*Purpose: We describe a unique method of treatment of duodenal perforation due to biliary stent using an over the scope clip-OTSC.

*Methods: A 68 year old female with a history of hepatitis B induced cirrhosis, and hepatic cancer was treated with a liver transplant. Postoperative course indicated high liver function labs, and endoscope retrograde echolangiopancreatography-ERCP showed an anastomotic biliary stricture, and donor-recipient duct mismatch. Sphincterotomy and placement of a stent treated the stricture.

At night, the patient developed gastrointestinal-GI symptoms and was found to have post-ERCP pancreatitis confirmed by amylase=520IU/L. She was given IV fluid until the pancreatitis resolved.

A few days later, the patient visited the hospital again with worsening GI pain, anorexia, and fever. Physical exam showed pain radiating from the epigastrium to the right upper quadrant, back, and right flank area.

Computerized Topography(CT) scans demonstrated a large abscess collection extending into the right paracolic gutter, and right perirenal fat with the biliary stent(BS) extending through the second portion of the duodenum into this collection, suggesting perforation of the duodenum due to the BS inserted. After draining the abscess percutaneously, the patient underwent esophagogastroendoscopy which showed the migration of the BS that resulted in the perforation of the duodenal wall by the distal end of the stent. The BS was removed, and the duodenal defect was closed with an OTSC. ERCP was then performed with placement of a double pigtail BS for treatment of patient’s initial biliary anastomotic stricture.

*Results: After the OTSC, the patient’s symptoms improved and returned on a regular diet. However, she later developed multiple cardiac abnormalities including sinus tachycardia on both Lead II, V1. ECG has also shown dilated left ventricle, ventricle failure, elevated Troponin I, and elevated pulmonary artery pressure. Abdomen CT showed contrast within the duodenal cavity concerning for persistent leak. The duodenal perforation was small, however the presence of endoscopic over the scope mucosal clip was identified and was believed to be maintaining a minor patency of the track from duodenal to retroperitoneal abscess that had been drained for some months by the biliary pigtail.

*Conclusions: Omental patch is the common treatment for post-ERCP pancreatitis and an abdominal lavage, which is a surgical procedure for treating perforated ulcers. In our case, the duodenal perforation was closed using an OTSC (non-surgical). In a retrospective study, it was found that using the OTSC offered a safer treatment option for patients with non-variceal upper GI bleeding with cardiovascular co-morbidity. Another systematic review shows the OTSC effectiveness of treatment for defects in the abdomen created by endoscopic resections and stent fixation. We add to the research the case of our patient, who did this procedure but developed cardiac symptoms.

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