An Uncommon Cause of Gastric Perforation.

Abstract

A 53-year-old man with diabetes mellitus and chronic hepatitis B was admitted to our hospital because of shortness of breath, chest tightness, and subsequent loss of consciousness and urinary incontinence. After endotracheal intubation and positive pressure ventilation, the vital signs were stable. The blood test results showed that the white cell count (27.61 × 109/L) was elevated and the glucose level was 20.88 mg/dL. Abdominal computed tomography (CT) with intravenous contrast confirmed the presence of gas in the peritoneal cavity and suspicious thickening of the stomach wall at the cardia, consistent with a gastrointestinal tract perforation (Figure A). Exploratory laparotomy was performed. Bubbles and edema were found in the omental bursa or lesser sac (Figure B). Near the gastric cardia, there was a visible peptic ulcer with associated perforation. The tissue around the ulcer was biopsied and the perforation repaired. The patient recovered well after surgery. However, significant swelling of the left neck was observed during physical examination. On further questioning, the patient reported that the swelling had been present for 2 months, had improved, and then recurred 2 weeks before presentation. Neck CT showed enlargement of the left submandibular gland with uneven enhancement and multiple enlarged bilateral cervical and submandibular lymph nodes (Figure C). Postoperative pathological findings suggested poorly differentiated adenocarcinoma, small cell carcinoma, and metastasis of lymph nodes (2/10). Ten days after the first surgery, the patient underwent radical gastrectomy (total gastrectomy with Roux-en-Y anastomosis). The patient's initial presentation may have been related to hypercarbic respiratory failure due to upper airway obstruction from his adenocarcinoma metastases. The patient's emergent intubation may have led to a rapid increase in pressure in the stomach, resulting in perforation of his gastric ulcer. (Informed consent was obtained from the patient to publish these images.)