A 38-year-old woman presented to our Emergency Department with severe abdominal pain.
She had no history of drug use or constipation.
She said that she had intermittent bloody diarrhea.
Physical examination revealed rebound tenderness and guarding over the abdomen.
Stool microscopy was negative for amoeba trophozoites or any parasites.
Fecal occult blood was found.
Sedimentation was 27 mm/s, CRP (nephelometry) was 65.6 mg/L (normal range 0–5), anti-nuclear antibody was 0.4 (0–0.8 negative), anti-ds DNA <10 (<20 negative), white blood cell count was 14.98 (normal range 4–10), hemoglobin level was 10.9, neutro-phil count was 13.14, platelet count was 473 (100–300), urea level was 17 mg/dl, BUN level was 7.94 mg/dl, creatinine level was 0.56 mg/dl, AST was 20 U/L, and ALT was 24 U/L.
HIV was negative.
Abdominal ultrasound scanning showed free fluid at the right paracolic, perihepatic, left paracolic gutters and pelvis.
Upon detection of air-fluid level and free air under the diaphragm on erect abdominal x-ray, emergency laparotomy was performed.
In the operation, multiple perforation areas were found in the sigmoid colon, descending colon, and transverse colon.
Wide resection of the transverse colon with descending and sigmoid colon resection was undertaken (Figure 1).
Pathergy test was positive.
The patient had recurrent oral and genital aphthous ulcers 4–5 times within the past year.
Eye examination results were normal.
Computed tomography revealed extensive thrombus within the inferior vena cava extending through the right and middle hepatic vein (Figure 2).
The patient received corticosteroid, anticoagulant, and immunosuppressive therapy.
Our patient is still alive and healthy 53 weeks later (Figure 3).
In macroscopy, the transverse colon was 50 cm and sigmoid and descending colon specimens were 27 cm in length.
Specimens of both colon segments were 4 cm in diameter.
Perforation areas were evident in the serosal surface.
Colonic wall and bowel mucosa was edematous and hyperemic.
Plicae were regular in their course.
There were 3 roundish, punched-out perforations in the transverse colon and 4 in the descending and sigmoid colon, which were somewhat separate from the colonic wall, with the largest being 2 cm in diameter (Figure 4).
There were multiple ulcers (the largest was 1 cm in diameter) in different locations, which were not merging together, and were somewhat separate from the surrounding mucosa via a certain limit, covered with exudate and surrounded by a hyperemic region.
There were no macroscopic lymph nodes in the serosa.
Numerous samples were taken from ulcerated and perforated regions and normal mucosa.
The samples were submitted for routine microscopic tissue follow-up.
Hematoxylin-eosin, tissue Giemsa and PAS-stained slides were prepared for examination.
In microscopic examination, there were neutrophil leukocyte and lymphocyte reaction around and within the walls and lumens of arterioles, and venules around the perforated and ulcerated lesions (Figures 5 and ​and6).6).
There were well-organized thrombi and intimal proliferation within some vessels (Figures 7 and ​and8).8).
There was marked acute peritonitis.
Surface epithelium and colonic crypts were regular within the colonic mucosa apart from the ulcerated or perforated lesions.
Samples were free of parasites or their eggs.