Subtle radiological signs of prepyloric gastric perforation in a preterm neonate

Neonatal gastric perforation is a rare, life-threatening surgical emergency. Early diagnosis is challenging because its clinical manifestations often overlap with those of necrotizing enterocolitis and spontaneous intestinal perforation. Radiological evaluation may provide the first evidence of perforation, but subtle imaging features that help localize its origin remain infrequently described. We report an extremely preterm infant who developed abdominal distension and respiratory deterioration during the first week of life. Abdominal radiographs demonstrated massive pneumoperitoneum. In addition to established signs of free intraperitoneal air, imaging showed medial displacement of the feeding tube and a focal linear extension of free air in the left upper abdomen adjacent to the stomach. The latter finding is presented as a preliminary radiographic observation. Emergency exploratory laparotomy confirmed an isolated prepyloric gastric perforation. Primary surgical repair was performed successfully, and the infant recovered gradually after surgery and had a satisfactory clinical outcome. This case highlights important radiographic nuances that were observed in association with gastric perforation. In addition to classic signs such as the Rigler sign, football sign, continuous diaphragm sign, and falciform ligament sign, subtle findings including progressive gastric distension, feeding tube displacement, and a focal left-sided linear gas extension were observed. The latter observation is provisionally referred to in this report as the ‘tail sign’ and requires validation. Careful interpretation of serial radiographs may provide valuable clues regarding the location of neonatal gastrointestinal perforation. The diagnostic and clinical relevance of these observations requires validation in larger cohorts.