CASE REPORT

Perforated
peptic ulcer

imaged
directly by
computed

tomography
Abstract

Perforation occu rs in
10% of patients with
peptic ulcer.
Computed
tomography (CT) may
show free
intraperitoneal gas
and/or extravasation of
oral contrast. While
the location of the free
gas or contrast may
suggest the site of
perforation, the
perforation itself is
difficult to
demonstrate. We
present a case of
perforated ulcer in
which the perforation
was imaged directly
byCT.

WK Loftus
FRACR *,'

LTC Chow
FRCPA#;

C Metreweli
FRCR •

* Dept. of Diagnostic Radiology
and Organ Imaging,

# Dept. of Pathology, Prince of Wales
Hospital, Chinese University of Hong Kong,

Shatin, N. T. Hong Kong

31 SA JOURNAL OF RADIOLOGY· June 1997

Introduction
Perforation is said to occur in 5-10%

of the overall population who have
peptic ulcer (PU).I Recurrent ulcera-
tion following surgery for PU is well
recognized and in 95% is secondary to
surgery for duodenal rather than gas-
tric ulcer. Itis seen in about 3% of cases.
Recurrent ulceration usually occurs
following a gastrojejunal anastomosis
but can develop even after vagotomy
alone. Typically, however, th se ulcers
develop at an anastomotic site and per-
foration of these recurrent ulcers oc-
curs in about 10%.2 While CT has no
role in uncomplicated PU, it is useful
in detecting perforation or penetration.
The principal CT signs of perforation
are extraluminal gas or, when adminis-
tered, extravasated oral contrast. The
location of a focal gas or contrast col-
lection indicates a perforation in that
area although the actual perforation
itself is unlikely to be seen,' even when
contrast is used.' The direct demonstra-
tion of an actual perforation does not
seem to have been previously reported.
We present a case in which the perfo-
ration was imaged by CT.

Case report
A 79 year old man presented with

sudden onset of severe abdominal pain
for 12 hours. Relevant past medical his-
tory included a Billroth type II gastrec-
tomy for PU more than 10 years be-
fore. Clinically the patient had an acute
abdomen. There was an elevated serum
amylase and the clinical differential
diagnosis was between pancreatitis and
a perforated peptic ulcer. Plain films
were unremarkable and did not reveal
free gas. US showed free fluid in the
abdomen consistent with either diag-
nosis.The gallbladder was norma] with
no gallstones but as the pancreas could

topagB32



PerforZlled peptic ulcer irn<lged
directly by oornpr.nc-d tOlllography

frompage31

not be visualised, due to bowel gas,the
patient was referred for CT. This dem-
onstrated intraperitoneal free gas and
fluid (Figure 1). There was a focal

Figure 1: Axial CT image shows free intraperitoneal gas
anteriorly and in the porta and extensive free fluid. Note
the nasogastric tube in the stomach remnant.

defect in the posterior wall of the gas-
tric remnant consistent with a perfo-
rated PU (Figures 2 and 3). The
patient refused surgery and died within
24 hours. Post mortem confirmed the

Figure 2: More caudal image directly imaging the
perforation (arrow) and showing an adjacent gas bubble.

Figure 3: Enlargement of Fig. 2 demonstrating
the perforation more clearly.

presence of a perforated peptic ulcer
measuring 15 x 20 mm (mean 17.5
mm) on the posterior stomach wall at
the site of the gastrojejunostomy (Fig-
ure 4) as well as extensive peritonitis.

Discussion
There are several reports on the CT

findings in perforated Pu. These find-
ings are of extraluminal gas and/or
extraluminal oral contrast. In a retro-
spective study involving 35 patients
with PU, two had perforation demon-
strated on CT although the actual per-
foration itself could not be identified.'
Similarly, in a report of three cases of
perforated PU, the site of perforation,
i.e. gastric or duodenal, could be iden-
tified by the location of extraluminal
gas or oral contrast, but not the actual
perforation itself" However, Fultz et al
could identify a discontinuity of the
bowel wall at the site of perforation in
three of nine patients with perforation
due to continuity of intra- and
extraluminal oral contrast through the
defect.' In our case the actual perfora-
tion itself was clearly seen even with-
out the use of oral contrast. It is not
clear why, given the incidence of per-
foration in PU, direct visualization of
the defect does not appear to have been
reported before. This perforation was
no larger than normal; its size (17.5
mm) was the same as the mean diam-
eter (17.6 mm) reported in a series of
80 cases of perforated pu.s

Allowing for the role of non-op-
erative management of a sealed-off
perforated PU, the presence of free gas
or extravasated oral contrast in the ap-
propriate clinical setting indicates the
need for operative intervention to re-
pair the perforated viscus. Actual visu-
alisation of the perforation itself as in
this case, however, unequivocally con-
firms the need for urgent surgery. In

32 SA JOURNAL OF RADIOLOGY· June 1997

Figure 4: Fixed, post mortem specimen of the
opened gastrojejunostomy seen from the front.
The large perforated anastamotic ulcer is clearly
demonstrated.

addition the knowledge of the exact site
of the perforation will enable the sur-
geon to locate and repair it as quickly as
possible. We feel that this case also sug-
gests that in patients with an acute ab-
domen of uncertain cause, where perfo-
rated PU is suspected, there may be a
role for helical scanning with reconstruc-
tions in the sagittal and coronal planes.
This should increase the likelihood of di-
rectly demonstrating these often sizeable
defects.

References

I. Jacobs JM, Hill MC, Steinberg WM. Peptic Ulcer
Disease: CT Evaluation. Radiology 1991; 178:7 45-748

2. Nyhus LM, Sheaff CM. Recurrent Ulcer. In: Wasteil
C, ed. Surgery of the esophagus, stomach and small
intestine 5th ed. Boston: Little Brown, 1995:531-540

3. Fultz PJ, Skucas J, Weiss SLo CT in Upper
Gastrointestinal Tract Perforations Secondary to
Peptic Ulcer Disease. Gastrointest Radiol 1992; 17:5-
8

4. Jeffrey RB, Federle MP, Wall S. Value of Computed
Tomography in Detecting Occult Gastrointestinal
Perforation. J ComputAssistTomog 1983; 7 (5): 825-
827.

5. Horowitz 1, Kukora IS, Ritchie WP. All Perforated
Ulcers are not alike. Ann Surg 1989;209(6):693-697.