P0592 - Perforation in Disguise: Endoscopic Rescue of a Chronic Ulcère Perforé-Bouché With Suture and Stent

Mayank Goyal, MBBS¹, Preeyati Chopra, MBBS², Mahin Bhatt, MBBS¹, Ashwariya Ohri, MBBS³, Khushboo Gala, MD¹, Navtej Buttar, MD¹
1Mayo Clinic, Rochester, MN; 2Mayo Clinic, Hartford, CT; 3Mayo Clinic, Indianapolis, IN

Introduction: Enteric ulcers can lead to free perforation or contained perforation depending upon their location and surrounding organs. Patients may present with abdominal pain, early satiety, nausea, postprandial distress, and melena. Untreated ulcers can lead to bleeding, perforation, penetration to surrounding organs, and obstruction from fibrotic structuring. Typically, penetrating peptic ulcer disease into the liver presents with dramatic symptoms, such as peritonitis or severe gastrointestinal hemorrhage. When the ulcer site is directly tamponades by adjacent organs (e.g., liver, pancreas, spleen), this leads to a contained perforated ulcer (Ulcère Perforé-Bouché), which may be an incidental endoscopic finding. When discovered, gas insufflation during the endoscopy may cause a leak, leading to abdominal catastrophe

Case Description/

Methods:

We present a case of middle-aged patient with past surgical history of Roux-en-Y gastric bypass with multiple revisions and pancreatic cyst, who had no known perforation underwent an endoscopic ultrasound during procedure a 1cm well epithelized ulcer opening to a 3 cm diverticulum was seen 2 cm into the Roux limb. The procedure was stopped with concerns of chronic contained perforated ulcer.

Due to post procedure pain the CT was done. CT scan revealed new pneumoperitoneum and a perforation at the gastrojejunostomy/proximal Roux limb, corresponding to the previously identified ulcer site. Due to complex surgical history, operative management was considered high-risk, and after a detailed discussion, the decision was made to proceed with endoscopic intervention.

On repeat upper endoscopy, a 2 cm gastric pouch from the GE junction to the gastrojejunal anastomosis was identified, consistent with her prior gastric bypass. The anastomosis had healthy mucosa and an intact staple line. Upon traversing the anastomosis, a 12 mm jejunal fistula was identified. The decision was made to close the fistula endoscopically. Two running sutures using 2.0 polypropylene were placed with cinches, resulting in excellent tissue approximation without bleeding. Finally, a covered WallFlex stent (18 mm x 15.3 cm) was deployed across the site under fluoroscopic guidance

On the three week follow up, there was no contrast or methylene leak was noted and the stent was removed.

Discussion:

This case highlights the role of endoscopic intervention as a viable, minimally invasive alternative to surgery in managing chronic perforated ulcer particularly in high-risk surgical candidates

 


Figure: 1A- fistula
1B- ulcere perfore bouche


Figure: 2a- pre procedure leak
2b- post procedure, with stent, showing absence of leak

Disclosures:
Mayank Goyal indicated no relevant financial relationships.
Preeyati Chopra indicated no relevant financial relationships.
Mahin Bhatt indicated no relevant financial relationships.
Ashwariya Ohri indicated no relevant financial relationships.
Khushboo Gala indicated no relevant financial relationships.
Navtej Buttar indicated no relevant financial relationships.

Mayank Goyal, MBBS¹, Preeyati Chopra, MBBS², Mahin Bhatt, MBBS¹, Ashwariya Ohri, MBBS³, Khushboo Gala, MD¹, Navtej Buttar, MD¹. P0592 - Perforation in Disguise: Endoscopic Rescue of a Chronic Ulcère Perforé-Bouché With Suture and Stent, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.