54 year old lady, presented with severe abdominal pain and obstipation for 4 days

54 year old lady, presented with severe abdominal pain and obstipation for 4 days

  • 54 year old lady, presented with severe abdominal pain and obstipation for  4 days.
  • No history of fever or vomiting.
  • Past surgical history –  Underwent LSCS 3 times.



  • Crohn’s disease with ileal perforation and peritonitis.


  • Crohn disease is an idiopathic inflammatory bowel disease characterized by discontinuous gastrointestinal tract inflammation.
  • The terminal ileum and proximal colon are most often affected.
  • Patients typically present with chronic diarrhea and recurrent abdominal pain, although occasionally the presentation is with a complication or an extraintestinal manifestation.
  • CT is the first imaging assessment for patients in the setting of an acute abdomen or for reassessment of complications in patients with known Crohn disease.

Common CT Imaging features include:

  • Mural hyperenhancement
  • Fat halo sign: submucosal fat deposition
  • Bowel wall thickening which is most frequently seen in the terminal ileum.
  • Comb sign: engorgement of the vasa recta
  • Perienteric fat stranding.
  • Affected bowel loops separated by focal/regionally increased fat (fibrofatty proliferation; creeping fat)
  • Strictures and fistulae with upstream dilatation.
  • Mesenteric/intra-abdominal abscess or phlegmon formation

Complications include:

  • Strictures.
  • Adhesions and bowel obstructions.
  • Fistulae.
  • Perianal fistula.
  • Perianal abscess.
  • Bowel perforation with free peritoneal air is a rare complication of Crohn’s disease.
  • It is seen to occur in 1–3% of Crohn’s disease patients as a first manifestation or, in the course of the disease.
  • Early diagnosis of bowel perforation is important and determines the survival rate.
  • Only 20% of patients with Crohn’s disease and intestinal perforation have pneumoperitoneum on X-ray of the abdomen and/or on erect chest X-ray. Thus CT plays a pivotal role in accurate diagnosis of both Crohn’s disease and also in determining the site of intestinal perforation.
  • Laparotomy and bowel resection should be considered if the perforation place is identified. However, in the absence of a clear site of perforation and without enteric contamination, a conservative surgical approach should be considered.


  • Furukawa A, Saotome T, Yamasaki M et al. Cross-Sectional Imaging in Crohn Disease. Radiographics. 2004;24(3):689-702. doi:10.1148/rg.243035120 – Pubmed
  • Gore R, Balthazar E, Ghahremani G, Miller F. CT Features of Ulcerative Colitis and Crohn’s Disease. AJR Am J Roentgenol. 1996;167(1):3-15. doi:10.2214/ajr.167.1.8659415 – Pubmed.
  • R.F. Leal et al. Free peritoneal perforation in a patient with Crohn’s disease – Report of a case. International Journal of Surgery Case Reports 4 (2013) 322–324.

Dr. Vishwanath Joshi
Consultant Radiologist.
Manipal Hospital Radiology Group (MHRG)
Manipal Hospital, Bengaluru.

Dr Rashmi Jayakar Poojary
Radiology resident
Manipal  Hospital, Yeshwanthpur, Bengaluru.