Perforated Viscus

Case contributed by Toronto RadCases
Unlisted case: This is an unlisted case only visible to the author and the editorial team. Unlisted cases can still be shared with individuals or with members of your verified institution.


Severe generalized abdominal pain


Free gas (most important finding). There is a tract of gas from the distal stomach which is visualized posteriorly. This was the source for pneumoperitoneum.

Case Discussion

  • Findings: Free gas (most important finding). In the absence of known benign cause, diagnosis is perforated viscus. Tract of gas from distal stomach is visualized posteriorly, which was the source.

  • Objectives:

    • To identify pneumoperitoneum and have a basic differential diagnosis

    • To practice identifying the source of pneumoperitoneum

  • Protocolling:

    • Contrast enhanced CT

  • Key points:

    • Anatomy:

      • Review small and large bowel anatomy

    • Differential diagnosis:

      • Perforated viscus (PUD, ischemic bowel, appendicitis, diverticulitis, etc)

      • Post-operative

      • Peritoneal dialysis

    • If perforated viscus is suspected, patient will go to OR.

    • Identifying the source of free gas:

      • Amount and location of gas collections (assess for intra and retroperitoneal gas)

      • Look for:

        • Localized air bubbles

        • Focal bowel wall thickening

        • Bowel wall discontinuity

        • Focal pathology (i.e. appendicitis, diverticulitis, PUD)

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