Use of the small bowel enema examination (enteroclysis) is increasing, and numerous reports have attested to its value, but virtually no complications have been reported. The author describes a 72-year-old man undergoing enteroclysis for weakness, anemia, and guaiac-positive stools in whom the duodenum was perforated during intubation. Radiologists should be aware of this potential complication, and inexperienced people should be supervised carefully during the procedure.
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