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Session: ePoster: Benign Abdominal 7 (Mon1015)

EP680 - Immunotherapy Induced Small Bowel Perforation: a case report and systematic review of the literature

Monday, May 12, 2025
10:31 AM – 10:36 AM PT

    ePoster Presenter(s)

  • Timothy Holleran, MD

    Clinical Fellow
    Cleveland Clinic Florida
    Weston, Florida, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Author(s)

  • CF

    Carlos Fernandez, MLIS MA AHIP

    Medical Librarian
    Cleveland Clinic Florida
    Weston, Florida, United States

    Disclosure information not submitted.

  • Nir Horesh, MD

    Resident Physician
    Cleveland Clinic Florida
    Cleveland Clinic Florida
    Weston, FL, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • Sameh H. Emile, MBBCh, MSc, MD, FACS

    Project Scientist
    Cleveland Clinic Florida
    Cleveland Clinic Florida
    Plantation , FL, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no relevant relationships with ineligible companies.

  • David Maron, MD

    Surgeon
    Cleveland Clinic Florida
    Weston, Florida, United States

    Disclosure information not submitted.

  • Steven D. Wexner, MD, PhD (Hon), MD, PhD (Hon), FACS, FRCS, FRCSI, MAMSE

    Emeritus Chair, Department of Colorectal Surgery
    Cleveland Clinic Florida
    Cleveland Clinic Lerner College of Medicine at Case Western Reserve University
    Weston, Florida, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no relevant relationships with ineligible companies.

    • Senior Author(s)

  • Marylise Boutros, MD (she/her/hers)

    Colorectal Surgeon
    Cleveland Clinic Florida
    McGill University
    Weston, Florida, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no relevant relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.
Timothy Holleran, MD: This individual has no financial relationships with ineligible companies.
Nir Horesh, MD: This individual has no financial relationships with ineligible companies.
Sameh H. Emile, MBBCh, MSc, MD, FACS: This individual has no relevant relationships with ineligible companies.
Steven D. Wexner, MD, PhD (Hon), FACS, FRCS, FRCSI, MAMSE, MD, PhD (Hon): This individual has no relevant relationships with ineligible companies.
Marylise Boutros, MD: This individual has no relevant relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: Immunotherapy has become a promising treatment for mismatch repair-deficient colorectal cancer and other malignancies. However, immune checkpoint inhibitors have been linked to enteritis, colitis, and, in rare cases, bowel perforation. The risk factors, clinical features, and outcomes of this severe complication are not well described.

Methods/Interventions: We present the case of a 71-year-old male with metastatic melanoma involving the lungs and adrenal glands, treated with nivolumab, who was undergoing treatment for checkpoint inhibitor colitis. Almost two years after his first dose of nivolumab, he presented with acute abdominal pain, peritonitis, and pneumoperitoneum on computed tomography. Diagnostic laparoscopy revealed a spontaneous 5mm perforation in the ileum, with purulent peritonitis. The patient was successfully treated with laparoscopic wash-out, small bowel resection, and anastomosis. A systematic review was performed to identify other cases of immunotherapy-related bowel perforation. Patient demographics, immunotherapy type and dosage, time to presentation, and outcomes were analyzed.

Results/Outcomes: This patient had an uncomplicated recovery, with bowel function returning after three days, and was discharged on postoperative day seven, following resolution of new-onset atrial fibrillation. Vedolizumab is planned for treating checkpoint inhibitor enteritis four weeks post-surgery. A systematic review identified 13 articles documenting immunotherapy-related bowel perforation, involving 13 patients (3 female, 10 male) aged 36 to 79 years. Melanoma and lung cancer were the most common malignancies (30.7% each). The small bowel was the most frequent perforation site (69.2%). Nivolumab was the most cited immunotherapy agent (53.4%), and 38.4% of patients were on combination therapy. Most patients (84.6%) did not have pre-existing tumor involvement in the bowel. Time from the start of immunotherapy to perforation ranged from 28 to 912 days, with 46.1% occurring within three months of treatment. Only three cases reported prior enteritis or colitis. The 90-day mortality rate was 23.1%.

Conclusion/Discussion: Bowel perforation from immunotherapy is rare but has high morbidity and mortality. In our review, nivolumab and combination immunotherapy were most associated with bowel perforation, with nearly half of cases occurring within 70 days of treatment initiation. Given the sudden onset and high mortality risk, maintaining a high index of suspicion is crucial for patients on immunotherapy who develop gastrointestinal symptoms. Close monitoring, particularly in the first three months, is essential for timely identification of perforation, which can improve outcomes. Further research is needed to identify predictors of immunotherapy-induced bowel perforation and to explore long-term outcomes of treatments for immunotherapy-related enteritis and colitis.