A 89-year-old female was admitted to our hospital recommended endoscopic gastrostomy. Her activity of dairy living was limitted by hemiplegia. It was difficult for her to intake food perorally. Endoscopic gastrostomy was done. But feeding trouble was occured frequently by the elevation of intraabdominal pressure. Then, endoscopic jejunostomy was intended. When jejunal tube guided endoscopically inserted in duodenal bulb, perforation was happened. Peritonitis and secondary pancreatitis were occured. But her accident was recovered by conservative treatment. This case report suggest that when endoscopic procedure was necessary for after-gastrostomized state, careful management was important.
