Peer Review Report For: Case Report: Acute peritonitis inaugurating Crohn's disease with spontaneous perforation in the peritoneal cavity [version 1; peer review: 1 approved with reservations, 1 not approved]

Résumé

Background: Crohn's Disease is a chronic, idiopathic, and transmural inflammatory condition that mainly affects the distal ileum. It is characterized by intricate pathophysiology and numerous complications, some of which can be fatal. In this report, we present a case study of acute generalized peritonitis resulting from the perforation of a distal ileal loop, inaugurating the diagnosis of Crohn's disease. Case presentation: A 43-year-old patient presented with a clinical presentation of acute peritonitis. He had a one-year history of intermittent abdominal pain and diarrhea. As the maximum pain was in the right iliac fossa, an acute appendicitis complicated with peritonitis was considered and the patient underwent laparoscopic exploration, without morphologic exploration. Peroperative observation found an inflamed conglomerate of small bowel loops associated with sclerolipomatosis, and purulent peritonitis by perforation of a distal ileal loop, 40 cm from the ileocaecal valve. A peritoneal toilet, ileocaecal resection, and ileo-colostomy were performed. The postoperative course was uneventful. Discussion: Various complications may arise during the evolution of Crohn’s disease. However, fatal complication such as generalized peritonitis leading to the diagnosis is rare. The underlying pathophysiology of free perforation remains unknown. The most common site affected is the terminal ileum. The surgical treatment is based on a limited resection of the affected bowel segment, followed by a temporary stoma. A primary anastomosis can be performed in selected patients. Conclusion: Perforative peritonitis as an initial presentation of Crohn's disease is challenging. Surgery is obviously required for acute peritonitis, with limited resection with or without anastomosis.

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