RSNA Case Collection - Duodenal perforation
7/21/2020
Figure legend: Upper gastrointestinal series obtained on the same day as the second CT scan. Frontal scout (A) of the upper abdomen shows no radiodense material in the upper abdomen. Frontal view (B) of the upper abdomen performed following the administration of 100 cc of iodinated contrast through a nasogastric tube shows contrast leakage from the second portion of the duodenum (yellow arrow) into the subhepatic region, confirming duodenal perforation.
Age and gender: 65 year old male
Clinical history & presentation: A patient with numerous medical co-morbidities presented to the emergency department 18 days following resection of ischemic small bowel due to small bowel obstruction secondary to adhesions from prior abdominal surgery. He was initially discharged post-operatively in stable condition, presented for his surgery clinic follow-up 2 days earlier with uncomplicated removal of staples, and began having acute upper abdominal pain after returning home from the visit. Since then, he had been unable to tolerate solid food, had no bowel movements, and had multiple bouts of non-bloody bilious vomitus. He denied fever, chills, purulent wound drainage, and bloody stool or emesis.
Physical exam: Wound was clean with minimal seropurulent drainage from the laparotomy incision periumbilically. No skin dehiscence. Abdomen was soft and mildly distended with focal tenderness in the periumbilical, right upper quadrant, and epigastric regions. There was rebound tenderness in the right upper quadrant. Bowel sounds were absent in all four quadrants.
Other diagnostic testing: WBC 11.2 x 103 /µL Lipase 791 U/L Lactate 1.6 mmol/L Bilirubin 0.7 mg/dL
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