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Background Peptic ulcer perforation is one of the most common surgical problems in daily practice. Although it can be easily diagnosed clinically, the clinical presentation can be less obvious in some cases leading to diagnostic pitfalls and mortality. This case report aims to highlight an atypical presentation of malignant gastric ulcer perforation in a patient with chronic abdominal pain. Case presentation A 78-year-old lady presented with chronic abdominal pain for 3 months. Investigations and imaging revealed T2N1M0 malignant gastric ulcer which was confirmed by endoscopy. Due to her low body mass index and underlying comorbidities, she was admitted for pre-operative optimization. However, she was a good 78 with the clinical frailty scale 4 and the National Early Warning Score 0 throughout the stay. On the night before the operation, she suddenly developed delirium. Further history revealed marked oliguria for 12 hours. There was mild abdominal distension without peritonism. She was catheterized and treated with fluids and antibiotics. X-ray suggested massive pneumoperitonium. Subsequently, she developed full-blown septic shock with rapid clinical deterioration within 3 hours. With the estimated Boey scoring of 3 and rapid clinical deterioration, the symptom control approach was decided. A palliative bedside ascitic tap was performed to relieve the discomfort. Four hours after the onset, unfortunately, the patient passed away. Conclusions Although gastric ulcer perforation usually presents with obvious symptoms, extra precaution should be exercised in elderly patients with chronic abdominal pain and comorbidities. We could learn that routine monitoring of urine output might aid in the early diagnosis of sepsis.

794 Diagnostic Pitfall in Atypical Presentation of Malignant Gastric Ulcer Perforation