Endoscopy in Outer Space: A Case of Contained Duodenal Perforation

Abstract

Duodenal perforation due to peptic ulcer disease (PUD) can result in significant morbidity and mortality if not managed appropriately. Non-operative management has been shown to be a safe strategy in a subset of these patients. The role and safety of endoscopy in assessment of perforation when diagnosis is equivocal has not been widely studied. We present a case where endoscopy was safely used in the evaluation of a patient who was found to have a duodenal perforation. An 88 year old male with a history of PUD presented with 4 weeks of abdominal pain, 10 pound weight loss, and multiple episodes of emesis with pain radiating to the right upper quadrant. The patient was clinically stable and had mild abdominal tenderness on examination. He had a leukocytosis (11.6) that resolved after his first hospital day. CT abdomen/pelvis showed inflammatory changes in the gallbladder fossa as well as a focal air/fluid collection within the duodenum suggesting a large duodenal diverticulum (Figure 1). The admitting surgical service did not believe his pain was biliary and sought an alternative diagnosis. He was started on cefotetan and a proton pump inhibitor. Endoscopy was chosen to help establish a diagnosis. On endoscopy, the esophagus and stomach were normal. In the duodenal bulb, a narrow luminal opening was visualized that appeared friable and irregular. The scope was advanced through the opening, and irregular appearing tissue with omental fat and areas of necrosis were seen (Figure 2). The endoscope was clearly outside of the luminal wall and likely within a contained perforated segment. A follow up upper GI series with barium showed a collection of contrast communicating with the first portion of the duodenum, likely representing a contained perforation (Figure 3). The initial plan was for surgical correction. However, conservative management was chosen given the high risk of the operation and the patient's clinical stability. After his symptoms improved, the patient was discharged tolerating a soft diet. While not a first-line choice, endoscopy may have a role in evaluating unclear cases that are found to involve perforation. In cases where the diagnosis may be in question, endoscopy may be safely performed. This path is consistent with the knowledge that up to half of all duodenal ulcers seal on their own within a short period of time. Our decision resulted in a good outcome, as this patient avoided an open surgery to characterize and treat his disease.Figure: Coronal image demonstrates duodenal thickening with small focus of intraluminal air (arrows) concerning for a duodenal diverticulum by radiology interpretation.Figure: Endoscopic appearance of tight stricture in the duodenal bulb (A), and then within the contained perforation with omental fat and necrosis directly visualized (B, C, and D).Figure: Upper GI series demonstrating luminal narrowing with fill of contrast within a likely contained perforated duodenal ulcer (arrow). Note there is no extravasation of contrast excluding a frank perforation.