Pressure-induced posterior gastric perforation in a patient with severe gastroparesis and prior Nissen fundoplication.

Gastric perforation is a life-threatening emergency most associated with peptic ulcer disease. In patients with altered foregut anatomy and impaired motility, alternative mechanisms may occur. We describe a non-verbal 27-year-old man with a history of esophageal atresia repair, severe gastroparesis, prior Nissen fundoplication, and gastrostomy tube dependence who presented with progressive abdominal distention and acute hypoxic respiratory failure. On presentation, he was tachycardic and tachypneic with significant metabolic derangements. Imaging demonstrated pneumoperitoneum and gastric perforation. Emergent exploratory laparotomy revealed a large posterior gastric defect measuring ~8-10 cm with significant contamination, requiring partial gastrectomy and staged damage-control management. A venting gastrostomy and feeding jejunostomy were placed at re-exploration, and the patient recovered following surgical and critical care management. This case demonstrates that impaired gastric decompression can lead to progressive overdistention and perforation, resulting in emergent surgical intervention.