Diagnosis of BD should be based on clinical criteria because there is no pathognomonic laboratory test to detect it.5
BD may be seen at any level of the gastrointestinal tract. A common gastrointestinal site other than the mouth is the ileocecal region.12
Gastrointestinal symptoms related to BD are abdominal pain, nausea and vomiting. Some symptoms present in emergency conditions, such as intestinal perforation or bleeding.10,13
Intestinal lesions are located on the antimesenteric side ().
Inflammatory bowel diseases should be kept in mind in the differential diagnosis of intestinal BD. The ulcers in intestinal BD may be aphtous or deep and round with a punched-out appearance. Although International Study Group criteria for BD accurately distinguish between BD and Crohn’s Disease,14
there are some common features. Like Crohn’s disease, BD manifests as discrete intestinal ulcers and discontinuous bowel involvement. Both of the diseases share extraintestinal manifestations, such as arthritis and uveitis. Rectal sparing is common for both. Longitudinal ulcers are rare in intestinal BD, but common in inflammatory bowel diseases. The ulcers may cause penetration, perforation or bleeding. Multiple ulcers are generally seen at multiple sites and may resolve with medical therapy. Our patient had multiple ulcers that led to intestinal perforation in the transverse colon. The remaining intestines were considered normal in gross appearance at laparotomy. A wide range of hallmarks were apparent in this case suggesting that the patient had BD, including changes of the non-ulcerative mucosa, venulitis on the order of vasculitis, characteristics of ulcers, absence of lymphoid aggregates and granulomas in the bowel.
There was no ulcerative lesion determined by lower and upper GI endoscopy performed three months after surgery. It is also possible that intestinal ulcers might have healed with the corticosteroid and immunosuppressant agents added to the patient’s therapy before endoscopic evaluation.
Treatment of BD is largely empirical, and a multidisciplinary approach is preferred. A multidisciplinary team should involve specialists in dermatology, rheumatology, ophthalmology, gastroenterology, immunology and others. Corticosteroids, immunosuppressants, and other agents such as colchicine and interferon are used for the treatment of BD.
Mesalazine and anti-tumor necrosis factors such as infliximab and thalidomide have been used for intestinal BD on a limited basis.15
The effectiveness of therapy on intestinal lesions is controversial because they can resolve spontaneously.16
Some reports state that corticosteroids may prolong the healing process and provoke perforations and pancreatitis.17
The recommended length of resection is controversial. Some authors advise wide surgical margins, while others recommend removal of only the grossly involved bowel.12,18
In another report, the length of resection did not affect the rate of recurrence or reoperation.12
We preferred resection of the involved colon in our patient because the perforations were limited to a short segment of the proximal transverse colon. The patient received a corticosteroid (Prednisolone), immunosuppressant (Azathioprime) and colchicine together. No ulcers were apparent within the gastrointestinal tract three months after surgical resection. As the probability of recurrence after the operation due to intestinal perforation or penetration is higher, follow-up endoscopies are planned in an outpatient setting. In addition, studies with large series and long-term follow up are necessary.
In conclusion, practitioners should be aware of intestinal involvement of BD, which accompanies ulceration of the intestine leading to perforation or hemorrhage. Colonic perforation is an unusual complication of BD and may occur anywhere in the colon without pioneering abdominal symptoms during the course of treatment. Urgent surgical resection is mandatory in case of colonic perforation. Successful surgical treatment would be expected with disease-free cut edges of the intestine.