JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Radiological Diagnosis: Perforated Gastric Ulcer
DIAGNOSIS
on CT, nonoperative management with gastric decompression, antibiotics, and proton-pump inhibitor is possible. However, surgery remains themainstay of treatment for gastric perforation when patient presents with shock, generalized peritonitis, or failure to improve with medical management. Closure is usually accomplished with an omental patch. 1
Peptic ulcer disease remains the most common cause for gastric perforation, typically secondary to H. pylori infection or acid hypersecretion states, with less common causes including blunt or penetrating trauma, neoplasm, foreign body ingestion, or iatrogenic injury. 1 Patient's with gastric perforation frequently present with acute onset epigastric pain. Associated peritonitis may also illicit mental status changes and signs of septic shock such as fever, hypotension, and tachycardia. 1 In cases where gastric contents are contained, minimal or no signs of peritonitis may be present. Since the clinical presentation of gastric ulcer perforation is nonspecific and varied, primary diagnosis relies heavily on imaging studies. 3 Radiography may be the first line of imaging in suspected abdominal pathology. Upright chest or abdominal radiographs can identify the presence of free air under the diaphragm, indicating a potential gastric perforation. 1 However, this radiographic finding is nonspecific sine it may be due to many other etiologies. CT remains a more reliable imaging modality in identification of both pneumoperitoneum as well as other signs of gastric perforation such as intraperitoneal free fluid or blood, extravasated oral contrast material, and gastric wall discontinuity. 3,4,5 A deep peptic ulcer typically associated with a local inflammatory reaction can induce soft tissue changes and gastric wall thickening which can likewise be visualized on CT. An ulcer crater may also be identified. 3,5 Given the superiority of CT to plain radiographs, CT has been proposed as the initial radiologic test to evaluate patients with acute abdominal pain.6 Fluoroscopic exams with luminal contrast studies allow real-time observations and are yet another potential imaging modality if a gastric perforation is suspected. In some cases, fluoroscopic studies are better in demonstrating the location, site of origin, or etiology of a gastrointestinal perforation. 6 When a perforated ulcer is suspected, the upper gastrointestinal study should initially be performed with a water-soluble contrast agent. 6 Peptic ulcers may perforate freely into the intraperitoneal space or into the lesser sac and retroperitoneum.6 Hyperattenuating fluid in the peritoneal cavity on post oral contrast CT imaging in the setting of suspected abdominal pathology should raise suspicion for hollow viscus perforation and may represent blood, contrast material, or a combination of both. In case presented, the patient was taken for an emergent exploratory laparotomy and was found to have 500-700 cc of dark clear intraperitoneal fluid, likely representing combined gastric contents, contrast material, and blood. A partially contained perforation of a prepyloric gastric ulcer was identified intraoperatively with extensive scarring of the distal stomach. Biopsy findings were also consistent with peptic ulcer disease.
REFERENCES
1. Nirula R. Gastroduodenal perforation. The Surgical Clinics of North America 2014;94:31- 2. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg 2000;24:277-83. 3. Guniganti P, Bradenham CH, Raptis C, Menias CO, Mellnick VM. CT of Gastric Emergencies. Radiographics : a review publication of the Radiological Society of North America, Inc 2015;35:1909-21. 4. Zissin R, Osadchy A, Gayer G. Abdominal CT findings in small bowel perforation. Br J Radiol 2009;82:162-71. 5. Horton KM, Fishman EK. Current role of CT in imaging of the stomach. Radiographics : a review publication of the Radiological Society of North America, Inc 2003;23:75-87. 6. Rubesin, S, Levine, M. Radiology diagnosis of gastric perforation. Radiologic Clinics of North America 2003;41:1095-1115. Jerry Liu , is a fourth year medical student at Tulane University School of Medicine in New Orleans, Louisiana; Nancy Emelife, MD , is a second year Radiology resident at Tulane University Health Sciences Center in New Orleans, Louisiana; Leslie McNabb, MD , is an Assistant Professor of Radiology at Tulane University Health Sciences Center in New Orleans, Louisiana; Jeremy Nguyen, MD , is an Associate Professor of Radiology at Tulane University Health Sciences Center in New Orleans, Louisiana; Donald Olivares, is the Digital Imaging Specialist and Graphic Designer for the Department of Radiology at Tulane University Health Sciences Center in New Orleans, Louisiana.
Approximately half of gastric ulcer perforations spontaneously seal. If the leak isconfinedandthere isnoextravasationof contrast
J La State Med Soc VOL 170 MARCH/APRIL 2018 71
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