Pneumoperitoneum Secondary to Pyloric Ulcer Perforation Following Diagnostic Esophagogastroduodenoscopy (OGDS)- From Scope to Operative Table

Background: Esophagogastroduodenoscopy (OGDS) is the primary diagnostic modality for upper gastrointestinal bleeding [1]. While generally safe [2], iatrogenic perforation risk increases in patients with compromised mucosa, where routine baropneumatic insufflation can easily rupture a fragile ulcer bed, demanding emergent exploratory laparotomy [3-5].

Case Presentation: A 71-year-old female presented with epigastric pain, vomiting, and melena. She reported long-term NSAID and corticosteroid use without proton pump inhibitor gastroprotection [6]. Following resuscitation for severe blood loss anemia, a diagnostic OGDS revealed a prominent duodenal (D1) diverticulum but no active bleeding or obvious ulceration [7]. Two hours post-procedure, she developed acute dyspnea, progressive abdominal distension, and rapid hemodynamic collapse requiring emergency intubation and vasopressor support [8]. An emergent abdominal computed tomography (CT) scan demonstrated massive tension pneumoperitoneum with a suspected pyloroduodenal perforation [9]. Emergency exploratory laparotomy confirmed a 1.5 cm anterior prepyloric perforation, which was successfully managed with omental patch repair [10].

Conclusion: Diagnostic OGDS carries a rare but lethal risk of baropneumatic perforation in patients with mucosal injury from chronic NSAID and corticosteroid use [4]. Furthermore, anatomical variants like duodenal diverticula can mask coexisting ulcers during endoscopy [7]. Clinicians must maintain high suspicion for tension pneumoperitoneum if acute cardiopulmonary distress develops post-endoscopy, as early recognition and prompt surgical intervention are vital for survival [5].