Small-bowel perforation after endoscopic resection of a Peutz-Jeghers polyp in an infant using double-balloon enteroscopy.

vides a facility for the diagnosis and treat− ment of small−intestinal disease [1]. To date its use has not been described in in− fants. A boy aged 3 years and 10 months who had small−intestinal bleeding under− went esophagogastroduodenoscopy in another hospital, when two gastric polyps were found. He was referred to us for DBE. Peutz−Jeghers syndrome was diagnosed on the basis of the findings of gastric polyps and circumoral pigmentation (l" Figure 1). DBE was performed after in− formed consent was obtained, using a Fu− jinon EN−450 P5/20 endoscope (Fujinon− Toshiba ES System Co. Ltd., Tokyo, Japan) under general anesthesia. A large polyp (3 cm) was found in the proximal jejunum, which had surface erosions (l" Figure 2 a). The polyp was removed using a diathermy loop. Histological examination confirmed the diagnosis of a Peutz−Jeghers polyp (l" Figure 2 b). There were erosions within the polyp (l" Figure 2 c), suggesting a pos− sible source of bleeding. A double−balloon colonoscopy performed subsequently was unremarkable, but ileoscopy was not pos− sible. A second DBE was performed 18 days lat− er because of hematochezia. No source of bleeding could be detected, but a perfora− tion was seen in the proximal jejunum while withdrawing the endoscope. At laparotomy, the perforation was found to be attached to an adhesion that was ex− tending from the distal ileum to the site of the former jejunal polyp. The perfora− ted segment was resected. On examina− tion of the entire intestine, there was no evidence of additional intestinal polyps. His postoperative course was unremark− able. The formation of an adhesion be− tween the site of the jejunal polyp and the terminal ileum suggests that a trans− mural intestinal injury had taken place during the resection of the jejunal polyp. The push and pull forces between parts of the small intestine were probably transmitted to the adhesion during the second DBE, leading to perforation. The potential benefits of DBE, combined with the facility for endoscopic resection of intestinal polyps [2] have to be balanced against the increased risk of perforation in infants.