Perforated gastric ulcer triggering acute cholecystitis: Case report of an uncommon and deceptive presentation

Perforated peptic ulcer disease (PUD) is a critical condition that can present with atypical symptoms, leading to misdiagnosis and treatment delays. While PUD classically presents with peritonitis, rare cases may induce localized inflammatory responses, mimicking other abdominal pathologies such as acute cholecystitis.

We report the case of a 29-year-old male with recurrent postprandial right upper quadrant (RUQ) and epigastric pain. Despite multiple emergency department (ED) visits, normal initial imaging led to misdiagnoses of gastroenteritis and gastroesophageal reflux disease (GERD) with cannabis-induced hyperemesis syndrome. On his third ED visit, he was diagnosed with a perforated gastric ulcer complicated by acute cholecystitis, requiring urgent surgical intervention.

This case highlights the diagnostic challenges associated with atypical presentations of perforated PUD. The absence of gallstones and initial negative imaging studies contributed to diagnostic delays. Advanced imaging, including computed tomography (CT), plays a crucial role in detecting subtle signs of perforation. Additionally, the inflammatory interaction between the gastric and hepatobiliary systems underscores the need for clinicians to consider ulcer-related complications when evaluating persistent epigastric and RUQ pain.

A high index of suspicion is essential when assessing patients with recurrent abdominal pain despite unremarkable initial evaluations. Early recognition and appropriate imaging can facilitate timely intervention, reducing morbidity associated with delayed diagnosis of perforated PUD and its complications.