Spontaneous Healing of Gastric Perforation after Endoscopic Ligation for Gastric Varices
A 53-year-old male patient with a 20-year history of alcohol use (50 g/day) and confirmed liver cirrhosis, was admitted to this medical center for hematemesis on November 23, 2002. His vital signs on admission were heart rate of 120 beats per minute, blood pressure of 90/60 mmHg, respiratory rate of 18 per minute, body temperature of 36.4℃, and room air oxygen saturation of 100%. On physical examination, the patient appeared to be acutely ill; anemic conjunctiva, spider angioma on the anterior chest, abdominal distension, and shifting dullness were also observed. Laboratory data showed hemoglobin level of 7.4 g/dL, white blood cell count of 11,400/µL, platelet count of 67,000/µL, serum creatinine of 1.2 mg/dL, blood urea nitrogen of 35 mg/dL, serum total bilirubin of 1.9 mg/dL, alkaline phosphatase of 231 IU/L, aspartate aminotransferase of 285 IU/L, alanine aminotransferase of 95 IU/L, albumin of 2.1 g/dL, and prothrombin time of 14.8 sec (International Normalized Ratio 1.26). Serum hepatitis B surface antigen and serum hepatitis C antibodies were negative. His Child-Pugh score was 8 (class B).\nWe started somatostatin (6 g/day) and cefotaxime (3 g/day) infusion but not gastric acid-suppressive agents. Two units of packed red blood cells were transfused and urgent esophagogastroduodenoscopy (EGD; GIF-XQ240, Olympus Optical Co., Tokyo, Japan) was performed. EGD findings showed a small non-bleeding esophageal varix and a nodular shaped gastric varix with stigmata at the fundus of the stomach. EVL was performed for emergency hemostasis using endoscopic pneumoactivated ligating devices (Sumitomo Bakelite Co., Ltd, Tokyo, Japan) in the left lateral decubitus position (). A sufficient amount of the lesion was sucked into the ligator cap, and a rubber band was applied to fully ligate the lesion. The procedure was completed without any events at that time.\nHowever, two days after the EVL, the patient complained of abdominal pain, and a perforation was observed at the post-EVL ulcer base on the gastric fundus at follow-up EGD (). Also, a few air bubbles were observed outside the posterior gastric wall of the fundus on abdominal computed tomography (). We diagnosed perforation after the band ligation of the gastric varices and recommended emergency surgery. However, the patient refused to undergo an emergency operation and was therefore treated with a supportive therapy consisting of nothing-by-mouth status, intensive care unit management, and continued intravenous administration of antibiotics for 10 days. After 10 days, findings on EGD revealed healing of the perforation site (). Oral intake was then resumed and the patient was discharged 25 days later. Three months after the discharge, a follow-up EGD indicated that the perforation site had healed completely ().