An unusual double-balloon enteroscopy finding: Duodenal perforation by an inferior vena cava filter

摘要

A 57-year-old man was admitted for significant GI bleeding (hematemesis, melena, and hemodynamic instability). His medical history included multiple myeloma, factor V Leyden mutation, and recurrent deep vein thrombosis; 4 years earlier he had a removable inferior vena cava (IVC) filter placed (A) and was started on warfarin therapy. Results of his admission laboratory tests showed a hemoglobin level of 9.0 g/dL and an international normalized ratio of 2.1. After resuscitation, blood transfusion, and vitamin K administration, the patient underwent unremarkable upper endoscopy and ileocolonoscopy. The next day a capsule endoscopy (CE) showed a mid jejunal stenosis with erosions. An oral double-balloon enteroscopy (DBE), performed as an outpatient procedure 10 days after CE, confirmed the jejunal stenotic tract "with nonbleeding erosions (potentially related to nonsteroidal anti-inflammatory drug consumption). Histology showed mild inflammation. Upon withdrawal and 30 cm distal to the pylorus, a fibrin-covered ulcer with a 5-mm metallic hook resembling an IVC filter element was seen to penetrate through the duodenal wall (B). CT confirmed the duodenal perforation (C, D, red arrow) and showed a posterior filter branch embedded in the L-2 vertebra (D, black arrow), causing a periosteal inflammatory reaction. The patient underwent surgical intervention "with filter removal and vena cava and duodenal suture, and fully recovered.