A case of neonatal gastric perforation misdiagnosed as neonatal necrotizing enterocolitis

Rationale: Neonatal gastric perforation (NGP) is a rare but life-threatening neonatal acute abdominal condition. Its clinical and imaging manifestations may overlap with those of necrotizing enterocolitis (NEC), making accurate preoperative localization of the perforation site challenging. This case highlights the diagnostic challenges and key points in the differential diagnosis of NGP when its initial presentation resembles NEC. Patient concerns: A male infant born at 33 weeks and 5 days of gestation, with a birth weight of 2500 g, was admitted on the fourth day of life because of abdominal distension for 14 hours, feeding refusal, and cessation of flatus and stool passage. Diagnoses: Abdominal ultrasonography revealed mild bowel wall thickening, absent intestinal peristalsis, and ascites, while an upright abdominal radiograph showed a large amount of free air beneath both hemidiaphragms. Based on the infant’s prematurity, abdominal distension, feeding refusal, and imaging findings, NEC complicated by gastrointestinal perforation was initially suspected. Emergency exploratory laparotomy revealed an approximately 1-cm perforation on the posterior gastric wall near the proximal greater curvature. No intestinal ischemia, necrosis, perforation, or gastrointestinal malformation was identified. The final diagnosis was NGP. Interventions: Immediately after admission, the infant received oxygen therapy, continuous monitoring, gastrointestinal decompression, anti-infective therapy, fluid replacement, and other supportive treatment. Emergency exploratory laparotomy, repair of the gastric perforation, peritoneal lavage, and drainage were subsequently performed. Postoperatively, respiratory support, gastrointestinal decompression, total parenteral nutrition, and other supportive treatments were provided. Outcomes: The infant recovered well after surgery, gradually resumed enteral feeding, and subsequently underwent successful removal of the gastric tube and abdominal drainage tube. At the 1-month follow-up, the infant was in good general condition and weighed 2.95 kg. Lessons: NGP should be considered in the differential diagnosis of neonates presenting with rapidly progressive abdominal distension and a large pneumoperitoneum, even when ultrasonographic findings suggest NEC. Pneumoperitoneum may indicate gastrointestinal perforation but cannot independently identify the site of perforation. In neonates whose clinical presentation is not entirely consistent with NEC or whose condition progresses rapidly, early surgical evaluation and, when necessary, timely exploratory surgery may help establish the diagnosis and facilitate targeted treatment.