Bleeding Duodenal Diverticulum with Iatrogenic Perforated Duodenal Diverticulum: Double Trouble

Background: Duodenal diverticulum is the second most common location following the large bowel. Only 1–5% of patients with DD are symptomatic. Complications of duodenal diverticulum includes obstruction of duodenum, biliary pancreatic duct, pancreatitis, haemorrhage, diverticulitis with or without perforation, and other biliopancreatic manifestations including fistula formation in the bile duct, choledocholithiasis and cholangitis, bezoar formation inside the diverticulum, perforation and bleeding. Surgical or non-surgical treatment are considered in selected patient in treating perforated duodenal diverticulum. Case Presentation: We present a 69 year old gentleman presented to emergency department with complaint of passing out blackish stool for 2 days duration associated with presyncopal attack. On arrival, patient appear pale with class 3 hypovolemic shock symptoms. Abdominal examination revealed mild tenderness over epigastric region without signs of peritonism. Digital rectal examination showed fresh melena. Oesophagogastroduodenoscopy (OGDS) showed a huge diverticulum at duodenum (D3) with pooling of blood and blood clots. In view of bleeding at D3 diverticulum,adrenaline was injected and haemoclipped was applied. Hemostasis from bleeding duodenal diverticulum was successfuly secured. However, patient had iatrogenic perforated duodenal diverticulum. Conclusion: We present a case of upper gastrointestinal bleeding from a D3 diverticulum with iatrogenic perforated duodenal diverticulum due to endoscopic hemostasisinjection.We treated this patient conservatively by keep nil by mouth and started on parentral nutritional support, intravenous antibiotics and serial abdominal examination. We advocate in duodenal diverticulum bleeding the application of endoscopic clips and injection should be use juridiously. In case of iatrogenic perforation of duodenum diverticulum due to endoscopic hemostasis can still be treated conservatively in stable, elderly patients with no signs of diffuse peritonitis and no clinical evidence of sepsis