Perforated Ulcers Shaleen Sathe, MS4 Christina 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 Perforated Gastric Ulcer US of the abdomen shows perihepatic fluid (blue arrow) and free fluid in the right paracolic gutter (not shown), concerning for intraperitoneal pathology. 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 • Complications: bleeding/hemorrhage, penetration into surrounding structures which can cause biliary or gastric obstruction, fistulae, abscesses, and perforation • 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 a) b) of the diaphragm Case courtesy of Dr Fateme Hosseinabadi , Marshall GB. Published Online: November 01, 2006 Radiopaedia.org, rID: 68445 https://doi.org/10.1148/radiol.2412040700 Leaping dolphins case courtesy of Dr Daniel J Bell, Cupola image: https://edon.com/wp- Radiopaedia.org, rID: 68459 content/uploads/2017/12/EDON_CUPOLA-1-600x650.jpg LINKS AND REFERENCES • Perforated peptic ulcer disease • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237817/ • ACR guidelines for workup of nonlocalized acute abdominal pain • https://acsearch.acr.org/docs/69467/Narrative/ • Radiopaedia • Peptic Ulcer Disease • Perforation • Radiographics.