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We evaluated a small group of patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by video capsule endoscopy (VCE) and/or double-balloon endoscopy (DBE), who underwent surgery in our hospital. The subjects were 20 patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by VCE and/or DBE, who underwent surgery between April 2004 and December 2008. VCE, DBE, and computed tomography were performed in 12, 17, and 20 patients, respectively. Eleven patients also had a biopsy taken during DBE, resulting in a definitive diagnosis in eight. Because of the risk of hemorrhage during DBE in five patients, a biopsy was not taken and the sites of the lesion were marked in these patients. Twenty patients underwent surgery, and the diagnoses were small-intestinal cancer in eight, gastrointestinal stromal tumor in seven, arteriovenous malformation in two, and Crohn’s disease, angioectasia, and leiomyoma in one each. The interval between the onset of symptoms and surgery was less than 50 days for six patients, 50–100 days for two, 100–200 days for five, and more than 200 days for seven. Preoperative small-bowel endoscopy proved useful for diagnosing the cause of hemorrhagic lesions in the small intestine.

We report the case of a perforated duodenal ulcer and diffuse peritonitis associated with an incarcerated hiatal hernia. A 77-year-old woman with a 17-year history of rheumatoid arthritis treated with nonsteroidal anti-inflammatory drugs, who had also been receiving treatment for non-Hodgkin's lymphoma over 4 years, was referred to us for investigation of nausea and vomiting. An abdominal compute tomography (CT) scan showed an incarcerated hiatal hernia and free air in the hernia sac. Emergency laparotomy revealed an incarcerated hiatal hernia involving the stomach, transverse colon, and omentum. A perforated ulcer was also found in the posterior wall of the first portion of the duodenum. The combination of these disorders is thought to be rare in patients with a hiatal hernia and free air in its sac. As the reported mortality of perforated gastric ulcer associated with a hiatal hernia is high, early elective surgery should be performed in patients with a duodenal ulcer associated with a hiatal hernia.