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Duodenal Perforation From Biliary Stent

Simons-Linares, C. Roberto MD, MSc1; Kichler, Adam J. DO1; Bhatt, Amit MD1

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doi: 10.14309/crj.0000000000000373
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CASE REPORT

A 59-year-old man with metastatic pancreatic cancer who had a 10 mm × 6 cm bare biliary metal stent placed 2 years earlier presented with melena and hypotension because of severe life-threatening upper gastrointestinal bleeding. Computer domography revealed a common bile duct metal stent in place, no free air, and no significant change in the pancreatic mass (Figure 1). Esophagogastroduodenoscopy revealed a very large oozing-cratered duodenal ulcer measuring 30 × 30 mm in the first portion of the duodenum that extended into the second portion of the duodenum (Figure 2). After washing of the ulcer, it was evident that the ulcer perforated the bowel wall with direct visualization of the pre-existing common bile duct metal stent (Figure 3). No endoscopic therapy could be performed. Interventional radiology performed embolization of the accessory right hepatic artery, and gastrointestinal bleeding was controlled. The patient did not have a history of nonsteroidal anti-inflammatory drug use or alcohol abuse and was Helicobacter pylori negative. We highlight a case of a severe contained duodenal ulcer that perforated and exposed the biliary stent, and because the ulcer was larger than our endoscopic tools, it had to be controlled with interventional radiology embolization. The teaching point is that endoscopists should be able to recognize certain limitations of endoscopic interventions and sometimes (similar to this case), other nonendoscopic interventions are the next best step in the patient's management.

Figure 1.
Figure 1.:
Computed tomography scan showing the metal biliary stent in place.
Figure 2.
Figure 2.:
Endoscopic view of the duodenal ulcer with adherent clot.
Figure 3.
Figure 3.:
Visualization of the biliary metal stent eroding and perforating into the duodenal wall.

DISCLOSURES

Author contributions: All authors contributed equally to this manuscript. A. Bhatt is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.