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Chronic disseminated intravascular coagulation (DIC) is a rare complication of an aortic aneurysm (AA), and it may go unnoticed because patients are often asymptomatic. The condition is sometimes first recognized when trauma or an invasive procedure triggers a sudden and severe difficulty in achieving hemostasis. Here, we report a case of chronic DIC that was diagnosed following intractable delayed bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer. The patient underwent two ESD procedures, one in 2021 and another in 2023, and experienced delayed bleeding after both. In 2021, hemostasis was easily achieved, and complication of his hemodialysis was suspected as the cause of subsequent delayed bleeding. However, when hemostasis proved difficult in 2023, chronic DIC caused by an AA was identified as the primary cause of the intractable bleeding. Although the patient had a mildly reduced platelet count before the initial ESD, the presence of chronic DIC went unnoticed. The successful hemostasis during the first procedure obscured the underlying cause of the bleeding and thrombocytopenia. Gastroenterologists should be aware of enhanced-fibrinolytic-type DIC associated with an AA and remain vigilant regarding its high bleeding risk when performing invasive treatments, including endoscopic procedures.

Histological biopsy is essential for diagnosing ampullary tumors; however, it can occasionally result in severe adverse events. A 49-year-old male underwent esophagogastroduodenoscopic screening, which revealed an ampulla of Vater with enlargement of the oral protrusion. An endoscopic biopsy was performed; several hours later, the patient developed severe acute pancreatitis requiring hospitalization. The biopsy result was benign, and no gallstones, ductal abnormalities, or other etiologies were identified on endoscopic ultrasonography or magnetic resonance cholangiopancreatography, and the biopsy was considered the most likely trigger. The patient recovered with conservative management and was discharged on day 14. No recurrence has been observed 3 months after discharge. Although acute pancreatitis following biopsy of the ampulla of Vater is extremely rare, it can be fatal. Endoscopists should be aware of this potential risk, carefully assess the necessity of biopsy, and ensure that patients provide informed consent before the procedure.

A 60-year-old female with abdominal pain and nausea was diagnosed with gallbladder cancer (cT3aN2M1, cStage IVB). Distant metastases had disappeared after 10 courses of chemotherapy, followed by conversion surgery consisting of subtotal stomach-preserving pancreaticoduodenectomy, partial hepatectomy, and dissection of para-aortic and regional lymph nodes. On postoperative day (POD) 3, additional drainage was performed from the median incision because of bile leakage (BL) from the choledochojejunostomy. The drain tube was removed on POD 89, and the patient was discharged. On the 13th day after discharge, BL was found from the median incision. Double-balloon endoscopy-guided endoscopic retrograde cholangiopancreatography was performed to investigate the cause of BL and decompress the bile duct. Although cholangiography revealed no obvious injury of the bile duct, endoscopic examination discovered a fistulous opening near the choledochojejunostomy, which was revealed to be the responsible lesion of the enterocutaneous fistula by contrast imaging. Closure of the enterocutaneous fistula was performed with a combination of embolization by gelatin sponge and endoscopic clip suturing. Rapid fistula closure was achieved after the procedure, and the patient was discharged without complications. This treatment method is considered a minimally invasive and effective therapeutic option for BL associated with postoperative enterocutaneous fistulas.

Endoscopic submucosal dissection (ESD) is an established treatment of superficial esophageal neoplasms. Common complications include bleeding, perforation, and stricture. However, delayed gastrointestinal perforation distant from the ESD site is exceptionally rare. We report the case of a woman in her 70s with a history of nonsteroidal anti-inflammatory drug (NSAID)-associated duodenal ulcer and Helicobacter pylori infection who underwent ESD for superficial esophageal squamous cell carcinoma. After eradication therapy and 2 months of proton pump inhibitor (PPI) use, both treatments were discontinued. Preoperative endoscopy confirmed a scarred duodenal ulcer. Intraoperative esophageal perforation occurred during ESD and was closed with clips. Postoperative computed tomography (CT) showed mediastinal emphysema without intra-abdominal free air. The patient was treated in high care with fasting and antibiotics, but without PPI therapy. Six days postoperatively, the patient developed acute abdominal pain. CT revealed free air near the duodenal bulb, and emergency endoscopy identified a 10-mm perforated duodenal ulcer at the scarred site. Endoscopic closure was unfeasible, and laparoscopic omental patch repair was performed. PPI therapy was resumed postoperatively, and the patient recovered uneventfully. This case suggests that stress-related mucosal disease may have contributed to duodenal perforation. Background risks included ulcer history and scarring, whereas alleviating factors included no NSAID/steroid exposure, eradicated H. pylori, and absence of infection at the esophageal perforation. Guidelines do not endorse routine PPI use after ESD, and consensus following iatrogenic perforation is lacking. This case suggests that prophylactic PPI therapy may be considered in patients with risk factors such as recent peptic ulcer disease or intraoperative perforation.

Endoscopic removal of accidentally ingested dental prostheses can be challenging as their irregular shapes can occasionally cause severe complications, such as gastrointestinal perforation. Here, we present the case of an older woman who was referred to our hospital following accidental ingestion of a bridge-type denture. Computed tomography revealed that the denture was lodged in the thoracic esophagus, with concurrent mediastinal emphysema. Endoscopic examination confirmed that the denture had penetrated the esophageal wall. Under general anesthesia, the denture was endoscopically removed using dual endoscopes, and a large esophageal perforation was closed with an over-the-scope clip (OTSC) and subsequently reinforced with Mantis clips. Although follow-up endoscopy 1 month later demonstrated remaining OTSC at the site of the esophageal perforation, 3-month follow-up endoscopy confirmed complete closure of the perforation. Overall, this case indicates the usefulness of the dual-endoscope approach for foreign-object removal and the OTSC system for closure of esophageal perforations, thus providing the chance of avoiding invasive treatment such as esophagectomy.