Giant posterior gastric perforation in a 40 years old male: a case report

Abstract

Posterior perforation of a gastric ulcer is a rare condition. Majority of benign gastric ulcers lie along the lesser curvature of stomach. Only 5-8% of these ulcers lie along the posterior wall of the body of stomach. The clinical presentation of patients is variable, depending upon the location of perforation. Ulcers located in the fundus or body of stomach may erode into the lesser sac which is less effective in sealing off the perforation. Gastric contents therefore, accumulate in the lesser sac and pass into the peritoneal cavity, resulting in generalized peritonitis. Posterior pyloric ulcers, on the other hand, are associated with rupture into retroperitoneum which may lead to abscess formation, adhesions and fibrosis. This explains why posterior gastric perforations are associated with delayed presentation, missed diagnoses and consequently, higher morbidity and mortality as compared to anterior perforations. Helicobacter pylori, smoking and consumption of alcohol and other illicit drugs, use of NSAIDs and advanced age (>60 years) are important predisposing factors for the development of gastric ulcers. Chest radiography demonstrating pneumoperitoneum and computed tomography showing retroperitoneal air and/or fluid collection play an important role in the diagnosis of gastric perforation and determination of site of perforation. The standard of treatment for all patients with gastric perforation is emergency exploratory laparotomy. A biopsy of the ulcer margins is essential to establish the histological diagnosis. Repair of the perforation is done as a simple double layer closure with omental patch, which is often accompanied by a feeding jejunostomy.