Perforated duodenal ulcer with ingested contrast leak
Acute epigastric pain. Erect chest radiograph initially reported as "no free gas". Patient deteriorated over 12 hours with hypotension and epigastric pain. CT to clarify.
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Free intraperitoneal gas and fluid containing the ingested contrast (arrow) adjacent to the liver with a focal defect in the superior duodenum leaking contrast (indicative of a perforated ulcer). Note thick-walled, enhancing small bowel indicative of so-called "shock" bowel due to systemic hypotension.