Conservative Management of an Endoscopic Duodenal Wall Perforation With Active Leak

Abstract

Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract. Nonperiampullary duodenal perforation is usually caused by direct trauma from the endoscope or therapeutic interventions, requiring surgical management. The indications for surgery include extravasation of contrast medium, presence of a fluid collection, severe peritonitis or severe sepsis. We present a rare case of endoscopic lateral duodenal wall perforation with active leak which was managed conservatively despite meeting criteria for surgery. A 62 year old female with cirrhosis secondary to non-alcoholic steatohepatitis underwent liver biopsy of both hepatic lobes via endoscopic ultrasound. The procedure was completed successfully without apparent complication. Soon after the procedure she developed severe abdominal pain in the right upper quadrant with referred pain to the right shoulder. Abdominal computed tomography (CT) without oral contrast showed inflammatory changes surrounding the first and second portions of the duodenum, scattered foci of free intraperitoneal air,and a tiny focus of air adjacent to the duodenal bulb. She was admitted to the hospital and antibiotics were started. She refused endoscopic closure attempt. On day 3, upper gastrointestinal (GI) Gastrografin imaging study showed evidence of perforation of the duodenum distal to the duodenal bulb with a leak localized around the duodenum and small pockets of intraperitoneal air. On day 7, upper GI study again showed persistent leak from the duodenum. As she remained clinically stable, surgery was not performed. She was discharged home on day 10. A third upper GI series was completed 6 days later at which time the duodenal leak was not present. Early diagnosis of endoscopic perforation of the duodenal wall allows early surgical intervention, and primary repair of the perforation may be all that is necessary. Mortality rate increases with late surgical management. However, despite meeting criteria for surgical management indicated by the presence of intraperitoneal free air on CT imaging and active extravasation of contrast on upper GI series, conservative management proved to be successful in this case. In conclusion, nonperiampullary duodenal wall perforation with active leak may be conservatively managed in certain cases where the leak is small and contained around the perforation site and as long as the patient displays stable clinical status.Figure 1Figure 2