Spontaneous gastric perforation in adolescence, can it be idiopathic? A report of two cases with review of management protocols

We present two unique cases of adolescents with a diagnosis of spontaneous gastric perforation (SGP), who presented with acute abdomen and features of perforation peritonitis. The first case is a 15-year-old boy, previously healthy, who presented with 2-day history of acute abdominal pain and signs of peritonitis. Upright chest and abdominal radiograph showed free subdiaphragmatic air, confirming perforation. Emergency laparotomy revealed a 1 cm × 1 cm perforation on the anterior wall of the stomach body with no ulcer or malignancy. The second case is a 14-year-old boy, with no prior medical illness, who presented with 3-day history of acute abdominal pain, high-grade fever, and signs of perforation peritonitis. Chest and abdominal radiograph (upright) revealed free gas under the diaphragm. The patient underwent an emergency laparotomy, which showed 0.5 cm × 0.5 cm perforation at the pylorus. Both patients underwent a Graham’s omental patch repair. Histopathology of the perforation margins in both patients showed only granulation tissue with inflammatory exudate (no evidence of malignancy or specific pathology). Both patients had a good postoperative recovery in the intensive care unit and subsequently discharged. Both cases highlight that SGP, though exceedingly rare in adolescents, can occur without warning in the absence of traditional risk factors. Prompt recognition of an acute surgical abdomen and immediate surgical intervention was lifesaving in our patients. Clinicians should include SGP in the differential diagnosis of acute abdomen with pneumoperitoneum, even in young patients with no risk factors, as early surgical management is critical for a favorable outcome.