Posterior gastric wall perforation and acute kidney injury after upper endoscopy with esophageal dilation: A case report

Table 1 Chronological timeline of the clinical course

Time point	Event and key findings
Day -7	Contrast-enhanced CT of the neck, thorax, and abdomen for oncological surveillance. Serum creatinine 1.1 mg/dL, eGFR 62 mL/minute/1.73 m2. No new pathology identified
Day -3	Upper gastrointestinal endoscopy for feeding difficulty. Tracheoesophageal voice prosthesis found migrated into the esophageal lumen; scope advanced with resistance posterior to the device. Bougie dilation of a proximal esophageal stricture; five gastric biopsies (prepyloric region, antrum, incisura angularis, greater curvature, and lesser curvature) obtained. Chronic active gastritis with H. pylori. No perforation or immediate complication documented
Day -3 to day 0	At home. No reliable symptom history obtainable because of nonverbal status
Day 0 (admission)	Emergency department arrival by ambulance with syncope. BP 84/50 mmHg, SpO2 88%, anuria. Creatinine 4.18 mg/dL (KDIGO stage 3 AKI), BUN 103 mg/dL, CRP 359 mg/L, K+ 6.56 mEq/L, pH 7.19. Contrast-enhanced abdominal CT: Posterior gastric wall perforation with contrast extravasation, free air, and four-quadrant free fluid
Day 0 (same day)	Emergency laparotomy: Four-quadrant bile-stained contamination; 2.5-cm full-thickness defect of the posterior wall of the gastric corpus. Gastric wedge resection, Witzel feeding jejunostomy, and four drains. Intraoperative endoscopy: Voice prosthesis in its expected esophageal position. Histopathology: Mucosal erosion, submucosal hemorrhage and edema with perforation; no ulcer or neoplasia; H. pylori not identified
Postoperative day 1	Admission to the ICU; mechanical ventilation via tracheostomy, vasopressor support, and broad-spectrum antimicrobial therapy
Postoperative day 2	CVVH started for refractory oliguria and azotemia; continued until death without renal recovery
ICU follow-up	CT: Left atrial thrombus (17 mm × 10 mm) and periportal fluid collection (63 mm × 34 mm). Transthoracic echocardiography: Separate left ventricular apical thrombus, with preserved systolic function. Therapeutic low-molecular-weight heparin started; no urgent cardiovascular surgical intervention indicated. Potassium normalized to 4.2 mEq/L
Postoperative day 10	Bile in the abdominal drains. Re-laparotomy: Detachment of the jejunostomy catheter with bile leakage; gastric staple line intact. Jejunal resection with side-to-side anastomosis, double-barrel ileostomy for drain-related ileal injury, surgical (Pezzer) gastrostomy, and three new drains. Histopathology: 1-cm perforation, active serositis, and ischemic necrosis at the surgical margins
Postoperative day 16 (April 30, 2025)	Death in the ICU from refractory multiorgan failure. As the index operation was performed on the day of admission, postoperative day 16 corresponded to hospital day 16

AKI: Acute kidney injury; BP: Blood pressure; CRP: C-reactive protein; CT: Computed tomography; H. pylori: Helicobacter pylori; ICU: Intensive care unit; KDIGO: Kidney Disease: Improving Global Outcomes; eGFR: Estimated glomerular filtration rate; BUN: Blood urea nitrogen; ICU: Intensive care unit; CVVH: Continuous veno-venous hemofiltration.