Presentation
Acute right upper abdominal pain.
Patient Data
Mild to moderate intra-peritoneal free fluid collection is mainly seen in the right paracolic gutter with blurred abdominal fat planes mainly at the upper abdomen.
Free gas (pneumoperitoneum) is seen in the upper abdomen and the hepatic falciform ligament related to the first part of the duodenum with a possible defect in the anterior wall.
Oral contrast CT study in the supine position (not shown) shows no definite contrast leakage.
Oral contrast CT study in the prone position revealed diffuse irregular thickening of the 1st part of the duodenum with a large ulcer crater and minimal oral contrast leakage related to it, barely seen in the axial cuts and more clearly seen in the coronal reconstruction.
Case Discussion
The CT findings before the oral contrast medium suggested a perforated duodenal ulcer with gas outlining the ulcer crater and extending around the adjacent liver
Oral contrast medium was administered and the patient was scanned again in the prone position. Minor contrast medium leakage from the first part of the duodenum confirmed the diagnosis.
Subsequent laparotomy confirmed the diagnosis of an anterior wall perforation in the first part of the duodenum. Surrounding fibrosis and early omental sealing may have limited the spread of gas and contrast medium. He recovered well following surgery with no complications.
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