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The emergency room diagnosis of gastrointestinal tract perforation: the role of CT

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Computed tomography (CT) plays an important role in the evaluation of patients presenting to the emergency department with a suspected spontaneous gastrointestinal tract (GIT) perforation. Prospective identification of the site of perforation helps the emergency department physician plan the appropriate treatment in a potentially unstable patient. The purpose of this pictorial essay is to review the CT approach a radiologist should take when evaluating the patient with suspected perforation in the emergent setting. A series of patients presenting to the emergency department with surgically proven GIT perforations were retrospectively reviewed, and key images were obtained. For the purposes of this review, the anatomy of the abdominal cavity in relation to sites of GIT perforation will be discussed. CT findings of perforation will be described, including free intraperitoneal/extraperitoneal air, bowel wall discontinuity, and localized inflammatory changes. The use of a bone window setting to increase the free air conspicuity will be emphasized. The mimics of pneumoperitoneum will be demonstrated, including pneumothorax, pneumomediastinum, and venous air. Using a systematic approach, CT can precisely determine the presence and site of a gastrointestinal perforation in a majority of patients. This greatly assists the surgeon in planning the correct surgical approach.

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  1. Bixby SD, Lucey BC, Soto JA, Theyson JM, Ozonoff A, Varghese JC (2006) Perforated versus nonperforated acute appendicitis: accuracy of multidetected CT detection. Radiology 241:780–786

    Article  PubMed  Google Scholar 

  2. Pinto A, Scaglione M, Pinto F, Romano L, Grassi R, Rotondo A (2000) Helical computed tomography diagnosis of gastrointestinal perforation in the elderly patient. Emerg Radiol 7(5):259–262

    Article  Google Scholar 

  3. Hainaux B, Agneessens E, Bertinotti R, De Maertelaer V, Rubesova E, Capelluto E, Moschopoulos C (2006) Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR Am J Roentgenol 187(5):1179–1183

    Article  PubMed  Google Scholar 

  4. Tirkes T, Sandrasegaran K, Patel AA, Hollar MA, Tejada JG, Tann M, Akisik FM, Lappas JC (2012) Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging. Radiographics 32(2):437–451. doi:10.1148/rg.322115032

    Article  PubMed  Google Scholar 

  5. Yoo E, Kim JH, Kim MJ, Yu JS, Chung JJ, Yoo HS, Kim KW (2007) Greater and lesser omenta: normal anatomy and pathologic processes. Radiographics 27(3):707–720

    Article  PubMed  Google Scholar 

  6. Cadenas Rodríguez L, Martí de Gracia M, Saturio Galán N, Pérez Dueñas V, Salvatierra Arrieta L, Garzón Moll G (2013) Use of multidetector computed tomography for locating the site of gastrointestinal tract perforations. Cir Esp 91(5):316–323. doi:10.1016/j.ciresp.2012.06.004

    Article  PubMed  Google Scholar 

  7. Saeki M, Hoshikawa Y, Miyazaki O et al (1998) Computed tomographic analysis of colonic perforation: “dirty mass”, a new computed tomographic finding. Emerg Radiol 5(3):140–145

    Article  Google Scholar 

  8. Oguro S, Funabiki T, Hosoda K, Inoue Y, Yamane T, Sato M, Kitano M, Jinzaki M (2010) 64-Slice multidetector computed tomography evaluation of gastrointestinal tract perforation site: detectability of direct findings in upper and lower GI tract. Eur Radiol 20(6):1396–1403. doi:10.1007/s00330-009-1670-5

    Article  PubMed  Google Scholar 

  9. Singh JP, Steward MJ, Booth TC, Mukhtar H, Murray D (2010) Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl 92(3):182–188. doi:10.1308/003588410X12664192075251

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  10. Kim HC, Yang DM, Kim SW, Park SJ (2014) Gastrointestinal tract perforation: evaluation of MDCT according to perforation site and elapsed time. Eur Radiol. doi:10.1007/s00330-014-3115-z

    Google Scholar 

  11. Cho HS, Yoon SE, Park SH, Kim H, Lee YH, Yoon KH (2009) Distinction between upper and lower gastrointestinal perforation: usefulness of the periportal free air sign on computed tomography. Eur J Radiol 69:108–113

    Article  PubMed  Google Scholar 

  12. Choi AL, Jang KM, Kim MJ et al (2011) What determines the periportal free air, and ligamentum teres and falciform ligament signs on CT: can these specific air distributions be valuable predictors of gastroduodenal perforation? Eur J Radiol 77:319–324

    Article  PubMed  Google Scholar 

  13. Zissin R, Hertz M, Osadchy A, Even-Sapir E, Gayer G (2008) Abdominal CT findings in nontraumatic colorectal perforation. Eur J Radiol 65(1):125–132

    Article  PubMed  Google Scholar 

  14. Imuta M, Awai K, Nakayama Y, Murata Y, Asao C, Matsukawa T, Yamashita Y (2007) Multidetector CT findings suggesting a perforation site in the gastrointestinal tract: analysis in surgically confirmed 155 patients. Radiat Med 25(3):113–118

    Article  PubMed  Google Scholar 

  15. Becker CD, Mentha G, Schmidlin F, Terrier F (1998) Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Eur Radiol 8:772–780

    Article  CAS  PubMed  Google Scholar 

  16. Macari M, Balthazar EJ (2001) CT of bowel wall thickening significance and pitfalls of interpretation. Am J Roentgenol 176(5):1105–1116

    Article  CAS  Google Scholar 

  17. Thornton E, Mendiratta-Lala M, Siewert B, Eisenberg RL (2011) Patterns of fat stranding. AJR Am J Roentgenol 197(1):W1–W14. doi:10.2214/AJR.10.4375

    Article  PubMed  Google Scholar 

  18. Casey L, Vu D, Cohen A (1995) Small bowel rupture after blunt trauma: computed tomographic signs and their sensitivity. Emerg Radiol 2(2):90–95

    Article  Google Scholar 

  19. Maniatis V, Chryssikopoulos H, Roussakis A, Kalamara C, Kavadias S, Papadopoulos A, Andreou J, Stringaris K (2000) Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging 25(4):373–379

    Article  CAS  PubMed  Google Scholar 

  20. Smith KS, Wilson TC, Luces L, Stevenson AA, Hajhosseini B, Siram SM (2013) Pneumoperitoneum 48 days after laparoscopic hysterectomy. JSLS 17(4):661–664. doi:10.4293/108680813X13794522666446

    Article  PubMed Central  PubMed  Google Scholar 

  21. Ho LM, Paulson EK, Thompson WM (2007) Pneumatosis intestinalis in the adult: benign to life-threatening causes. AJR Am J Roentgenol 188(6):1604–1613

    Article  PubMed  Google Scholar 

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Conflict of interest

We wish to confirm that there are no known conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing, we confirm that we have followed the regulations of our institutions concerning intellectual property.

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Correspondence to Samuel Borofsky.

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Borofsky, S., Taffel, M., Khati, N. et al. The emergency room diagnosis of gastrointestinal tract perforation: the role of CT. Emerg Radiol 22, 315–327 (2015).

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