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Perforated posterior peptic ulcer disease with lesser sac collection

Case contributed by Hoe Han Guan
Diagnosis almost certain

Presentation

Acute onset of right hypochondrial pain with fever.

Patient Data

Age: 40 years
Gender: Male

Ultrasound requested to assess hepatobiliary system. Noted dilated common bile duct (patient has recent history of open cholecystectomy for choledocholithiasis).
Finding of ill-defined heterogeneous echogenicities collection adjacent to dilated common bile duct.

Impression:
Suspicious collection adjacent to CBD and duodenum which can represent biloma or collection within the lesser sac.

Proceeded with urgent contrast-enhanced CT abdomen.

Abnormal bowel wall thickening noted at the gastric antrum, pylorus and the duodenal bulb (D1), mainly at the posterior wall.
Significant amount of fat streakiness, fluid collection and multiple air locules (pneumoperitoneum) confined within the lesser sac, located posterior the aforementioned thickened bowel wall.
Delayed scan performed after ingestion of POSITIVE oral contrast, noted extravasation of the oral contrast into the lesser sac as high density air-fluid layers.
Focal short segment of small bowel ileus noted at periumbilical region due to inflammatory process.

Common bile duct is dilated , measuring up to 1.0cm. A few hyperdense intraluminal lesions at the distal CBD which represent choledocholithiasis, largest measuring 0.5cm. Upstream dilatation of bilateral intrahepatic biliary ducts. No aerobilia. The wall of the CBD appears to be thickened and enhancing.
Absence of gallbladder is in keeping with previous cholecystectomy.

Annotated images showed the abnormal fluid collection and fat streakiness confined to the lesser sac, as well as the oral contrast extravasation post oral contrast infection.

Case Discussion

Posterior peptic ulcer perforation is a relatively rare comparing the more common anterior peptic ulcer perforation. But it is still considered as surgical emergency with high mortality rate.

Patient usually has late and insidious non-specific presentation and can be missed in laparotomy. Gastric ulcers of the anterior wall and curvatures perforated freely into the peritoneal space which can be easily to be detected as air under diaphragm on radiograph. Comparing to posterior gastric ulcer perforation, it can perforate into retroperitoneal space and lesser sac such as in this case, obscuring the detection of pneumoperitonum on erect chest radiograph or abdominal radiograph by clinician or radiologist. CT scan with or without positive oral contrast is preferred imaging modality.

Patient went on to have emergency laparotomy for peptic ulcer perforation repair.

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