileal 
perforation
Case Report:
A  19-year  old  girl  was  referred  to  our  hospital  for 
management of acute abdomen. She had a history of 
colicky pain abdomen with distension and vomiting for 
four months. All these complaints became more severe 
for the past 3 days. Vomiting was bilious and associated 
with  decreased  urine  output.  Her  past  and  personal 
histories  were  not  contributory.  Family  history  was 
positive  for  tuberculosis.  On  examination,  she  was 
malnourished, dehydrated and pale. BP was 100/70 and 
pulse  rate  was  110  per  minute.  Abdomen  was 
distended and warm with loss of bowel sounds.
An erect x-ray abdomen was taken which showed gas 
under diaphragm with dilated bowel loops. She under-
went exploratory laparotomy under general anesthesia. 
Peritoneal fluid was feculent. Entire length of the bowel 
was inspected and findings accurately recorded. Multi-
ple strictures (Figure 1) and 3 perforations (Figure 2) 
were present in the distal ileum all within 60 cm from 
ileocecal junction. Ileal mesentery was thick and friable 
with no palpable adenopathy. Large bowel and rest of 
the small bowel was grossly normal. Around 70 cm of 
ileum was resected and a hand-sewn ileo-ileal anasto-
mosis was performed in two layers. Patient had an un-
eventful postoperative recovery.
Figure 1: Multiple strictures in the ileum
Histopathological examination of the resected ileum 
showed Crohn's disease. After postoperative recov-
ery,  the medical  gastroenterology department  was 
involved  in  her  care.  Immunosuppression  (6-Mer-
captopurine,  1.5mg/kg)  was  started.  The patient is 
currently on follow-up with no clinical evidence of 
disease recurrence.
Figure 2: Perforations in the ileum
Discussion:
Crohn’s  disease  (CD)  is  a  chronic  relapsing  and 
remitting inflammation of the bowel involving all its 
layers  and  characterized  by  noncaseating 
granulomas.  It  has  an  unpredictable  course  and 
surgical  management  is  challenging.  Majority  of 
patients with CD require surgery as time progresses, 
such  that  78%  and  90% undergo  surgery  after  20 
years and 30 years of symptoms, respectively.(1) The 
most common indication for surgery in case of small 
bowel  CD  is  obstruction  due  to  a  terminal  ileal 
stricture  while  perforation,  fistulae  and  abscess 
formation  account  for  the  remaining.  The 
indications  for  surgery  in  Crohn's  colitis  include 
abscesses  (25%),  perianal  disease  (23%),  failure  to 
thrive  (21%),  toxic  megacolon (19%)  and  intestinal 
obstruction  (12%).(2)  Failure  of  medical 
management  in  the  form  of  persisting  symptoms 
despite aggressive therapy,  recurring symptoms on 
tapering and worsening symptoms during therapy is 
another indication for surgical intervention.
Though contained ileal perforation with septic fea-
tures and inflammatory abdominal mass is common, 
free perforation into the peritoneal cavity with gen-
eralized  peritonitis  is  a  rare  presenting  feature  of 
Crohn's disease with an incidence of 1-3% in West-
ern countries.(3) Only 100 cases have been reported 
in literature.(4) In patients with intra-abdominal sep-
sis,  a  delay  in  surgery  for  presurgical  nutritional 
http://ojhas.org 2
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
restoration may be detrimental,  especially  because 
the benefit  of presurgical  nutrition is  unproven in 
prospective  studies.(5)  Therefore  an  emergency 
surgery is warranted.
Resection  is  the  procedure  of  choice  for  Crohn's 
ileitis. Most commonly, the disease involves the ter-
minal ileum and caecum requiring ileocecal resec-
tion. When caecum is spared and adequate length of 
healthy  ileum,  approximately  7-10cm  proximal  to 
ileocecal valve remains, an ileal resection with end- 
to-end ileal anastamosis can be performed. This pre-
serves the ileocecal valve and helps to minimize di-
arrhea post-surgically.(6)
A study by Fazio et al (7) resolved the controversy 
regarding  optimal  margin  width  at  resection  of 
Crohn's  disease.  It  showed that  large  margins  are 
not beneficial and there was no statistically signifi-
cant difference in recurrence rates between patients 
with histologically involved and uninvolved margins. 
However, the surgeon has to choose the line of re-
section based on intraoperative  assessment  of  ex-
tent of disease. Proximal level of involvement is de-
termined by palpation of mesenteric border of the 
bowel.  In involved areas,  the phenomenon of fat-
wrapping (or fat hypertrophy), a feature peculiar to 
Crohn's  disease  (8)  will  obscure  the  bowel  wall, 
which becomes palpable  when normal  intestine is 
reached. A few centimeters away from this point will 
be an appropriate line of resection and small apht-
hous ulcers seen inside the bowel lumen shall not 
require further extension of resection.(6)
The technique of intestinal anastomosis in Crohn's 
disease has been a matter of debate for quite some-
time. A longer side-to-side anastomosis may be ben-
eficial  over an end-to-end anastomosis as it  is  be-
lieved that a large caliber anastomosis will take long 
time  to  produce  stenosing  obstruction.  However, 
published data to date does not show superiority of 
one  particular  type  of  intestinal  anastomosis.(9) 
Anastomosis can be hand-sewn or performed with a 
stapler.  Under appropriate  conditions  like  minimal 
peritoneal contamination in a patient with hemody-
namic stability and good nutrition, resection and pri-
mary anastomosis  is  a  safe procedure with  a  leak 
rate of less than 1 percent.(10) Nevertheless, in high 
surgical  risk  candidates  and  patients  with  free 
colonic  perforation or  fulminant  peritonitis,  resec-
tion  with  proximal  ileostomy  is  the  treatment  of 
choice.(11) Primary closure of the perforation is ab-
solutely contraindicated under any circumstances.
As no single surgery for Crohn's disease is curative, 
these patients always have a very high risk of recur-
rence,  the  prevention  of  which  should  be  in  the 
mind of every surgeon operating on Crohn's disease. 
Young age,  short  disease duration and perforating 
disease are risk factors for early postoperative recur-
rence.(12) Unfortunately, our patient had all  these 
risk factors. There is evidence to suggest the use of 
some types of medical therapy to prevent both en-
doscopic  and  symptomatic  recurrence  of  Crohn's 
disease  after  surgery.  Besides  being  inappropriate 
for maintenance therapy in nonsurgical Crohn's pa-
tients, steroids have proved inefficient for prophy-
laxis  against  disease  recurrence.  Although there is 
evidence and support  for  the efficacy of other  5-
acetylsalicylate preparations in the maintenance of 
postsurgical  remission,  the overall  beneficial  effect 
of mesalamine is small. Only a modest benefit has 
been  shown  with  azathioprine  and  6-Mercaptop-
urine.  But  since  there  is  much  stronger  evidence 
supporting their  use  in  maintenance therapy  after 
medically-induced  remission,  their  use  is  probably 
justified in high-risk post-operative patients.(13) Fi-
nally, smoking cessation is strongly advocated in all 
post-operative  patients  as  it  has  been  found  that 
smokers have double the rate of recurrence.(13)
We  wish  that  the  above-mentioned  facts  will  be 
helpful for surgeons in intraoperative decision mak-
ing when such a rare cause of ileal perforation is en-
countered. We conclude by stating that a team with 
a conservative surgeon and an aggressive physician 
will be ideal for optimal management of Crohn's dis-
ease.
References:
1. Mekhijan HS, Sweitz DM, Watts HD et al. Nation-
al cooperative Crohn's disease study: Factors de-
termining  recurrence  of  Crohn's  disease  after 
surgery. Gasteroenterology 1979;77:907-913.
2. Fazio  VW,  Wu JS.  Surgical  therapy  for  Crohn's 
disease  of  the  colon  and  rectum.  Surg  Clin  
North Am 1997;77:197-210.
3. Tomaszczyk M, Zwemer DA.  Int Surg 2005;90(3 
Suppl):S45-7.
4. Veroux M, Angriman I, Ruffolo C et al.  Minerva  
Chir 2003;58(3):351-4.
http://ojhas.org 3
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.
5. Ellis LM, Copeland EM, Souba WW. Perioperative 
nutritional  support.  Surg  Clin  North  Am 
1991;71:493-507.
6. Delaney  CP,  FazioVW.  Crohn's  disease  of  the 
small  bowel.  Surg  Clin  North  Am 
2001;81:137-158.
7. Fazio VW, Marchetti F, Church JM et al. Effect of 
resection margins on the recurrence of Crohn's 
disease  in  the  small  bowel.  Ann  Surg 
1996;224:563-573.
8. Sheehan AL, Warren BF,  Gear MWL, et al.  Fat-
wrapping  in  Crohn's  disease:  Pathological  basis 
and  rrelevance  to  surgical  practice.  Br  J  Surg 
1992;79:955-958.
9. Scarpa M, Angriman I et al. Role of stapled and 
hand-sewn anastomosis in recurrence of Crohn's 
disease.  Hepatogastroenterology 
2004;51:1053-57.
10. Hurst RD, Molinari M, Chung TP et al. Prospec-
tive study of the features, indications and surgi-
cal treatment in513 consecutive patients affect-
ed by Crohn's disease. Surgery 1997;122:661-7.
11. Wexner SD et al. Surgery of Crohn's disease in-
cluding stricturoplasty. In: Robert J Baker, Josef E 
Fischer,  eds.  Mastery  of  Surgery,  4th  edition. 
2001. Philadelphia: Lippincott Williams & Wilkins. 
Pp. 1446-7.
12. Assche GV, Rutgeerts P. Medical management of 
postoperative  recurrence  in  Crohn's  disease. 
Gastroenterol Clin N Am 2004;33:347-360.
13. Yamamoto T. Factors  affecting recurrence after 
surgery  for  Crohn's  disease.  World  J  Gastroen-
terol 2005;11:3971-3979.
http://ojhas.org 4
OJHAS  Vol 6 Issue 4(6) Bhat MS, Ashfaque M, Balu K, Madhusudhanan J, Sendhil RK. A Rare Presentation of Crohn's Disease.


Sriram Bhat M

Ashfaque M

Balu K

Madhusudhanan J

Sendhil RK

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A Rare Presentation of Crohn's Disease

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