Abstract Introduction Postoperative gastric perforation is rare but can rapidly progress to severe respiratory failure and circulatory collapse. Early recognition requires a high index of suspicion, particularly when patients re-present shortly after abdominal surgery with sudden deterioration. We describe a case of delayed gastric perforation manifesting initially as profound mixed acidosis, hypoxemia, and shock, highlighting critical care considerations in the evaluation of postoperative decompensation. Case Description An 82-year-old man with hypertension and diabetes underwent open recurrent incisional hernia repair with mesh removal and two separate resections of small-bowel due to damage from dense adhesions to the mesh. Definitive abdominal wall reconstruction was deferred due to intraoperative contamination. He recovered initially, tolerated diet, and discharged home on post-operative day 2.Two days later, he returned with abrupt severe abdominal pain, vomiting, and progressive distension. On arrival, he was hypotensive (79/42 mmHg), hypothermic (94.5 °F), tachypneic and hypoxemic (SpO2 91% on room air). He rapidly decompensated in the ED despite initial resuscitation and was emergently intubated. Laboratory evaluation showed lipase 2229 U/L, CRP 14.3 mg/dL, lactate 10.5 mmol/L, and a hemoglobin drop from 15.8 to 10.9 g/dL within one hour. Arterial blood gas demonstrated profound mixed metabolic and respiratory acidosis (pH 6.94, PaCO2 63 mmHg, PO2 71 mmHg and HCO3⁻ 13.6 mmol/L). CT abdomen/pelvis revealed markedly dilated small bowel loops with air-fluid levels and decompressed distal small bowel and colon suggesting small bowel obstruction, extensive pneumoperitoneum, and moderate free fluid, raising concern for visceral perforation.He was taken urgently to the operating room. Exploratory laparotomy revealed 5 liters of intra-abdominal succus, necrosis of the proximal greater curvature of the stomach, and frank gastric perforation, necessitating partial gastrectomy and temporary AbThera closure. Postoperatively, he was in refractory vasoplegic shock, requiring escalating doses of multiple vasopressors. Patient continued to deteriorate despite escalating measures, finally the family decided to withdraw care. Discussion Delayed gastric perforation following abdominal surgery is an uncommon but devastating complication. This case illustrates the importance of recognizing abdominal catastrophes presenting primarily with respiratory failure and severe metabolic acidosis. Massive abdominal distension reduces diaphragmatic excursion and functional residual capacity, precipitating rapid hypoventilation, while profound lactic acidosis overwhelms compensatory respiratory drive. The severe mixed acidosis and early ventilatory decline warranted immediate mechanical ventilation. Peritoneal contamination led to distributive shock and vasopressor-refractory vasoplegia, consistent with fulminant intra-abdominal sepsis. Early CT imaging, surgical consultation, and aggressive resuscitation remain critical, though mortality is high once multiorgan failure develops. This abstract is funded by: None
Amer et al. (Fri,) studied this question.