What is a pyloric gastric perforation?

Pyloric Gastric Perforation: Definition and Clinical Entity

A pyloric gastric perforation is a full-thickness breach in the gastric wall occurring at or near the pylorus (the gastric outlet connecting the stomach to the duodenum), most commonly caused by peptic ulcer disease, resulting in leakage of gastric contents into the peritoneal cavity and subsequent peritonitis. 1

Anatomical Location and Significance

• Pyloric perforations occur specifically at the gastric outlet region where the stomach transitions to the duodenum 1
• These perforations represent a distinct subset of gastroduodenal perforations with unique surgical challenges due to their proximity to critical structures including the common bile duct and ampulla of Vater 1
• Large pyloric ulcers (≥2 cm) near the pylorus often require distal gastrectomy rather than simple repair, unlike perforations in other gastric locations 1

Etiology and Pathophysiology

• Helicobacter pylori infection is the primary etiologic factor in peptic disease leading to pyloric perforation 1
• Additional causative factors include NSAID use, corticosteroids, smoking, high-salt diet, and physiological stress in critically ill patients 1
• The perforation creates a full-thickness gastrointestinal wall injury with release of intraluminal gastric contents (acid, enzymes, bacteria, food particles) into the peritoneal cavity 2

Clinical Presentation

• Severe, sudden-onset epigastric pain that may become generalized is the hallmark presentation 1
• Abdominal distension, tenderness, and rigidity with masked liver dullness and absent bowel sounds develop as peritonitis progresses 1
• Fever and signs of systemic sepsis may be present 1
• Important caveat: Localized or generalized peritonitis may be present in only two-thirds of patients, making physical examination findings potentially equivocal, particularly with contained or sealed perforations 1

Diagnostic Findings

• Laboratory tests show leukocytosis, metabolic acidosis, and elevated serum amylase, though these are non-specific 1, 3
• CT scan with IV contrast is the diagnostic imaging modality of choice, demonstrating extraluminal gas, intra-abdominal fluid, air pockets around the stomach and duodenum, and thick reactive intestinal wall 1
• Chest/abdominal X-ray can be used initially if CT is unavailable, looking for pneumoperitoneum 1

Critical Distinction from Other Gastric Perforations

• Pyloric location perforations require different surgical considerations than gastric body or fundal perforations 1
• Distal gastrectomy is specifically reserved for large perforations near the pylorus, whereas simple omental patch repair suffices for most other gastric locations 1
• The proximity to the ampulla of Vater and common bile duct necessitates careful intraoperative assessment and may require cholangiography 1
• 10-16% of gastric perforations are caused by underlying gastric carcinoma, making biopsy mandatory during repair 1, 4

Management Implications

• Immediate surgical exploration is required for unstable patients with peritonitis 1, 4
• Small pyloric perforations (<2 cm) can be managed with laparoscopic or open simple suture with omental patch 1, 4
• Large pyloric perforations (≥2 cm) typically require distal gastrectomy due to location and concern for malignancy 1
• Antibiotic therapy duration depends on patient classification: 4 days for immunocompetent non-critically ill patients with adequate source control, up to 7 days for immunocompromised or critically ill patients 1