Causes of Gastric Perforation
The most common cause of gastric perforation is peptic ulcer disease, with Helicobacter pylori infection being the primary etiologic factor, followed by NSAID use, steroids, smoking, and high-salt diet. 1
Primary Etiologic Factors
Peptic Ulcer Disease (Most Common)
- H. pylori infection is the main causative agent in gastroduodenal ulcer perforation, representing the predominant mechanism worldwide 1
- NSAIDs and corticosteroids are the second most important pharmacologic causes, both affecting acid secretion in the gastric mucosa 1
- Smoking and high-salt-content diet contribute as modifiable risk factors that alter gastric mucosal integrity 1
- Stress ulcers occur particularly in critically ill patients in ICU settings or post-surgery, where diagnosis may be obscured in sedated or unconscious patients 1
Iatrogenic Causes
- Endoscopic procedures including endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and stricture dilation carry perforation risk 1
- ERCP-related perforations occur through multiple mechanisms: duodenoscope trauma, sphincterotomy complications, and guidewire manipulation, with overall risk <1% but mortality of 7.8-9.9% 1
- Risk factors for ERCP perforation include older age, longer procedure duration, sphincter of Oddi dysfunction, non-dilated bile duct, and altered anatomy (e.g., Billroth II) 1
Traumatic Causes
- Foreign body ingestion (sharp objects like fish bones) can cause insidious perforation with delayed presentation 2
- Blunt or penetrating trauma may cause immediate or delayed perforation through lacerations, transections, mural hematomas, or full-thickness contusions 1
Vascular Causes
- Chronic gastric ischemia secondary to atherosclerosis can lead to perforation, particularly in patients with diabetes, peripheral vascular disease, and hypertension 3
- This represents an underdiagnosed but potentially fatal condition requiring urgent recognition 3
Geographic Variations
- In low- and middle-income countries, typhoid fever (Salmonella enterica) is the most common cause of gastrointestinal perforation, with mortality ranging from 4.6% to 39%, particularly in children 1
- Abdominal tuberculosis affecting the ileocecal region can cause perforation, though this is less common in gastric locations 1
Important Clinical Pitfalls
Delayed diagnosis beyond 6 hours after perforation is associated with increased mortality and hospital length of stay 1. The classic sub-diaphragmatic air on chest x-ray may be absent, and CT scan is more sensitive in stable patients 4, 5. In critically ill ICU patients, lack of typical signs and symptoms in sedated or unconscious patients can obscure the diagnosis 1.
Mortality Considerations
Gastroduodenal ulcer perforations carry mortality rates up to 30% despite advances in medical therapy 1, 6. Perforation accounts for approximately 40% of all ulcer-related deaths, making it the most common indication for emergency operation despite being less frequent than bleeding (perforation:bleeding ratio approximately 1:6) 1.