S4779 Behind Bars, Out of Sight: Catastrophic NSAID-Induced Duodenal Perforation in an Incarcerated Patient

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for musculoskeletal pain due to their anti-inflammatory and analgesic effects. However, by inhibiting prostaglandin synthesis, NSAIDs compromise the gastrointestinal (GI) mucosal barrier, increasing the risk of mucosal injury, ulceration, bleeding, and perforation. Chronic NSAID use is a well-established risk factor for peptic ulcer disease (PUD), though complications have become increasingly rare due to the accessibility of gastroprotective agents such as proton pump inhibitors (PPIs) and H2 blockers. Case Description/Methods: A 28-year-old incarcerated man with no known medical history presented with sudden-onset hematemesis and left upper quadrant abdominal pain. He had been taking naproxen 500 mg twice daily for 6 months following a metatarsal fracture. On EMS arrival, he was hypotensive (BP 80/40 mmHg), tachycardic (HR 140), and briefly unresponsive. Labs revealed leukocytosis (20.0 × 10⁹/L), hemoglobin 10.1 g/dL, elevated BUN/Cr ratio (35.7), and lactate 2.7 mmol/L. His Glasgow-Blatchford Bleeding Score was 11. Computed tomography angiography showed a 5.4 × 4.6 cm hyperdense gastric body lesion and a suspected contained perforation at the gastroduodenal junction. He received IV fluids, pantoprazole, antibiotics, and 4 units of packed red blood cells in 24 hours of admission. After 60 hours in the intensive care unit, he was transferred to step-down but developed recurrent massive hematemesis. Emergent endoscopy revealed a large, circumferential, cratered duodenal bulb ulcer with active bleeding. Given the ulcer’s size and associated perforation, empiric gastroduodenal artery embolization was performed despite no contrast extravasation. Discussion: This case illustrates rare but life-threatening complications of nonsteroidal anti-inflammatory drug use - duodenal perforation and massive upper GI bleeding. Despite initial hemodynamic stabilization, delayed esophagogastroduodenoscopy (EGD)—due to concern for converting a contained perforation—may have contributed to recurrent hemorrhage. While caution with insufflation is warranted, early EGD evaluation should still be strongly considered in patients with high-risk features, to promptly identify and manage bleeding sources. This case also underscores broader systemic issues, including the risks of unmonitored nonsteroidal anti-inflammatory drug use and the healthcare disparities faced by incarcerated individuals. Limited access to medical oversight, gastroprotective strategies, and preventive education likely contributed to the severity of this patient’s presentation.