Derek Lim, DO1, Shinban Liu, DO1, Nicholas Morin, DO1, Vadim Meytes, DO2. 1NYU Langone Medical Center – Brooklyn, 2Vassar Brothers Medical Center
Case Presentation: A 64-year-old female with a past medical history of chronic back pain with daily NSAID use had complaints of 5 days of abdominal pain, malaise, nausea, and vomiting. She was tachycardic in the emergency room with generalized peritonitis on physical exam. A CT scan of the abdomen demonstrated extraluminal air and oral contrast extravasation in the lesser sac, suggestive of a gastric perforation.
A diagnostic laparoscopy was performed and upon initial inspection, the lesser omental sac was noted to be full of succus and air. The greater curvature was dissected and a 3cm pre-pyloric perforated ulcer was identified on the posterior surface of the stomach. An omental patch was secured with seromuscular 2-0 silk sutures across the ulcer. An esophagogastroduodenoscopy visualized the repaired non-bleeding ulcer and a post-pyloric NGT was placed intraoperative. The remainder of her hospital course was uncomplicated and her diet was advanced after a negative gastrograffin study.
Discussion: Posterior gastric ulcer perforations are an uncommon surgical emergency. Less than 1% of peptic ulcer perforations occur in the posterior stomach. Symptoms vary depending on the location of the perforation. Posterior pre-pyloric perforation causes leakage of stomach contents within the lesser sac. Generalized peritonitis occurs with contamination through the Foramen of Winslow into the peritoneal cavity. Posterior post-pyloric perforation contaminates the retroperitoneal space and may present as back pain or retroperitoneal abscess formation. CT imaging is the modality of choice to identify the location and extent of the perforation. Gastric perforations may be repaired with an omental patch, wedge resection, or gastric reconstruction depending on the size of the perforation. In rare instances, perforations may be contained on imaging and can be managed nonoperatively through careful observation, gastric decompression, bowel rest, and empiric antibiotics. However, extreme vigilance with a low threshold for operation is warranted with conservative management.
Conclusion: posterior gastric ulcer perforations are rare and insidious, requiring prompt diagnosis and treatment. The clinical presentation may be atypical and a CT scan is the gold standard for diagnosis. Laparoscopic and open approaches are both acceptable methods of repair depending on operator skill and clinical status of the patient.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94115
Program Number: P036
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster