A Case of Repeated Small Bowel Perforation due to Cholesterol Crystal Embolization

Abstract

Cholesterol crystal embolization refers to embolization of the scattered contents of a ruptured atherosclerotic plaque to peripheral vessels causing end-organ damage by mechanical plugging. The case involved an 86-year-old man who presented to our hospital because of abdominal pain. An abdominal CT scan revealed free air in the abdominal cavity. The patient was operated on with a diagnosis of generalized peritonitis caused by gastrointestinal perforation. During surgery we confirmed small bowel perforation and performed partial enterectomy. Histopathology revealed embolization of cholesterol crystals in arteries in the small bowel wall. The patient complained of abdominal pain on the 13^th postoperative day, suggesting a recurrent bout of gastrointestinal perforation. Surgery was performed. A perforation was identified in the small intestine where was different from the previous perforation site, and partial enterectomy was performed. Histopathology revealed the same findings as the previous perforation. The perforation was considered to be caused by bowel ischemia associated with cholesterol crystal embolization. He developed pneumonia with septicemia and died on the 64^th day after the initial operation.
Gastrointestinal perforation due to cholesterol crystal embolization carries an extremely high fatality rate. In order to save the patient's life, we should sufficiently consider in selecting operative procedures and maintain symptomatic treatments according to general condition of the patient.