40 Colonic Perforation in Newly Diagnosed Acute Severe Ulcerative Colitis Despite Early Infliximab Infusion

Background: Acute severe ulcerative colitis (ASUC) is a medical emergency requiring prompt therapy; however, approximately 30%–40% of patients are steroid-refractory and require additional therapy such as infliximab (IFX). Despite the efficacy of IFX as rescue therapy, delayed surgical intervention after biologic treatment can increase the risk of adverse outcomes, including perforation. Although toxic megacolon complicates less than 5% of severe UC cases, it remains a life-threatening condition requiring urgent recognition and management. Delayed perforation after IFX induction in newly diagnosed ASUC, despite initial symptomatic improvement, is rarely reported. This case illustrates such a scenario. Methods: We reviewed the hospital course, imaging, endoscopy, histopathology, and surgical details of a patient with newly diagnosed ASUC who received corticosteroids and IFX induction prior the patient developing colonic perforation requiring an emergent colectomy. Results: A 53-year-old male presented with 3 weeks of abdominal pain and diarrhea. Initial CT demonstrated diffuse colonic wall thickening involving the ascending, descending, sigmoid, and rectum. The patient underwent a colonoscopy and an esophagogastroduodenoscopy (EGD). EGD revealed mild chronic gastritis without ulceration; biopsies were negative for Helicobacter pylori. Colonoscopy showed diffuse severe colonic inflammation characterized by edema, erythema, friability, scarring, and deep ulcerations throughout the colon, with loss of vascular pattern. Small bowel mucosa appeared normal. Random colon biopsies demonstrated chronic active colitis with mucosal ulceration, negative for granulomas, dysplasia, and cytomegalovirus. The patient initially received intravenous (IV) methylprednisolone and mesalamine suppositories. He did not show significant improvement after receiving 5 days of IV steroids and so was treated with an IFX infusion (5 mg/kg). The day after receiving IFX, the patient reported significant improvement in abdominal pain and decreased diarrhea and was discharged with clinical improvement. However, 8 days after discharge, he returned to the hospital with worsening abdominal pain and diarrhea. A CT scan demonstrated persistent colitis and colonic gaseous distention. A second IFX infusion (5 mg/kg) was administered, 15 days after the first infusion. Three days later he developed acute abdominal pain and repeat imaging revealed pneumoperitoneum and pneumatosis in the distal descending/proximal sigmoid colon, consistent with perforation. An emergent total abdominal colectomy with end ileostomy was performed. Histopathology confirmed chronic active colitis with ulceration and pseudo polyps consistent with UC, negative for granulomas and dysplasia. Conclusions: This case highlights a rare but serious complication: delayed colonic perforation following IFX induction in newly diagnosed ASUC, despite initial improvement. Given that up to one-third of ASUC patients require colectomy despite biologic therapy and that delayed surgery increases morbidity, clinicians should maintain vigilance for signs and symptoms that could suggest impending complications, even after induction treatment with a biologic agent resulted in clinical improvement and should consider early surgical consultation if symptoms and signs of progression recur. Further research is needed to identify predictors and optimize surgical timing in biologic-treated ASUC.