S4152 Perforation in Disguise: Endoscopic Rescue of a Chronic Ulcère Perforé-Bouché With Suture and Stent

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 1 cm 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, computed tomography (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 gastroesophageal 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 × 15.3 cm) was deployed across the site under fluoroscopic guidance. On the 3 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. Watch the video: https://tinyurl.com/25ACGS4152