The subsequent operative note said "...Findings: D1 1.5 cm anterior perforation with free small bowel content and pus throughout abdomen, perihepatic area, right paracolic gutter, and pelvis (aprox. 2L) ... Procedure: Laparoscopic repair of perforated duodenum, primary suture repair with omental patch and washout..."

The case highlights how non-feculent free fluid and a large amount of intraperitoneal free air point towards and upper GI perforation rather than a lower GI perforation.

The keyed axial image suggests D1 perforation based on the impression of a mural defect seen along the lateral wall.

Incidentally, the CT scan is low quality due to off centering artifact (the couch was positioned too low by the radiographer).