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Imaging Assessment of Gastroduodenal Perforations

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Imaging Assessment of Gastroduodenal Perforations Imaging Assessment of Gastroduodenal Perforations Dario Picone, MD,* Roberta Rusignuolo, MD,* Federico Midiri, MD,* AntonioLoCasto,MD,* Federica Vernuccio, MD,* Fabio Pinto, MD,† and Giuseppe Lo Re, MD* Gastroduodenal perforation is an emergency situation that usually requires early recognition and well-timed surgical treatment. It can arise from different natural, iatrogenic, or traumatic causes, and it can present with various symptoms especially in the early phase. This article reviews the role of the different imaging techniques in the diagnosis of gastroduodenal perforation, focusing on the direct and indirect signs that are encountered in conventional radiography and computed tomography; our personal experience is also provided. Semin Ultrasound CT MRI 37:16-22 C 2016 Elsevier Inc. All rights reserved. Introduction to perforation are quite frequent. Peptic ulcer disease is a major cause of gastroduodenal perforation; it is less frequently due to astrointestinal (GI) tract perforation is a pathologic trauma, necrotic or ulcerated malignancies, or iatrogenic Gcondition caused by trauma (blunt or penetrating injuries.11 Ulcer disease may be due to Helicobacter pylori trauma, foreign body ingestion, or iatrogenic injury) or by infection or frequent use of aspirin or other nonsteroidal anti inflammatory (enteritis), ischemic (mesenteric infarction, vol- inflammatory drugs. Peptic ulcer is characterized by the loss of vulus, intussusception, or vasculitis), or neoplastic condi- normal mucosal integrity, inflammation, and focal penetration 1-3 tions. Except for part of the bowel and the duodenum that changes the normal mural anatomy. According to the that are retroperitoneal, the rupture of hollow organs causes location of the ulcer, different consequences may be encoun- pneumoperitoneum. Pneumoperitoneum may be “sympto- tered: anterior ulcer may perforate directly into the peritoneal 4-6 matic” when air leaks out of an intraperitoneal hollow organ cavity, whereas posterior stomach or duodenal ulcers often containing gas, or “asymptomatic” (also defined as benign or cause a covered perforation.12 Most common sites of perfo- 5 “pneumoperitoneum without peritonitis”) ; the latter may be ration due to peptic ulcers are gastric antrum and duodenal caused by surgery, paracentesis, tubal insufflation, postpartum bulb, whereas perforation due to blunt trauma usually occurs and pregnancy exercises, sexual intercourse, peroxide enema, in the descending and horizontal segments of the duodenum pneumatosis cystoides intestinalis, sternotomy, and colono- because of their firm attachment, in the acutely angled 6-8 scopy, and usually resolves spontaneously. Regarding the flexures, or it is related to compression against the type of GI tract perforations, they can be divided into “covered” vertebral column.11-13 The primary mechanism of duo- or “free perforations” and this differentiation is very important denal injury is a rapid deceleration with visceral tearing at in the therapeutic approach because surgical treatment has to the junction of the intraperitoneal (free) and retroper- be immediate for free perforations whereas it can be delayed for itoneal (fixed) portions of the duodenum, such as that 1-10 covered perforation. Gastroduodenal diseases that can lead between the third and fourth portions.14 Perforation often occurs at tumor sites or surgical anastomoses as well.12-15 Tumor rupture (Fig. 1) and GI tract perforation *Section of Radiological Sciences, DIBIMED, University of Palermo, Palermo, have been also reported in patients with cancer, especially Italy. in GI tract stromal tumor treated with imatinib, a tyrosine †Department of Diagnostic Radiological Imaging, Marcianise Hospital, 12-16 Marcianise (CE), Italy. kinase inhibitor. Iatrogenic lesions related to the use Address reprint requests to Giuseppe Lo Re, MD, Via Cristofaro Scobar 1, of esophagoduodenoscopy represent a cause of gastro- 90145 Palermo, Italy. E-mail: [email protected] duodenal tract perforation. Other iatrogenic causes are 16 http://dx.doi.org/10.1053/j.sult.2015.10.006 0887-2171/& 2016 Elsevier Inc. All rights reserved. Imaging assessment of gastroduodenal perforations 17 Imaging Ultrasonography Ultrasonography is not sensitive in identifying free gas in the peritoneal cavity but it is a noninvasive, relatively simple, and repeatable examination, which can identify indirect findings of bowel perforation as intraperitoneal free fluid and intestinal paresis.21 Conventional Radiography On plain films, a direct finding of perforation is free intra- peritoneal gas (Figs. 2 and 3); indirect diagnostic findings are intraperitoneal free fluid and paralytic ileum (Fig. 2).22-24 In patients with critical illness, radiographic examination may be Figure 1 Contrast-enhanced abdominal CT scan shows the presence of performed in the supine decubitus, with anteroposterior and pneumoperitoneum and irregular thickening of the gastric wall lateral view of the abdomen and anteroposterior view of the representing a stomach cancer. thorax. In cooperative patients, posteroanterior and lateral views of the abdomen in upright position or in left lateral or endoscopic retrograde cholangiopancreatography, place- prone decubitus are acquired. The evidence of free intra- 17 fi ment of inferior vena cava filter, and biliary stents. peritoneal air is considered as a direct or indirect nding of perforation: in the film taken upright, air is located in the subdiaphragmatic regions (direct sign) (Figs. 2 and 3); supine Clinical Presentation abdominal films show typical pneumoperitoneum findings The diagnosis of GI tract perforation is based on the clinical (Fig. 2), such as translucent triangle, lucent liver, perihepatic examination integrated with imaging. The clinical symptoms gas collections, Rigler sign (indirect sign), cupola sign, and and signs vary according to the site and etiology of the football and cap of doge signs; in other cases, there is the fl perforation and they have to be differentiated with other acute outlining of various peritoneal re ections, the falciform, teres, 20 abdominal pathologies such as acute pancreatitis and acute and lateral umbilical ligaments, as well as the urachus sign. cholecystitis.6 Localizing the pain may facilitate the diagnosis as a localized peritoneal inflammation develops exactly at the Computed Tomography level of the injured organ involving the corresponding Computed tomography (CT) is considered as the most abdominal wall segment. Patients with gastroduodenal perfo- sensitive modality for the diagnosis of pneumoperitoneum ration present with the symptoms of a local or generalized peritonitis due to the leakage of luminal contents in the peritoneal cavity. A lesion of the gastroduodenal wall may lead to intra-abdominal contamination with peritonitis or abscesses.12 Site, size, and duration of perforation may determine the type and intensity of peritoneal contamination; other factors such as time from the last meal, coexistent diseases, and presence or absence of an ileus or bowel obstruction may also contribute. Anatomical site of perforation influences the type and the severity of enteric contamination18: microbiological contamination increases from proximal to distal side of the GI tract and this is due to the fact that bacterial load is inversely related to the toxicity of organ fluid composition. The stomach and the duodenum show the lowest number of microorganisms due to the presence of acid and biliary, and pancreatic secretions.18 From a clinical point of view, patients with gastric or duodenal perforation usually present with highly acute pain due to a rapid chemical peritonitis usually followed by a systemic inflammatory response,12 but, in some cases, the clinical features may be nonspecific, as in patients with covered perforation (particularly in the early stage), or in those treated 1-19 with steroid drugs or immunocompromised patients. How- Figure 2 Posteroanterior abdominal x-ray in a 59-year-old man with ever, gastroduodenal perforations should be suspected in abdominal pain shows the presence of air under the right diaphrag- patients who present with acute pain and abdominal wall matic dome (black arrow), radiolucency of the liver (*), Rigler'ssign rigidity and history of ulceration.20 (þþ), and some air-fluid levels (white arrow) in the small intestine. 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