Perforated pyloric channel ulcer with free spillage of oral contrast
Presentation
Abdominal pain.
Patient Data
Perforation of the superior aspect of the pylorus with free leakage of oral contrast into the upper abdomen. Small amount of free air. Medium ascites and peritonitis.
Annotated images with red arrow indicating the location of the leak, best seen on a combination of coronal and sagittal images.
Case Discussion
Teaching points:
1. Oral contrast can be very helpful for evaluating peptic ulcer disease, and in this case obviates the need for IV contrast as it clearly shows the site of perforation. Notice the fluid contrast level in the right upper quadrant.
2. The pattern of free air here is also very helpful. In advanced presentations like this one, it can sometimes be challenging to identify the site of perforation because this patient has fluid throughout the abdomen and pelvis and small bowel peritonitis due to the inflammatory nature of the gastric contents. This might lead you to think that the perforation is from the small bowel. There are even a few fine locules of air in the pelvis, which could make you consider a sigmoid colon perforation. However, the majority of the air is in the upper abdomen and surrounding the liver, and there are several fine locules near the porta hepatis. This supports a site of perforation in the upper abdomen, as no clear pathway for that much air heading cranially is delineated in the pelvis.
3. If you have a challenging scan like this one and you are not sure, you can always recall the patient and have them drink oral contrast, repeat the scan without an addition IV dose, and see if the fluid around the liver changes density indicating and upper GI source of leakage. Smaller leaks may not be as obvious was this one, but you can often detect a substantial change in HU levels of the free fluid.
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