Presentation
Sharp unrelenting abdominal pain, nausea, and vomiting. AKI.
Patient Data
Few small locules of free intraperitoneal air. Visible ulcer channel arising from the cranial aspect of the gastric antrum with small extraluminal collection. Fluid and stranding in the porta hepatis with hepatic subcapsular collection containing mostly conforming to the right hepatic lobe.
Dilated and inflamed gallbladder, which could represent reactive inflammation given the adjacent perforated ulcer or an additional diagnosis of acute cholecystitis. Calcifications within the gallbladder wall suggesting porcelain gallbladder.
After administration of oral contrast, there is increasing, higher density of the subcapsular fluid and fluid just outside of the lumen of the site of perforation in the cranial aspect of the gastric antrum. For example, Hounsfield units after contrast administration just outside of the lumen of the gastric antrum measures 52 versus 6, and within the hepatic subcapsular collection 29 versus 9. This confirms spillage of ingested oral contrast into the spaces due to ulcer perforation. There is also increasing free intraperitoneal air.
Annotated images show increasing high density extraluminal material at the site of perforation and within the subcapsular space, indicating free intraperitoneal spillage of ingested oral contrast.
Case Discussion
The few small locules of free intraperitoneal air in the upper abdomen fluid, small extraluminal collection above the gastric antrum, and stranding/inflammation about the porta hepatis is sufficient to confidently diagnose perforated gastric or duodenal ulcer.
To increased diagnostic confidence, the patient was given a small amount of oral contrast and delayed images were taken. This is a great use of oral contrast even in the setting of acute renal injury when intravenous contrast cannot be given. There is an accumulation of high density, extraluminal material outside of the site of perforation and within the hepatic subcapsular space, consistent with free spillage through the ulcer channel. There is also more free intraperitoneal air on the delayed images.
The inflammation of the gallbladder was felt to be reactive, but superimposed acute cholecystitis would also be possible.
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