Gastric Perforation at the Extremes of Age: A Comparative Case Report of NSAID-Associated High-Grade Dysplasia versus Methamphetamine-Induced Ischemic Perforation

Background : Gastric perforation is a surgical emergency with evolving etiologies. While traditionally linked to NSAID use in elderly individuals, a rising incidence in young adults is associated with substance abuse. This report compares two distinct cases to highlight the demographic and pathophysiological dichotomy facing surgeons today. Case Report : We present two contrasting cases of gastric perforation. The first is an 85-year-old male with chronic NSAID use who presented with an acute perforation. Histopathology of the ulcer edge unexpectedly revealed high-grade dysplasia. The second patient was a 32-year-old male with a history of polysubstance abuse, including methamphetamine, who presented with a diagnostically challenging ischemic perforation that required a CT scan for diagnosis after an initial negative radiograph. Both patients were managed successfully with modified Graham patch omentoplasty. Discussion : These cases represent fundamentally different disease processes: one driven by chronic prostaglandin inhibition leading to a premalignant lesion, and the other driven by acute sympathomimetic-induced vasoconstriction causing ischemic necrosis. The comparison underscores two critical lessons: the need for a high index of suspicion and liberal use of cross-sectional imaging in young patients with substance abuse, and the nonnegotiable mandate for routine ulcer edge biopsy in all perforation cases to identify the underlying pathology such as dysplasia. Management must extend beyond surgical repair to include oncological surveillance or addiction rehabilitation, tailored to the underlying etiology.