Gastric Perforation after Cesarean Delivery: An Unintended Consequence of the Opioid Epidemic

Abstract

Learning objectives: (1) Review gastric perforation as a rare complication of non-steroidal anti-inflammatory drug (NSAID) use after caesarean delivery. (2) Understand risks of NSAID overuse in response to opioid epidemic. Case presentation: A healthy 30-year-old G1 underwent a primary caesarean delivery. She presented to the Emergency Department on postoperative day 6 complaining of nausea, vomiting, and acute onset severe abdominal pain. She was taking ibuprofen 400 mg every 4 h for pain. She feared opioid use due to concern for addiction. CT of the abdomen and pelvis revealed pneumoperitoneum consistent with postoperative change. The working diagnosis was postoperative ileus, and she was treated conservatively. On hospital day 7, she developed peritoneal signs. Exploratory laparotomy showed a large gastric perforation through the anterior and posterior walls of the stomach. She underwent a distal partial gastrectomy, gastrojejunostomy (Billroth II procedure), and omental pedicle 'J' flap. She was discharged on hospital day 12. Discussion: In response to the current opioid epidemic, there has been a growing antipathy toward opioid use irrespective of need or indication. Non-opioid based pain management frequently relies on NSAIDs. While widely available and generally considered safe, NSAIDs have been associated with gastrointestinal complications including perforation. Opioids remain an important and safe component of postoperative pain management for most women. More than 95% of post-operative women use opioids without developing substance use disorder. This case should serve as a cautionary tale to those promoting an abrupt change in the management of post-operative pain.