S5371 An Unusual Duodenal Diverticulum Perforation During Diagnostic Endoscopic Ultrasound and Successful Endoscopic Rescue With an Over-the-Scope Clip

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: A 61-year-old woman with a complex medical history, including quiescent pulmonary sarcoidosis, limited cutaneous scleroderma, and chronic obstructive pulmonary disease 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. This was confirmed with EGD and closed using an 11 mm OTSC clip. Notably, an EGD/EUS performed 3 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 gastrointestinal series and CT abdomen with oral contrast, 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 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.