P5754 - An Unusual Duodenal Diverticulum Perforation During Diagnostic Endoscopic Ultrasound and Successful Endoscopic Rescue With an Over-the-Scope Clip

Wei Tang, MD¹, Deepali Tewari, MD², Daniel Basta, MD³, Virendra Tewari, MBBS, MD, DM, FACG²
1Westchester Medical Center, Valhalla, NY; 2New York Medical College, Valhalla, NY; 3Westchester Medical Center, Elmwood Park, NJ

Introduction: Duodenal diverticula are common and typically asymptomatic; however, perforation is a rare but potentially life-threatening complication, with a reported mortality of approximately 8%. Surgical management has traditionally been the mainstay of treatment. We present a rare case of duodenal diverticulum perforation caused by diagnostic endoscopic ultrasound (EUS), which was successfully managed endoscopically using an over-the-scope (OTSC) clip.

Case Description/

Methods: A 61-year-old woman with a complex medical history, including quiescent pulmonary sarcoidosis, limited cutaneous scleroderma, and COPD on home oxygen, presented for esophagogastroduodenoscopy (EGD) to evaluate worsening reflux and epigastric pain along with a repeat EUS for surveillance of a previously noted dilated main pancreatic duct. Her surgical history was notable for multiple intra-abdominal procedures, including a radical pelvic mass resection with lower anterior resection and several complex abdominal wall reconstructions for recurrent hernias.

Following completion of a diagnostic radial EUS exam, a perforation was identified in distal duodenal bulb (Fig.1A-B). This was confirmed with EGD and closed using an 11 mm OTSC clip (Fig. 1C-D). Notably, an EGD/EUS performed three years earlier had documented a difficult-to-visualize duodenal diverticulum in the same location.

The patient was admitted for observation and started on empiric antibiotics. Post-procedure imaging, including an upper GI series and CT abdomen with oral contrast (Fig. 2A-B), revealed extensive pneumoperitoneum but no contrast extravasation, indicating successful closure. She remained clinically stable without signs of sepsis or worsening symptoms. Follow-up imaging on hospital day 6 (Fig. 2C-D) showed resolution of pneumoperitoneum and no evidence of leak. She was discharged in stable condition.

Discussion: Duodenal diverticulum perforation is a rare but serious condition, traditionally managed surgically. In this case, the likely mechanism was barotrauma during insufflation, with the EUS scope tip with balloon occluding the diverticular opening. Prompt identification and endoscopic closure using an OTSC clip allowed successful non-surgical management. This case underscores the importance of early recognition and highlights an unusual mechanism of perforation due to diverticulum blow out during diagnostic EUS, as well as the feasibility of endoscopic repair with prompt recognition.


Figure: Figure 1. Endoscopic Diagnosis and Management of Duodenal Diverticulum Perforation.

A duodenal diverticulum in the distal bulb was identified in prior EGD (A). During the current EUS, a focal mucosal defect was identified in the distal duodenal bulb (B), suspicious for a perforated diverticulum. An 11mm OTSC was deployed (C), well positioned, achieving immediate hemostasis (D).


Figure: Figure 2. Evolution of Upper GI Series and CT Abdomen Images.

Immediately following duodenal diverticulum perforation closure, CT abdomen with oral contrast (A) and upper GI series (B) demonstrated extensive pneumoperitoneum (red arrows) without contrast extravasation, confirming successful closure. Repeat imaging on hospital day 6 (C, D) showed resolution of the pneumoperitoneum, and an endoclip in the duodenal bulb (blue arrow) with no evidence of duodenal leak.

Disclosures:
Wei Tang indicated no relevant financial relationships.
Deepali Tewari indicated no relevant financial relationships.
Daniel Basta indicated no relevant financial relationships.
Virendra Tewari indicated no relevant financial relationships.

Wei Tang, MD¹, Deepali Tewari, MD², Daniel Basta, MD³, Virendra Tewari, MBBS, MD, DM, FACG². P5754 - An Unusual Duodenal Diverticulum Perforation During Diagnostic Endoscopic Ultrasound and Successful Endoscopic Rescue With an Over-the-Scope Clip, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.