Perforated duodenal ulcer

Case contributed by A.Prof Frank Gaillard

Presentation

Acute severe right lower abdominal pain. Recent loss of weight. Dysphasia.

Patient Data

Age: 75 years
Gender: Male
Modality: X-ray

Large amounts of free intraperitoneal gas are seen, most easily appreciated under the right diaphragm. Small bowel pattern is unremarkable. Two calcified masses are seen projecting over the right sacroiliac joint on the right. No pneumobilia. 

Modality: CT

There is free gas noted within the peritoneal cavity.  There is  mild thickening of the gastric antrum, as well as the first part of the duodenum. There is also free fluid seen within the peritoneal cavity. The density of the fluid in the subhepatic region and the right para colic gutter is approximately 80 Hounsfield unit and the fluid in the pelvis is approximately 30 Hounsfield units.  There is suspicion for a small tract of contrast which could represent the site of viscus perforation in the region of the junction of the first and second part of the duodenum.  This could also account for the increase density of the fluid in the right para colic gutter when compared to the pelvis secondary to some leakage of the oral contrast. 

There is also the appearance of a duodenal diverticulum arising from the second part of the duodenum projecting medially. The rest of the small bowel is unremarkable.  The colon is relatively decompressed particularly the transverse and descending colon. There is no significant diverticular disease.  No definite collection seen within the pelvis.  

There is a calcified density in the right iliac fossa anterior to the psoas muscle which most likely represents calcified lymph node.  The bladder, kidneys, spleen and adrenals are unremarkable.  Small cyst seen in the lower pole of the right kidney.  There is prominence of the extra hepatic common bile duct with a diameter up to 7mm which is probably within normal limits for age.  The pancreas appears normal. 

 The lung bases appear relatively clear.  

Modality: Annotated image

Small track of contrast passes through the anterior wall of the D1/2 junction (blue arrow) with the fluid in the region and around the liver being hyperdense (red arrow) consistent with extravasation of oral contrast. 

Note also the presence of a medially projecting duodenal diverticulum (orange) adjacent to the second part of the duodenum (D2) (orange). The first part of the duodenum and pylorus are anterior (yellow). 

Case Discussion

The patient went on to have laparotomy which confirmed the presence of a perforated duodenal ulcer. 

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Case Information

rID: 18593
Case created: 14th Jul 2012
Last edited: 28th Sep 2016
Inclusion in quiz mode: Included

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