Duodenal ulcer caused by a surgical clip after laparoscopic cholecystectomy.

A 56-year-old woman presented with a 1-month history of right upper quadrant abdominal pain after a laparoscopic cholecystectomy for gallstones. Her medical history included endoscopic retrograde cholangiopancreatography (ERCP) performed 4months prior to the laparoscopic cholecystectomy for the treatmentof common bile duct (CBD) stones. During this procedure duodenal ulcers had also been found at the duodenal bulb and she had therefore taken proton pump inhibitors (PPIs) for 3months. Physical examination revealed tenderness in the right upper quadrant of her abdomen. Abdominal ultrasonography showed that the bile ducts were not dilated. Esophagogastroduodenoscopy (EGD) revealed an ulcer with a wire-like object in the duodenal bulb (●" Fig.1). An abdominal computed tomography (CT) scan showed that part of a surgical clip was located in the lumen of the postbulbar zone of the duodenum (●" Fig.2). A duodenal ulcer resulting from a surgical clip placed during the laparoscopic cholecystectomy was diagnosed. The patient’s abdominal pain subsided gradually after further PPI use. An EGD performed 1 month later showed that the ulcer had improved, but the clip was protruding further (●" Fig.3a). The clip was retrieved using biopsy forceps, which led to mild bleeding (●" Fig.3b), and a hemoclip was applied to close the ulcer. The patient continued using PPIs and subsequently experienced an uneventful course. Surgical clip-related complications after laparoscopic cholecystectomy can include clip migration into the CBD, bile leak, and clip embolism [1]. A surgical clip-related duodenal ulcer is a rare complication after laparoscopic cholecystectomy and may be caused by two proposed mechanisms [2]. First, as the clip lies adjacent to the duodenum and may directly erode the duodenal wall, it emerges in the base of the ulcer. Second, a pre-existing ulcer can transiently perforate and capture the clip during the healing process. The management of a surgical clip that is present in a duodenal ulcer remains controversial. Although spontaneous detachment of such clips has been reported [3], endoscopic clip removal is recommended [1].