Prepyloric Gastric Ulceration Associated With Intermittent Nonsteroidal Anti-inflammatory Drug (NSAID) Use and Unintentional Exposure Through Herbal Supplements: A Case Report

Abstract

Perforated peptic ulcer (PPU) remains a common cause of an acute abdomen and a surgical emergency associated with significant morbidity and mortality when diagnosis and treatment are delayed. The primary established risk factor is the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs), alongside advanced age and a history of peptic ulcer disease. While the consumption of herbal supplements has increased worldwide and may cause mild gastric mucosal irritation, their role is minimal compared to the direct causal impact of NSAID exposure in severe gastrointestinal complications. This report presents a case of a perforated prepyloric gastric ulcer linked to the chronic, unintentional consumption of undeclared NSAIDs in herbal supplements, such as Ortiga mas Ajo Rey (OAR). This case underscores the clinical necessity of obtaining an exhaustive medication history - including over-the-counter and alternative preparations - when evaluating patients with an acute abdomen, as patients may inadvertently ingest NSAIDs through unregulated herbal products. A 60-year-old female patient with a history of well-controlled systemic hypertension presented with sudden-onset severe epigastric pain radiating to the right flank. The patient reported chronic NSAID use for several years, along with intermittent self-medication with a herbal supplement containing garlic and nettle. Chest radiography revealed free subdiaphragmatic air, highly suggestive of hollow viscus perforation. The patient underwent emergency exploratory laparotomy, which revealed a 2 cm perforated prepyloric ulcer (Johnson type III) with generalized peritonitis. Surgical management consisted of ulcer closure with continuous suturing and Graham patch placement, with an uneventful postoperative course and no immediate complications. This case emphasizes that chronic NSAID exposure, including inadvertent exposure through adulterated over-the-counter herbal supplements containing undeclared pharmacologically active ingredients, represents the most plausible etiologic factor for peptic ulcer perforation in this patient. In contrast, the herbal components themselves cannot be considered causal based on the available evidence. A comprehensive medication history that specifically includes prescription drugs, over-the-counter NSAIDs, herbal supplements, and other nonprescription products is essential for identifying otherwise overlooked ulcerogenic risk factors. Early recognition of these exposures, together with prompt diagnosis and timely surgical intervention, remains critical to reducing morbidity and mortality in patients with PPU.