CT Case 062
A 65-year-old lady presents with abrupt onset of epigastric pain radiating to her back and right shoulder. Over the last few hours her pain is now becoming more generalised.
She gives a history of intermittent gnawing epigastric pain for the last few weeks. There is a history of regular NSAID use (both Ibuprofen and Meloxicam) following an ankle injury one month prior.
An erect Chest X-ray is performed
Describe and interpret her CXR
CXR interpretation
This is a mobile erect PA CXR, the pertinent finding here is air under the diaphragm, representing pneumoperitoneum, and confirming the suspicion of a perforated viscous.
A CT scan of the abdomen is performed
Describe and interpret the CT images
This case illustrates features of perforated gastric ulcer.
Gastric ulcers are difficult to visualise on CT, when they are big (approx. 2cm or more) they can be seen on CT as an outpouching along the gastric wall. Other features like oedema or wall thickening of the gastric wall can help in directing attention to the presence of an ulcer.
Presence of pneumoperitoneum confirmed perforation of the ulcer.
This case demonstrates large volume of pneumoperitoneum, which may not be seen in all cases. Nodularity along the margins of an ulcer, although not seen here, should raise suspicion of a malignant ulcer, and search for associated lymphadenopathy needs to be done.
Clinical Pearls
Gastrointestinal perforation can be due to a number of causes.
A few of the common causes to consider are;
- Duodenal / peptic ulcer
- Ischemia
- Obstruction
- Appendicitis
- Diverticulitis
- Trauma
The erect CXR helps us in confirming a perforation, however absence of free air cannot exclude perforation.
CT is the exam of choice to identify the cause, look for complications and to direct surgical management.
On CT we look for the presence and distribution of intraperitoneal air which may help identify the site of perforation, we also look for radiological features of peritonitis (ascites in conjunction with peritoneal and mesenteric thickening), or of a contained perforation.
In this case, the patient gave a history that is quite classic for perforated peptic ulcer; that is, abrupt onset of severe pain with radiation to back and shoulder. The prodrome of several weeks of more dull pain likely represented undiagnosed peptic ulcer in the context of NSAID use.
Perforation requires urgent washout in theatre to limit progression to systemic infection. This patient received broad spectrum antibiotics to cover for gut flora organisms (ampicillin, gentamicin and metronidazole), an IV proton pump inhibitor, and was promptly taken to theatre for washout. She underwent laparoscopy which involved peritoneal lavage and repair of perforated gastric ulcer with an omental patch.
References
- Hartung M. Abdominal CT: peptic ulcer disease. LITFL
TOP 100 CT SERIES
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).