Double Prepyloric Gastric Ulcer Perforations Managed with Emergency Gastrojejunostomy and Feeding Jejunostomy: A Rare Case Report

The perforation of prepyloric gastric ulcer is a surgical emergency that carries a high morbidity burden, but the rate of occurrence of double prepyloric perforation is extremely low, which thus presents both diagnostic and operative challenges. The presented case is of a 57-year-old male from India, who presented with a five-day history of abdominal pain, nausea, vomiting, and constipation. Cultural Extended Focused Assessment with Sonography for Trauma (E-FAST) and clinical examination indicated peritonitis with intra-abdominal fluid, thus warranting emergency exploratory laparotomy. During the intraoperative period, about 800 mL of purulent fluid was drained and 2 cm and 1.5 cm adjacent prepyloric perforations were detected along the lesser curvature. The patient had severe intraoperative malnutrition, which was manifested through cachexia, depleted omental fat, and hypoalbuminaemia and required a surgical approach based on his compromised physiological reserve. The perforations were primarily closed and then a gastrojejunostomy with feeding jejunostomy was done to provide sufficient gastric bypass and postoperative nutritional support. Histopathologic examination of the patient revealed gastric ulceration with mucosal denudation, fibrinous exudate, bacterial colonies, and inflammatory infiltration, which were consistent with perforation. The patient responded to antibiotics, analgesia, and enteral feeding, which was achieved through jejunostomy, with a gradual improvement in the clinical condition. Oral intake was then started and tolerated. After four weeks, the feeding jejunostomy was removed, and the patient also remained asymptomatic on follow-up. The case of double prepyloric ulcer perforations is quite rare, and it highlights the necessity of immediate surgical intervention and an individual approach to patients with poor nutritional status. Reporting of such cases is significant to provide insights into optimal operative decision-making in complex cases of upper gastrointestinal perforation.