Presentation
Severe abdominal pain and fever.
Patient Data
Only oral contrast was used in this study, not intravenous contrast. Several locules of free intraperitoneal air within the upper abdomen, with a large amount of free air along the anterior aspect of the liver surface. Perihepatic/subhepatic dense material consistent with free intraperitoneal spillage oral contrast, indicating the site of perforation is nearby. Small amount of pelvic ascites which does not appear as dense as the oral contrast. The site of perforation can be seen in the gastric antrum, evidenced by a visible channel which extends into the subhepatic space abutting the lower left hepatic lobe, consistent with a perforated gastric ulcer.
Arrows indicate the site of perforation in the gastric antrum in coronal, sagittal, and axial planes.
Case Discussion
This case is an excellent demonstration of the use of oral contrast, even when intravenous contrast cannot be used. The utilization of oral contrast made identification of the site of perforation relatively straightforward: Intraperitoneal spillage of oral contrast about the left hepatic lobe indicated at the site of perforation is likely in the stomach or duodenum. A visible channel can be best seen on coronal reformatted images extending through the gastric wall into the subhepatic space. 1 mm thin cut images are also included which assist visualization of the channel. With this degree of confidence, the study can be simply reported as a perforated gastric antral ulcer, with free intraperitoneal fluid and air.
This specific information was highly valuable to the surgeon who repaired the ulcer: He was able to perform a more limited/directed intra-abdominal incision rather than perform an exploratory abdominal surgery, decreasing the risk of wound healing complications, as this patient waited until symptoms became quite progressed before presenting.
In the absence of use of oral contrast, a perforated gastric or duodenal ulcer could still be favored given that the free intraperitoneal air was primarily concentrated within the upper abdomen, despite the fact that most of the fluid is within the pelvis.
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