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PowerPoint PresentationChristina LeBedis, MD
CASE HISTORY
54-year-old male with known history of hypertension presents with 2
days of acute onset abdominal pain, nausea, vomiting, and diarrhea,
with periumbilical tenderness and abdominal distention on exam,
without guarding or rebound tenderness.
Labs, including CBC, CMP, and lipase, were unremarkable in the
emergency department.
Radiograph Perforated Duodenal Ulcer
Radiograph of the chest in the AP projection shows large amount of
free air under diaphragm (blue arrows), suggestive of
intraperitoneal hollow viscus perforation.
CT Perforated Duodenal Ulcer
CT of the abdomen in the axial projection (I+, O-), at the level of
the inferior liver edge, shows large amount of intraperitoneal free
air (blue arrows) in lung window (b), and submucosal edema in the
gastric antrum and duodenal bulb (red arrows), suggestive of a
diagnosis of perforated bowel, most likely in the region of the
duodenum.
US of the abdomen shows perihepatic fluid (blue arrow) and free
fluid in the right paracolic gutter (not shown), concerning for
intraperitoneal pathology.
US Perforated Gastric Ulcer
Radiograph Perforated Gastric Ulcer
Supine radiograph of the abdomen shows multiple air- filled dilated
loops of large bowel, with air lucencies on both sides of the
sigmoid colon wall (green arrows), consistent with Rigler sign and
perforation.
CT Perforated Gastric Ulcer
CT of the abdomen in the axial (a) and sagittal (b) projections
(I+, O-) shows diffuse wall thickening of the gastric body and
antrum (green arrows) with an ulcerating lesion along the posterior
wall of the stomach (red arrows), and free air tracking adjacent to
the stomach (blue arrow), concerning for gastric ulcer perforation.
Differential diagnosis includes gastric malignancy.
CLINICAL FOLLOW UP
Following the clinical diagnosis, the patient was taken to the OR
for exploratory laparotomy with modified Graham patch repair. Upper
GI gastrograffin study 3 days post-op showed no leak. On the day of
discharge, the patient was tolerating a regular diet, with minimal
pain. The patient was found to be positive for H. pylori and was
seen by his PCP at an outside hospital for treatment.
Surgical pathology revealed duodenal mucosa with epithelial surface
erosion and mucosal congestion, consistent with perforated chronic
peptic ulcer.
IN A NUTSHELL: Perforated Ulcer • Endoscopy is the gold standard
for diagnosis of uncomplicated peptic ulcer
disease (PUD) • Limited role of imaging in the diagnosis of PUD •
Advantages of imaging include:
a) identifying presence of intraperitoneal air b) determining the
underlying cause of perforation and potentially the site of
perforation
• Imaging findings • Chest X-Ray: free air under diaphragm •
Abdominal radiograph: signs of pneumoperitoneum, including Rigler
sign • CT: identify small volumes of gas, potentially find cause of
perforation, or plan for
surgery
• Variants: marginal ulcer s/p gastric bypass surgery, perforation
of ulcerated gastric malignancy, irritation dysplasia or marginal
carcinoma
VOICE RAD MODALITY AND DISEASE by Dr. Christina LeBedis
(2020) Can follow IN A NUTSHELL CONTENT
Template Just a guide: This is Dr…. and I wanted to discuss the
diagnosis of (modality of ..disease). The most important findings
of the (disease on modality) include (major criteria) Sometimes you
may also find (minor criteria). You must always remember to look
for (complications or other nuances of the disease) Other diseases
to consider include (ddx) and you may want to recommend (other
imaging or lab tests) (Duration 30-45 seconds)
OLA #1
Which of the following is a strategy that can be used to identify
the site of perforation on CT?
a) Looking for focal areas of fat stranding or gastric/bowel wall
thickening
b) Following bubbles of free intraperitoneal air toward an area of
stomach/bowel
c) Finding a point of discontinuity in the gastric or bowel
wall
d) All of the above
OLA #2
All of the following are ways that an upper GI study can provide
useful information in diagnosing and managing a perforated peptic
ulcer except ________________.
a) To confirm an equivocal appearance on CT
b) To detect the exact location of perforation
c) To diagnose gastric or duodenal perforation as the primary
study
d) To assess for leak after surgical repair of the perforated ulcer
prior to advancing diet
Imaging Spectrum: Perforated Marginal Ulcer s/p Roux-en-Y Gastric
Bypass Surgery
CT of the abdomen in the axial projection (I+, O+) shows large
amount of free air (blue arrow), with focal defect seen at the
gastrojejunostomy anastomosis (red arrow) concerning for the site
of perforation.
Imaging Spectrum: Malignant Ulcer
CT of the abdomen in the axial (a) and sagittal (b) projections
(I+, O-) shows hyperenhancement and wall thickening (blue arrows)
along the posterior antrum of the stomach, around a region of
ulceration (red arrows). Inside the ulcer cavity, there is
hyperdense material which may represent hemorrhage (green arrows).
The differential diagnosis includes a gastric ulcer and ulcerating
gastric malignancy with associated hemorrhage.
Imaging Spectrum: Bleeding from Duodenal Ulcer Requiring Arterial
Embolization
CT of the abdomen in the axial projection (I+, O-) shows active
extravasation of contrast in the proximal duodenum (red arrow),
most likely from adjacent branches of gastroduodenal artery,
consistent with bleeding from known duodenal ulcer.
DISCUSSION • Peptic ulcer disease (PUD) affects about 4 million
people worldwide annually
• Lifetime prevalence of perforation in those with PUD is ~5% •
Mortality of perforated peptic ulcers (PPU) is 1.3%-20%
• Hallmark of PPU is triad of abdominal pain, tachycardia and
abdominal rigidity
• Common etiologies: H. pylori, smoking, NSAID and steroid use,
alcohol • H. pylori prevalence in patients with perforated duodenal
ulcers ranges from 50%-80%
• Management • Test for H. pylori and treat with triple (PPI,
clarithromycin, and amoxicillin) or quadruple
(bismuth, metronidazole, tetracycline, and PPI) therapy, urea
breath test to check for successful treatment
• Non-operative: nasogastric suction for decompression to allow
sealing of perforation, IV fluids, antibiotics, and close clinical
assessment
• Operative: exploratory laparotomy with omental patch repair is
the gold standard, and may consider laparoscopic surgery
Other Images
More Signs of Pneumoperitoneum
Radiographs of the chest showing a) dolphin sign, seen when
intraperitoneal air outlines diaphragmatic muscle slips, and b)
cupola sign, seen when air accumulates under the central tendon of
the diaphragm
Marshall GB. Published Online: November 01, 2006
https://doi.org/10.1148/radiol.2412040700 Cupola image:
https://edon.com/wp-
content/uploads/2017/12/EDON_CUPOLA-1-600x650.jpg
a) b)
Case courtesy of Dr Fateme Hosseinabadi , Radiopaedia.org, rID:
68445 Leaping dolphins case courtesy of Dr Daniel J Bell,
Radiopaedia.org, rID: 68459
• Radiopaedia • Peptic Ulcer Disease • Perforation