A 72-year-old man who had previous histories of hypertension and chronic renal failure and had received a catheterization for heart failure one month before presented to our hospital with abdominal pain. There was tenderness in the entire abdomen and necrotic findings with pain affecting the bilateral toes. An abdominal CT scan showed intraabdominal free air. We performed emergency surgery with a diagnosis of diffuse peritonitis caused by gastrointestinal perforation. During surgery we detected multiple ulcers and a perforated portion in the small intestine. Partial resection of the small intestine was performed. The histopathological diagnosis was small bowel perforation caused by cholesterol crystal embolization. The patient was discharged from our hospital on the 21^st postoperative day, but he developed and died of gastrointestinal bleeding on the 49^th postoperative day.

Gastrointestinal perforation due to cholesterol crystal embolization is extremely rare and is reported to carry a poor prognosis. Although steroid therapy is reported to be effective in some cases, no effective therapies have been established. If it causes intestinal perforation, appropriate selection of surgical procedure and careful intraoperative management are important. We report a rare case of small bowel perforation caused by cholesterol crystal embolization with some literature review.