Presentation
Abdominal pain.
Patient Data
Pneumoperitoneum in the upper abdomen. Small amount of ascites. Mild thickening and mucosal hyperenhancement of the first portion of the duodenum with possible discontinuity of the wall best seen on coronal reformatted images. Reactive enteritis of small bowel in the left abdomen. No other acute findings.
Diagnoses
PREOPERATIVE DIAGNOSIS
Perforated hollow viscus.
POSTOPERATIVE DIAGNOSIS
Perforated duodenal ulcer just distal to the pylorus. This was an anterior perforation with gross contamination in the entire peritoneal cavity with gastric succus.
Procedure/Description
...Her abdomen is entered through an upper midline incision. Upon entering the abdomen, there is cloudy but not malodorous fluid present with fibrinous exudate on all serosal surfaces. A great volume of this was suctioned out and on exploration, she is found to have a perforation in the anterior portion of the 1st portion of the duodenum. The duodenum is exposed after retractors are placed and Kocherized and the duodenum rotated up into the field. The ulcer is opened longitudinally along the long axis of the duodenum and through the pylorus and then closed transversely with interrupted simple sutures of 3-0 GI silk. The abdomen is irrigated out and suctioned free of all fluid after closure of the perforation and a small piece of omentum pedicalized off the right side of the transverse colon and swung up into apposition with the duodenum. This is sutured all around the periphery of the pyloroplasty repair using interrupted 3-0 GI popoff silks....
Case Discussion
When reading this case, it is clear that there is perforation of hollow viscus. However, the location of perforation is not obvious. The majority of the free fluid is layering within the pelvis, which might lead to some people to think that perforated diverticulitis as the cause. However, no free intraperitoneal air is present within the pelvis, which would be an expected finding.
The free intraperitoneal air is in the upper abdomen, particularly around the liver, strongly suggesting an upper abdominal source. There is subtle thickening and hyperenhancement of the first portion of the duodenum, with a few fine locules of air and fluid surrounding it. This should strongly suggest a perforated ulcer as the most likely cause. Additionally, on the reformatted images, there may be discontinuity of the lumen. This case may have likely benefited from the use of oral contrast, which is used in some emergency departments for non-traumatic imaging.
Notice the reactive enteritis of the small bowel in the left abdomen, due to the gastric/duodenal secretions. This was noted as "cloudy fluid with fibrinous exudate on all serosal surfaces" in the operative report.