Emergency surgical approach for abdominal trauma in a patient with Crohn’s disease: case report and literature review

Abstract

Introduction:

Crohn’s disease (CD) is a chronic, relapsing inflammatory condition that affects the gastrointestinal tract, associated with abscesses, fistulas, and perforations. Owing to impaired integrity and proximal dilatation secondary to strictures, CD patients may be predisposed to perforations after blunt abdominal trauma.

Case presentation:

A 29-year-old male was admitted to a tertiary hospital after a motor vehicle accident. He underwent chest drainage for pneumothorax and remained stable. Abdominal computed tomography scan revealed pneumoperitoneum and thickening of small bowel loops. He had a prior diagnosis of CD but was lost to follow-up and therapy. Exploratory laparotomy showed jejunal perforation with multiple stenoses and inflammation. Segmental enterectomy and stapling of the bowel ends were performed, followed by temporary peritoneostomy due to instability. Reoperation 48 hours later included resection of a segment of jejunum, construction of a right-sided jejunostomy, and a left-sided mucous fistula. He remained hospitalized for 30 days for nutritional support. Later, intestinal continuity was restored by enteroenteric isoperistaltic anastomosis, Heineke–Mikulicz stricturoplasties, and dilation of remaining stenoses. Postoperative recovery was uneventful, and immunobiologic therapy was initiated.

Discussion:

CD’s transmural inflammation predisposes to spontaneous intestinal perforation more often than in the general population, but trauma-related perforations are rare, occurring along mesenteric borders of longitudinal ulcers near stenoses. Limited resection is generally recommended, while primary anastomosis may be unsafe in contaminated fields with active disease.

Conclusion:

There is no consensus for CD patients sustaining abdominal trauma. This case underscores the importance of individualized surgical strategies in minimizing associated morbidity and mortality.

Introduction

Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD). It usually presents insidiously but may also manifest as a fulminant condition with overlapping features that require emergency treatment^[1^]. Pharmacological therapy has traditionally been the first-line approach, with surgery considered a last resort or an option in cases of medical therapy failure. However, in recent years, early surgical intervention has gained ground in some instances and among more severe patients, particularly due to the advent of less invasive surgical techniques^[2,3^].

HIGHLIGHTS

• Blunt abdominal trauma can cause intestinal perforation in patients with Crohn’s disease (CD) due to compromised bowel integrity.

• A patient with untreated CD who suffered jejunal perforation after a car accident may require multiple surgeries.

• The surgical management of traumatic perforations in CD patients is complex, with no clear consensus, emphasizing the need for tailored strategies.

It is known that approximately 40% of patients with CD, particularly those with small bowel involvement, perianal disease, or diagnosis between 45 and 59 years of age, undergo some surgical procedure within 10 years of diagnosis^[4–6^]. Among the surgical complications associated with CD, intestinal perforation is one of the most frequent, followed by fistulas and abscesses^[4^]. This is attributed to chronic intestinal inflammation and fragility. Surgical urgencies and emergencies in patients with CD are associated with high rates of morbidity and mortality, which can be explained by preoperative immunosuppression and malnutrition, exposing these patients to an increased risk of complications.

Regarding perforations due to blunt abdominal trauma in the general population, the incidence is below 0.3% and is therefore considered rare^[7,8^]. The small intestine is the most commonly affected site, and considerable force is usually required. Few case reports in the literature discuss intestinal perforation following blunt abdominal trauma in patients with CD. In these patients, perforation may be masked by other injuries and by medications used during the initial management of polytrauma^[6,8^].

Methodology

This study adheres to the SCARE Criteria 2025 for reporting surgical case reports^[9^]. The patient gave written informed consent to publish this case report and accompanying images.

Case report

A 29-year-old male patient was brought by ambulance to the emergency department of a tertiary university hospital following a motor vehicle accident with vehicle rollover on a highway. On initial evaluation by the Trauma Surgery team in the emergency room, he was agitated and aggressive. The patient was diaphoretic and tachypneic, with vital signs notable for tachycardia, but normal blood pressure. Respiratory examination revealed asymmetric chest expansion with reduced movement on the right side; percussion of the right hemithorax demonstrated hyperresonance, and auscultation showed markedly diminished breath sounds on the right, with preserved breath sounds on the left. Abdominal examination showed a distended and tense abdomen with visible guarding; palpation elicited significant tenderness in all quadrants, with rebound tenderness, involuntary guarding, and rigidity, and no masses were palpable due to diffuse guarding.

A focused assessment with sonography for trauma (FAST) examination was performed before the abdominal computed tomography (CT) scan and was negative for free intra-abdominal fluid. Chest radiography performed in the emergency room revealed a right-sided pneumothorax, which was treated with a right-sided water-seal chest drainage. Following initial management and maintenance of hemodynamic stability, an abdominal CT scan was performed, revealing segmental thickening of the small bowel, predominantly involving the jejunoileal loops, with mural hyperenhancement, alternating areas of luminal narrowing and upstream dilatation, findings consistent with active inflammatory bowel disease (IBD), with Crohn’s disease (CD) pattern. Associated pneumoperitoneum was also identified, raising concern for intestinal perforation in the setting of blunt abdominal trauma and prompting urgent surgical intervention (Fig. 1).

Figure 1.

Contrast-enhanced abdominal computed tomography (CT) scan on the patient’s admission. Axial images demonstrate segmental thickening of small bowel loops, predominantly involving the jejunum and ileum, with mural hyperenhancement, alternating areas of luminal narrowing and upstream dilatation, consistent with active Crohn’s disease (white arrows). Associated pneumoperitoneum (red arrow) and free fluid in the cavity (green arrow) are noted, supporting the diagnosis of intestinal perforation in the setting of blunt abdominal trauma.

The patient had been diagnosed with CD in 2016, with follow-up initiated at this same institution, but he had been lost to follow-up and off treatment for the last three years. He reported alcohol use and smoking. The magnetic resonance enterography performed in 2016 at the CD diagnosis showed extensive proximal ileal involvement characterized by mural thickening, mucosal hyperenhancement, and predominant submucosal edema, with the longest affected segment measuring approximately 18.0 cm, associated with marked luminal narrowing at the jejunoileal junction and upstream dilatation consistent with subocclusive activity, findings compatible with CD. The patient was classified as A2L3B2 according to the Montreal classification. Pre-admission symptoms and abdominal CT findings were consistent with active small bowel CD. The patient mentioned that he had lost weight and felt crampy abdominal pain after meals with occasional abdominal distension in the last 6 months before the accident.

Emergency surgical intervention was indicated, and the patient underwent exploratory laparotomy by the Trauma Surgery team. Intraoperative findings included jejunal perforation and multiple downstream areas showing inflammatory changes characteristic of CD, with mesenteric thickening, tissue friability, and areas of stenosis, some short and some long. Segmental enterectomy and stapling of the bowel ends were performed, followed by vacuum-assisted peritoneostomy due to intraoperative hemodynamic instability (Fig. 2). Damage-control surgery was selected due to severe intra-abdominal sepsis and hemodynamic instability during the surgery. Exploration revealed a large volume of hematic and enteric contamination, diffusely edematous and friable small-bowel loops, and two mesenteric-border jejunal perforations approximately 100 cm distal to the ligament of Treitz with associated ischemic changes. These findings, combined with marked bowel inflammation, poor tissue quality, and ongoing vasopressor-dependent hemodynamic instability (ASA IV), precluded safe primary anastomosis. Segmental enterectomy with stapled bowel ends and temporary negative-pressure peritoneostomy was therefore performed to achieve rapid source control and allow planned second-look surgery.

Figure 2.

Images of the emergency surgical approach. (A) A close-up view of the jejunal loop with intestinal perforation and thickened, inflamed bowel wall. (B) The resected surgical specimen is shown, with the perforation located near the mesentery. (C) The opened surgical specimen highlights ulcerated areas and perforations.

Histopathological examination revealed architectural distortion, a lymphocyte and plasma cell inflammatory infiltrate of the full-thickness intestinal wall with a patchy, segmental distribution, areas of mucosal ulceration that did not penetrate deep layers of the intestine, as well as some non-necrotizing granulomas (Fig. 3). The absence of transmural necrosis, together with the presence of non-necrotizing granulomas and chronic intestinal mucosal injury, favored a diagnosis of CD rather than ischemic, purely traumatic, or acute infectious etiologies. Although no specific microbiological studies, such as acid-fast bacilli or fungal stains, were documented in the pathology report, exclusion of infective granulomatous mimics was based on histomorphological features and clinical correlation.

Figure 3.

Histological findings of the surgical specimen resected during the trauma surgery. Histopathological examination showed architectural distortion, a lymphocyte and plasma cell infiltrate in the full-thickness intestinal wall, areas of mucosal ulceration, and some non-necrotizing granulomas. (A) Ulcerated area, with inflammatory infiltrate mainly in the mucosa, architectural distortion, and granuloma in the muscular layer. 4× magnification. (B) The white arrow indicates a granuloma, and the gray one points to the inflammatory infiltrate. 10× magnification. (C) Detail of the non-caseating granuloma. 20× magnification. (D) Lymphocyte and plasma cell infiltrate. 40× magnification.

The patient remained stable and underwent a second surgery 2 days later, which was planned and included an 8-cm enterectomy, construction of a right-sided jejunostomy 1 meter distal to the ligament of Treitz, and creation of a mucous fistula in the efferent loop on the left abdominal wall. The length of the small bowel between the mucous fistula and the ileocecal valve was 2.5 m. Cholecystectomy was also performed due to gallbladder distension with a thin wall and areas of laceration.

The patient remained hospitalized for 30 days following the second procedure for nutritional support, antibiotic therapy, and preoperative planning for reintervention. During this period, under the care of the Coloproctology team, he received total parenteral nutrition and oligomeric enteral nutrition through a tube inserted into the mucous fistula, resulting in the achievement of solid stools. Additionally, medications were administered to reduce jejunostomy output, and wound care was provided for partial dehiscence.

The patient required prolonged individualized parenteral nutrition (TPN). Before the third surgery, TPN was administered via brachial venous access, providing approximately 1999 kcal/day, with a non-protein caloric supply of 1519 kcal/day and a calorie: nitrogen ratio of 79.13. The macronutrient distribution comprised 46% carbohydrates, 30% lipids, and 24% protein. The regimen included comprehensive micronutrient and trace element supplementation, such as multivitamins (A and B), zinc, selenium, magnesium, calcium, potassium, sodium, and oligoelements. Following the third surgery, the patient remained fasting, and individualized TPN was continued intravenously on a continuous 24-hour basis. Nutritional tolerance and metabolic stability were monitored through regular clinical assessment and biochemical surveillance, including glycemic control with insulin, tailored electrolyte replacement, and antiemetic therapy, reflecting standard management strategies for patients with high-output jejunostomy and short-bowel–associated postoperative nutritional dependence.

He underwent elective surgical reintervention by the Coloproctology team, with exploratory laparotomy revealing eight stenotic areas in the small intestine and a Meckel’s diverticulum, with improvement of the inflammatory pattern and signs of disease in remission. Segmental enterectomy of the ostomy edges was performed, and intestinal continuity was restored via hand-sewn, side-to-side isoperistaltic enteroenteric anastomosis, combined with Heineke–Mikulicz stricturoplasties and dilation of remaining annular stenoses. The side-to-side isoperistaltic enteroenteric anastomosis was performed using a continuous 3-0 polyglactin suture on a cylindrical needle. No protective stoma was created because the anastomosis was close to the ligament of Treitz, and the abdominal cavity was closed in layers (Fig. 4).

Figure 4.

Images of the intestinal transit reconstruction surgery. (A) The ostomies are visible after they are released from the abdominal wall. (B) Small bowel segment with stenoses. (C) A close-up of a Meckel’s diverticulum. (D) Another segment with a long stenosis. (E) A hand-sewn enteroenteric anastomosis (arrow) and Heineke–Mikulicz stricturoplasty. (F) The final appearance of the surgical procedure shows a layered closure of the midline laparotomy and placement of a flat drain in the abdominal cavity.

The postoperative course following definitive surgery was uneventful. Oral feeding was reintroduced on postoperative day 7, and the patient was discharged on postoperative day 15, completing 47 days of hospitalization.

During the perioperative period of the three surgeries, the patient received intravenous ciprofloxacin (400 mg every 12 hours) and metronidazole (500 mg every 6 hours). Analgesic management after surgeries included intravenous dipyrone (1 g every 6 hours) and opioid analgesia with morphine (10 mg every 4 hours) and tramadol (100 mg every 8 hours). Adjunctive therapies comprised antiemetics (ondansetron and dimenhydrinate), proton pump inhibitors, and pharmacological thromboprophylaxis with enoxaparin.

At medium-term follow-up (approximately 1 year after trauma and staged abdominal surgery), the patient showed good clinical, nutritional, and functional recovery, with regular bowel movements, no gastrointestinal complaints, and no trauma- or IBD-related readmissions; body weight was 63 kg, reflecting a 3-kg gain, with a BMI of 20.7 kg/m², indicating adequate nutritional status. He remained clinically stable on adalimumab administered every 14 days, with ongoing outpatient nutritional counseling and laboratory monitoring. A detailed timeline summarizing the sequence of clinical events, surgical interventions, and nutritional management throughout the patient’s hospitalization and follow-up is provided in Table 1, and the surgical parameters for each surgery are depicted in Table 2.

Table 1.

Timeline of clinical course, staged surgical interventions, and nutritional management.

Clinical stage	Description	Time after admission in days
Admission	The patient was admitted to the emergency unit following a motor vehicle accident.	0
Initial management	Chest tube placement was performed for a right-sided pneumothorax, followed by hemodynamic stabilization.	0
Imaging diagnosis	Abdominal computed tomography (CT) scan revealed pneumoperitoneum and thickening of the small bowel loops.	0
First surgery (emergency)	An exploratory laparotomy was performed, including segmental enterectomy with stapling of the bowel ends. Temporary peritoneostomy was required due to intraoperative hemodynamic instability.	0
Second surgery	After stabilization in the ICU, the patient underwent a second surgical procedure 2 days later.	2
Reoperation procedure	Resection of a jejunal segment was performed, with construction of a right-sided lateral jejunostomy and creation of a left-sided lateral mucous fistula.	2
Nutritional support period	The patient remained hospitalized for 30 days after the second procedure for nutritional support, antibiotic therapy, and planning of definitive surgical reconstruction.	2-32
Definitive reconstruction (elective surgery)	After the 30-day hospitalization period, elective surgery was performed to restore intestinal continuity.	32
Discharge	The patient was discharged on postoperative day 15 following the definitive surgery, totaling 47 days of hospitalization.	47

CT, computed tomography; ICU, intensive care unit.

Table 2.

Detailed intraoperative and perioperative clinical and surgical characteristics of the three surgical procedures.

Variable	Surgery 1	Surgery 2	Surgery 3
Surgical approach	Exploratory laparotomy	Exploratory laparotomy	Exploratory laparotomy
Main procedures performed	Segmental enterectomy; vacuum-assisted peritoneostomy	Segmental enterectomy; right jejunostomy; left mucous fistula; closure of peritoneostomy	Segmental enterectomy of previous ostomy edges; intestinal transit reconstruction with manual latero-lateral isoperistaltic small bowel anastomosis; dilation of stenotic small bowel segments; Heineke–Mikulicz stricturoplasties; closure of the abdominal wall
Estimated blood loss (EBL)	300 ml	Not reported	Not reported
Type of anesthesia	General anesthesia	General anesthesia	General anesthesia
Vasopressor use (intraop)	Yes	Yes	No
Maximum vasopressor dose	Norepinephrine 0.45 µg/kg/min	Norepinephrine 5 mL/h (4 lines), discontinued	Not applicable
Intraoperative fluids	Ringer’s lactate 2000 ml; Voluven 500 ml; sodium bicarbonate 250 ml	Not reported	Ringer’s lactate 6000 ml; normal saline 250 ml; starch solution 500 ml
Intraoperative urine output	100 ml	Not reported	400 ml
Intraoperative fluid balance	+750 ml	Not reported	+550 ml
Hemoglobin at the end of surgery	11.6 g/dl	9.7 g/dl	9.5 g/dl
Abdominal Drains placed	Vacuum-assisted peritoneostomy (open abdomen) for temporary abdominal closure	No intra-abdominal surgical drains	Three Penrose drains (pelvis, left paracolic gutter, peri-anastomotic); one Portovac drain in the subcutaneous
Airway at the end of surgery	Intubated	Intubated	Extubated in the operating room
Immediate postoperative neurological status	Sedated, RASS – 4	Awake, RASS – 2	Awake, RAAS – 0
Immediate postoperative hemodynamics	Hemodynamically unstable	Stable after vasopressor withdrawal	Stable without vasopressors
Drain outputs (early postop)	–	–	Portovac: 80 ml sero-hematic; Penrose: 110 ml sero-hematic
Postoperative urine output	1200 ml/12 hours	1750 ml/12 hours	600 ml/12 hours
Antibiotics used	Ciprofloxacin + Metronidazole	Ciprofloxacin + Metronidazole	Ciprofloxacin + Metronidazole

RASS, Richmond Agitation–Sedation Scale; EBL, estimated blood loss.

Table 3 summarizes the serial laboratory findings from admission through hospitalization and postoperative follow-up, including hematological, metabolic, coagulation, and renal parameters, which enable an objective assessment of disease severity, clinical progression, and recovery over time.

Table 3.

Laboratory parameters on admission, during hospitalization, and at postoperative follow-up.

Parameter	Admission	ICU	Inpatient clinic	6 months after the last surgery
Acid–base/perfusion
Ph	7.138	–	7.423	–
Bicarbonate (mmol/l)	10.9	–	26.5	–
Base excess (mmol/l)	−18.0	–	+2.4	–
Lactate (mmol/l)	11.2	–	1.4	–
Po2 (mmhg)	75.5	–	118	–
Hematology
Hemoglobin (g/dl)	18.4	7.8	10.0–10.5	14.8
Hematocrit (%)	56.1	23.0	29.1–32.6	44.1
White blood cells (×103/µl)	3.72 → 14.11	10.72	16.6	5.51
Platelets (×103/µl)	152–268	64	258	216
RDW (%)	–	–	–	15.9
Coagulation
INR	1.23	–	1.30	–
APTT (s)	–	26.8–30.5	28.8	–
Fibrinogen (mg/dl)	136.6	–	242	–
Renal function
Urea (mg/dl)	–	62–77	43	–
Creatinine (mg/dl)	1.12–1.19	1.52	0.64–0.79	1.06
EGFR (ml/min/1.73 m2)	–	61–70	>90	>90

APTT, activated partial thromboplastin time; EGFR, estimated glomerular filtration rate; ICU, intensive care unit; INR, international normalized ratio; RDW, red cell distribution width; WBC, white blood cells.

Discussion

CD is a chronic idiopathic IBD, characterized by periods of activity alternating with remission, and it can affect any part of the gastrointestinal tract. Histopathologically, it is defined by chronic transmural inflammation^[5,6^]. Patients with CD are at increased risk of spontaneous intestinal perforation compared to the general population due to the transmural nature of the disease and the use of immunosuppressive medications for clinical control^[6^]. In most cases, even in patients with more severe disease, when there is no surgical urgency or emergency, medical therapy remains the first-line treatment. Elective surgery is indicated when patients are refractory to medical therapy and present with obstructive or fistulizing features^[3^].

Surgical management should be guided by the individual characteristics of the disease, including location and severity^[2^]. Surgery is ultimately required in approximately 80% of patients with CD^[5,10^], and emergency procedures are indicated in cases of acute intestinal obstruction, intra-abdominal sepsis, hemorrhage, acute toxic colitis, or perianal sepsis^[8^].

Patients with CD may be more prone to spontaneous intestinal perforation than the general population, yet it remains a rare occurrence (1–3%) among all spontaneous intestinal perforations^[1,4,6^]. When considering intestinal perforations in CD due to blunt abdominal trauma, these events are even more uncommon, with few reports in the literature (Table 4). Only eleven cases of intestinal perforation have been documented as a complication of trauma in patients with a prior diagnosis of CD^[6^]. In our review, we identified three cases in which the patient had no previously confirmed diagnosis of CD; however, histopathological analysis from emergency surgery confirmed the diagnosis, corroborating imaging and intraoperative findings^[7,8,11^].

Table 4.

Reported cases in the literature of abdominal trauma in patients with Crohn’s disease.

Author	Number of cases	Sex/age	Therapy for IBD	Trauma mechanism	Radiological evaluation	Management	Outcome
Bunni et al, 2008	1	Male 21 years old	CE	Abdominal trauma during a soccer match.	Abdominal CT with pneumoperitoneum and perforation in the ascending colon.	Laparotomy: CD in the small intestine and right colon, and two perforations in the ascending colon. Right colectomy and primary anastomosis.	Reapproach for washing: no complications.
Babiker et al, 2022	1	Male 25 years old	–	Car accident.	CT abdomen with pneumoperitoneum and free fluid in the pelvis.	Laparotomy: presence of injury at the junction between the cecum and ascending colon with cavity contamination, hemoperitoneum. Ileotyphlectomy with ileocolonic anastomosis and loop ileostomy.	Closure of the ileostomy: without complications
Foula et al, 2023	1	Male 18 years old	IFX + AZA	Car accident.	Abdominal CT: thickened terminal ileum with contrast uptake in the mucosa and a small collection between the bowel loops.	Observation: Abdominal X-ray with pneumoperitoneum diagnosed on the 2nd day of hospital admission. Laparoscopy: ileal perforation and signs of CD in the distal ileum. Segmental enterectomy with ileostomy and mucous fistula.	Discharge 16th PO After 6 weeks: ileostomy closure
Pérez- Jiménez et al, 2020	2	Male 20 years old; 39 years old	MTX + ADA; AZA	Abdominal trauma during football; abdominal trauma during martial arts.	Abdominal CT: pneumoperitoneum, free fluid, and thickening of the ascending colon. Abdominal CT: pneumoperitoneum with alteration in the transverse colon.	Laparotomy: presence of perforation in the ascending colon (hepatic angle) and fecal peritonitis. Right colectomy. Laparotomy: perforation in two points of the transverse colon. Enlarged right colectomy and primary anastomosis.	Surgical wound with infection. Discharge at the 8th PO: uneventful.
Tomita et al, 1993	1	Male 23 years old	SULFA	Car accident.	Abdominal CT: pneumoperitoneum and free fluid.	Laparotomy: 3 jejunal perforations. Segmental enterectomy and primary anastomosis.	Fistula on the 9th PO.
Lucke-Wold et al, 2016	1	Male 15 years old	–	Car accident.	Abdominal CT: free fluid, pneumoperitoneum, and thickening of the terminal ileum.	Laparotomy: perforation in the terminal ileum (antimesenteric border) with contamination of the cavity. Segmental enterectomy, damage control, and temporary closure of both afferent and efferent loops.	Reoperation after 2 days: ileotyphlectomy with ileocolic anastomosis.
Maconi et al, 2013	1	Male 46 years old	Anti-TNFα	Blunt abdominal trauma during skiing.	Abdominal CT: thickened bowel loops, free fluid, pneumoperitoneum, and ileosigmoid fistula.	Laparotomy: perforation in the distal ileum and ileosigmoid fistula. Ileotyphlectomy with manual ileocolonic anastomosis, and sigmoidectomy with a colonic mechanical anastomosis.	No incidents.
Onwubiko et al, 2014	1	Female 13 years old	–	Blunt abdominal trauma with acceleration and deceleration injury.	CT abdomen: thickening of the distal ileum and cecum, with pneumoperitoneum.	Laparoscopy converted to laparotomy: perforation in the distal ileum and thickening of the entire segment of the terminal ileum. Ileothyphlectomy with primary anastomosis.	6th PO: intra-abdominal collection. Percutaneous drainage.
Wagner et al, 2011	1	Male 22 years old	–	Car accident.	Abdominal CT: wall thickening and enhancement of the ileum mucosa, pneumoperitoneum, and free fluid in the cavity.	Laparoscopy converted to laparotomy: free fluid, ileal perforation, and inflammatory process. Ileotyphlectomy with primary anastomosis.	Uneventful. Discharged on the 9th PO.
Johnson et al, 1990	1	Male 26 years old	CE	Blunt abdominal trauma during a basketball game.	Abdominal CT: pneumoperitoneum.	Laparotomy: perforation in the sigmoid colon. Rectosigmoidectomy with terminal colostomy.	No incidents.

ADA, adalimumab; AP, anatomopathological examination; AZA, azathioprine; CD, Crohn’s disease; CE, corticosteroid; CT, computed tomography; IBD, inflammatory bowel disease; ICV, ileocecal valve; IFX, infliximab; MTX, methotrexate; PO, postoperative; SULFA, sulfasalazine; TNFα, tumor necrosis factor alpha.

Several studies have shown that the most effective method for early diagnosis of traumatic lesions in IBD patients, particularly perforations, is abdominal CT, as it provides direct and indirect radiological signs of intestinal injury^[6^]. Direct signs include discontinuity of the bowel wall, extraluminal gas, and extraluminal contrast material^[6^], as observed in the CT findings of the present case. In patients with coexisting IBD, CT interpretation becomes more challenging due to pre-existing inflammatory signs in imaging studies^[6^]. In all case reports found in the literature involving patients with abdominal trauma, the diagnosis of perforated acute abdomen was made by abdominal CT, with findings of pneumoperitoneum, as well as, in some cases, ileal thickening and free intraperitoneal fluid.

Although abdominal CT is the most effective imaging modality for the early diagnosis of traumatic abdominal injuries, interpretation can be particularly challenging in patients with pre-existing IBD, as chronic inflammatory changes may overlap with acute trauma-related findings. In the present case, during the initial emergency surgery, multiple strictures and active inflammation were identified distal to the site of perforation, involving approximately 2.5 m of small bowel, which rendered complete resection of all diseased segments unfeasible due to the high risk of short bowel syndrome. At the time of the second intervention, due to persistent concerns regarding bowel perfusion and healing capacity, and persistent areas of stenosis associated with ongoing inflammatory activity, precluded safe restoration of intestinal continuity, as an anastomosis constructed proximal to these strictures would have carried a substantial risk of postoperative intestinal obstruction. Finally, at the time of the third surgery, the same pattern of persistent stenosis was observed, so, in addition to the bowel anastomosis, stricturoplasties were performed in the areas of stenosis of the small bowel downstream of the anastomosis.

Traumatic perforation usually occurs along the mesenteric border of longitudinal intestinal ulcers^[6,10^] and is frequently associated with areas of inflammatory or fibrotic stenosis^[1^]. In such cases, the perforation typically occurs proximal to small bowel strictures^[1^]. This is attributed to intestinal wall fragility resulting from chronic inflammation and repeated cycles of relapse and remission^[6,12^]. Moreover, perforation and injury may occur with mild mechanisms, without the need for high-force blunt trauma^[7^], as reported by Bunni et al, Pérez-Jiménez et al, Maconi G et al, Onwubiko et al, and Johnson et al, in which intestinal perforations occurred after blunt abdominal trauma during sports activities^[4,7,12–14^].

The surgical management of traumatic intestinal lesions in patients with CD remains controversial^[5^]. In our case, intraoperative hemodynamic instability justified the use of a damage-control approach during the first operation. In the context of active CD and intra-abdominal contamination, primary anastomosis carries a substantial risk of failure. Therefore, temporary diversion or bypass represents a safer strategy for initial stabilization in critically ill patients, allowing definitive reconstruction to be postponed until inflammatory activity and physiologic derangements are adequately controlled^[1^]. The creation of a primary anastomosis is debatable due to the compromised bowel wall from the ongoing inflammatory process of CD, the presence of active disease, and potential peritoneal contamination^[6^]. In most cases reported in the literature, primary anastomosis was performed, with resection limited to the injured, perforated segment; however, due to the reasons listed above and the evident severe active CD in the segments downstream from the site of injury, a temporary diversion was performed.

Although the postoperative course was uneventful in the majority of abdominal trauma cases with intestinal perforation in patients with CD reported in the literature, these patients are at higher risk of intra-abdominal sepsis and postoperative complications due to their clinical status, often presenting with malnutrition and immunosuppression from the disease itself. In critically ill patients, proximal and distal diversion during emergency surgery should be considered for initial stabilization^[1^].

The reported patient had previously been treated with infliximab in the first 2 years of the diagnosis but had been off CD-specific therapy for three years due to loss of follow-up, which likely contributed to disease recurrence. Given the prolonged period without immunobiologic treatment at the time of trauma and initial surgical management, prior medication was not considered to have influenced the immediate postoperative course. Nevertheless, this aspect is clinically relevant, as patients receiving active immunosuppressive or biologic therapy may have a higher risk of postoperative infectious complications after any surgical procedure, including trauma surgery, underscoring the importance of individualized perioperative risk assessment in this population^[15^]. During the hospital admission and stay, prognosis was further worsened by active CD in the setting of major abdominal trauma, intestinal perforation, and the need for multiple staged surgical procedures, including segmental enterectomies, jejunostomy, and delayed reconstruction, all of which are recognized markers of complicated disease behavior.

Our case report can be situated among reports describing complex open surgical rescue in the real world, where staged and pragmatic decision-making is often required. A recent case report on open surgical repair of a thoracoabdominal aortic aneurysm with severe vertebral erosion in a low- and middle-income country (LMIC) setting highlights how multidisciplinary teams must rely on open techniques, damage-control principles, and individualized perioperative management when advanced endovascular or hybrid options are unavailable^[16^]. Similarly, in our patient, intraoperative instability, active CD, and contamination necessitated a staged open surgical approach rather than definitive reconstruction at the index operation, underscoring the importance of adaptable surgical strategies in high-risk emergencies.

Additionally, our report aligns with literature describing the management of uncommon acute abdominal surgical conditions in resource-limited environments. A recent case of a para-vesical internal hernia presenting with complete small bowel obstruction illustrates the challenges of emergency decision-making, reliance on available imaging, and the need for prolonged postoperative care in settings with constrained resources^[17^]. These issues parallel our experience, in which trauma-triggered intestinal perforation in the setting of active CD required multiple staged operations and extended inpatient nutritional support, reinforcing the relevance of tailored operative planning and multidisciplinary care in real-world surgical practice.

This case highlights three generalizable lessons for surgeons managing trauma in patients with IBD: (1) maintain a low threshold for staged or damage-control surgical strategies in the setting of active disease and physiologic instability; (2) anticipate prolonged nutritional support needs and involve nutrition services early; and (3) pursue early multidisciplinary planning, including close collaboration with gastroenterology, to enable timely initiation or adjustment of biologic therapy and optimize postoperative outcomes.

Conclusion

There is no consensus regarding the surgical management of patients with CD, whether in elective or emergency settings. The treatment of these patients becomes even rarer and more controversial when addressing blunt abdominal trauma and traumatic acute abdomen. Accordingly, this case and its management, from admission to the trauma bay, through surgical interventions, to the treatment provided in the inpatient setting, may offer a new perspective on the care and attention required for trauma in patients with CD, potentially reducing morbidity and mortality associated with such cases.

Ethical approval

This case report was conducted with approval from the Ethics Committee of the University of Campinas (CAAE 80309424.4.0000.5404).

Consent

The patient provided written informed consent for the publication of this case report and its accompanying images. The Editor-in-Chief of this journal can review a copy upon request.

Conflicts of interest disclosure

The authors declare no competing interests or personal relationships that could influence the work reported in this paper.

Sources of funding

No funding was received for this research.

Author contributions

G.S.P.: data collection and authored the paper; M.M.S.S.: data collection and assistance in manuscript preparation; I.C.: manuscript preparation; M.L.S.A.: manuscript preparation; G.P.F.: final revision of the manuscript; R.F.L.: supervision, data collection, and final revision of the manuscript.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Raquel Franco Leal.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.