Stomach perforation is considered to be a medical emergency and may be seen after peptic ulcer, use of non-steroidal anti-inflammatory drugs, complications from surgery or malignant diseases, and foreign body injury. Abdominal pain and an epigastric sensation are notable symptoms, while some individuals have a completely asymptomatic course. The diagnosis rests on findings obtained during history taking and imaging studies, with computed tomography being the gold standard.
Stomach perforation can be life-threatening if not recognized on time, and various causes have been described in the literature . Peptic ulcer disease (PUD) and perforation, long-term administration of non-steroidal anti-inflammatory drugs (NSAIDs), malignancies involving the gastrointestinal system (GI), medical procedures (eg. intubation, GI surgery), and ingestion of foreign bodies (toothpicks, metal coins, etc.), either incidental or intentional, are notable etiologies of stomach perforation       . In addition, incarcerated hiatal hernia is also reported as a condition that may lead to perforation . The clinical presentation is often nonspecific, with most common symptoms being abdominal distension and pain accompanied by an abnormal sensation in the epigastric area and reduced appetite . Signs of peritonitis might be seen as well . Perforation caused by foreign bodies tend to have a chronic course, and days or weeks often pass before the diagnosis is made  . On the other hand, severe forms have an abrupt onset, in which case a prompt diagnosis is imperative. Unfortunately, some patients may have an asymptomatic presentation, thus the diagnosis might be delayed for a significant period of time .
Because of the nonspecific presentation of gastric perforation, many studies have stressed the importance of a proper physical examination and a detailed patient history  . Patients should be asked about the duration of symptoms and the nature of their onset, whereas assessment of risk factors (underlying malignant disease or peptic ulcer, use of NSAIDs, recent upper gastrointestinal tract instrumentation or ingestion of foreign bodies) is also vital during clinical assessment. Once a presumptive diagnosis of an upper GI pathology is made, imaging studies are the next step of the diagnostic workup. Barium studies are not recommended in the setting of gastrointestinal perforation, but plain radiography of the chest and abdomen (lateral images are superior to posteroanterior) can be a useful initial method that is able to detect free air under the diaphragm in up to 75% of cases  . However, contrast-enhanced CT, considered as the gold standard , is employed in the presence of inconclusive findings on abdominal X-rays. Typical signs are defects in the stomach wall and the presence of gas in the supramesocolic compartment (the space over the transverse mesocolon in the peritoneum) . Abdominal ultrasonography has also been described as a useful tool in the evaluation of gastric perforation . Finally, a biopsy of the lesion at the site of perforation, especially if suspicion toward a malignancy exists, might be performed , primarily through endoscopic techniques.