Gastric perforation at the extremes of age: a comparative case report of NSAID-associated high-grade dysplasia versus methamphetamine-induced ischemic perforation.

backgroundGastric perforation is a surgical emergency with evolving etiologies. While traditionally linked to the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in elderly individuals, a rising incidence in young adults is increasingly associated with polysubstance use. This report compares two distinct cases to highlight the demographic and pathophysiological dichotomy facing surgeons today. CASE REPORT: We present two contrasting cases of gastric perforation. The first is an 85-year-old male with chronic NSAID use who presented with an acute perforation, with histopathology of the ulcer edge unexpectedly revealing high-grade dysplasia. The second case involves a 32-year-old male with a history of polysubstance use, including methamphetamine, who presented with a diagnostically challenging ischemic perforation that required computed tomography for diagnosis following an initially negative upright abdominal radiograph. Both patients were successfully managed with modified Graham patch omentoplasty. DISCUSSION: These cases represent fundamentally different disease processes: one driven by chronic prostaglandin inhibition leading to a premalignant lesion, and the other by acute sympathomimetic-induced vasoconstriction resulting in ischemic necrosis. This comparison underscores two critical lessons: the importance of maintaining a high index of suspicion and the liberal use of cross-sectional imaging in young patients with polysubstance use, and the non-negotiable mandate for routine ulcer edge biopsy in all perforation cases to identify underlying pathology such as dysplasia. Management must extend beyond surgical repair to include oncological surveillance or addiction rehabilitation, tailored to the underlying etiology.