Duodenal perforation after endoscopic hemoclip application for bleeding from Dieulafoy's lesion in a duodenal diverticulum.

摘要

A 79-year-old woman visited the emergency department because of hematochezia and melena and was admitted. EGD was performed on the third day of admission and showed fresh blood clots on the second portion of the duodenum. Oozing of fresh blood was found at the opening of the periampullary diverticulum after removal of blood clots. Advance of a forward-viewing endoscope (Olympus XQ 260; Olympus Optical Co, Ltd, Tokyo, Japan) into a huge diverticulum was possible and enabled visualization of the bleeding focus, the Dieulafoy's lesion with oozing of blood in the diverticulum. After treatment by using 3 disposable hemoclips (9-mm-long, 90deg angle, Olympus HX-600-090L;Olympus) With a forward-viewing endoscope, the bleeding was completely controlled. However, a smallmucosal defect was noted at the site where the hemoclip was applied. Thus, an additional hemoclip was deployed.On that evening, the patient complained of right upper quadrant pain and tenderness. Abnormal air densities were noted at the right upper quadrant on a plain radiograph; retroperitoneal pneumoperitoneum, which was apparent by air densities around the kidney that were arising from a duodenal perforation, was found on abdominal CT. Conservative treatments, including nasogastric aspiration, fluid therapy, and the use of broad-spectrum antibiotics, were done. On the 17th day, the patient was discharged after confirmation of no abnormal air density on an abdominal plain radiograph and loss of the lesion on EGD.