title: Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU).
abstract: BACKGROUND
  The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation.
  
  
  METHODS
  We present the case of a 63-year-old male who presented to our institution's emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation.
  
  
  CONCLUSIONS
  Due to the patient's hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation.
  
  
  CONCLUSIONS
  This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD.
authors.affiliation: University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA. Electronic address: jason.chertoff@medicine.ufl.edu.
authors.forename: Jason
authors.initials: J
authors.lastname: Chertoff
authors.affiliation: University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA.
authors.forename: Vikas
authors.initials: V
authors.lastname: Khullar
authors.affiliation: University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA.
authors.forename: Lucas
authors.initials: L
authors.lastname: Burke
keywords: Duodenal perforation; Nonsurgical; Resuscitation; Shock; Surgical
references.citation: World J Emerg Surg. 2014 Jan 24;9(1):11
references.pmid: 24461069
references.citation: Int J Colorectal Dis. 2011 Sep;26(9):1183-90
references.pmid: 21526372
references.citation: J Gastrointest Surg. 2008 Oct;12(10):1783-9
references.pmid: 18683006
references.citation: Gastrointest Endosc. 2001 May;53(6):620-7
references.pmid: 11323588
references.citation: J Gastrointest Surg. 2005 Dec;9(9):1229-35: discussion 1236
references.pmid: 16332478
references.citation: Endoscopy. 2009 Nov;41(11):941-51
references.pmid: 19866393
references.citation: Arch Surg. 2007 May;142(5):448-54; discussion 454-5
references.pmid: 17515486
references.citation: Surgery. 2010 Oct;148(4):876-80; discussion 881-2
references.pmid: 20708766
references.citation: World J Surg. 2000 Mar;24(3):256-8
references.pmid: 10658057
references.citation: Gastrointest Endosc. 2012 Oct;76(4):838-59
references.pmid: 22831858
references.citation: Clin Endosc. 2014 Jul;47(4):341-5
references.pmid: 25133122
references.citation: Dis Colon Rectum. 2014 Jul;57(7):875-81
references.pmid: 24901689
references.citation: Clin Endosc. 2013 Sep;46(5):522-8
references.pmid: 24143315
references.citation: Arch Surg. 2007 Nov;142(11):1059-64
references.pmid: 18025334
references.citation: Am J Surg. 2001 Apr;181(4):319-32
references.pmid: 11438266
references.citation: Endoscopy. 2002 Apr;34(4):293-8
references.pmid: 11932784
references.citation: Am J Surg. 1993 Jun;165(6):700-3
references.pmid: 8506969
references.citation: Surgery. 1999 Oct;126(4):658-63; discussion 664-5
references.pmid: 10520912
references.citation: Gastrointest Endosc. 2002 Jun;55(7):784-93
references.pmid: 12024128
references.citation: Arch Surg. 2012 Jan;147(1):81-8
references.pmid: 22250120
references.citation: Ann Surg. 2000 Aug;232(2):191-8
references.pmid: 10903596