The khat ulcer: a silent perforation from a daily habit — a case report from East Africa

Perforated peptic ulcer (PPU) is a critical surgical emergency associated with high morbidity and mortality. Traditional risk factors include Helicobacter pylori infection, nonsteroidal anti-inflammatory drug (NSAID) use, smoking, and severe physiological stress. Khat ( Catha edulis ) is a widely consumed plant stimulant in the Horn of Africa and the Arabian Peninsula that alters gastric physiology, delays gastric emptying, and reduces mucosal blood flow, yet its specific association with acute PPU remains underreported. A 40-year-old male driver with no prior medical history or baseline peptic ulcer symptoms presented with a 1-week history of progressive abdominal pain, persistent vomiting, and absolute constipation. Social history was notable for daily consumption of ~ 30 g of khat for five years, alongside irregular meal patterns. Examination revealed tachycardia and generalized peritonitis with guarding. Laboratory workup demonstrated prominent leukocytosis. Contrast-enhanced abdominal computed tomography (CT) confirmed pneumoperitoneum secondary to acute perforation of a chronic anterior duodenal ulcer. The patient underwent emergency exploratory laparotomy and successful surgical repair using an omental (Graham) patch. Postoperative recovery was uneventful; he was discharged on day 7 on an 8-week oral proton-pump inhibitor regimen, tested negative for H. pylori , and was referred for behavioral khat-cessation support. This case highlights an acute perforation of a chronic peptic ulcer in a heavy khat user lacking conventional risk factors. It underscores the importance of obtaining a detailed regional substance use history and utilizing targeted contrast-enhanced CT imaging when clinical or plain radiological findings require definitive surgical localization. Further epidemiological studies are needed to evaluate khat habituation as an independent risk factor for peptic ulcer complications.