Presentation
Sharp pain in the abdomen without relief for three days. Vomiting. History of duodenal ulcer.
Patient Data
Pneumomediastinum – free air in the mediastinum around the heart and esophagus.
Pneumoretroperitoneum – a large amount of extraluminal free air in the abdomen is present in the retroperitoneal space – anterior and posterior pararenal space bilaterally but more on the right, perirenal space on the right, caudal to the duodenum and anterior to the aorta and vena cava inferior, towards the two paracolic gutters, until the inguinal canals. There are air bubbles around the duodenum without confirmation of loss of integrity of the duodenal wall.
In the retroperitoneal space there is a collection of multiple free air bubbles and increase of the fat tissue attenuation which is located caudally of the right renal vein in the right anterior pararenal space behind the duodenum, centrally and ventrally to the inferior vena cava and aorta, down into the pelvis and the inguinal canals, more on the left side. Its biggest size is at the level of the aortic bifurcation: 12.6 x 5.0 cm.
Case Discussion
As the patient had history of duodenal ulcer and the characteristic distribution of the extraluminal air, there was suspicion of perforated duodenal ulcer and consequent abscess formation. After the patient was sent to surgery with laparotomy, the proposed diagnosis of duodenal perforation was confirmed.
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