Atlas of Gastroenterological Endoscopy
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Spontanous perforation with hemorrhage and endoscopic treatment
The following pictures present an extraperitoneal spontaneous perforation. The patient had a history of ulcer disease and was admitted for acute onset epigastric pain. Upper endoscopy showed a subcardial ulcer with a suspected site of perforation. We suspected a fistula since the patient suffered of a mesothelioma. Contrast medium spread evenly paraesophageal, showing no fistulous canal. Therefore a spontaneous perforation was suspected, no contrast medium could be shown in the intraperitoneal cavity. A second ulcer was found in the pyloric canal. The hemorrhage was successfully treated, the perforation was closed by several hemoclips. Conservative broad spectrum antibiotic treatment prevented mediastinitis. The patient recovered quickly.
Spontaneous perforation with hemorrhage Spontaneous perforation with hemorrhage
First a small clot is seen subcardially with the endoscope in an inverted position and washed away by water jet. After further removing a coagulum with the biopsy forceps a site of recent perforation is seen.
Spontaneous perforation- x ray Spontaneous perforation- x ray
With an ERCP catheter the orifice is intubated. The catheter runs nearly parallel to the scope left.
Move the mouse´s arrow onto the picture to magnify and colour the tip of the catheter.
Injecting contrast medium reveals paraesophageal trapping of the contrast just next to the endoscope.
Move the mouse´s arrow onto the picture to magnify and colour the fistula.
Spontaneous perforation with hemorrhage Spontaneous perforation with hemorrhage
After manipulation with the ERCP catheter the perforation site produces an arterial hemorrhage. The hemorrhage is treated by fibrin glue instillation, yet at the upper margin an oozing hemorrhage is still seen. Note the fibrin strings in the upper portion of the picture.
Spontaneous perforation- clipping Spontaneous perforation- 1 weeks after clipping
Definite treatment of the hemorrhage is achieved by applying several hemoclips to the site. This at the same time facilitates the complete closure of the perforation. This picture was taken one week after initial treatment. The ulcer and presumably the perforated gastric wall is healing.