Presentation
Generalized abdominal pain mainly at the right iliac fossa with nausea and vomiting two days ago.
Patient Data
Ultrasound study shows mild intra-peritoneal free fluid more prominent at the right upper abdomen and perihepatic. A fluid track is seen related to the gallbladder.
A frontal abdominal radiograph shows free air under the diaphragm.
Evidence of pneumoperitoneum with free intraperitoneal gas seen at the perihepatic region. Mild to moderate intraperitoneal and perihepatic fluid collection involving the right paracolic gutter and iliac fossa. Oral contrast leak is seen free at the perihepatic region with a contrast tract seen extending from the anterior wall of the D1/2 junction. Blurred peritoneal fat planes are more prominent at the upper abdomen.
Annotated images clarify the leaking tract at ultrasound and CT. It also points to the prominent fluid collection at the right paracolic gutter and iliac fossa causing Valentino syndrome.
Perforated ulcer at the anterior duodenal wall (D1/2).
Case Discussion
Perforated peptic ulcer disease occasionally presents with symptoms similar to acute appendicitis due to leakage into the right iliac fossa (Valentino syndrome). The radiographic picture of pneumoperitoneum, intraperitoneal collection, and oral contrast leak is straightforward to the diagnosis of perforated peptic ulcer disease.
X-ray and Ultrasound contribution: Dr/ Somia Elbadawy
Intra-operative photos contribution: Dr/ Adel Abdelwahed