Presentation
Patient presented to ER with acute upper abdominal pain.
Patient Data
Erect abdomen radiograph shows free air under the diaphragm with prominent small bowel loops.
Multiple axial contiguous cuts were taken through the abdomen and pelvis without intravenous contrast injection, with per-oral positive contrast in a supine position. The coronal and sagittal images were reformatted from an axial prone sequence.
There is a small wall defect seen at the anterosuperior aspect of the pyloroduodenal region just at the beginning of the first part of the duodenum. Few air loculi are seen extending from the stomach to the undersurface of the liver through this defect with evidence of a rim of contrast seen smearing the undersurface of the liver. Perigastric fat stranding is seen without evidence of loculated collections or masses.
Mild amount of pneumoperitoneum and intraperitoneal free fluid are seen.
Contrast opacification of the gall bladder is seen without sizable entero-biliary fistula detected.
A hypodense left adnexal lesion is seen (proved to be cyst by sonography).
Both lung bases show multiple atelectatic bands, minimal opacities and minimal pleural reactions.
Annotated images showing the site of perforation, at the anterosuperior wall of the first part of duodenum with leaking air foci.
Case Discussion
The patient was presented to the ER with acute upper abdominal pain. Erect frontal radiograph of the abdomen revealed mild amount of pneumoperitoneum. The possibility of perforated bowel was raised and further evaluation with CT was requested.
The patient received positive oral contrast through a nasogastric tube and the obtained routine axial cuts showed a possible perforation at the anterosuperior aspect of the first part of the duodenum. The axial cuts were then retaken in a prone position which showed minimal extraluminal contrast leak at the suggested site of perforation.
The patient was sent to OR and a duodenal perforation was confirmed.
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