Gastric Necrosis and Perforation Secondary to Severe Diabetic Gastroparesis in a Young Woman With Type 1 Diabetes Mellitus: A Case Report

Diabetic gastroparesis is a common chronic complication of diabetes mellitus, usually manifesting as nausea, vomiting, early satiety, and impaired glycemic control. Its progression to acute gastric dilatation with ischemic necrosis and perforation is exceptionally rare but carries a very high mortality. We report the case of a 19-year-old woman with poorly controlled type 1 diabetes mellitus and recurrent diabetic ketoacidosis (DKA) who developed gastric necrosis and perforation presumptively attributable to severe diabetic gastroparesis. Over approximately four months, she experienced progressive epigastric pain, recurrent vomiting, and weight loss. Serial computed tomography (CT) documented the evolution: an initially unremarkable stomach, followed by marked gastric and duodenal distension with an antral air-fluid level, and finally pneumoperitoneum with abundant free intraperitoneal fluid, with perforation confirmed at laparotomy. She presented critically ill with severe DKA (pH 6.87, glucose 1002 mg/dL) and septic shock. Emergency exploratory laparotomy disclosed approximately 3.5 L of gastrobiliopancreatic fluid and food debris, with ischemic necrosis of the gastric fundus and multiple perforations (the largest measuring 1.5 cm). A partial (fundic) gastrectomy with two-layer gastrorrhaphy was performed. The postoperative course was marked by septic shock and severe malnutrition (albumin 1.8 g/dL). This case illustrates that severe diabetic gastroparesis can, although rarely, culminate in gastric ischemia and perforation, a surgical emergency, and highlights the value of serial imaging, aggressive glycemic and nutritional management, and timely surgical source control. With aggressive resuscitation, source control, broad-spectrum antimicrobial therapy, and structured nutritional support, the patient improved; she was extubated, weaned from vasopressors, and progressed to enteral nutrition, with a favorable prognosis at the most recent assessment.