Imaging of

Alimentary Tract
Perforation
Luigia Romano
Antonio Pinto
Editors

123
Imaging of Alimentary Tract Perforation
Luigia Romano • Antonio Pinto
Editors

Imaging of Alimentary
Tract Perforation
Editors
Luigia Romano Antonio Pinto
Department of Radiology Department of Radiology
“A. Cardarelli” Hospital “A. Cardarelli” Hospital
Naples Naples
Italy Italy

ISBN 978-3-319-08191-5 ISBN 978-3-319-08192-2 (eBook)

DOI 10.1007/978-3-319-08192-2
Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014951824

© Springer International Publishing Switzerland 2015

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Preface

Alimentary tract perforations represent an emergency and life-threatening

condition requiring prompt diagnosis and surgical treatment in most cases.
Diagnosis depends on clinical suspicion: The clinical symptoms of free
perforation are associated with the underlying cause of the perforation, and
the clinical presentations of patients with a perforated viscus are quite vari-
able. Imaging examinations play an important role in order to determine the
correct diagnosis and ensure an appropriate treatment to the patient.
The purpose of this book is to illustrate and discuss causes and imaging
features related to cases of alimentary tract perforation from the esophagus to
the rectum, occurring in radiology practice. Signs of a pneumoperitoneum on
plain abdominal film, on abdominal ultrasonography, and on Multi-detector
row Computed Tomography are extensively illustrated; moreover, the role of
plain abdominal film, abdominal ultrasonography, and Multi-detector row
Computed Tomography are addressed. In addition, imaging of gastrointestinal
tract perforation in the pediatric patient, in the elderly patient, and in the
oncological patient are presented.
We hope that this book will provide important information to Residents in
Radiology, Radiologists, and Physicians daily involved in the Emergency
Department in the management of patients with suspected alimentary tract
perforation.

Naples, Italy Luigia Romano

Naples, Italy Antonio Pinto
September 2014

v
Contents

1 Diagnostic Approach to Alimentary

Tract Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Francesca Iacobellis, Daniela Berritto, and Roberto Grassi
2 Plain Film Signs of Pneumoperitoneum . . . . . . . . . . . . . . . . . . . 9
Antonio Pinto, Roberta Grassi, and Carlo Liguori
3 Ultrasonographic Assessment
of Gastrointestinal Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Massimo Valentino and Libero Barozzi
4 Esophageal Perforation: Assessment with Multidetector
Row Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Nicola Gagliardi, Ciro Stavolo, and Angela De Gennaro
5 Role of Multidetector Row Computed Tomography
in the Diagnosis of Gastroduodenal Perforation . . . . . . . . . . . . 29
Daniela Vecchione, Giovanna Russo, and Raffaella Niola
6 Small Bowel Perforations: Imaging Findings . . . . . . . . . . . . . . . 37
Stefania Romano
7 Acute Perforated Appendicitis: Spectrum of
MDCT Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Stefania Daniele, Silvana Nicotra, and Carlo Liguori
8 Acute Perforated Diverticulitis: Spectrum of
MDCT Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Maria Giuseppina Scuderi and Teresa Cinque
9 Colorectal Perforation: Assessment with MDCT. . . . . . . . . . . . 61
Gianluca Ponticiello, Loredana Di Nuzzo,
and Pietro Paolo Saturnino
10 MDCT Imaging of Blunt Traumatic Bowel
and Colonic Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Francesco Iaselli, Isabella Iadevito, Franco Guida,
Giacomo Sica, Giorgio Bocchini, and Mariano Scaglione

vii
viii Contents

11 MDCT Imaging of Gastrointestinal Tract

Perforation Due to Foreign Body Ingestion . . . . . . . . . . . . . . . . 79
Roberta Cianci, Valentina Bianco, Gianluigi Esposito,
Andrea Delli Pizzi, and Antonella Filippone
12 Pneumoretroperitoneum: Imaging Findings . . . . . . . . . . . . . . . 85
Antonio Pinto, Carlo Muzj, and Giuseppe Ruggiero
13 Imaging of Gastrointestinal Tract Perforation
in the Pediatric Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Cecilia Lanza, Elisabetta Panfili, and Andrea Giovagnoni
14 Imaging of Gastrointestinal Tract Perforation
in the Elderly Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Alfonso Reginelli, Anna Russo, Duilia Maresca,
Fabrizio Urraro, Giuseppina Fabozzi, Francesco Stanzione,
Alfredo D’Andrea, Ciro Martiniello, and Luca Brunese
15 Imaging of Gastrointestinal Tract Perforation
in the Oncologic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Luigia Romano, Sonia Fulciniti, Massimo Silva,
Riccardo Granata, and Giuseppe Ruggiero
16 Role of Multidetector Row Computed
Tomography in the Diagnosis of Acute Peritonitis
Due to Gastrointestinal Perforation . . . . . . . . . . . . . . . . . . . . . . 133
Vittorio Miele and Barbara Sessa
17 Abdominal Compartment Syndrome
and Gastrointestinal Tract Perforation . . . . . . . . . . . . . . . . . . . . 147
Ciro Acampora, Rosa Ignarra, and Antonio Pinto

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
 Diagnostic Approach
to Alimentary Tract Perforations 1
Francesca Iacobellis, Daniela Berritto,
and Roberto Grassi

1.1 Introduction emergency department even if its role is currently

debated; ultrasound (US) and computed
Alimentary tract perforations represent an emer- tomography (CT) traditionally have been the dom-
gency and life-threatening condition requiring inant cross-sectional imaging modalities for evalu-
prompt diagnosis and surgical treatment [1]. ating acute thoracic, abdominal, and pelvic
Diagnosis depends on clinical suspicion and conditions; magnetic resonance (MR) is not yet
especially on imaging examinations that allow us widely used in diagnostic work-up of patients with
to define the presence, the level, and cause of per- acute abdominal pain, but can be useful in the dif-
foration [2]. ferential diagnosis of acute abdomen in specific
These details are essential to define an appro- patients (pregnancy, pediatric patients) [7].
priate management and the surgical approach.
Bowel perforation can be spontaneous, trau-
matic, or iatrogenic in etiology and can occur 1.2 Clinical Symptoms
both in the upper and lower intestines [1–4]. and Etiology
The clinical diagnosis, particularly in the early
stage, is difficult as the symptoms may be vari- The clinical symptoms are related to the cause
able and nonspecific [5]. and the site of the perforation, so the clinical pre-
The standard treatment is prompt surgery, and sentation is variable. Nevertheless, an “acute
if the diagnosis and treatment are delayed, the abdomen” is usually present [7].
patient morbidity (sepsis and multiorgan failure) Other clinical manifestations include nausea,
results in 75 % and mortality in 30 % [1, 6]. The vomiting, fever, localized abscess formation,
imaging plays an important role to determine the inflammatory mass, fistulas, and gastrointestinal
diagnosis and ensure an appropriate treatment to hemorrhage. Rare complications secondary to
these patients. perforation are septicemia, portal pyemia or pyo-
Plain abdominal X-ray still remains the most genic abscess, enterovascular fistulas, and even
frequently requested imaging examination in the endocarditis.
Usually the pain is initially localized in the
suggested site of origin but may move to a differ-
F. Iacobellis, MD (*) • D. Berritto • R. Grassi ent site by the time the patient is examined to cul-
Department of Radiology, Second University of Naples, minate – if not promptly treated – in diffuse,
Piazza Miraglia 2, Naples, 80138, Italy
poorly localized abdominal pain [8].
e-mail: [email protected];
[email protected]; The etiology spontaneous, traumatic, or
[email protected] iatrogenic is suggested by the clinical history.

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 1

DOI 10.1007/978-3-319-08192-2_1, © Springer International Publishing Switzerland 2015
2 F. Iacobellis et al.

The esophageal perforation is more com- In the available literature, it is emphasized

monly iatrogenic, caused by endoscopic that plain abdominal X-ray should not be used
procedures – dilatation for strictures and achala- as a routine investigation in patients with
sia [9] – or by surgical complications [10]. undifferentiated abdominal pain, unless there is
The traumatic etiology, which is less common, clinical suspicion of bowel obstruction [20].
can result from penetrating sharp injuries or from The detection of free intraperitoneal gas on the
gunshot [11]. plain X-ray usually indicates bowel perforation.
A spontaneous rupture − 15 % of cases – can The reported specificity of plain X-ray for pneu-
be due to intensive vomiting or Boerhaave syn- moperitoneum ranges from 50 to 70 % according
drome [12, 13]. to some AA [8] and from 53 to 89.2 % according
Other causes are represented by foreign body to other AA [23], but the site of perforation is
ingestion and esophageal tumors [1, 14, 15]. almost never elucidated. It is also reported that
Peptic ulcers are the main cause of gastroduo- pneumoperitoneum or retroperitoneum may be
denal perforation, followed by necrotic or ulcer- not be detected in up to 49 % of patients [24].
ated malignancies, blunt or penetrating trauma, Experimental studies [25] have shown that as
and iatrogenic causes [1, 2, 8]. little as 1 ml of gas can be detected below the
The main etiologies for small bowel perfora- right hemidiaphragm on properly exposed erect
tion are inflammatory, infectious, and ischemic chest radiographs [5].
conditions, small bowel diverticulitis, mechani- Signs of esophageal perforation can be seen on
cal obstruction, trauma, malignancy, iatrogenic posteroanterior and lateral plain chest radio-
causes, and foreign bodies [1, 16]. graphs. Such signs are indirect findings and
Colon and rectum perforations are related to include pleural effusion, pneumomediastinum,
tumors, inflammatory pathologies, iatrogenic subcutaneous emphysema, hydrothorax, pneumo-
causes, and foreign bodies [1, 15, 17]. thorax, and collapse of the lung. If a water-soluble
contrast medium is administered, it will reveal a
contrast leak in most cases of esophageal perfora-
1.3 Imaging tion [13]; water-soluble contrast should be used
instead of barium contrast to avoid barium-related
1.3.1 Plain Abdominal X-Ray inflammation of mediastinum if there is perfora-
tion. If the initial contrast swallowing study is
Even if in the American College of Radiology negative, imaging should be repeated after 4–6 h
(ACR) appropriateness criteria [18] the enhanced if the clinical suspicion remains [12].
CT of the abdomen and pelvis is considered Plain abdominal radiograph is usually per-
the most appropriate examination for patients formed in upright and supine decubitus; in addi-
with fever, non-localized abdominal pain, and tion, upright chest films and/or left lateral
no recent surgery, plain radiography remains decubitus abdominal films can also be used (in the
the most frequently requested examination per- detection of small amounts of free air that may be
formed as initial imaging in the assessment of interposed between the free edge of the liver and
patients who present with acute abdominal pain the lateral wall of the peritoneal cavity). In criti-
to the emergency department [7, 19, 20, 21, 22]. cally ill patients, the supine decubitus is preferred,
Plain abdominal radiograph is widely available with anteroposterior and lateral views of the abdo-
and can be easily performed. It can exclude men and anteroposterior view of the thorax [19].
major illness such as bowel obstruction and per- Supine abdominal radiograph allows detec-
forated viscus [7]. However, it should be con- tion of moderate or large amounts of free intra-
sidered that plain abdominal film exposes the peritoneal air, but is insensitive in detecting small
patient to 35 times the radiation dose of a chest amounts of free intraperitoneal air; upright
X-ray (0.7 mSv) and then its use must be care- abdominal radiographs are better than supine in
fully assessed anyway [7]. showing pneumoperitoneum; however, because
1 Diagnostic Approach to Alimentary Tract Perforations 3

the X-ray beam is centered on the mid-abdomen, that US allows diagnosing or confirming one of
and the exposure is high, small amounts of free the possible differential diagnosis or provides
air can be obscured. Left lateral decubitus radio- information in 65 % of patients [7].
graph of the abdomen can show small amounts of Diagnostic value of plain X-ray (erect chest
free air if the heavy exposure does not compro- film) compared versus US in the detection of
mise the detection. On upright posteroanterior pneumoperitoneum in patients with suspected
chest radiograph, the central X-ray beam pene- bowel perforation showed US sensitivity of 92 %
trates air in the superior portion of the subdia- (versus 78 % of plain abdominal film), a negative
phragmatic recess along its long axis and usually predictive value of 39 % (versus 20 %), and spec-
does not burn out small amount of free air. The ificity of 53 % (versus 53 %) concluding that
upright lateral chest radiograph is more sensitive ultrasound is more sensitive than plain radiogra-
than the posteroanterior chest radiograph in phy in the diagnosis of pneumoperitoneum [23],
detecting small amounts of pneumoperitoneum even if establishing the cause and location of the
as the long axis of X-ray beam can show small air perforation is difficult with US [7].
collection that may remain trapped anterior to the Other AA detected a lower sensitivity for the
liver [5, 8, 19, 26, 27]. US if compared with radiography (76 % versus
Several signs of intraperitoneal free air, direct 92 %, respectively), suggesting the use of US
finding of perforation, were described: in the only in selected cases [35].
upright thoracic film, the air in the subdiaphrag- The US examination is conducted with patient
matic regions and, on the supine abdominal films, in supine position, preferably with the thorax
the outlining of various peritoneal reflections slightly elevated (10–20°) [36]; the linear array
between the mesenteric folds. transducers (10–12 MHz) are more sensitive than
In other cases, indirect sign of perforation convex transducers(2–5 MHz) in the detection of
could be visible such as translucent triangle, intraperitoneal free air for their size and shape
lucent liver, perihepatic gas collections, Rigler’s and for their resolution [36].
sign, and cupola sign, and football and cap of US signs of free intraperitoneal air are repre-
Doge signs can be detected [19, 28–30]. sented by echogenic lines or spots with comet-
Some AA retain that in the presence of clini- tail reverberation artifacts adjacent to the
cal signs of acute abdominal pathology, pneumo- abdominal wall. These signs are best detected in
peritoneum identified on plain X-ray obviates the the prehepatic space using linear probes.
need for further imaging and constitutes an indi- If a pneumoretroperitoneum is present, the
cation for laparotomy [31, 32] even if in the detection of the air around the duodenum and the
majority of cases, further imaging is useful to head of the pancreas and especially ventral to the
clarify the site and the etiology of perforation. great abdominal vessel lead to the picture of
“vanishing” vessels [37].
Indirect signs of bowel wall perforation
1.3.2 US detectable at US are represented by intraperito-
neal free fluid and/or reduced intestinal peri-
Abdominal US examination is particularly indi- stalsis [36].
cated in patients in whom radiation should be US main limits are represented by the opera-
avoided, as well as children and pregnant woman, tor dependence and by the poor cooperation of
being a noninvasive, rapid diagnostic, wide avail- some patients due to the abdominal pain; obese
able and low-cost method [33]. It represents an patients and patients with subcutaneous emphy-
optimal first-line imaging method in emergency sema are difficult to scan too [36]. Furthermore,
department [7, 34]. US has low sensitivity in the detection of retro-
Some AA reports that US could provide use- pneumoperitoneum; so, it should not be consid-
ful information in 56 % of patients with acute ered definitive in excluding a pneumoperitoneum
abdominal pain, and in another study it is reported [7, 35].
4 F. Iacobellis et al.

1.3.3 Multidetector CT (MDCT) site of perforation [38] even if CT detection of

pathognomonic image findings of bowel perfora-
MDCT is considered most valuable imaging tion is uncommon [39, 44, 47]; CT multiplanar
technique for identifying the presence, site, and reconstruction is very helpful in the identification
cause of alimentary tract perforations [2, 3, 38, of alimentary tract perforations, and the lung
41, 42] and some AA consider CT as the primary window setting could be used to assist in detec-
technique for the diagnosis of acute abdominal tion of free gas [7, 42].
pain, except in patients clinically suspected for In patients with esophageal perforation, a col-
acute cholecystitis – in which US represents the lection of air or fluid in the mediastinum, pleural
technique of choice [7]. effusions, pneumocardium, and pneumoperito-
MDCT is superior to single helical CT allow- neum are important diagnostic findings. The site
ing a rapid execution of the diagnostic exam also and the degree of perforation may be easier to
in patients with difficulties to perform prolonged judge by CT than by plain chest X-ray [12].
breath holds; the thinner collimation may Free air located around the liver and stomach
improve the visualization of CT findings sugges- is suggestive for a gastroduodenal perforation. If
tive of colonic perforation too [8]. free air is detected predominantly in the pelvis
The CT examination in emergency setting is and supramesocolic and inframesocolic regions,
performed with the administration of intravenous a perforation of the colon or appendix is more
(iv) contrast medium and includes the thorax if likely [38].
an esophageal perforation is suspected and/or the Extraluminal intra- or retroperitoneal air can
entire abdomen, from the dome of the diaphragm occur without GI tract perforation too. Various
to the pelvic floor; the administration of iv con- causes were described, such as mechanical venti-
trast medium facilitates a good accuracy and a lation and pulmonary barotraumas, peritoneal
high level of diagnostic confidence [7]. lavage performed prior to CT, pneumothorax,
The range of sensitivity and specificity of chest injury, and entry of air via the female geni-
MDCT for gastrointestinal perforation is between tal tract [39].
80 and 100 % [43]. The CT diagnosis of alimen- MDCT accuracy in predicting the site of per-
tary tract perforation is based on direct CT find- foration may rise to 86 % [5, 38], and the addi-
ings, such as discontinuity of the bowel wall and tional information gained may be useful in either
the presence of extraluminal air and on indirect directing or avoiding surgery in patients with
CT findings, such as bowel wall thickening, pneumoperitoneum on plain X-ray.
abnormal bowel wall enhancement, abscess, and In the last years, with the increased use of CT,
inflammatory mass adjacent to the bowel [40]. the diagnosis of contained perforations is more
Bowel wall discontinuity is a pathognomonic common, and it is possible to consider a conser-
image finding for bowel perforation and can pre- vative treatment [7]. The monitoring of selected
dict the perforation site before surgery, the CT patients with alimentary tract perforations with
detection rate of bowel wall discontinuity was repeated CT studies helps in nonoperative man-
low. A previous study with single spiral CT agement. However, in patients with peritonitis,
reported 0–8 % detection rate of bowel wall dis- the CT does not significantly alter the manage-
continuity on initial CT scans [44, 45]. The rela- ment or the surgical approach [31].
tively infrequent detection of this finding is partly A further specific finding of alimentary tract
due to the small size of the lesion [39]. perforations is the extraluminal leakage of oral
Free air was detected using CT in only approx- contrast medium that is also considered diagnos-
imately 50 % of the cases of small bowel perfora- tic for bowel perforation, so it could be useful to
tion [29, 40, 42]. opacify the entire alimentary tract with a suffi-
The detection of extraluminal air bubbles, cient quantity of contrast agent especially when
focal defects of bowel wall, and segmental bowel an upper intestinal tract perforation is suspected
wall thickening allows us to correctly identify the [8] even if the overall detection rate of extraluminal
1 Diagnostic Approach to Alimentary Tract Perforations 5

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x rays in the emergency department. Emerg Med J raphy for the detection of pneumoperitoneum. Acad
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21. Reginelli A, Mandato Y, Solazzo A, Berritto D, 36. Coppolino F, Gatta G, Di Grezia G, Reginelli A,
Iacobellis F, Grassi R (2012) Errors in the radiological Iacobellis F, Vallone G, Giganti M, Genovese E
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22. Grassi R, Di Mizio R, Pinto A, Romano L, Rotondo A 37. Nurberg D, Mauch M, Spengler J, Holle A, Pannwitz
(2004) Serial plain abdominal film findings in the H, Seitz K (2007) Sonographical diagnosis of pneu-
assessment of acute abdomen: spastic ileus, hypotonic moretroperitoneum as a result of retroperitoneal per-
ileus, mechanical ileus and paralytic ileus. Radiol foration. Ultraschall Med 28(6):612–621
Med 108(1–2):56–70 38. Hainaux B, Agneessens E, Bertinotti R, De Maertelaer V,
23. Chen SC, Yen ZS, Wang HP, Lin FY, Hsu CY, Chen Rubesova E, Capelluto E, Moschopoulos C (2006)
WJ (2002) Ultrasonography is superior to plain radi- Accuracy of MDCT in predicting site of gastrointestinal
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Surg 89:351–354 39. Brofman N, Atri M, Hanson JM, Grinblat L,
24. Hefny AF, Abu-Zidan FM (2011) Sonographic diag- Chughtai T, Brenneman F (2006) Evaluation of bowel
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Shock 4(4):511–513 CT. Radiographics 26:1119–1131
25. Miller RE, Nelson SW (1971) The roentgenologic 40. Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang
demonstration of tiny amounts of free intraperitoneal HK (2009) Gastrointestinal tract perforation: MDCT
gas: experimental and clinical studies. AJR Am J findings according to the perforation sites. Korean J
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26. Pendergrass EP, Kirk E (1995) Significance of gas 41. Rossi G, Grassi R, Pinto A, Ragozzino A, Romano L
under right dome of diaphragm with discussion of (1998) New computerized tomography sign of intesti-
hepatoptosis. Am J Roentgenol 22:238–246 nal infarction: isolated pneumoretroperitoneum or
27. Woodring JH, Heiser MJ (1995) Detection of pneu- associated with pneumoperitoneum or late findings of
moperitoneum on chest radiographs: comparison of intestinal infarction. Radiol Med 95(5):474–480
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Conventional plain-film radiology, ultrasonography 43. Cadenas Rodríguez L, Martí de Gracia M, Saturio
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39(1):52–56 Garzón Moll G (2013) Use of multidetector computed
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tomography for locating the site of gastrointestinal 47. Hawkins AE, Mirvis SE (2003) Evaluation of bowel
tract perforations. Cir Esp 91:316–323 and mesenteric injury: role of multidetector CT.
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L, Grassi R (2004) Blunt trauma to the gastrointes- Papadopoulos B, Malka V (2005) Accuracy of com-
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 Plain Film Signs
of Pneumoperitoneum 2
Antonio Pinto, Roberta Grassi, and Carlo Liguori

2.1 Introduction diaphragm [3]. The upright chest radiograph can

enable detection of as little as 1 mL of free air
Pneumoperitoneum is caused by rupture of a hol- located beneath the right or left hemidiaphragm
low viscus which includes the stomach, small [4]. In the emergency setting, in critically ill
bowel, and large bowel, with the exception of those patients, radiographic examination is performed
portions that are retroperitoneal in the duodenum in the supine decubitus, with anteroposterior and
and colon. The most frequent cause of spontaneous lateral view of the abdomen and anteroposterior
pneumoperitoneum is perforation of a gastric or view of the thorax [5].
duodenal ulcer. The magnitude of free air is vari- It is crucial that the radiologist become famil-
able, being related to the size and site of the ulcer. iar with the signs of pneumoperitoneum that can
A large perforation allows more rapid passage of be discerned on the supine film of the abdomen
air. Pneumoperitoneum may also be observed with because that may be the only radiograph avail-
a variety of other conditions including recent able for interpretation [2].
abdominal surgery, trauma, infection, paracentesis,
and pneumatosis intestinalis [1]. After laparotomy,
air will usually be present for 3–7 days, gradually 2.2 Etiology and Clinical
decreasing in volume daily [2]. Presentation
Upright posteroanterior chest radiogra-
phy traditionally has been used for the initial There are four etiologic categories of pneumo-
examination of patients suspected of having peritoneum: iatrogenic, spontaneous, traumatic,
pneumoperitoneum. Pneumoperitoneum is visu- and miscellaneous [6]. Iatrogenic causes include
alized as a translucent crescent or area below the surgery, recent endoscopy, peritoneal dialysis,
feeding tube placement, use of gynecologic
instruments, and vigorous respiratory resuscita-
A. Pinto (*) • C. Liguori tion. Spontaneous causes comprise peptic ulcer
Department of Radiology, perforation, intestinal ischemia, bowel obstruc-
“A. Cardarelli” Hospital,
Via Cardarelli 9, Naples I-80131, Italy
tion, toxic megacolon, and inflammatory condi-
e-mail: [email protected]; tions such as acute appendicitis, tuberculosis, and
[email protected] necrotizing enterocolitis. Traumatic causes can
R. Grassi (*) be blunt or penetrating, either of which can deter-
Department of Internal and Experimental Medicine mine intestinal perforation. Miscellaneous causes
Magrassi-Lanzara, Institute of Radiology, include drugs (steroidal drugs, nonsteroidal anti-
Second University of Naples, Naples I-80131, Italy
e-mail: [email protected]
inflammatory drugs) and pneumatosis coli or

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 9

DOI 10.1007/978-3-319-08192-2_2, © Springer International Publishing Switzerland 2015
10 A. Pinto et al.

intestinalis. Miscellaneous causes may also be chest radiograph in detecting small amounts of
female genital tract related (after coitus, orogeni- pneumoperitoneum. However, many patients
tal sex, and even sometimes following exercise in with an acute abdomen are too sick or debilitated
the postpartum period) [6, 7]. to stand erect for the time necessary to permit air
Because the clinical symptoms of free perfo- to migrate to the least dependent portion of the
ration are associated with the underlying cause of peritoneal cavity. Miller and Nelson [12] showed
the perforation, the clinical presentations of that as little as 1–2 mL of free air could be
patients with perforated viscus are quite variable. detected if a strict protocol of positioning the
Patients will typically present with the acute patient in the left lateral decubitus position for
onset of abdominal pain that is persistent, pro- 10–20 min and then in the upright position for an
gressive, and unremitting. Severity of the pain additional 10 min was followed. This protocol is
will depend on the type and amount of intestinal of limited use for patients with clinical symptoms
contents released into the peritoneal cavity. that preclude a wait of this duration and in those
Patients may have associated symptoms includ- patients unable to cooperate by maintaining the
ing fever, nausea, and vomiting. On physical optimal position described.
examination, a patient with intestinal perforation The left lateral decubitus position is also
will typically manifest diffuse tenderness to pal- uncomfortable, raising further questions about
pation and peritonitis [8]. Recognizing a perfora- patient compliance. In the emergency setting, in
tion and establishing the cause and site of the critically ill patients, radiographic examination is
perforation can yield crucial information for the generally performed in the supine decubitus, with
surgeon [3]. anteroposterior and lateral view of the abdomen
and anteroposterior view of the thorax [5].

2.3 Plain Abdominal

Radiographs 2.4 Signs of Pneumoperitoneum
on Plain Radiographs
Conventional radiography is commonly the ini-
tial imaging examination performed in the diag- There are many possible radiographic appear-
nostic workup of patients who present with acute ances of pneumoperitoneum.
abdominal pain to the emergency department. On upright posteroanterior chest radiography,
Plain radiography can demonstrate 55–85 % of pneumoperitoneum is visualized as a translucent
patients with pneumoperitoneum [9]. This exam- crescent or area below the diaphragm (Fig. 2.1).
ination is widely available, can be easily per- Pneumoperitoneum can also be detected on left
formed in admitted patients, and is used to lateral decubitus radiograph of the abdomen
exclude major illness such as perforated viscus, (Fig. 2.2) and on cross-table lateral abdominal
bowel obstruction, and foreign body ingestion radiograph (Fig. 2.3).
[10]. Moreover, plain abdominal film is useful in On supine abdominal radiograph, free perito-
the evaluation of the different types of ileus neal air may become visible and, in various
(spastic ileus, hypotonic ileus, mechanical ileus, shapes and sizes, may be located in different
and paralytic ileus) [10]. positions. These free air signs can be categorized
Conventional radiography includes supine and into four groups: bowel-related signs, right upper
upright conventional abdominal radiography and quadrant signs, peritoneal ligament-related signs,
upright chest radiography [3]. On upright pos- and other signs [13].
teroanterior chest radiography, pneumoperito- Bowel-related signs include the following:
neum is visualized as a translucent crescent or • Rigler sign. The Rigler sign (Fig. 2.4), also
area below the diaphragm. As reported in litera- known as the bas-relief sign or the double-
ture [11] the upright lateral chest radiograph is wall sign, is the visualization of both sides
more sensitive than the upright posteroanterior of the bowel wall, on a radiograph of the
2 Plain Film Signs of Pneumoperitoneum 11

Fig. 2.1 Upright posteroanterior chest radiograph:

evidence of free air beneath the right and left Fig. 2.4 Anteroposterior supine abdominal radiograph
hemidiaphragms shows the Rigler sign (arrow)

Fig. 2.5 Cross-table lateral radiograph of the abdomen

showing the triangle sign (arrow)

Fig. 2.2 Left lateral decubitus film of the abdomen in a abdomen obtained with the patient in the
patient with free peritoneal air resulting from gastric supine position, in the presence of a large vol-
perforation ume of free air so that the bowel loops can be
separated from each other [14].
• Triangle sign. Free intraperitoneal air accu-
mulating among three adjoining bowel loops
or two bowel loops and the parietal peritoneum
(Fig. 2.5) appearing as a triangular radiolu-
cency is called the triangle sign [15].
Right upper quadrant signs include the
following:
• Hyperlucent liver sign. On the supine radio-
graphs, the blacker density of the large intra-
peritoneal free gas anterior to the ventral
hepatic surface replacing the brightness of the
Fig. 2.3 Cross-table lateral abdominal radiograph dem- hepatic shadow is called the hyperlucent liver
onstrating the presence of pneumoperitoneum sign (Figs. 2.6 and 2.7) [15].
12 A. Pinto et al.

• Fissure for ligamentum teres sign. This sign

refers to a characteristic elongated area of
hyperlucency that represents intraperitoneal
gas trapped within the fissure for the ligamen-
tum teres [17].
• The visible gallbladder. On supine abdominal
radiograph, the gallbladder is seen as a homo-
geneous opacity because of surrounding free
intraperitoneal air [18].
• Doge cap sign. This sign refers to triangle-
shaped free air accumulated in Morison pouch
on supine abdominal films [15, 19].
• Hepatic edge sign. An oblong saucer or cigar-
shaped collection of free air may be seen in
Fig. 2.6 Anteroposterior supine chest radiograph shows the subhepatic space with its long axis directed
the hyperlucent liver sign superomedially following the liver contour
[15, 20].
• Dolphin sign. The undersurface of the long
costal muscle slips of the diaphragm that
indented the adjacent air-filled space in the
right upper quadrant on supine films is a sign
of pneumoperitoneum [21].
Peritoneal ligament-related signs include the
following:
• Falciform ligament sign. The intraperitoneal
free air may outline the falciform ligament,
which is seen as a linear density situated lon-
gitudinally within the right upper abdomen
(Fig. 2.7) [15, 22].
• Extrahepatic ligamentum teres sign. The liga-
mentum teres is another anterior peritoneal
ligament that can be visualized on plain radio-
graphs. It is a firm fibrous cord representing
the remnant of an obliterated left umbilical
vein. On supine radiographs, the extrahepatic
ligamentum teres may be seen when outlined
by free air anywhere along the course of the
ligament [23].
• The “inverted V” sign. Free air outlining the
Fig. 2.7 A supine radiograph of the abdomen showing
the hyperlucent liver sign, the falciform ligament sign
lateral umbilical ligaments makes these struc-
(arrow), and the mesoappendix sign (arrows) in a perfo- tures visible in the lower abdomen, forming an
rated patient “inverted V” as they course inferiorly and
laterally from the umbilicus [24, 25].
• Urachus sign. When pneumoperitoneum
• Anterior superior oval sign. This sign refers to occurs, the urachus may be seen as a thin mid-
a single or multiple oval, round, or pear- line linear structure in the lower abdomen
shaped gas bubbles projected over the liver from the umbilicus to the dome of the urinary
shadow [15, 16]. bladder [26].
2 Plain Film Signs of Pneumoperitoneum 13

• The transverse mesocolon and root of small Although the upright and left decubitus pro-
bowel mesentery signs. The intraperitoneal jections are the most sensitive views for the
free air can determine the identification of the radiographic recognition of small collections
transverse mesocolon and the root of the small of free intraperitoneal air, the role of the
bowel mesentery on plain abdominal radio- supine projection should not be minimized
graphs obtained in the supine and in the prone especially in the critically ill patients. There
position [27]. are many useful signs that may contribute to a
• The mesoappendix sign. In the presence of a diagnosis of free air at supine radiography.
large amount of pneumoperitoneum, the
mesoappendix may be observed on the supine
radiograph as a radiopaque linear stripe References
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abdomen (Fig. 2.7). 1. Pinto A, Scaglione M, Pinto F et al (2000) Helical
computed tomography diagnosis of gastrointestinal
Other signs of pneumoperitoneum are the
perforation in the elderly patient. Emerg Radiol
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cency in the shape of an American football neal and retroperitoneal spaces. In: Baker SR (ed) The
abdominal plain film. Appleton & Lange, Norwalk/
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The oval radiolucency seen in the football sign Imaging patients with acute abdominal pain.
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Detection of pneumoperitoneum: optimum body
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and CT findings in 166 consecutive patients. Eur J
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figuration of the lucency. 6. Ly JQ (2003) The Rigler sign. Radiology 228:706–707
• Left-sided anterior superior oval sign. Chiu 7. Manchanda R, Refaie A (2005) Acute pneumoperito-
neum following coitus. CJEM 7:51–53
et al. [13] defined a single or multiple oval,
8. Brown CVR (2014) Small bowel and colon perfora-
round, or pear-shaped free air projected over tion. Surg Clin North Am 94:471–475
the left upper quadrant abdomen as the “left- 9. Roh JJ, Thompson JS, Harned RK et al (1983) Value
sided anterior superior oval sign.” of pneumoperitoneum in the diagnosis of visceral per-
foration. Am J Surg 146:830–833
• Subphrenic radiolucency. Radiolucency that
10. Grassi R, Di Mizio R, Pinto A et al (2004) Serial plain
appeared beneath the diaphragm, either right abdominal film findings in the assessment of acute
or left side on the supine chest radiographs, abdomen: spastic ileus, hypotonic ileus, mechanical
has been defined as “subphrenic radiolu- ileus and paralytic ileus. Radiol Med 108:56–70
11. Woodring JH, Heiser MJ (1995) Detection of pneu-
cency” [13].
moperitoneum on chest radiographs: comparison of
• Focal radiolucency. The abnormal gas pattern upright lateral and posteroanterior projections. AJR
presenting on the supine films without fitting Am J Roentgenol 165:45–47
any sign mentioned above has been called 12. Miller RE, Nelson SW (1971) The roentgenologi-
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Roentgenol Radium Ther Nucl Med 112:574–585
Conclusions 13. Chiu Y-H, Chen J-D, Tiu J-D et al (2009) Reappraisal
The diagnosis of hollow-organ perforation is of radiographic signs of pneumoperitoneum at emer-
gency department. Am J Emerg Med 27:320–327
based on the evidence of pneumoperitoneum.
14. Rigler LG (1941) Spontaneous pneumoperitoneum: a
Pneumoperitoneum can be an indicator of roentgenologic sign found in the supine position.
potentially serious intraperitoneal disease. Radiology 37:604–607
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15. Cho KC, Baker SR (1994) Extraluminal air diagnosis 23. Cho KC, Baker SR (1997) Visualization of the extra-
and significance. Radiol Clin North Am 32:829–844 hepatic segment of the ligamentum teres: a sign of free
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17. Cho KC, Baker SR (1991) Air in the fissure for the Radiology 107:47–48
ligamentum teres: new sign of intraperitoneal air on 25. Bray JF (1984) The “inverted V” sign of pneumoperi-
plain radiographs. Radiology 178:489–492 toneum. Radiology 151:45–46
18. Radin R, Van Allan RJ, Rosen RS (1996) The visible 26. Jelaso DV, Schultz EH (1969) The urachus – an aid
gallbladder: a plain film sign of pneumoperitoneum. to the diagnosis of pneumoperitoneum. Radiology 92:
AJR Am J Roentgenol 167:69–70 295–296
19. Brill PW, Olson SR, Winchester P (1990) Neonatal 27. Grassi R, Catalano O, Pinto A et al (1996) Case
necrotizing enterocolitis: air in Morison pouch. report: identification of the transverse mesocolon and
Radiology 174:469–471 root of small bowel mesentery; a new sign of pneumo-
20. Menuck L, Siemers PT (1976) Pneumoperitoneum: peritoneum. Br J Radiol 69:774–776
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J Roentgenol 127:753–756 roentgen sign. Radiology 74:65–67
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matic muscle slips on supine plain radiographs: a sign 231:81–82
of pneumoperitoneum. Radiology 203:431–433 30. Mindelzun RE, McCort JJ (1986) The cupola sign of
22. Han SY (1980) Variations in falciform ligament with pneumoperitoneum in the supine patient. Gastrointest
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 Ultrasonographic Assessment
of Gastrointestinal Perforation 3
Massimo Valentino and Libero Barozzi

3.1 Introduction mesentery. In case of gastrointestinal perforation,

a correct interpretation of the artifact due to free
Gastrointestinal perforation is diagnosed by dem- air eventually present can lead to the correct
onstrating air or intestinal content in the perito- diagnosis.
neum or retroperitoneum. The diagnosis of free
air in the abdominal cavity is usually made with
x-ray, both chest radiography in the standing 3.2 Technique
position and abdominal radiography in the
upright and left lateral position. Miller et al. The concept of visualizing abdominal air using
reported that as little as 1–2 ml of free intraperi- US is not new. In fact, one of the most compre-
toneal air can potentially be imaged [1]. However, hensive and detailed studies on the topic was
in clinical practice, x-ray may not detect small published nearly 30 years ago [4]. Seitz et al.
amount of air on radiography, and CT is often observed that US examination of patients with
requested. recent cholecystectomy was impeded by strong
Recently, ultrasonography (US) has emerged hyperechoic reverberation and shadowing arti-
as a useful diagnostic technique in patients with facts caused by postoperative free air.
acute abdomen also for detecting pneumoperito- Most authors agree that the best place to look
neum [2]. US is routinely performed to investi- for pneumoperitoneum by US is in the right
gate patients with abdominal pain, including hypochondrium, superficial to the liver, with the
those having gastrointestinal perforation as final patient in the supine position with the thorax
diagnosis [3]. During abdominal examination slightly elevated or in a semilateral decubitus
of these patients, US images all the contents position [5]. If the patient is studied in a left
of the abdominal cavity, including bowel and semilateral decubitus, free air collects in the ven-
tral hepatoperitoneal space. In his study, Asrani
was able to demonstrate that air at US can be
M. Valentino (*)
Dipartimento Diagnostico, U.O. di Radiologia, observed in all quadrants of the abdomen, with
Ospedale S. Antonio Abate, Tolmezzo (UD), 83 % being observable in the right hypochon-
Via Morgagni, 18, Tolmezzo (UD) 33028, Italy drium, 75 % in the umbilical region, and in 8.3 %
e-mail: [email protected] in the right lumbar region [6]. Another study sug-
L. Barozzi gests positioning the patient supine with 10–20°
Dipartimento Servizi, U.O. Radiologia OM e Area inclination for a better visualization of air [7].
Nord-Ovest, Ospedale Maggiore, Bologna,
Largo Nigrisoli 2, Bologna 40100, Italy In the clinical practice, patients are studied
e-mail: [email protected] in the supine position, searching for the same

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 15

DOI 10.1007/978-3-319-08192-2_3, © Springer International Publishing Switzerland 2015
16 M. Valentino and L. Barozzi

Linchenstein [8]. It consists in a succession of

roughly horizontal (or slightly curved) lines that
generate a striped pattern, alternating dark and
clear lines at regular intervals. They can be large
or very narrow. The reverberation echo hides the
information below, as does an acoustic shadow.
Larger air collections make bright, highly echo-
genic lines with distal reverberation and shadow-
ing artifacts (Fig. 3.2). Smaller air bubbles can
appear as bright punctuate foci with or without
ring-down artifacts (Fig. 3.3).

3.2.1.2 Shifting Phenomenon

Reverberation is not specific for pneumoperito-
neum unless it is possible to demonstrate the
“shifting” of air in the cavity when the patient
was repositioned. It is therefore needed to move
the patient on the left semilateral decubitus posi-
tion observing the shifting of the air in the space
between peritoneum and liver or in the hepatore-
nal space. Excessive gas in an abscess can mimic
Fig. 3.1 Sites of free intraperitoneal air in the abdomen the shifting phenomenon. For this reason,
on US examination (Modified from Beyer and Modder Karahan and colleagues proposed an original
[21]) method for the detection of pneumoperitoneum
[9]. While the patient is in the supine position, if
findings of the trauma (free fluid in the abdomi- the reverberation artifact is visible, a slight pres-
nal space), and if a perforation is suspected, the sure is applied to the abdominal wall using the
semilateral decubitus position is added (Fig. 3.1). probe. During this maneuver, the free intraperito-
neal air is expelled from the region anterior to the
liver to other parts of the peritoneal cavity, and
3.2.1 US of Pneumoperitoneum consequently, the reverberation artifact became
much less prominent. Conversely, when the pres-
Free air in abdominal cavity can give direct or indi- sure on the probe is released, maintaining the
rect signs. The main US signs of the presence of contact with the skin surface, the free gas return
pneumoperitoneum include strong reverberation to the epigastric region and the artifact echo pat-
anterior to the liver surface, the shifting phenome- tern became more prominent. On real-time US
non, and the enhancement of the peritoneal stripe. examination, repetition of this maneuver appears
The indirect signs are the presence of intraperito- like the opening and closing of scissors, leading
neal free fluid and the decreased bowel motility. to the term “scissors maneuver.” The diagnostic
accuracy values in the diagnosis of pneumoperi-
3.2.1.1 Reverberations toneum obtained by the authors with the adding
Air is a medium posing high resistance and of this maneuver was very high, and they reported
impermeability to ultrasound waves, making it a a sensitivity of 94 %, specificity of 100 %, PPV
strong reflector. Free air can be visualized as hor- of 100 %, and NPV of 98 %.
izontal or vertical reverberations originating in
the peritoneum and extending to the lower edge 3.2.1.3 Peritoneal Stripe
of the monitor. The reverberation echo, generated This finding was first described by Muradali et al.
by an air structure, was well described by [10], and it was termed the “peritoneal stripe.”
3 Ultrasonographic Assessment of Gastrointestinal Perforation 17

a b

Fig. 3.2 Sagittal sonographic section of the right hypo- Computed tomography confirms the large amount of air
chondrium using a linear probe showing reverberation superficial to the liver (b, white arrows). At laparotomy,
artifacts which obscure the right lobe of the liver (a). the patient had perforated peptic ulcer

Fig. 3.3 Sagital sonographic section of the right hypo-

chondrium using a curvilinear probe. Small air bubble Fig. 3.4 Sagittal sonographic section of the right hypo-
anterior to the liver causing ring-down artifact (white chondrium with curvilinear probe. Enhanced peritoneal
arrows). This patient presented with normal vital signs stripe (white arrows)
had moderate abdominal pain due to perforated
diverticulitis.
stripe was thickened. The animal model was than
Under an animal experimental model, they were demonstrated in nine patients who underwent
able to demonstrate that tiny bubbles of free air laparoscopy, and it was documented for all four
produced focal enhancement and apparent thick- quadrants of the abdomen. The enhanced perito-
ening of the peritoneal stripe with or without neal stripe indicates free intraperitoneal air and
multiple reflection artifacts, depending on the permits its differentiation from intraluminal
amount of the peritoneal air. In the cases of air bowel gas (Fig. 3.4). In the US imaging of the
within the intestinal bowel, overlying peritoneal abdomen, it is possible to identify a single or a
stripe was normal, whereas in the cases of double thin echogenic line between the anterior
extraluminal (intraperitoneal) air, the peritoneal abdominal wall and the anterior liver surface.
18 M. Valentino and L. Barozzi

Intraperitoneal free fluid and decreased bowel

motility are indirect signs, but in the adequate
clinical context can help in the diagnosis [11].
Peritonitis caused by gastrointestinal perforation
leads to a paralytic or adynamic ileus, a condition
characterized by gas-fluid stasis, with a reduction
in intestinal movement [12].

3.3 Causes of Bowel Perforation

The most common causes of gastrointestinal per-

foration are as follows:
• Peptic ulcer
• Appendicitis
• Sigmoid diverticulitis Fig. 3.5 Pneumoperitoneum due to peptic ulcer perfora-
• Bowel malignancy tion: small amount of air visualized in the falciform liga-
• Crohn’s disease ment medially to the gallbladder wall (black arrows)
• Sharp foreign body
One of the hallmarks of bowel perforation
useful for identification of the site of the perfora- structure in the right lower quadrant with an
tion is the inflamed fat, like in appendicitis and outer diameter of greater than 6 mm. A small
diverticulitis. “Inflamed fat” represents the quantity of periappendiceal fluid is often pres-
defense mechanism of omentum and mesentery ent and aspecific. It may be present in both
to stop the bowel perforation. Sometimes this nonperforated and perforated appendicitis and
mechanism is effective; sometimes it is less in many other conditions, both surgical and
effective, and an open perforation can lead to the nonsurgical. A large quantity of fluid in the
surgery treatment. Whether this process is going presence of an inflamed appendix may repre-
to be successful (and a nonoperative management sent pus from perforated appendicitis and then
can be indicated) cannot be judged from the is usually accompanied by paralytic ileus [13].
imaging findings alone, and a combination of In case of perforation, an appendiceal abscess
clinical and imaging findings needs to be can be visible as a circumscribed collection,
considered. walled off by omentum, mesentery, and bowel
• Peptic ulcer. Uncomplicated duodenal ulcer (Fig. 3.6).
is becoming quite rare, since most symptom- • Sigmoid diverticulitis. Diverticulitis is inflam-
atic patients have already been treated with mation of a diverticulum. It can be uncompli-
proton pump inhibitors before any test is cated, or it can result in complications such as
done. Pneumoperitoneum can sometimes be perforation. Uncomplicated diverticulitis con-
visualized by US: small amount of air with sists in inflammation of colonic diverticulitis
fluid can be visualized in the falciform liga- and/or microperforation of the wall of the
ment or medially to the gallbladder wall diverticulum, which results in peridiverticulitis
(Fig. 3.5). or phlegmon. In complicated diverticulitis that
• Appendicitis. Appendiceal perforation is a ensues, the process is associated with an
common complication of acute appendicitis. abscess, a free perforation, or a fistula. In the
The criteria for the diagnosis of acute appendi- past decade, US has been largely proposed in
citis by sonography are well established: iden- this diagnosis because of its ability to identify
tification of a noncompressible blind-ending the disease and to detect its complications [14].
3 Ultrasonographic Assessment of Gastrointestinal Perforation 19

Fig. 3.6 Acute appendicitis

a b
with appendiceal abscess
visible as a circumscribed
collection at US (a white
arrows) and confirmed at
contrast-enhanced CT (b).
Note the appendicoliths
within the collection (black
arrow)

a b

S
C

Fig. 3.7 Abscess from perforated acute sigmoid diverticulitis (S). At US (a) it appears as a fluid collection containing
(C) echoes and producing dirty shadowing from air (white arrow). Contrast-enhanced CT confirmed the diagnosis (b)

The complications of diverticulitis depend on involve an adjacent bowel loop, the bladder, or
the location of the diverticulum, whereas an the uterus [15].
intraperitoneal diverticulum can result in a free • Crohn’s disease. Inflammatory bowel dis-
perforation into the peritoneal cavity, or an eases, such as Crohn’s disease, may produce
intraperitoneal abscess, or sometimes in a fis- inflammation of various intensities, includ-
tula formation with the neighbor organs. The ing perforation with abscesses formation.
free air in the peritoneal cavity can be depicted Intra-abdominal abscesses occur up to 30 %
as a hyperechoic line along the hepatic surface of Crohn’s disease, as a consequence of fistu-
or the peritoneal line. An abscess appears as a las or as a postsurgical complication [16]. At
fluid collection usually containing echoes and US, abscesses appear as hypoechoic mass
producing dirty shadowing from contained air containing internal ring-down artifacts due to
(Fig. 3.7). A fistula is identified as a linear the presence of air. US sensitivity for detec-
hypoechoic tract extending from the tip of the tion of intra-abdominal abscesses in Crohn’s
diverticulum into the inflamed fat. It can disease is quite high [17].
20 M. Valentino and L. Barozzi

• Bowel malignancy. The most common pre- Conclusions

senting symptoms of bowel carcinoma are US plays an important role in patients with
related to changes in bowel habits, bleeding, acute abdominal pain as a first-line imaging
abdominal pain, abdominal mass, weight method able to provide the correct diagnoses
loss, anorexia, and other characteristics in a high percentage of cases. In gastrointesti-
related to metastasis. It is not uncommon for nal diseases, it can identify specific signs of
patients having such diseases to present with perforation, such as reverberation, the shifting
perforation, which might be free or contained phenomenon, and the enhancement of the
or result in a fistula formation. Free perfora- peritoneal stripe. Emphasis on air artifacts
tion leads to secondary peritonitis, while con- may establish the final diagnosis and guiding
tained or fistulous perforation has a variable the correct workup.
outcome. Cecal and sigmoid carcinomas are
the most common malignant diseases that
may present with abscess or free perforation. References
The US appearances in these cases are the
same as the previous reported for Crohn’s dis- 1. Miller RE, Nelson SW (1971) The roentgenologic
ease and sigmoid diverticulitis. It can be help- demonstration of tiny amounts of free intraperitoneal
gas: experimental and clinical studies. Am J
ful to identify a segmental, eccentric mass of
Roentgenol Radium Ther Nucl Med 12:574–585
the intestinal wall eventually with liver metas- 2. Lee DH, Lim JH, Ko YT, Yoon Y (1990) Sonographic
tasis [18]. detection of pneumoperitoneum in patients with acute
• Sharp foreign body. Gastrointestinal perfora- abdomen. AJR Am J Roentgenol 154:107–109
3. Puylaert J, van der Zant F, Rijke A (1997) Sonography
tion is most often secondary to extrinsic or
and the acute abdomen: practical considerations. AJR
intrinsic obstruction, but occasionally it may Am J Roentgenol 168:179–186
be due to other factors such as foreign bodies. 4. Seitz K, Reising KD (1982) Ultrasound detection of
A lot of cases of bowel perforation caused by free air in the abdominal cavity. Ultraschall Med 3:4–6
5. Ghaffar A, Siddiqui TS, Haider H, Khatri H (2008)
foreign bodies have been reported in the liter-
Postsurgical pneumoperitoneum – comparison of
ature, with fish bones and chicken bones being abdominal ultrasound findings with plain radiogra-
the most common objects, followed by tooth- phy. J Coll Physicians Surg Pak 18:477–480
picks and cocktail sticks [19]. Foreign body- 6. Asrani A (2007) Sonographic diagnosis of pneumo-
peritoneum using the ‘enhancement of the peritoneal
associated perforation commonly occurs at
stripe sign’. A prospective study. Emerg Radiol 14:
the point of acute angulation and narrowing, 29–39
and the most common sites of perforation are 7. Grechenig W, Peicha G, Clement HG, Grechenig M
the terminal ileum and colon, the appendix, (1999) Detection of pneumoperitoneum by ultrasound
examination: an experimental and clinical study.
and the right side or left side diverticulum.
Injury 30:173–178
The case of colon perforation by foreign body 8. Linchenstein D (2005) US in the critically ill.
due to previously undiagnosed colon cancer is Springer, Berlin/Heidelberg
also not uncommon [20]. Ultrasonography 9. Karahan O, Kurt A, Yikilmaz A, Kahriman G (2004)
New method for the detection of Intraperitoneal free
may a useful modality for the identification of
air by sonography: scissors maneuver. J Clin
foreign bodies that may appear as a linear Ultrasound 32:381–385
echogenic structure usually accompanied by a 10. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-
posterior acoustic shadow, embedded in a Simpson D (1999) A specific sign of pneumoperito-
neum on sonography: enhancement of the peritoneal
large reactive inflammatory mass. In such
stripe. AJR Am J Roentgenol 173:1257–1262
cases, computed tomography may easily con- 11. Grassi R, Romano S, D’Amario F et al (2004) The rel-
firm the diagnosis. evance of free fluid between intestinal loops detected
3 Ultrasonographic Assessment of Gastrointestinal Perforation 21

by sonography in the clinical assessment of small 16. Nagler SM, Poticha SM (1979) Intra-abdominal
bowel obstruction in adults. Eur J Radiol 50(1):5–14 abscesses in regional enteritis. Am J Surg 173:350–354
12. Grassi R, Di Mizio R, Pinto A, Romano L, Rotondo A 17. Maconi G, Bollani S, Bianchi Porro G (1996)
(2004) Serial plain abdominal film findings in the Ultrasonographic detection of intestinal complica-
assessment of acute abdomen: spastic ileus, hypotonic tions in Crohn’s disease. Dig Dis Sci 41:1643–1648
ileus, mechanical ileus and paralytic ileus. Radiol 18. Lim JH (1996) Colorectal cancer: sonographic find-
Med 108:56–70 ings. Am J Roentgenol 167:45–47
13. Puylaert J (2003) Ultrasonography of the acute abdo- 19. McGregor DH, Liu X, Ulusarac O, Ponnuru KD,
men: gastrointestinal conditions. Radiol Clin North Schnepp SL et al (2011) Colonic perforation resulting
Am 41:1227–1242 from ingested chicken bone revealing previously
14. Liljegren G, Chabok A, Wickbom M, Smedh K, undiagnosed colonic adenocarcinoma: report of a
Nilsson K (2007) Acute colonic diverticulitis: a sys- case and review of literature. World J Surg Oncol 9:24
tematic review of diagnostic accuracy. Colorectal Dis 20. Rathaus V, Erez I, Zissin R (2006) Ileal perforation
9:480–488 due to an ingested fragment of a skewer. J Ultrasound
15. Valentino M, Serra C, Ansaloni L, Mantovani G, Pavlica Med 25:389–391
P, Barozzi L (2009) Sonographic features of acute 21. Beyer D, Modder U (1988) Diagnostic imaging of the
colonic diverticulitis. J Clin Ultrasound 37:457–463 abdomen. Springer, Berlin
 Esophageal Perforation:
Assessment with Multidetector 4
Row Computed Tomography

Nicola Gagliardi, Ciro Stavolo,

and Angela De Gennaro

4.1 Introduction and present with Mackler’s classic triad of vomit-

ing followed by lower thoracic pain and
Esophageal perforation is still associated with a subcutaneous emphysema may quickly be sus-
high mortality rate, even after surgical repair. A pected of having an EP [4]. Many patients, how-
variety of stresses can result in an esophageal ever, present with less specific symptoms such as
perforation as a dramatic increase in intraluminal severe respiratory distress, thoracic pain, hypo-
pressure caused by retching as in Boerhaave’s tension, or shock suggestive of myocardial
syndrome, blunt chest injury or abdominal infarction or acute aortic dissection. Because EP
trauma, and iatrogenic manipulation by instru- is a life-threatening condition that may rapidly
mentation. These events can result in an increased progress to acute mediastinitis and septic shock,
wall tension followed by perforation [1]. We clinical suspicion of EP must follow a quick and
must consider also perforations due to ingestion accurate diagnosis with the aim to improve prog-
of foreign bodies that can directly penetrate the nosis for these patients. An accurate diagnosis
esophageal wall, perforations due to caustic indeed provides therapeutic indications for con-
ingestion (Fig. 4.1), and neoplastic perforations. servative or surgical treatment [5]. In most cases
Perforations caused by gunshots or penetrating the site of perforation is the thoracic esophagus
chest trauma are extremely rare [2, 3]. The major- (50–55 %), and distal esophagus is perforated
ity of injuries (>80 %) are iatrogenic, and the with a lower frequency (25–30 %). Cervical
increasing use of endoscopic procedures such as esophagus is seldom perforated (15–18 %) [1, 6].
esophagogastroscopy (EGS), transesophageal
echocardiography (TEE), and endosonography
(EUS) resulted in an increased incidence of 4.2 Iatrogenic Injuries
EP. Patients who have a history of similar events
Iatrogenic injuries are the most common causes
of EP. Many endoscopic procedures such as
N. Gagliardi (*) • C. Stavolo
Department of Radiology, “A. Cardarelli” Hospital, EGS, TEE, and EUS can result in an abnormal
Via Antonio Cardarelli, 9, Naples 80131, Italy wall tension from instrumentation and subse-
e-mail: [email protected]; quent transmural perforation (Fig. 4.2a, b). CT
[email protected] appearances of iatrogenic EP are variable
A. De Gennaro depending on the site and size of perforation and
Department of Diagnostic Imaging and Radiotherapy, the time elapsed since the onset of symptoms
Federico II University,
Via S. Pansini, 5, Naples 80131, Italy [7]. Beyond these frequent causes, we must
e-mail: [email protected] remember palliative treatment of esophageal ste-

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 23

DOI 10.1007/978-3-319-08192-2_4, © Springer International Publishing Switzerland 2015
24 N. Gagliardi et al.

nosis using laser therapy, electrothermal therapy, a

and stent placement (Fig. 4.3a, b). EP can also be
a complication of sclerotherapy of esophageal
varices and surgery of hiatal hernias and rarely
occur during placement of Sengstaken-
Blakemore tube or insertion of nasogastric tube
[8]. A large number of most patients present the

Fig. 4.1 Esophageal-pleural fistula after caustic inges- Fig. 4.2 (a, b) Iatrogenic perforations during endoscopy:
tion: thickened esophageal (white arrow) and gastric esophagus (arrow) and extensive pneumomediastinum
(white arrowheads) walls; left pleural effusion (black (arrowheads) with early subcutaneous emphysema on the
arrows) right axilla

a b

Fig. 4.3 (a, b) Esophageal perforation after stent place- (white arrow); thickened esophageal wall (black arrow);
ment: (a) pneumomediastinum (black arrowheads); Rigth (b) intraluminal esophageal stent (black arrowheads);
pleural effusion (white arrowheads) left pleural effusion pneumomediastinum (black arrows)
4 Esophageal Perforation: Assessment with Multidetector Row Computed Tomography 25

a cricopharyngeal relaxation during vomiting

results in abruptly intraluminal pressure increase,
sufficient to breach esophageal wall [10]. In these
cases the distal left posterior wall is the most
common site of rupture, which results in a pneu-
momediastinum and left pleural effusion.

4.4 Foreign Bodies and Other

Causes

The esophagus is a common site of impaction of

b swallowed foreign bodies. EP can occur directly,
by full-thickness wall lesion, or indirectly by
snap intraluminal pressure increase due to vomit-
ing with an esophageal obstruction [11]. Direct
wall perforation may be caused by sharp objects
such as bones, dental work with hooks, pins and
screws, or nails. In these cases, it can realize a
periesophageal abscess formation [11, 12].
Improper foreign body removal by endoscopy
can also cause determinate EP. In more difficult
cases with a transfixed foreign body, you would
prefer to shatter and then pull it out. Sometimes
Fig. 4.4 (a, b) Esophageal perforation after stricture dil- foreign bodies can cause only a mucosal lesion
atation in achalasia: (a) thickened esophageal wall (white
arrow); pneumomediastinum (black arrow); left pleural
which can cause parietal pneumatosis (Fig. 4.5a,
effusion (black arrowheads); pneumothorax (white b). Neoplasm can also cause determinate EP. This
arrowhead); (b) pneumomediastinum (white arrows); happens in advanced lesions that cause a progres-
pleural effusion (white arrowheads) sive wall erosion. Such events are often associ-
ated with bleeding [3]. EP due to gunshot or
classic Mackler’s triad but someone have atypi- penetrating chest trauma are extremely rare. In
cal symptoms and the diagnosis of EP is not ini- most cases it comes to autopsy. However, in
tially suspected. Other patients have only one or patients who have a thoracic gunshot or knife
two of the Mackler’s triad symptoms. In these lesion that are submitted to CT scanning, EP
cases, a history of a recent endoscopic procedure must be considered [13].
should recommend the execution of a CT scan
because an early diagnosis improves the progno-
sis of these patients [2, 9]. 4.5 CT Findings

The most frequent useful CT findings of EP are

4.3 Intraluminal Pressure manifested by extraluminal variable amounts of
Increase air, in relationship with elapsed time, secondly
periesophageal fluid collection. CT allows the
Intraluminal pressure increase is a frequent cause visualization of very small air or fluid collec-
of EP. This increase may occur for iatrogenic tions, otherwise undetectable, in cases of small
causes, such as during stricture dilation as in tears [5, 14]. Pleural effusions, combined or
achalasia (Fig. 4.4a, b) or, spontaneously, as in not with pneumothorax, are most frequently
Boerhaave’s syndrome, in which an incomplete present. Distal perforations are usually asso-
26 N. Gagliardi et al.

a b

Fig. 4.5 (a, b) Esophageal parietal pneumatosis after foreign body ingestion: (a) white arrows; (b) black arrows

ciated with a left-side pleural effusion or a

hydropneumothorax, while a middle perforation a
is often associated with a right-side pleural effu-
sion. This allows to detect makes it possible to
assume the location of the EP [15]. Another CT
sign such as esophageal thickening may allow
further characterization of the process. In patients
with foreign body ingestion, CT allows you to
identify the size and the exact spatial position of
the foreign body, very useful data for removing.

4.6 Complications
b
Whatever its cause and the site of perforation, EP
is a common point of origin for potentially life-
threatening complications which may involve
different intrathoracic organs. Mediastinitis at
first and then pneumonia, lung abscess, and
empyema are among the most commonly seen
complications [16]. Tissue destruction due to
mediastinitis may result in development of a fis-
tula between the esophagus and adjacent struc-
tures including pleural cavity, tracheobronchial
tree, and stomach and very rarely aorta (Fig. 4.6a,
b) [17]. Due to these reasons, you must use CT
because contrast esophagograms allow identifi-
cation of EP but not all its complications. CT
helps to delineate complications and provides
valuable information for early initiation of an Fig. 4.6 (a, b) Esophageal-pleural fistula after iatrogenic
appropriate management strategy [17, 18]. injury: (a, b) black arrows
4 Esophageal Perforation: Assessment with Multidetector Row Computed Tomography 27

Conclusions 7. Younes Z, Johnson DA (1999) The spectrum of spon-

taneous and iatrogenic esophageal injuries: perfora-
Contrast-enhanced CT evaluation of EP
tions, Mallory-Weiss tears and hematomas. J Clin
requires a high index of suspicion in relation Gastroenterol 29(4):306–317
to anamnesis of the patient and attention to 8. Jackson RH, Payne DK, Bacon BR (1990) Esophageal
findings that may be subtle yet significant. perforation due to Nasogastric intubation. Am J
Gastroenterol 85(4):439–442
Due to particular anatomic orientation of the
9. Shcmidt SC, Strauch S, Rosch T et al (2010)
esophagus, multiplanar reformatted images Management of esophageal perforations. Surg Endosc
are ideally suited to this purpose. They allow a 24:2809–2813
better appreciation of the extent of perforation 10. Pinto A, Romano L (2014) Imaging of foreign bodies.
Springer, Milan
and their complications and also the possible
11. Li ZS, Sun ZX, Zou DW, Xu GM, Wu RP, Liao Z
involvement of adjacent structures. (2006) Endoscopic management of foreign bodies in
Multidetector CT promotes the radiologist’s the upper-GI tract: experiences with 1088 cases in
ability to diagnose accurately EP, reducing China. Gastrointest Endosc 64(4):485–492
12. Wu JT, Maxott KL, Wall MJ Jr (2007) Esophageal
delays in diagnosis and improving outcomes
perforations: new perspectives and treatment para-
in these patients [19]. digms. J Trauma 63(5):1173–1184
13. Cabrera-Hinojosa J, Diaz-Rosales J, Lenin ED,
Arambula-Melendez P (2009) Esophageal perforation
by gunshot: conservative surgical treatment. Calicut
References Med J 7(3):4–6
14. Backer CL, Lo Cicero J III, Hartz RS et al (1990)
1. Hhuber-Lang M, Henne-Bruns D, Schmitz B, Wurel Computed tomography in patients with esophageal
P (2006) Esophageal perforation: principles of diag- perforation. Chest 98:1078–1080
nosis and surgical management. Surg Today 36: 15. Gimenez A, Franquet T, Erasmus JJ, Martinez S,
332–340 Estrada P (2002) Thoracic complications of esopha-
2. Eisen GM, Baron TH, Dominitz JA et al (2002) geal disorders. Radiographics 22:247–258
Guide-line for the m management of ingested foreign 16. Port JL, Kent MS, Korst RJ, Bacchetta M, Altroki NK
bodies. Gastrointest Endosc 55(7):802–806 (2003) Thoracic esophageal perforations: a decade of
3. Ferguson MK (1997) Esophageal perforations and experience. Ann Thorac Surg 75(4):1071–1074
caustic injury: management of perforated esophageal 17. Eroglu A, Turkyilmaz A, Aydun Y, Yekeler E,
cancer. Dis Esophagus 10(2):90–94 Karaoglanoglu N (2009) Current management of
4. Brinster CJ, Singhal S, Lee L, Marshall BM, Kaiser esophageal perforations: 20 years experience. Dis
LR, Kucharczuk JC (2004) Evolving options in the Esophagus 22(4):374–380
management of esophageal perforation. Ann Thorac 18. Exaros DN, Malagri K, Tsatalou EG et al (2005)
Surg 77(4):1475–1483 Acute mediastinitis: spectrum of computed tomogra-
5. With CS, Templeton PA, Attar S (1992) Esophageal phy findings. Eur Radiol 15:1569–1574
perforation: CT findings. AJR Am J Roentgenol 19. Soreide JA, Viste A (2011) Esophageal perforation:
160:767–770 diagnostic work-up and clinical decision-making in
6. Pate JW, Walker WA, Cole FH Jr, Owen EW, Johnson the first 24 hours. Scand J Trauma Resusc Emerg Med
WH (1989) Spontaneous rupture of the esophagus: a 19:66
30-years experience. Ann Thorac Surg 47:689–692
 Role of Multidetector Row
Computed Tomography 5
in the Diagnosis
of Gastroduodenal Perforation

Daniela Vecchione, Giovanna Russo,

and Raffaella Niola

Gastroduodenal perforation is an emergency antrum and duodenal bulb (Figs. 5.1 and 5.6)
clinical situation that usually requires early rec- Variable location of the ulcer produces different
ognition and well-timed surgical treatment. It can consequences; a deep anterior ulcer may perforate
arise from different natural, iatrogenic, or trau- directly into the peritoneal cavity, whereas poste-
matic causes, and it can present with various rior stomach or duodenal ulcers often cause a
symptoms especially in the early phase. confined perforation.
A precise diagnostic classification is funda- Other reported causes are traumatic, neoplas-
mental in order to propose the best therapeutic tic, foreign body ingestion, and iatrogenic.
approach and is usually based on detecting pres- With regard to iatrogenic causes, blunt trauma
ence, site, cause, and extension of the extralumi- usually induces perforation of the descending
nal leakage [1]. and horizontal segments of duodenum because of
their firm attachment and the compression against
the vertebral column.
5.1 Etiology and Mechanism
of Perforation

The most common reported cause of gastroduo-

denal perforation is ulcer disease linked to both
infection with Helicobacter pylori and frequent
use of aspirin (ASA) and other nonsteroidal anti-
inflammatory drugs (NSAID) [2].
The presence of a peptic ulcer induces loss of
normal mucosal integrity, local inflammation,
and focal penetration that leads to local patho-
logic changes of the normal mural anatomy.
Gastroduodenal perforation related with peptic
ulcer is usually located at level of the gastric
Fig 5.1 Axial MPR CT image. Perforation of the anterior
wall of the gastric antrum. Focal defect in the anterior wall
D. Vecchione (*) • G. Russo • R. Niola of the gastric antrum associated with surrounding mural
Department of Radiology, “A. Cardarelli” Hospital, thickening (white arrow). Pneumoperitoneum (black
A. Cardarelli, Naples 80131, Italy arrow). Extraluminal fluid with small free air bubble
e-mail: [email protected]; inside (white arrowhead). Intraperitoneal fluid in subhe-
[email protected]; [email protected] patic space (black arrowhead)

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 29

DOI 10.1007/978-3-319-08192-2_5, © Springer International Publishing Switzerland 2015
30 D. Vecchione et al.

Neoplastic causes usually depend on the pres- Microbiological contamination increases from
ence of a tumor that can lead to obstruction or proximal to distal side of the gastrointestinal
increased endoluminal pressure (Fig. 5.7). tract; the stomach and duodenum show the low-
Perforation can also arise from foreign bodies est number of vital microorganisms per gram of
that can be ingested either intentionally or acciden- luminal contents due to a hostile local environ-
tally; this injury can cause perforation either through ment from acidic, biliary, and pancreatic secre-
direct damage or endoluminal obstruction. tions, and in fact the bacterial load is inversely
In the era of diagnostic and therapeutic use of related to the toxicity of organ fluid composition
esophagoduodenoscopy, iatrogenic lesion repre- [7, 8].
sents an increasing cause of gastroduodenal per- Organ-specific fluid composition affects not
foration. Other iatrogenic causes are related to only bacterial load but also bacterial species
the placement of inferior vena cava filter, ERCP, composition with consequent different early pre-
and biliary stents [3] (Fig. 5.5). senting symptoms from a perforated hollow vis-
cus that can be helpful for the diagnosis. For
example, patients suffering from gastric or duo-
5.2 Diagnosis denal perforation usually present with highly
acute pain due to a rapid chemical peritonitis usu-
A correct diagnosis of gastroduodenal perfora- ally followed by a systemic inflammatory
tion strictly relies on signs and symptoms referred response. In the untreated patients or in those
by the patient and detected during clinical who have late presentation, the perforation can
examination. For example, the presence of inter- also proceed to an infected peritonitis and sepsis
mittent abdominal pain, gastroesophageal reflux, [9].
ongoing symptoms and sudden exacerbation of Laboratory tests are usually performed to get a
pain in known peptic ulcer disease, and recent correct diagnosis or to facilitate the differential
trauma or diagnostic/therapeutic intervention fol- diagnoses. Routinely ordered tests include a
lowed by worsening pain should alert the clini- complete blood cell count with differential, coag-
cian for the presence of injury [2]. ulation panel, electrolyte panel, liver function
The location of the pain facilitates definitive tests, urinalysis, lipase or amylase, arterial blood
diagnosis, because with the time a localized peri- gas, and serum lactate level [10, 11].
toneal inflammation develops exactly at level of Laboratory tests are usually nonspecific, but
the injured organ involving a correspondent leukocytosis, metabolic acidosis, and hyperamy-
abdominal wall segment. lasemia may be indicative of the presence of
Patients with gastroduodenal perforation usu- perforation.
ally present with signs and symptoms of either Plain abdominal films are the initial diagnos-
local or generalized peritonitis due to the leakage tic tool in patients with clinically suspected gas-
of luminal contents in the peritoneal cavity. troduodenal perforation. In addition to upright
For instance, a lesion of the gastroduodenal and supine abdominal radiographic images,
wall provokes intra-abdominal contamination upright chest films and/or left lateral decubitus
with peritonitis or abscesses [4]. abdominal films should be included for the accu-
The type and the intensity of peritoneal con- rate evaluation of perforation [1].
tamination strictly rely on the site, size, and dura- The radiologic feature of perforation is the
tion of perforation other than other factors such presence of air and/or fluid in the peritoneal cavity,
as time from the last meal, coexistent diseases, retroperitoneal spaces, mesentery, or ligaments of
presence or absence of an ileus or bowel obstruc- organs. In some cases, pneumomediastinum or
tion, etc. subcutaneous emphysema can also be detected.
The anatomic site of perforation heavily influ- About one-third of cases of gastroduodenal perfo-
ences the type and the severity of enteric contam- ration do not present with pneumoperitoneum on
ination [5, 6]. abdominal radiographs. This situation is usually
5 Role of Multidetector Row Computed Tomography in the Diagnosis of Gastroduodenal Perforation 31

caused by a very small perforation, perforation overall accuracy of CT for predicting the site of
well contained by adjacent organs, or empty stom- bowel perforation has been reported to range
ach at the time of perforation [12]. between 82 and 90 %. However, the recent intro-
The reported sensitivity in the detection of duction of multidetector row CT has improved
extraluminal air on plain radiography is 50–70 % the accuracy of CT for predicting the site of GI
[13, 14]. tract perforation [16, 21, 24–26].
US is considered a useful diagnostic tool According to the perforation site the CT find-
because even if it is not actually helpful to iden- ings may be different. In this chapter, CT findings
tify intraperitoneal free gas, it could identify of gastroduodenal tract perforation will be
some suggestive findings of gastrointestinal per- reported.
foration such as the decreased peristalsis and the
presence of intraperitoneal free fluid. It is worth
to note that usually in the case of gastroduodenal 5.3 CT Technique
perforation the evidence of free peritoneal fluid is
the only finding of injury, but unfortunately US Whole abdomen, from the dome of the diaphragm
study is not able to define the exact cause for its to the pelvic floor, should be scanned with a mul-
presence (peritoneal reaction or perforated intes- tidetector CT (MDCT). The protocol used with a
tinal loop) [15, 16]. 64-row MDCT included, after the pre-contrast
When a perforation of the gut is not proved by images have been acquired, a helical axial acqui-
plain radiograph and more accurate assessment sition at 70 s after the intravenous injection of
regarding the site and cause of perforation is contrast material (400 mgI/mL; 100–150 mL at a
needed, a contrast examination may be indicated. rate of 2–3 mL/s), a 1- to 2.5-mm collimation and
Water-soluble iodinated contrast material is reconstruction in 0.625 mm contiguous slices.
administrated orally, if gastroduodenal tract is the The analysis was immediate on a workstation,
suspected site of perforation. It may demonstrate allowing multiplanar reconstructions that were
extraluminal contrast material leakage as a direct used systematically. In our hospital, we use CT
sign of bowel perforation. However, the reported scanning without oral contrast administration for
sensitiveness of extravasation of oral contrast evaluating bowel perforation. In fact, even if the
material on plain radiograph varies from 19 to contrast may improve the detection of the lesions
42 % [17–19]. site of the posterior gastrointestinal wall, on the
CT is now estimated the most valuable imag- other site, it becomes difficult to identify a perfo-
ing technique to identify the presence, site, and ration in the axial scan, when the lesion lies just
etiology of gastrointestinal (GI) tract perforation near the anterior bowel wall.
[17]. Although extraluminal leakage of oral con-
CT is indicated in two different cases: when trast material has been reported to be a specific
clinical suspicion is high, but there is no pneumo- finding for bowel perforation, several authors
peritoneum on the plain abdominal radiograph; the queried about the extra benefit of oral contrast
clinical signs are atypical, or, instead, peritonitis is [13, 17, 22, 27]. Several reports adduce safety
present with no etiological explanation [20]. issues (i.e., the risk of aspiration and the subse-
Several authors have illustrated the direct and quent complications), the potential delay in the
indirect CT findings of bowel perforation, and diagnosis, and the lack of substantial extra bene-
free extraluminal air has been regarded as a major fit for detecting bowel perforation.
imaging finding to identify the GI tract perfora- Further, the slow progression of the oral con-
tion [17, 21–24]. trast material in the GI tract in a patient suffering
CT is more sensitive than plain radiography in from paralytic ileum, and the quick sealing of the
determining the presence of perforation because perforation site, may preclude extraluminal leak-
it can also display a small amount of free extralu- age of oral contrast material in patients with GI
minal, intraperitoneal, or retroperitoneal air. The tract perforation [17].
32 D. Vecchione et al.

5.4 CT Findings images are indeterminate. Although extraluminal

air is highly specific for making the diagnosis of
We classified the CT findings of GI tract perfora- GI tract perforation, it may be absent in gastroduo-
tion as direct and indirect findings. The first one denal perforation, and especially at the onset of
included extraluminal air (free air) and direct visu- symptom [16]. The sensitivity of plain radiograph
alization of GI tract wall rupture. The second one to detect free extraluminal air is not high [1, 24]; in
included focal bowel wall thickening (>8 mm in contrast, CT is highly sensitive for detecting pneu-
gastroduodenal wall), abnormal bowel wall moperitoneum and very small free air bubbles. To
enhancement, inflammatory changes (abscess and enhance this sensitivity, CT images should also be
an inflammatory mass adjacent to the bowel), or a assessed in the wide window setting that distin-
fluid collection in the surrounding soft tissues or guishes air from fat densities [11, 14]. The amount
organs [1, 21, 23, 28, 29]. Direct visualization of and location of free air could be different accord-
the discontinuity of the bowel wall can specify the ing to the perforation site. A large amount of intra-
presence and site of GI tract perforation, which is peritoneal air usually indicates gastroduodenal
marked by a low-attenuating cleft that usually runs perforation, except for bowel perforation, which is
perpendicular to the bowel wall on CT [17, 24] caused by obstruction or an endoscopic procedure.
(Figs. 5.1 and 5.2). However, this cleft has been Air in the lesser sac is commonly due to posterior
reported to be observed less frequently than free perforation of the stomach or duodenum. Free air
air on CT, and a cleft is usually seen in less than or an air-fluid level crossing the midline and an
50 % of the patients with GI tract perforation [21, accentuating falciform ligament (the “falciform
23, 24, 28]. The relatively infrequent detection of ligament sign”) (Fig. 5.6) and free air confined in
this finding is partly due to the small size of the the intrahepatic fissure for the ligamentum teres
lesion [23]. MDCT with multiplanar reformation (the “ligamentum teres sign”) have been consid-
images may help identify discontinuity of the ered to be useful findings in patients with perfora-
bowel wall, and especially when the axial CT tion of the duodenal bulb or stomach. Air trapped
in the mesenteric folds is seldom seen in gastric
perforation. Pneumoretroperitoneum is caused by
perforation of descending horizontal duodenal
tract. Gas in the retroperitoneum does not spread
freely as in the peritoneal space; specifically, when
the amounts is small, it tends to remain regional
with respect to the boundaries of the retroperito-
neal compartment in which it arises. Extraluminal
free air in the right anterior pararenal space is the
reliable CT finding for diagnosing duodenal perfo-
ration beyond the bulbar segment [1, 17, 28, 30]
(Fig. 5.5).
It should be noted that extraluminal intra- or
retroperitoneal air could occur without GI tract
perforation. Various causes can produce air, such
as mechanical ventilation and pulmonary baro-
traumas, peritoneal lavage that is performed prior
to CT, pneumothorax, chest injury, and entry of
Fig. 5.2 Coronal MIP CT image. Covered perforation of air via the female genital tract. Thus, additional
the duodenal bulb. Focal defect in the wall of the duodenal
CT findings that are indicative of GI tract perfo-
bulb (white arrow). Intraluminal air (black arrow). Small
extraluminal free air bubble (white arrowhead). ration intensify the significance of extraluminal
Intraperitoneal fluid (black arrowhead) free air [17, 23].
5 Role of Multidetector Row Computed Tomography in the Diagnosis of Gastroduodenal Perforation 33

Fig. 5.3 Axial MIP CT image. Covered perforation on

the 2nd tract of the duodenum. Very small free air bubble
adjacent to the duodenal wall (white arrow). Small amount
of free fluid in the lesser sac (black arrow). Fluid gastric
distension (white arrowhead). Duodenal wall thickening Fig. 5.4 Coronal MIP CT image. Perforation on the 3rd
(black arrowhead) tract of the duodenum. Small free air bubble in close prox-
imity to the duodenal wall (white arrow). Wall of the 3rd
tract of the duodenum (black arrow). Free fluid in left
anterior pararenal space associated with local “dirty fat”
In addition to the presence of GI tract perfora- density (white arrowhead)
tion, concentrated free air bubbles in close prox-
imity to the bowel wall may help determine the
site of perforation because free air bubbles tend reconstructions, provided by MDCT, is huge for
to be in the vicinity of the bowel wall from which the advantages in the search for wall opening
they arise, and especially when the amount of air when it is not visible on the axial slides [20]. In
is small [17, 21]. our experience, multiplanar reconstruction
Among various disease entities, peptic ulcer images were routinely performed, which we
disease is a major cause of gastroduodenal perfora- found to be useful of determining the precise
tion, followed by necrotic or ulcerated malignan- location of bubbles of extraluminal air and
cies, iatrogenic injuries, and traumatic injuries defects in the gastroduodenal wall.
[1, 17]. Accuracy of MDCT in predicting site of However, a large percentage of perforated
gastrointestinal tract perforation is 86 %. Three gastric and duodenal ulcers seal off quickly.
findings were statistically significant predictors of Furthermore, ulcers on the posterior wall of the
a correct localization of the perforation: ulceration stomach and duodenum may perforate into the
or focal defect of the gastroduodenal wall, air bub- pancreas, lesser omentum, transverse mesocolon,
bles in close contact with the stomach or the duode- liver, spleen, biliary tree, or colon.
num, segmental bowel wall thickening [1, 21] Posterior wall peptic ulcers most commonly
(Figs. 5.1, 5.2, and 5.3). These findings can be perforate into the pancreas, resulting in pancreatitis
associated with adjacent “dirty fat” density and or true abscess formation. Ulcers that perforate into
local fluid between the duodenum and the pancre- the biliary tree or colon also may lead to fistula.
atic head (Fig. 5.4). Overall, the supramesocolic Abscess in the left lobe of the liver or spleen may
location of the peritoneal fluid is a persuasive argu- result from posterior wall penetrating ulcers. As a
ment for the diagnosis of ulcer perforation [20]. result, MDCT may be the first modality to suggest
The breach in the gastroduodenal wall is the diagnosis of a perforated posterior wall peptic
found in 36 % of the cases using conventional, ulcer. Small bubbles of gas or pockets of fluid may
whereas the contribution of the multiplanar be seen trapped near the wall of the stomach or
34 D. Vecchione et al.

Fig. 5.6 Axial MPR CT image. Perforation of the duode-

nal bulb. Extraluminal free fluid with a very small air bub-
ble inside (white arrow). Focal defect in thickened wall of
Fig. 5.5 Coronal MIP image: Iatrogenic perforation of the duodenal bulb (black arrow). Pneumoperitoneum
the duodenum inferior knee caused by biliary stent. Distal (white arrowhead). Falciform ligament sign (black
tip of biliary stent located in right pararenal anterior space arrowhead)
(white arrow). Retroperitoneal free air (back arrow).
Retroperitoneal free fluid, right pararenal anterior space
(white arrowhead). The 3rd tract of the duodenum (black
arrowhead)

duodenum, near the surface of the pancreas, or in

the mesenteries near the duodenal bulb and stom-
ach (hepatogastric and hepatoduodenal ligaments).
Small bubbles of air also may be detected in the
greater or lesser peritoneal sac. MDCT may also
reveal evidence of pancreatitis, especially in the
pancreatic head, or ascites [31, 32].
Surgeons frequently choose to oversee a per-
forated ulcer because there is less than a 20 %
recurrence rate with therapy. So in patients who
have not had surgery, MDCT is an excellent Fig. 5.7 Axial MIP CT image. Neoplastic lesion infiltrat-
ing and perforating the posterior wall of the gastric body.
modality for detecting the extraluminal changes Discontinuity in the posterior wall of the gastric body
associated with a perforation. (white arrow). Neoplastic lesion infiltrating the posterior
A CT-demonstrated postoperative abscess wall of the gastric body and the fundus, portal vein, and
may be caused by the persistence of the inflam- caudate lobe of liver (black arrow). Free air bubbles in the
lesser sac (white arrowhead)
matory reaction, continuing or previous perfora-
tion at the treated site, or continuing or sealed off
anastomotic or staple line leak. Determination of Anastomotic leaks may be detected at gastro-
the cause of a postoperative abscess may require enteric anastomoses. Leaks may also occur at the
a luminal contrast study. Luminal contrast stud- overseen proximal duodenal stump after Billroth
ies are not unfailing in detecting the leaks, II surgery or after Graham plication of perforated
because a leak may have sealed off by the time a duodenal ulcers. The postoperative contrast
contrast study is performed (Figs. 5.5, 5.6, and examination may show contrast material outside
5.7) [31, 33]. the expected lumen of the bowel filling a collec-
5 Role of Multidetector Row Computed Tomography in the Diagnosis of Gastroduodenal Perforation 35

a b

Fig. 5.8 (a) Axial MIP CT image (CT performed after CT image (CT performed after oral administration of
oral administration of Gastrografin®). Anastomotic dehis- Gastrografin®). Anastomotic dehiscence in sleeve gastrec-
cence in sleeve gastrectomy. Gastrografin® in gastric tomy. Gastrografin® in gastric lumen (white arrow).
lumen (white arrow). Gastrografin® extraluminal leakage Gastrografin® extraluminal leakage (black arrow). Metal
(black arrow). Metal stitches (white arrowhead). stitches (white arrowhead). Pneumoperitoneum (black
Pneumoperitoneum (black arrowhead). (b) Sagittal MIP arrowhead)

tion or fistula. MDCT also is useful for demon- become the first step imaging technique in a
strating the size and location of an abscess cavity busy emergency department and in all patients
or guiding percutaneous drainage of an abscess with clinical suspicion of gastroduodenal tract
collection. At last, anastomotic or staple line perforation, because of its costs and availabil-
dehiscence also may occur after vertical banded ity of the equipment [29].
gastroplasty or gastric bypass procedures for In our experience, sensitivity of the plain films
morbid obesity [34] (Fig. 5.8). allowed a correct identification of a huge percent-
age of patients with direct findings of perfora-
Conclusion tions. When the first plain film is negative, it is
It is crucial to make a prompt and correct diag- useful to repeat it few hours later [13, 29].
nosis of GI tract perforation with respect to the MDCT is useful in the diagnosis of gastro-
presence, site, and cause of perforation, and duodenal ulcer perforation when the clinical
this helps the physician choose the optimal examination combined with the plain abdomi-
therapeutic option. MDCT allows radiologists nal films does not provide a clear diagnosis or
not only to detect intra-abdominal free air but when a pneumoperitoneum or atypical signs
also to precisely determine the anatomic site of have not been detected on plain film.
GI tract perforation without the use of oral con- The use of three-dimensional reformatting
trast material. CT findings such as discontinu- is mandatory to improve the detection of the
ity of the bowel wall, concentrated bubbles of wall breach when it has not been showed on
extraluminal air in close proximity to the bowel the axial slices [20].
wall, and abrupt bowel wall thickening with or
without an associated phlegmon or abscess are
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 Small Bowel Perforations: Imaging
Findings 6
Stefania Romano

6.1 Introduction Because the clinical signs and symptoms of

these injuries are often not specific and usually
Perforation of the gastrointestinal tract is a com- develop late, a timely diagnosis of damages requir-
mon surgical presentation [1], may occur sponta- ing operative repair depends almost exclusively on
neously in various gastrointestinal diseases, or their early detection by the radiologist on com-
may develop due to an ingested foreign body, puted tomography (CT) examination [4]. Actually,
iatrogenic complication, and blunt or penetrating CT exam is even more considered as a good initial
injuries [2]. However, perforation of the mesen- imaging examination in patients with an acute
teric small bowel represents not a frequent cause abdomen [3]. CT findings in the setting of small
of an acute abdomen and can be due to different bowel perforations are often subtle but, when pres-
etiologies [3]: in underdeveloped countries, ent, may help the radiologist determine a specific
infection is probably the most common cause, cause of perforation and make the correct diagno-
while in industrialized nations, perforation may sis [3]. In fact, in recent years, CT has been shown
be due to Crohn’s disease, diverticulitis, foreign to be accurate for predicting the site of GI perfora-
body, trauma, tumor, mechanical obstruction, pri- tion and has become the investigation of choice
mary ischemic event, or iatrogenic causes [3]. A [1, 3, 4]: differentiating features consequently
prompt diagnosis of hollow viscus perforation is strongly facilitate the accurate multidisciplinary
strongly required, in order to avoid significant preoperative evaluation, necessary to plan patient
morbidity and mortality from hemorrhage, peri- management and potential surgical approach [1].
tonitis, or abdominal sepsis [4]. Whereas conven-
tional radiograph still represents in most
institutions the first imaging method used in 6.2 Imaging Findings
patient with acute abdomen and suspected perfo-
rations and detection of extraluminal air on radio- Perforation of the small intestine represents an
graphs of the chest or abdomen is often the initial emergent medical condition for which the diag-
clue to the diagnosis [2], however, this finding nosis is usually not made clinically but by CT, a
may be not visible when the perforation is small, common imaging modality used for the diagnosis
rapidly sealed, or well contained [2]. of acute abdomen [5]. A spontaneous pneumo-
peritoneum usually indicates perforation of a hol-
low viscus and requires undelayed operative
S. Romano intervention [6].
Department of Radiology, “A. Cardarelli” Hospital,
Viale Cardarelli 9, Naples 80131, Italy A plain film examination is often performed
e-mail: [email protected] before surgery to establish a definitive diagnosis

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 37

DOI 10.1007/978-3-319-08192-2_6, © Springer International Publishing Switzerland 2015
38 S. Romano

[6]: with careful attention to technique and local- thickness around or less than 1 mm could repre-
izing anatomic features, it can be a valuable sent a tool to better achieve good quality refor-
examination, capable of detecting even a very mations and related useful informations for the
small collection of free air [6], if technically ade- diagnosis of the perforation site in patients with
quate. The presence of free abdominal gas as pneumoperitoneum [10].
well as indirect findings of perforation could be
appreciable at the conventional radiograph [7]:
jejunal and ileal perforations could be diagnosed 6.3 Considerations
by direct or indirect findings [7]. It is important to
note that jejunal are more rare than ileal perfora- The etiology of small intestine perforations
tions and more difficult to identify by conven- seems to influence the diagnostic performance
tional radiology [7], which could miss also the also in CT examinations: in blunt small bowel
presence of free gas signs [7]. perforation, discontinuity of the bowel wall and
Although sonography may not be considered extraluminal gas has been reported, respectively,
as a first-line investigation of choice in suspected on 19.2 and 74.4 % of examinations [11], attest-
small intestinal perforation [8], identification of ing a CT diagnosis as highly specific but not sen-
free intraperitoneal fluid and intestinal peristalsis sitive [11].
alterations may aid the radiologist in the early Inflammatory conditions of the small intes-
diagnosis [7, 8]. tines could be considered in evaluating CT exam-
At CT examinations, direct features that sug- inations of patients with acute abdomen and
gest small bowel perforation which are often suspected hollow viscus perforations. Crohn’s
associated with secondary CT signs of bowel disease and other inflammatory conditions and
pathology include extraluminal air and oral con- complications with presence of abscesses must
trast [5]: whereas the use of i.v. contrast medium be accurately noted in location and distribution.
could be considered essential in emergency A rare condition causing perforations almost
exam, the use of oral endoluminal contrast is localized and covered is represented by the small
more often – if not exclusively – done in elec- bowel diverticulitis [12], in which wall thicken-
tive conditions. CT findings related to intestinal ing of the small bowel loop and an adjacent
perforation include the presence of free gas or inflammatory mass containing air bubbles [12]
fluid within the supra- and/or inframesocolic could be noted. Small bowel diverticula are rare
compartments, segmental bowel wall thicken- and mostly asymptomatic [12], but they become
ing, bowel wall discontinuity, free air location, clinically relevant when complications arise,
mottled extraluminal air bubbles or micro- such as diverticulitis [12]. The symptoms of jeju-
pneumoperitoneum, stranding of the mesenteric noileal diverticulitis are nonspecific, and the
fat, and abscess formation [1, 9] (Figs. 6.1, 6.2, diagnosis is performed mainly by imaging stud-
6.3, and 6.4). However, the imaging findings ies [12], especially CT. Small bowel diverticulitis
may be also subtle or only indirectly related to at CT usually presents as a focal inflammatory
the site or etiology of perforation [1]. In order lesion, and the differential diagnosis includes
to improve efficient diagnosis, the use of slice perforated neoplasm, foreign body perforation,

Fig. 6.1 A 38-year-old patient with acute abdomen from peritoneal air in the abdomen can be appreciated (e, f);
ileal perforation. CT examination shows the presence of note some bubbles of gas in the soft tissue of the right
free peritoneal air with falciform ligament sign (a, b) and abdominal wall (small arrow in g). Small intestinal loops
some small peritoneal bubble gas; multiplanar reconstruc- of jejunum and proximal ileum are collapsed, whereas in
tions seem to show the evidence of bowel discontinuity at the pelvis, free peritoneal air (longer arrow in g) sur-
level of the left colonic flexure (c, arrow in d); however, rounds an ileal loop distended by fluid with signs of endo-
surgery revealed the presence of an ileal perforation. luminal stasis (f)
Small amount of peritoneal fluid and presence of free
6 Small Bowel Perforations: Imaging Findings 39

a b

g
40 S. Romano

a b

Fig. 6.2 A 90-year-old patient with acute abdomen due to rant with parietal thickening (a). Note the evidence of
perforation from small bowel complicated obstruction. CT bowel segment distended by fluid and with decreased
shows the presence of small amount of free peritoneal fluid enhancement in the right iliac fossa (b). The presence of
(a, b), fluid distension of the stomach, moderate distension small amount of free air surrounding a bowel loop in the
of some small intestinal loops at the left abdominal quad- right iliac fossa is evident (c, arrow and star in d)

small bowel ulceration from nonsteroidal anti- ing [15]. In the presence of focal perforation of
inflammatory drug use, Crohn’s disease, and the gastrointestinal tract, the specific site of per-
diverticulitis [13, 14]. foration seems to be identifiable on CT in
Different and various processes may cause 85–90 % of cases [11, 16]. Moreover, in addition
acute peritonitis from perforations: on CT, in to directly visualizing the site of perforation,
addition to the small bowel findings, there is associated CT findings to look for include a clus-
some combination of free intraperitoneal gas or ter of extraluminal gas bubbles close to the sug-
fluid, mesenteric edema, and peritoneal thicken- gestive perforation site as well as an abscess
6 Small Bowel Perforations: Imaging Findings 41

a b

c d

Fig. 6.3 An 88-year-old patient with perforation from them characterized by altered trophism. Multiplanar ref-
small bowel obstruction. CT shows the presence of free ormation shows the presence of linear mesenteric gas sur-
peritoneal air (a–d), small amount of free fluid, small rounding a small intestinal loop in the left abdominal
bowel proximal loops moderately distended, some of quadrant suggestive of fissuration (arrowhead in d)

formation [11, 16] especially in covered perfora- the specific air distribution could be also influ-
tions. In patients affected by severe disease and enced by the perforation site, the elapsed time
poorer outcome from intestinal perforations, the after perforation, and the amount of pneumoperi-
attenuation of the peritoneum on non-contrast CT toneum [18]. Therefore, prediction of the perfo-
has been reported as significantly lower, presum- ration site using specific free air distributions
ably reflecting a greater degree of edema [17]. could be considered as limited [18].
The specific air distribution seems to be more fre- A correctly performed CT examination repre-
quently present in patients with gastroduodenal sents the basic condition for an efficient diagno-
perforations than lower gastrointestinal tract per- sis. Administration of intravenous contrast
forations [18]; however, the specific air distribu- medium could be considered important for all the
tion had a less significant role than the strong acute intestinal conditions in order to evaluate the
predictors of the site of bowel perforation [18]. bowel wall feature and enhancement, essential
Periportal free air sign has been reported as a use- and useful for all differential diagnoses. In sus-
ful finding that can help to distinguish upper from pected gastrointestinal perforations, the incre-
lower gastrointestinal tract perforation: when this mental diagnostic value of low-thickened around
sign is present, upper gastrointestinal tract or less than 1 mm slice reconstructions for direct
perforation is strongly suggested [19]. However, visualization of the perforation site in patients
42 S. Romano

a order to make a suggestive diagnostic frame

(Fig. 6.1). With respect to conventional plain
film, CT is able to detect extraluminal air in more
cases and could actually represent a good imag-
ing tool to differentiate the various types of gas-
trointestinal perforations [20]. Among not
frequent causes of pneumoperitoneum, there are
also the ingested foreign bodies such as generally
unconsciously ingested chicken and fish bones
[21]. From a clinical point of view, the acute pre-
sentations of this intestinal damage are nonspe-
cific, mimicking more common acute abdominal
conditions [21]: at CT thickened intestinal seg-
b
ment with localized pneumoperitoneum, sur-
rounded by fatty infiltration and associated with
already present or developing obstruction or sub-
obstruction, could represent the most common
CT signs; however, the specific diagnosis could
be done by the identification of the foreign bodies
[21]. The high specificity of the CT diagnosis in
making avoidance of surgical exploration possi-
ble has been reported not only in the latter case of
perforations just reported [21] but also in evaluat-
ing postoperative acute abdominal conditions
such as post-laparoscopic interventional proce-
dures [22]. In case of evaluation of patients who
underwent laparoscopic procedures more fre-
quently such as cholecystectomies, the eventual
intestinal perforation due to trocar injury leads to
Fig. 6.4 A 56-year-old patient with anastomotic leaks extensive pneumoperitoneum [22]. In fact, small
well documented by the endoluminal positive contrast
medium (a, b)
bowel injuries should be suspected when at CT
examination a large or an increasing amount of
free air is detected following laparoscopic proce-
with nontraumatic free pneumoperitoneum has dures [22].
been already assessed [10] as well as the agree- CT diagnosis of perforation is essentially
ment between readers as significantly higher with based on direct findings of extraluminal air or
thin slices and reformatting [10]. Regarding the positive oral contrast medium, as well as on indi-
CT features related to small bowel perforation, rect findings of an abscess or an inflammatory
the presence of extraluminal air is the first finding mass or a bowel wall-related phlegmon or abscess
to search for, from the CT-falciform ligament with fluid in the mesentery or surrounding a radi-
sign crossing the midline to scattered pockets of opaque foreign body [23]. The CT sensitivity in
air [20]. Small bowel wall thickening (>3 mm) intestinal perforations in the emergency setting is
[20], either segmental or diffuse, could represent high; however, further evaluations by the use of
the second important finding to note for. All the endoluminal positive contrast medium could be
eventual associated signs such as intestinal fluid required to demonstrate the site and nature of the
or gas distension or collapsed loops, abscess for- perforation [2], especially in postoperative intes-
mation, peritoneal, fat stranding evidence [20], tine to evaluate any eventual anastomotic leaks
they have to be considered as puzzle pieces in (Fig. 6.4).
6 Small Bowel Perforations: Imaging Findings 43

Perforation is also a serious life-threatening In conclusion, although if CT seems to be able

complication of lymphomas involving the gastro- to accurately predict upper gastrointestinal tract
intestinal tract [24]; although some perforations perforation with high reliability [9] than for other
occur as the initial presentation of gastrointestinal perforation sites, knowledge of whole CT find-
lymphoma, others occur after initiation of chemo- ings predicting perforation site can overall
therapy [24]. It has been reported that the median improve the diagnostic accuracy [9] also in eval-
day of perforation after initiation of chemother- uating the small intestine.
apy is 46 days and 44 % of perforations occur
within the first 4 weeks of treatment [24]; damage
to the intestinal microvasculature resulting in References
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Diffuse large B-cell lymphoma has been reported findings in small bowel perforation. Br J Radiol
82(974):162–171
as the most common lymphoma associated with 2. Macari M, Balthazar EJ (2001) Review: computed
perforation [24]; compared with indolent B-cell tomography of bowel wall thickening: significance
lymphomas, the risk of perforation was higher and pitfalls of interpretation. AJR Am J Roentgenol
with aggressive B-cell lymphomas or T-cell/other 176:1105–1116
3. Hines J, Rosenblat J, Duncan DR et al (2013)
types [24]. The small intestine has been reported Perforation of the mesenteric small bowel: etiologies
as the most common site of perforation (59 %) in and CT findings. Emerg Radiol 20(2):155–161
intestinal lymphomas [24], which remains a sig- 4. LeBedis CA, Anderson SW, Soto JA (2012) CT imag-
nificant complication more frequently associated ing of blunt traumatic bowel and mesenteric injuries.
Radiol Clin North Am 50(1):123–136
with aggressive than indolent lymphomas [24]. 5. Cho CK, Baker SR (2005) Manifestations of intra-
Perforation often occurs at tumor sites or surgical peritoneal air. In: Meyers MA (ed) Dynamic radiol-
anastomoses as well [25]. Tumor rupture and gas- ogy of the abdomen: normal and pathologic anatomy.
trointestinal perforation have been also reported Springer, New York, pp 309–331
6. Kim HC, Yang DM, Kim SW et al (2014)
in patients with gastrointestinal stroma tumor Gastrointestinal tract perforation: evaluation of
treated with imatinib, a tyrosine kinase inhibitor MDCT according to perforation site and elapsed time.
[27]. Intestinal perforations may also result from Eur Radiol 24:1386–1393
intraperitoneal chemotherapy for advanced ovar- 7. Broder JF, Amedani AG, Liu SW et al (2013)
Emergency department contrast practices for abdomi-
ian cancer [28], and the resulting bowel injury nal/pelvic computed tomography – a national survey
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Finally, controversies exist regarding the Radiology appropriateness criteria. J Emerg Med
need for contrast agents for emergency abdomi- 44(2):423–433
8. Hainaux B, Agneessens E, Bertinotti R et al (2006)
nal computed tomography examinations [29]. A Accuracy of MDCT in predicting site of gastrointestinal
survey on the US Academic Emergency tract perforation. AJR Am J Roentgenol 187:1179–1183
Departments to document national practice [29] 9. Singh JP, Steward MJ, Booth TC et al (2010)
was recently performed in which respondents Evolution of imaging for abdominal perforation. Ann
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were asked about their institutions’ use of oral, 10. Kuzmich S, Burke CJ, Harvey CJ et al (2013) Sonography
intravenous (i.v.), and rectal contrast for vari- of small bowel perforations. AJR Am J Roentgenol
ous abdominal/pelvic CT indications [29]. 201:W283–W291. doi:10.2214/AJR.12.9882
Intravenous contrast was the most frequently 11. Ghahremani GG (1993) Radiologic evaluation of sus-
pected gastrointestinal perforations. Radiol Clin
cited contrast [29], with at least 90 % of respon- North Am 31(6):1219–1234
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cations [29]. Oral contrast was more variably plain film radiology, ultrasonography and CT in
used and rectal contrast was rarely used [29]. jejuno-ileal perforations. Acta Radiol 39(1):52–56
13. Coulier B, Tancredi MH, Ramboux A (2004) Spiral
Among the most common indications for which CT and multidetector-row CT diagnosis of perfora-
no contrast agent has been used, viscus perfora- tion of the small intestine caused by ingested foreign
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14. Ho AC, Horton KM, Fishman EK (2000) Perforation of 22. Graña L, Pedraja I, Mendez R et al (2009) Jejuno-ileal
the small bowel as a complication of laparoscopic chole- diverticulitis with localized perforation: CT and US
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25(4):373–379 24. Katz DS, Scheirey CD, Bordia R et al (2013)
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Bowel perforation in intestinal lymphoma: incidence diffuse small bowel disorders. Radiol Clin North Am
and clinical features. Ann Oncol 24(9):2439–2443 51:45–68
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19. Benjamin RS, Blanke CD, Blay JY et al (2006) air distributions be valuable predictors of gastroduo-
Management of gastrointestinal stromal tumors in the denal perforation? Eur J Radiol 77:319–324
imatinib era: selected case studies. Oncologist 27. Cho HS, Yoon SE, Park SH et al (2009) Distinction
11:9–20 between upper and lower gastrointestinal perforation:
20. Ghekiere O, Lesnik A, Millet I et al (2007) Direct usefulness of the periportal free air sign on computed
visualization of perforation sites in patients with a tomography. Eur J Radiol 69:108–111
non-traumatic free pneumoperitoneum: added diag- 28. Yeung KW, Chang MS, Hsiao CP et al (2004) CT
nostic value of thin transverse slices and coronal and evaluation of gastrointestinal tract perforation. Clin
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 Acute Perforated Appendicitis:
Spectrum of MDCT Findings 7
Stefania Daniele, Silvana Nicotra, and Carlo Liguori

7.1 Introduction In order to lower the probability of useless

laparotomy, MDCT use has been increased.
Acute appendicitis represents one of the most fre- Thanks to high sensitivity (87–99 %) and speci-
quent abdominal surgical emergencies. Ready ficity (92–99 %), especially among adults, this
diagnosis of this pathology significantly reduces imaging modality has become the technique of
morbidity and mortality, which can be signifi- choice for an accurate diagnosis [3]. MDCT
cantly higher in cases with complications. availability in the appendicitis diagnostic flow
Whereas in most patients acute appendicitis chart dramatically lowered unnecessary laparot-
can present in a quite easy to diagnose scenario, omy percentage (2 %) [4].
using clinical and laboratory data, some cases can Nowadays MDCT use is the option of choice
have a very hazy or atypical manifestation form- in cases of suspected acute appendicitis in
ing a hard to diagnose surgical event. Moreover it patients presenting equivocal symptoms and
is important to consider that many other abdomi- unclear instrumental data. Nevertheless this is the
nal pathologies can mimic appendicitis signs and only modality able to assess pathology severity
symptoms, increasing the differential diagnosis grade with consequential different therapeutic
issue [1]. Since the difficult diagnostic process approaches.
raises the very high percentage of unnecessary
surgical appendicectomy or simple laparotomy,
anteriorly to MDCT (multi-detector computed 7.2 Normal Anatomy
tomography) era (14–30 %) [2].
Vermiform appendix is a blind-ended tube vary-
ing 2–20 cm (cm) in length, usually located
S. Daniele
2–3 cm below the ileocecal valve and having a
Department of Radiology, “A. Cardarelli” Hospital, 1–2 cm thickened wall. In normal conditions the
Via Carmine 22, Pozzuoli, NA 80078, Italy lumen is occupied by fluid or gas and surrounded
e-mail: [email protected] by homogeneous fat tissue. According to Wakeley
S. Nicotra classification, five appendix location varieties
Department of Radiology, “A. Cardarelli” Hospital, can been encountered: sub-cecal, pelvic, pre-
Via Terracina 311, Napoli, NA 80125, Italy
e-mail: [email protected]
ileal, post-ileal and retrocecal [5].
In most cases it has the classical inferomedial
C. Liguori (*)
Department of Radiology, “A. Cardarelli” Hospital,
or retrocecal position (75 %), less frequent is the
Via Corcione 116, Aversa, NA 81031, Italy sub-cecal or pelvic (20 %) and pre- or post-ileal
e-mail: [email protected] location (5 %) [6].

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 45

DOI 10.1007/978-3-319-08192-2_7, © Springer International Publishing Switzerland 2015
46 S. Daniele et al.

7.3 Clinical Presentation • Neoplasia (colon adenocarcinoma, carcinoid,

Kaposi sarcoma and lymphoma)
In 80 % of cases acute appendicitis is diagnosed • Metastasis (colon and breast)
on a clinical presentation basis, and its incidence is Obstruction of the ileo-appendicular valve deter-
slightly higher in males (men, 78–92 %; women, mines an increasing pressure in the lumen of the
58–85 %). appendix caused by the mucosal continuous secre-
Typical presentation (50–60 % of cases) is tion, with consequent distension of the viscera.
characterised by abdominal diffuse visceral pain Visceral distension leads to bacterial multipli-
subsequently localised in right quadrants, cation in the appendix, and increased luminal
anorexia, nausea, vomiting, fever, right pelvic pressure causes occlusion of the wall veins and
mass and laboratory leucocytosis. In 20 % of capillaries with consequential vascular conges-
patients, it can be atypical with a large variety of tion. Progressive lumen enlargement and increas-
signs and symptoms [1]. ing wall pressure can subsequently determine
Elderly patients, because of the large number of arterial blood supply reduction, especially in less
differential diagnoses taken into account, often rep- vascularised zones, like the antimesenteric por-
resent the most challenging clinical issue. Young tion of the loop, and the process finally ends up
females are difficult to diagnose as well considering into wall infarct and perforation.
that gynaecological pathologies can mimic a similar On the other hand it is important to underline
scenario. Finally children, in relation to confused that gas, fluid or a clear appendicolith can be pres-
clinical history, are always complicated to diagnose. ent in normal appendix too, and presence cannot
Appendix anatomical location can condition be considered an unequivocal sign of acute appen-
clinical presentation of the acute pathology, since it dicitis [2].
is mandatory to understand well anatomical posi- On the anatomopathological basis acute
tion variants: in cases of retrocecal appendicitis, appendicitis can be classified in three different
right lumbar pain can be the first symptom, in the types accounting for micro- and macroscopic
absence of pain under deep abdominal palpation. characteristics of the surgical specimen:
In cases of pelvic or sub-cecal appendicitis, • Catarrhal appendicitis: inflammation is lim-
the only manifestation can be represented by uri- ited to mucosal layer.
nary or pelvic pain associated with diarrhoea, • Phlegmonous appendicitis: wall inflammation
because of rectal irritation, in the absence of is more extensive than the previous with pari-
abdominal discomfort. etal microscopic phlegmon presence.
Pre- or post-ileal appendicitis can be silent in • Gangrenous appendicitis: is characterised by
terms of abdominal manifestation and character- parietal extensive necrosis.
ised only by vomiting or diarrhoea caused by sec-
ondary ileal loop inflammation.
MDCT is extremely helpful in atypical appen- 7.5 Differential Diagnoses
dicitis diagnoses [7].
Acute appendicitis must be differentiated by several
other acute abdomen causes. Main factors can affect
7.4 Aetiology and Pathogenesis appendicitis diagnosis: anatomical position of the
inflamed appendix, severity of the inflammation
In more than 90 % of cases, acute appendicitis is related (complicated or simple), age of the patient and sex.
to an obstructive cause. Obstruction may be due to: Other pathologies potentially can mimic
• Appendicolith presence (more than 50 % of appendicitis scenario and can be grouped into
cases) four entities:
• Lymphoid hyperplasia of the appendix wall • Surgical issues
• Foreign bodies – Bowel obstruction
• Parasitic infection (oxyuriasis) – Intussusceptions
7 Acute Perforated Appendicitis: Spectrum of MDCT Findings 47

– Acute cholecystitis lumen fluids, faecal material, air, or appendico-

– Perforated duodenum ulcer lith can be found even in non-pathological condi-
– Mesenteric lymphadenitis tions. Regular appendix wall can measure up to
– Meckel’s diverticulitis 0.1 cm [7].
– Colonic diverticulitis In case of inflammation the aspect can be dif-
– Pancreatitis ferent according to pathology severity and pres-
• Urological issues ence of complications. A pathologic appendix
– Right renal colic shows constantly an enlarged lumen with caliber
– Right pyelonephritis wider than 0.6 cm. This specific finding has been
• Gynaecological issues described as extremely sensitive (sensitivity
– Ectopic pregnancy 100 %) and constantly encountered in all inflam-
– Functional ovarian cyst bleeding mation cases, independently of appendicitis
– Ovarian cyst torsion severity. On the other side it has a low specificity,
– Salpingitis or pelvic inflammatory disease since a normal appendix characterised by a wide
(PID) caliber can be seen in normal subjects too.
• Clinical issues Wall thickness enlargement is another specific
– Gastroenteritis characteristic of acute appendicitis with a diam-
– Inflammatory bowel disease eter for each wall wider than 0.2 cm; thickening
– Diabetic cheto-acidosis is usually asymmetric and is coupled with pari-
– Herpetic pain X–XI nerve root etal enhancement alteration. Increased enhance-
Most frequently seen are mesenteric lymphad- ment of the wall is a typical sign of inflammation
enitis, ovarian cyst, Crohn’s disease, enterocolitis, caused by increment of blood supply; it can be
bowel obstruction, disease and diverticulitis [8]. seen in 86 % of acute appendicitis and 100 % of
cases with catarrhal aetiology [2].
A reduced wall enhancement or a patchy pat-
7.6 CT Findings tern indicates the reduced vascularisation areas,
usually achieved in more severe inflammation
Whereas during the single-slice CT scanner era conditions with subsequent ischemic parietal
appendix visualisation was often difficult, intro- zone formation; these two signs are usually pres-
duction of MDCT scanner technology, acquisi- ent in case of gangrenous appendicitis [2].
tion protocol standardisation and operator Inflammation progression in acute appendici-
confidence improvement, made normal appendix tis leads to involvement of the adipose tissue sur-
routinely assessable [7]. rounding the viscera. Evaluation of the appendix
A non-pathological appendix finding automat- surrounding fat is mandatory: in cases of missed
ically can exclude appendicitis presence, much appendix direct visualisation, the absence of fat
easier than the absence of inflammation signs. alterations can exclude appendicitis presence
Consequently surgeons ask for the chance to with same certainty [10]. In 69–100 % of acute
directly visualise the appendix, because in such appendicitis, an increased density of the appen-
cases there is a significant implementation of CT dicular fat (dirty fat sign) can be encountered [9].
examination negative predictive value [9]. In a second step, in the course of pathology pro-
Almost never, as a tubular and curved structure, gression, fluid collections (phlegmon) surround-
it can be visualised in a single slice, requiring mul- ing the appendix, without a clear wall, can be
tiple contiguous axial plans. Multiplanar recon- seen. When the phlegmon acquires a definite
structions (MPR) give fundamental help for a thick wall, showing peripheral enhancement after
correct identification and displaying of the viscera. medium contrast administration, it is a clear sign
In normal condition length can vary between 4 of progression into abscess.
and 25 cm (medium 9 cm) and maximum diam- In advanced cases appendix inflammation can
eter (wall to wall) can achieve 0.6 cm. In the involve adjacent structures and preliminarily the
48 S. Daniele et al.

caecum. In such cases caecal wall thickens just tions and mainly perforation. Presence of perfo-
around the site of appendix insertion generates ration significantly increases morbidity and
the arrowhead sign (Fig. 7.1), which is assessable mortality [3] and can condition therapeutic treat-
in 30 % of acute appendicitis cases with a 100 % ment. In some cases when it is present, often
specificity [11]. associated to abscess formation, surgical treat-
In cases of severe appendicitis, it is important ment is avoided in a first-line choice and medical
to identify the presence of potential complica- therapy or percutaneous drainage is preferred.
Perforation dramatically increases the risk of
complications after surgical period.
From this aspect comes the importance of a
correct pathology definition in the preoperative
setting using a high sensitive and specific
technique.
There are five MDCT signs of appendix perfo-
ration which are very specific:
• Enhancing defect foci of the wall: it has high
sensitivity, specificity and accuracy (95, 97
and 96 %, respectively) [3]. Some authors,
otherwise, underline the possibility of arte-
fact presence that hampers the utility of the
sign in cases of specific technical factors such
as peristaltic movement of the surrounding
bowel loops or close presence of bony struc-
tures. It is mandatory to consider positive the
defect only in clear, not equivocal cases
(Figs. 7.2 and 7.3).
Fig. 7.1 MDCT MPR coronal oblique image shows
inflammation of the appendix with fluid-filled lumen, • Abscess presence: abscess is defined as a well-
associated to inflammatory thickening of the caecal wall circumscribed fluid collection with thick wall

Fig. 7.2 MDCT axial (a) and MPR oblique (b) images Parietal enhancement defect can be appreciated (arrows)
show inflamed appendix with the presence of appendico- as a sign of perforation with associated fluid in the sur-
lith inside and moderate amount of fluid in the lumen. rounding fat space
7 Acute Perforated Appendicitis: Spectrum of MDCT Findings 49

showing positive enhancement. Gas can be

seen in the context of the collection due to
anaerobic bacterial presence or due to a direct
communication with appendicular lumen.
Many authors consider this sign the most spe-
cific for perforation diagnosis [2–12] (Fig. 7.4).
• Phlegmon presence: it is defined as a fluid col-
lection without a clear wall associated to an
increased fat tissue density. Many authors
consider this event as a highly specific sign of
perforation (95 %) but with a low sensitivity
(40 %) (Fig. 7.5).
• Extraluminal air: it is defined as a bubble gas
presence outside the appendix showing a high
specificity (98 %) but low sensitivity (22–35 %)
for perforation assessment. Especially in very
skinny subjects, with a poor fat presence in the
abdomen, bowel loop gas can sometimes mimic
an extraluminal gas collection.
• Extraluminal appendicolith: it is the presence
of a calcified nucleus outside the appendix,
Fig. 7.3 Surgical finding from patient in Fig. 7.1. After showing a very high specificity for perforation
appendicectomy wall necrotic area (arrow) corresponds diagnosis (100 %) but poorly sensitive (32 %)
exactly to not enhancing portion depicted at MDCT; (Fig. 7.6).
extracted appendicolith (circle) causing appendicitis

Fig. 7.4 MDCT axial (a) and MPR coronal (b) images show appendicular abscess with air-fluid level. In the rectangle
(a, b) appendicolith obstructing the appendix valve and thick enhancing wall of the abscess can be appreciated
50 S. Daniele et al.

Fig. 7.5 MDCT axial (a) and MPR sagittal (b) images portion of the appendix is characterised by not enhancing
show fluid collection without enhancing wall surrounding wall as a sign of perforation
the appendix. In the rectangle (a, b) the distal inferior

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nucleus (arrow) outside the appendix with associated appendicitis: comparison of 5 and 10 mm CT section
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10. Niholaidis P, Hwang CM et al (2004) The nonvisual- 12. Tsuboi M, Takase K et al (2008) Perforated and nonper-
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 Acute Perforated Diverticulitis:
Spectrum of MDCT Findings 8
Maria Giuseppina Scuderi and Teresa Cinque

8.1 Introduction The incidence increases with age, and diver-

ticulosis is rather uncommon in people under 40
Colonic perforation is a common complication of years of age: in fact it occurs in 10 % of people
diverticulitis that requires early diagnosis and over age 40, in 50 % of people over 60 and in
treatment. 70 % in people over 80 years [1].
MDCT, without bowel preparation, allows Diverticula develop from the outpouching of
high-resolution multiplanar detection of diver- the mucosa and submucosa through the muscular
ticula perforation because it is the most valuable layers of the wall, in the loci of minoris resisten-
imaging technique for identifying the wall of the tiae where penetrating vessels cross through the
colon as well as the surrounding pericolic fat and wall.
the presence, the site and the cause of the GI Diverticula can be found anywhere through-
perforations. out the colon, most frequently in the sigmoid
The spectrum of MDCT findings of the diver- tract [2]. They can be less or more numerous and
ticulum perforation depends on the site of the may have a variable size usually between 2 mm
lesion (if perforation regards the retroperitoneal and 2 cm, but giant diverticula (up to 25 cm), usu-
or the intraperitoneal space) and on the entity of ally solitary, have been described in the sigmoid
the inflammatory process. tract [3].
Diverticula usually present as air-filled pock-
ets, but it is not so rare to find spontaneously
8.2 Diverticular Disease: hyperdense or calcified diverticula from dehydra-
Diverticulitis tion of faecal material trapped in the diverticular
pocket because of the lack of muscular layer in
The presence of an uninflamed diverticula (diver- the wall and the narrowing of the neck that pre-
ticular disease or diverticulosis) occurs more vent clearance from the faecal material.
commonly in Western countries, correlated to Occlusion by stool or food particles may lead
diet low in fibre and to other causes of increased to bacterial overgrowth and local tissue isch-
intracolonic pressure. aemia that starts an inflammatory process.
Complicated diverticulitis is due to possible
microscopic, usually covered, perforation with
M.G. Scuderi (*) • T. Cinque extension into the pericolic fat and possible for-
Department of Radiology, “A. Cardarelli” Hospital, mation of an abscess or a phlegmon [4].
Largo A. Cardarelli, Naples 80131, Italy
e-mail: [email protected]; The abscess may be confined in the pericolic fat
[email protected] and may spread along the retroperitoneal fat planes

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 53

DOI 10.1007/978-3-319-08192-2_8, © Springer International Publishing Switzerland 2015
54 M.G. Scuderi and T. Cinque

Fig. 8.1 Diverticular microperforation: little amount of free air associated with thickening of the sigmoid wall, diver-
ticular pouch and perivisceral signs (mild, fuzzy hyperdensity and stranding of pericolic tissue, arrows)

or the peritoneal recesses or into the adjacent long segment of the colonic wall and with signs
organs as fistulous tract to the small bowel, blad- related to a cellulitic process into the perivisceral
der, vagina, uterus and adnexa or abdominal wall. tissue: hyperdensity (sometimes very slight and
Rarely, diverticulitis results in free peritoneal fuzzy) and increase of perivisceral lymphatics
perforations (only 1 or 2 % of diverticulites pre- and vessels presenting as hyperaemia and strand-
senting with acute abdominal pain have free ing of the pericolic fat are the first signs of inflam-
perforation). mation eventually associated with thickening of
The clinical spectrum of diverticular disease the retroperitoneal or peritoneal folds [6].
varies from asymptomatic diverticulosis to fatal Phlegmon may appear, in proximity of the
complication such as generalized peritonitis inflammation site, as a little mass, round or ovu-
(worse if faecal) from rupture of a peridiverticu- lar, that is hyperdense (from +15 to +35 HU),
lar abscess or from free rupture of an uninflamed enhanced after MDCT and surrounded by slightly
diverticulum (Fig. 8.1) [5]. dense tissue (Fig. 8.2).
A fluid, hypodense, collection with surround-
ing thickened, hyperdense inflammatory wall due
8.3 Spectrum of MDCT Finding to an abscess may be more frequently found.
Small air-bubble or air-fluid levels may be con-
The diagnosis of acute diverticular perforation tained in the centre of the collection (Fig. 8.3).
requires the presence of the diverticula usually The presence, the grade of thickness and of
associated with circumferential thickening of a post-contrastographic density and the presence of
8 Acute Perforated Diverticulitis: Spectrum of MDCT Findings 55

septa and air-bubble levels are related to the ments, a retroperitoneal or peritoneal extension
grade of the abscess maturation. of the process may happen.
The spectrum of MDCT findings of diverticu- When perforation is associated with an abscess
lum perforation depends on the site of the lesion formation, the abscess can be confined to the pel-
and on the involvement of the retroperitoneal or vis or can extend far into the abdomen.
peritoneal spaces. When the peritoneal cavity is involved, the
The most frequent perforation site is the sig- abscessual collection is always well delimited by
moid colon; the transverse colon accounts for thickened peritoneal folds presenting as a dense
approximately 18 % of perforations, whereas and uniform capsule.
perforation of the cecum and the right colon is In the sigmoid perforation MDCT has excel-
rare (only 5 % of perforations). The sigmoid lent contrast resolution to detect the presence of
mesocolon and thus the subperitoneal space are small amounts of free extraluminal air in close
most frequently involved but, due to the continu- proximity to the intestinal wall thickening or cen-
ity of the spaces beneath the posterior parietal tred within paracolic inflammatory tissue in the
peritoneum and abdominal pelvic walls with the pericolic space. Extraluminal air can always be
root of the sigmoid mesentery and pelvic liga- detected with adequate window setting even if
there are only small bubbles [7].
In sigmoid free perforation a greater amount of
air can diffuse into the subperitoneal space, the ret-
roperitoneal space of the pelvis, of the abdomen
and also, through the diaphragmatic hiatus, of the
thorax and of the neck resulting in pneumomedias-
tinum and cervical emphysema [8] (Fig. 8.4).
In case of colonic perforation (left and right
colon), air bubbles are preferentially located in
the pericolic fat (contained perforation)
(Fig. 8.5) [7].
In case of free perforation into the peritoneal
Fig. 8.2 Phlegmon, (arrows): hyperdense tissue (from cavity, the air rapidly reaches the most antide-
+15 to +35 HU), enhanced after MDCT contiguous to a clive position usually in the anterosuperior part
diverticulitis site and microbubbles of free air of the involved peritoneal recess (Fig. 8.4).

Fig. 8.3 Parasigmoid abscess: hypodense fluid collection, contained in the mesosigma, with an air-fluid level, and
delineated by thickened, hyperdense inflammatory rim
56 M.G. Scuderi and T. Cinque

Fig. 8.4 Retroperitoneum

from diverticular perforation:
free air in the mesosigma and
perirenal space
8 Acute Perforated Diverticulitis: Spectrum of MDCT Findings 57

Fig. 8.6 Dirty mass (faecal abscess, arrows) fistulized to the abdominal wall

The risk of an adverse outcome is highest if In the absence of bladder catheterization, air
the perforation of the diverticular or of the in the bladder associated with signs of sigmoid
abscess wall allows faecal discharge in the perito- diverticulitis and thickening of the bladder wall,
neum. The presence of spilled faeces or “dirty usually in a posterolateral site, suggests a fistula.
mass” in the lower abdomen is a specific indica- Bladder collection of the stool and faecaluria
tor of colonic perforation [9]. may be observed (Fig. 8.8).
A CT features an extravasated faeces that is a
low-attenuation soft tissue mass containing small
air bubbles (Fig. 8.6). 8.4 Diagnostic Findings
The spread of the inflammatory process into for Adequate Management
adjacent organs may have several clinical presenta-
tions such as hydronephrosis, psoas abscess, The traditional, surgical, Hinchey classification
abdominal wall abscess [10] and spondylodiscitis. has been used, before the advent of MDCT imag-
Fistulization more frequently can involve ing, to verify the extent and the degree of the pel-
small bowel loops (Fig. 8.7) or the bladder, espe- vic and abdominal disease at the time of surgery.
cially in men. In women, uterine, adnexal or vag- It is a four-graded classification with a peri-
inal fistulization can occur. colic abscess confined by the mesentery of the

Fig. 8.5 Colonic perforation: evidence of pneumoperitoneum and air bubbles preferentially located in the pericolic fat
(arrows)
58 M.G. Scuderi and T. Cinque

Fig. 8.7 Ileocolic fistula in

diverticulitis: long fistulous
track (arrow) between the
colonic wall and an ileal loop

colon in grade I, pelvic abscess resulting from 8.5 Differential Diagnosis

a local perforation of a pericolic abscess in
grade II, generalized purulent peritonitis from The typical clinical signs of an acute diverticuli-
rupture of a pericolic or pelvic abscess into the tis are represented by localized pain and guarding
general peritoneal cavity in grade III and faecal in the left lower quadrant, fever and leucocytosis.
peritonitis from free perforation of a diverticu- However clinical signs may be atypical, and a CT
lum or abscess with faecal discharge in grade differential diagnosis becomes necessary.
IV [1]. The CT diagnosis of acute diverticulitis is
Nowadays the surgical treatment and the man- based on the assessment of the diverticula associ-
agement of diverticulitis have changed, and a ated with inflammatory signs and on the exclu-
CT-guided classification (Ambrosetti) is pre- sion of other pathological conditions.
ferred [11–15]. From a clinical point of view, in the acute right
In mild diverticulitis the thickening of the lower quadrant, a differential diagnosis may be
colonic wall is <3 mm and is associated with required from an appendicitis and a right-sided or
perivisceral signs. a redundant sigmoid colon diverticulitis. In this
Moderate diverticulitis has significant wall case multiplanar reconstructions are very helpful
thickening (>3 mm) determining segmental to individuate the anatomical structure involved
lumen narrowing in association with phlegmon and the perivisceral signs. It is not so rare, in fact,
or small abscess. to find a very elongated sigma with inflamed diver-
Severe diverticulitis is defined as parietal ticular pouches in the right lower quadrant in close
thickening >5 mm with abscess greater than 5 cm relationship with the cecum and normal appendix;
or perforation. or otherwise an inflamed appendix, eventually
These findings help to discriminate those related to an ectopic, pelvic cecum, goes in close
patients with mild diverticulitis or with an contact to an uninflamed sigmoid diverticula [16].
abscess less than 3 cm, which are generally More frequently in the acute left lower quadrant,
treated with antibiotics, from those in whom an the main pathology in differential diagnosis with
abscess greater than 3 cm may be percutane- diverticulitis perforation is colon carcinoma. In per-
ously drained [12]. forated colon carcinoma the pericolic fat stranding
In some cases of complicated diverticulitis, and vascular engorgement can mimic diverticulitis.
the ureter may be trapped in the inflammatory But greater wall thickening, often eccentric, of a
phlegmon and may require a presurgical stenting short segment of the colon and local lymphadenop-
or a careful legation at the time of intervention. athy are more indicative of carcinoma.
8 Acute Perforated Diverticulitis: Spectrum of MDCT Findings 59

Fig. 8.8 Colovesical fistula: faecal abscess contiguous to the thickened sigmoid wall and fistulous track to the bladder
wall (thickened and hyperdense, arrows); faecal material in the catheterized bladder

3. Thomas S, Pee RL, Evans LE, Haarer KA (2006) Best

Other colonic inflammatory conditions, such cases from AFIP: giant colonic diverticulum.
as Crohn’s disease or ulcerative colitis and pelvic Radiographics 26:1869–1872
inflammatory disease, may require a differential 4. Werner A, Diehl SJ, Farag-Soliman M, Duber C (2003)
Multi-slice spiral CT in routine diagnosis of suspected
diagnosis.
acute left-sided colonic diverticulitis: a prospective
In diverticulitis, a colovesical fistula is sug- study of 120 patients. Eur Radiol 13:2596–2603
gested by the endoluminal air and by the thick- 5. Stoker J, vanRanden A, Lameris W, Boermeester MA
ening of the bladder wall usually in a (2009) Imaging patients with acute abdominal pain.
Radiology 253:31–46
posterolateral site, whereas a colovesical fistula
6. DeStiger K, Keating D (2009) Imaging update: acute
from a Crohn’s disease usually involves the ter- colonic diverticulitis. Clin Colon Rectal Surg
minal ileum and the right anterior surface of the 22(3):147–155
bladder. 7. Pinto A, Scaglione M, Giovine S (2004) Comparison
between the site of multislice CT signs of gastrointes-
tinal perforation and the site of perforation detected at
surgery in forty perforated patients. Radiol Med
108(3):208–217
References 8. Pyong WCJ (2011) Pneumomediastinum caused by
colonic diverticulitis perforation. J Korean Surg Soc
1. Jacobs DO (2007) Diverticulitis. N Engl J Med 80:S17–S20
357:2057–2066 9. Saeky M, Hoshikawa Y, Miyazaki O (1998)
2. Horton KM, Corl FM, Fishman EK (2000) CT evalua- Emergency computed tomographic analysis of
tion of the colon: inflammatory disease. Radiographics colonic perforation: dirty mass, a new CT finding.
20:399–418 Radiology 5:140–145
60 M.G. Scuderi and T. Cinque

10. Vasileios R, Anna G, Christos L (2013) Abdominal 13. Stocchi L (2010) Current indications and role of sur-
wall abscess due to acute perforated sigmoid diverticu- gery in the management of sigmoid diverticulitis.
litis: a case report with MDCT and US findings. Case World J Gastroenterol 16(7):804–817
Rep Radiol 2013:565928. doi: 10.1155/2013/565928 14. Biondo S, Lopez Borao J, Millan M (2012) Current
11. Ambrosetti P, Becker C, Terrier F (2002) Colonic status of the treatment of acute colonic diverticulitis: a
diverticulitis: impact of imaging on surgical manage- systematic review. Colorectal Dis 14(1):1–11
ment- a prospective study of 42 patients. Eur Radiol 15. Moore F, Catena F, Moore E (2013) Management of
12:1145–1149 perforated sigmoid diverticulitis. Position paper.
12. Siewert B, Tye G, Kruskal J, Sosna J, Opelka F (2006) World J Emerg Surg 8:55
Impact of CT-guided drainage in the treatment of 16. Yaacoub IB, Boulay I, Jullès MC (2011) CT findings
diverticular abscess: size matters. AJR Am J of misleading features of colonic diverticulitis.
Roentgenol 186:680–686 Insights Imaging 2(1):69–84
 Colorectal Perforation:
Assessment with MDCT 9
Gianluca Ponticiello, Loredana Di Nuzzo,
and Pietro Paolo Saturnino

9.1 Introduction lic abscesses to large intra-abdominal or pelvic

abscesses and purulent or fecal peritonitis [3].
Colorectal perforation represents a medical con- Today the mortality rates of colorectal perfora-
dition where CT plays an important role for diag- tion have remained unchanged over the last two
nosis and identifies the etiology of acute decades, even with the many improvements in
abdomen. Colorectal perforations are severe con- medical therapy, intensive care, and surgical
ditions with a high rate of mortality. This is due techniques [4]. This situation may reflect a lack
to the fact that patients afflicted with these perfo- of knowledge about the condition and strategies
rations are often the elderly, with various coexist- to prevent it [5].
ing morbidities [1]. The frequency of colorectal
perforation in the general population is not well
known because many cases of minor colorectal 9.2 Causes of Colorectal
perforations are probably missed as the condition Perforation
resolves itself before the patient goes to the spe-
cialist or because studies are not performed early Nontraumatic colorectal perforation can be
enough in the course of the disease. Sometimes, caused by inflammatory, neoplastic, or ischemic
many colorectal perforations are misdiagnosed as etiology as well as by iatrogenic injuries and as a
other colonic infection or inflammatory diseases. postoperative complication. The perforation sites
The clinical manifestations depend on a number of the large intestine can frequently be correlated
of factors, including the size of the perforation, with their causes [6]. Malignant neoplasm, diver-
the level of extra colonic contamination, and the ticulitis (in Western countries), blunt trauma, and
body’s ability to contain this contamination [2]. ischemia are common causes of perforation on
Colorectal perforation presents different clinical the left side of colonic loops. Inflammatory bowel
features from peridiverticulitis and small perico- disease, diverticulitis (in eastern countries), and
penetrating trauma tend to be observed on the
right side of the colonic loops. The cecum can be
perforated in patients with mechanical colonic
G. Ponticiello (*) • L. Di Nuzzo • P.P. Saturnino obstruction. Iatrogenic injuries usually involve
Department of Radiology, “A. Cardarelli” Hospital, the rectum and sigmoid colon. Penetration of the
Via A. Cardarelli, 9, Naples 80131, Italy
serosal layer of the colon may lead to either a
e-mail: [email protected];
[email protected]; covered perforation, with phlegmon and abscess
[email protected] formation and localized peritonitis, or less

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 61

DOI 10.1007/978-3-319-08192-2_9, © Springer International Publishing Switzerland 2015
62 G. Ponticiello et al.

frequently to free perforation into the retroperito- low-attenuating cleft that usually runs perpen-
neum or the intraperitoneal cavity, depending on dicular to the bowel wall on CT. However, this
the involved colonic segment. The clinical and cleft is observed less frequently than free air on
laboratory data can help in establishing the cause CT, and a cleft is usually seen in less than 50 % of
of the perforation [7, 8]. the patients with GI tract perforation. This is
related to the small size of the lesion. MDCT with
post-processing images can be helpful in identify-
9.3 CT Technique ing discontinuity of the bowel wall [9–13].

The entire abdomen from the dome of the dia-

phragm to the pelvic floor should be scanned. 9.5.2 Extraluminal Air
Contiguous axial images at 2.5 mm thickness are
obtained, and multiplanar reformations may be Free air localization depending on the perforation
applied when necessary. After the precontrast site can detected in intraperitoneal or retroperito-
images have been acquired, CT scanning is initi- neal spaces. Colonic perforation, like gastroduode-
ated 70–80 s after the intravenous injection of nal perforation, can appear as massive
contrast media (iodine) at high concentration pneumoperitoneum with free gas all over the abdo-
(400 mgl/mL), at a rate of 3–4 mL/s. Sometimes men and pelvis. If free gas is present only in the
it can be useful, especially when we suspect iat- pelvis, the colon, and not the small bowel, is the
rogenic perforation, to use hydrosoluble iodine usual site of perforation. The reverse is true for
contrast by retrograde way (rectum). supramesocolic free gas. However, during sigmoid
perforation we can have free air only in the supra-
mesocolic compartment; in this case we must find
9.4 Gas Localization and General focal signs such as wall thickening and pericolonic
CT Findings stranding to identify the site of perforation [9–13].

Computed tomography (CT) is helpful in detect-

ing extraluminal gas. 9.6 Indirect CT Findings
Multi-detector CT (MDCT) is superior to single
helical or conventional CT as it is able to provide Indirect CT findings are represented by bowel
rapid, high-volume coverage and diagnostic images wall thickening, abnormal bowel wall enhance-
even in patients unable to perform prolonged ment (includes interruption or lack of bowel wall
breath-holds. A study of MDCT showed 86 % enhancement on enhanced scan), abscess, and an
accuracy in predicting the site of perforation. The inflammatory mass adjacent to the bowel [13].
diagnosis of gastrointestinal (GI) tract perforation
is based on direct CT findings, such as discontinu-
ity of the bowel wall and the presence of extralumi- 9.7 Colonic Neoplasm
nal air, and on indirect CT findings [9–13]. and Perforation

Perforation related to colonic tumors has a

9.5 Direct CT Findings reported incidence of 1.2–9 %. The perforation
related to tumor mostly occurs at the cecum, sec-
9.5.1 Discontinuity ondary to marked prestenotic dilatation with a
of the Bowel Wall competent ileocecal valve, or at the site of the
tumor, due to tumor necrosis.
Direct visualization of the discontinuity of the On CT, both the perforation and the colonic tumor
bowel wall can identify the presence and site can be seen; colonic carcinoma results in diffuse or
of GI tract perforation, which is marked by a focal bowel wall thickening and pericolonic strand-
9 Colorectal Perforation: Assessment with MDCT 63

ing (Fig. 9.1). Once the tumor invades the serosal fat, 9.8 Colonic Ischemia
there is increased possibility of perforation with and Stercoral Perforation
abscess formation and gas leak (Fig. 9.2) [7, 14].
Stercoral perforation is related to a localized
mucosal ulceration and ischemic pressure necro-
sis of the bowel wall for vascular occlusion,
caused by a stercoraceous mass, most often
involving the sigmoid or rectosigmoid.
Risk factors include conditions leading to
longstanding constipation, often in bedridden
patients, such as drug-induced constipation (nar-
cotics, nonsteroidal anti-inflammatory drugs,
postoperative analgesia, and methadone), sclero-
derma, and an underlying obstructing colonic
lesion such as neoplasm or stricture [15].
The most useful tool for diagnosis of stercoral
perforation is abdominopelvic CT [16]. The main
specific CT finding of vascular impairment of the
Fig. 9.1 Expansive solid lesion of the descending colon colonic wall (ischemia) is lack or poor enhance-
with free small air bubbles near the lesion (arrow) and
pneumoperitoneum (curved arrow)
ment of its wall and often, in relation to focal
fecal distension of the colonic lumen, is indica-
tive of stercoral perforation (Fig. 9.3) [8]. Other
CT findings are free intraperitoneal air (Fig. 9.4),
colonic mural thickening, and adjacent fat strand-
ing [17].

Fig. 9.2 Modest quote of pneumoperitoneum between Fig. 9.3 Stercoraceous mass of rectal-sigma (curved
intestinal loops and below the diaphragm (arrows) arrow) and lack of wall contrast enhancement (arrows)
64 G. Ponticiello et al.

Fig. 9.5 Gaseous distention of the colon due to recent

colonoscopy (arrows)

Fig. 9.4 Supramesecolic and undermesocolic free intra-

peritoneal air (arrows)

9.9 Iatrogenic Injury:

Perforation During
Colonoscopy

Post-colonoscopic perforation is rare. These iat-

rogenic perforations occur in approximately 1 in
1,000 patients. The clinical presentation varies
from acute abdomen to subtle clinical findings.
In diagnostic colonoscopy the rectosigmoid Fig. 9.6 Discontinuity of the anterior sigma wall (arrow)
with modest quote of perivisceral free air (curved arrow)
is the most common site of perforation fol-
lowed by the cecum, while post-polypectomy
perforation, in therapeutic colonoscopy, occurs pneumothorax, a CT is recommended [7, 18].
at the site of the excised polyp. A perforated As we said before, about direct findings, in iat-
site is typically a large anti-mesenteric tear of rogenic perforation, we can find free retroperi-
colonic wall if it is caused by the shaft of the toneal gas in the anterior pararenal space caused
endoscope. Furthermore, a smaller perforation by perforation of the posterior walls of the sig-
can be found in an injury from the tip of the moid, ascending, and descending colon.
endoscope. If a perforation is clinically sus- When we have anterior wall sigmoid perfora-
pected and conventional chest and abdominal tion, the direct sign is discontinuity of the bowel
X-ray exclude free abdominal or subdiaphrag- wall with free extraluminal air near the lesion and
matic air, air within the colonic wall, subcuta- eventually in the intraperitoneal spaces (Figs. 9.5
neous emphysema, or pneumomediastinum or and 9.6).
9 Colorectal Perforation: Assessment with MDCT 65

9.10 Perforation After Colon:

Rectal Surgery (Anastomotic
Dehiscence)

The most alarming complication following

colorectal surgery is anastomotic leakage which
is associated with a high mortality rate.
Different factors are involved: the type of sur-
gery (higher risk after restorative proctocolec-
tomy or rectal resection), the extraperitoneal site
of the anastomosis, the type of the anastomosis
(higher risk after coloanal or ileal-anal pouch or
colorectal), the stapled anastomosis, and the
intraoperative complications.
The risk of leakage has become gradually
higher for low and ultralow coloanal anastomosis
[19–21].
CT represents the modality of choice for the
optimal recognition of postoperative complications
and for the assessment of patients with postopera-
tive sepsis. Most postoperative CT features overlap
between patients with and without clinically impor-
tant anastomotic leak (CIAL). The only feature
seen statistically more frequently with CIAL is
peri-anastomotic loculated fluid containing air. Fig. 9.7 Sigma resection with air-fluid collections around
Evident anastomotic leak is suspected on the the colon – rectal anastomosis (arrows)
basis of a large hydropneumoperitoneum or if
pneumoperitoneum enlarges on successive exam-
inations. Usually the collection is situated between
the rectum and the sacrum, and the rectum is ante-
riorly displaced by the collection. Sometimes we
can find the fluid collections around the anasto-
motic site also in patients without anastomotic
leakage. The key point for suspicion of a leakage
is visualization of air or contrast into the fluid col-
lection (Figs. 9.7 and 9.8) [22, 23].

9.11 Inflammatory Bowel

Fig. 9.8 Air-fluid collections around the anastomotic site
Disease (IBD) (arrow) with free air along the anterior abdominal wall
(curved arrow)
Perforating complications in IBD are rare. In
ulcerative colitis (UC), free perforation, occur- perforation (Figs. 9.9 and 9.10). Free perforation
ring in about 2 %, is often associated with toxic in Crohn’s disease (CD) is not so common (3 %),
megacolon, caused by marked colonic dilatation often it occurs during exacerbation of toxic coli-
in acute presentation. In UC when perforation tis, while sealed-off perforations are more fre-
involves the sigmoid, we can have free air only quent in CD, related to the transmural
in the supramesocolic compartment; in this case, inflammatory process and inter-loop adhesions,
we must find focal signs such as wall thickening leading to phlegmon and abscess formation with
and pericolonic stranding to identify the site of localized peritonitis [24].
66 G. Ponticiello et al.

7. Rubesin SE, Levine MS (2003) Radiologic diagnosis

of gastrointestinal perforation. Radiol Clin North Am
41:1095–1115
8. Zissin R, Hertz M, Osadchy A et al (2008) Abdominal
CT findings in nontraumatic colorectal perforation.
Eur J Radiol 65:125–132
9. Sung HK, Sang SS, Jeong YY et al (2009) Gastrointestinal
tract perforation: MDCT findings according to the
Perforation Sites Korean. J Radiol 10:63–70
10. Ghekiere O, Lesnik A, Hoa D et al (2007) Value of
computed tomography in the diagnosis of the cause of
nontraumatic gastrointestinal tract perforation. J
Comput Assist Tomogr 31:169–176
11. Maniatis V, Chryssikopoulos H, Roussakis A et al
Fig. 9.9 Widespread wall colon and sigma thickening (2000) Perforation of the alimentary tract: evaluation
with transmural ulceration and fluid collection in the pel- with computed tomography. Abdom Imaging 25:
vic cavity (arrows) 373–379
12. Stuhlfaut JW, Soto JA, Lucey BC et al (2004) Blunt
abdominal trauma: performance of CT without oral
contrast material. Radiology 233:689–694
13. Singh JP, Steward MJ, Booth TC (2010) Evolution of
imaging for abdominal perforation. Ann R Coll Surg
Engl 92:182–188
14. Zissin R, Hertz M, Osadchy A (2008) Abdominal CT
findings in nontraumatic colorectal perforation. Eur J
Radiol 65:125–132
15. Heffernan C, Pachter HL, Megibow AJ et al (2005)
Stercoral colitis leading to fatal peritonitis: CT find-
ings. Am J Roentgenol 184:1189–1193
16. Kumar P, Pearce O, Higginson A (2011) Imaging
manifestations of faecal impaction and stercoral per-
foration. Clin Radiol 66:83–88
17. Jeonghyun Kang, Min Chung (2012) A stercoral per-
foration of the descending colon. J Korean Surg Soc
82:125–127
18. Zissin R, Konikoff F, Gayer G (2006) CT findings of
Fig. 9.10 Modest quote of pneumoperitoneum below the iatrogenic complications following gastrointestinal
diaphragm (arrow) endoluminal procedures. Semin Ultrasound CT MR
27:126–138
19. Pronio A, Di Filippo A, Narilli P et al (2007)
Anastomotic dehiscence in colorectal surgery.
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in generalized peritonitis. Relation to cause and risk ing study? Dis Colon Rectum 50:197–203
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2. Michael RBK, Norman SW (1999) Surgery of the anastomotic bowel leak. Clin Radiol 62:37–42,
anus, rectum and colon, 2nd edn. Bailliere Tindall, Computed tomography (CT) is the most readily avail-
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3. Morris CR, Harvey IM, Stebbings WS et al (2002) gastrointestinal tract (LGIT) leak
Epidemiology of perforated colonic diverticular dis- 22. Danse E, Goncette L, Kartheuser A (2007) Optimal
ease. Postgrad Med J 78:654–658 diagnosis of anastomotic colorectal leak by combina-
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 MDCT Imaging of Blunt Traumatic
Bowel and Colonic Perforation 10
Francesco Iaselli, Isabella Iadevito, Franco Guida,
Giacomo Sica, Giorgio Bocchini,
and Mariano Scaglione

10.1 Epidemiology accidents (RTA, 70–85 %), followed by

and Etiopathogenesis aggressions and falls from heights. The incidence
of these conditions is significantly higher in
The intestine represents the third most frequently childhood in relation to the incomplete matura-
involved structure in blunt abdominal trauma tion of the muscles of the abdominal wall (in this
(BAT) after the liver and the spleen. Injuries of age group, one of the most common causes is
the small bowel and of the colon are relatively represented by impact of the handlebar of bicycle
uncommon, being found in approximately 3–5 % against the abdominal wall) [5–7].
of patients undergoing laparotomy and in about With regard to intestinal perforations from
1 % of patients evaluated with computed tomog- RTA, an increase of the incidence of these condi-
raphy (CT) [1–3]. tions has been registered after the introduction of
Pathogenic mechanisms at the basis of small seat belts, which compress the intestinal loops at
bowel and colonic traumatic perforations are sub- impact creating a “closed” hollow viscus; the sub-
stantially three, acting isolated or combined: sequent increase of the intraluminal pressure
• A direct force may crush the gastrointestinal exposes to the risk of bursting injuries. The pres-
tract between the vertebrae and the anterior ence of a “seat belt mark” sign is not surprisingly
abdominal wall. considered a reliable predictor of bowel injury [8].
• A rapid deceleration may produce a shearing The effect of a traumatic force applied to the
force between fixed and mobile portions of the intestinal wall is determined by the type and the
involved tract. severity of the traumatic insult, the anatomical
• A sudden increase in intraluminal pressure features of the segments involved, the degree of
may result in bursting injuries [1, 2, 4]. distension of the intestinal lumen, and the charac-
The leading cause of small bowel and colonic teristics of the intestinal content (a high content
perforations in BAT is represented by road traffic of fibers makes the loop more susceptible to
“bursting” injuries) [9].
F. Iaselli (*) • I. Iadevito • F. Guida • G. Sica The most common site of traumatic intestinal
G. Bocchini • M. Scaglione perforation is the small intestine (70 %). In par-
Dipartimento di Diagnostica per Immagini, ticular are more exposed to damage the loops
Clinica “Pineta Grande”,
Via Domitiana, Km 30, Castel Volturno,
close to points of anatomical or constituted fixity,
Caserta 81100, Italy where mobile and fixed portions of the gut are
e-mail: [email protected]; contiguous and therefore susceptible to shearing
[email protected]; [email protected]; force: proximal jejunum near the ligament of
[email protected]; [email protected];
[email protected]
Treitz, distal ileum near the ileocecal valve, and

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 67

DOI 10.1007/978-3-319-08192-2_10, © Springer International Publishing Switzerland 2015
68 F. Iaselli et al.

intestinal segments close to bridles and adhesions 10.2 Limits of Clinical

[2, 9]. Rapid deceleration represents the primary and Laboratoristic
mechanism of blunt duodenal injury causing tear- Assessment
ing at the junction of the intraperitoneal (free) and
retroperitoneal (fixed) portions of the duodenum, Tenderness is the most common sign of perito-
such as between the third and fourth portions. neal irritation at physical examination of the
Associated signs of pancreatic injury should be abdomen in patients with small bowel or colonic
sought in all cases, considering the very low inci- perforation from BAT: these patients, in fact,
dence of isolated duodenal lesions in adults [10]. have significantly higher rates of abdominal ten-
When perforation occurred at mobile seg- derness than patients with non-perforative small
ments of the small bowel, predicting the exact bowel and colonic injuries, and the presence of
perforation site may be difficult [11]. this clinical finding should always raise the suspi-
Colon injury from BAT is uncommon, being cion of a severe intra-abdominal injury [3, 14].
diagnosed in about 0.5 % of all major blunt trau- Signs observed less frequently are decrease of
mas and in 10.6 % of patients undergoing laparot- bowel sounds, markings, and distention
omy. Most of these lesions are of partial thickness, appearance.
and only 3 % of patients undergoing laparotomy Clinical diagnosis of small bowel and colonic
have full-thickness colonic tears [7, 12]. perforation in BAT is often challenging for sev-
Small bowel and colonic injuries from BAT eral reasons:
can be divided into major and minor according to • Objective data are often nonspecific, and
a prognostic criterion: “minor” intestinal lesions symptoms of peritoneal irritation are found in
include incomplete lacerations of the intestinal only half of the alert, non-comatose patients.
wall, intramural hematomas, and parietal contu- • Clear clinical signs of peritonitis have late
sions; the only intestinal “major” injury in BAT is onset (may not appear for hours), especially in
the full-thickness parietal tear resulting in small the cases of perforations of the small intestine,
bowel or colonic perforation. whose content is characterized by neutral pH,
In the broad spectrum of intestinal injuries from low bacterial charge, and weak enzymatic
BAT, small bowel and colonic perforations repre- activity.
sent a significant condition for several reasons: • Symptoms can be hidden or attenuated by
• The interruption of the intestinal wall creates a concomitant injuries, as in the case of major
continuity between the septic intraluminal trauma or neurological impairment due to
ambient and the peritoneum. The risk of involvement of the head or spinal cord, or by
chemical peritonitis and contamination of the medications which can mask pain and
peritoneal cavity by enteric pathogens imposes guarding,
to perform proper therapeutic interventions in • The attention for suspicious signs from the
the quickest time possible [9]. gastrointestinal tract can be reduced by coex-
• A direct traumatic force involving vascular isting, distracting lesions, such as femur frac-
structures afferent to the affected loops may tures [9, 15, 16].
lead to coexisting active bleeding or ischemic Previous studies reported that using clinical
sufferance of the intestine, deprived of its vas- assessment alone as the indication for laparotomy
cular supply [13]. Both conditions result in a to treat bowel or mesenteric injuries is associated
worse prognosis with respect to the cases of with a negative laparotomy rate that may be as
isolated involvement of the loop. high as 40 % [17, 18].
• Perforation may occur several hours after the Low values of specificity have been also
traumatic event, as a consequence of structural described for laboratory parameters used in the
primary alterations of the intestinal wall assessment of patients with BAT [17, 18].
induced by trauma or, more frequently, as a Diagnostic peritoneal lavage (DPL), accord-
result of the associated vascular lesions [2, 11]. ing to different authors, is more sensitive than CT
10 MDCT Imaging of Blunt Traumatic Bowel and Colonic Perforation 69

(even if performed with oral and endovenous slice thickness, and a reconstruction interval
contrast medium, slice thickness, and multidetec- values equals to 1 mm and completed by multi-
tor scanners) in identifying small bowel or planar reconstructions [19, 21].
colonic perforations and is limited, by practical Basal scans may be useful to detect free peri-
factors, excessive sensitivity (even minor, self- toneal air and to highlight the spontaneous hyper-
limiting injuries may be emphasized), low speci- density of fluid collections [2]. A biphasic,
ficity in assessing the site and the extent of the arterial, and venous assessment after the intrave-
intraperitoneal damage, and lack of sensitivity nous infusion of 120–150 ml of iodinated con-
for traumatic perforations of retroperitoneal vis- trast material at sufficient rate (≥3 ml/s) is
cera [14]. recommended in order to detect active bleeding
and to identify perfusion abnormalities of the
walls of the intestinal loops. According to the
10.3 Minor Diagnostic Tools “whole body” CT protocol for trauma, an acqui-
sition in the late phase, 3–5 min after starting the
Although ultrasonography (US) can identify infusion, may be useful in order to rule out low-
peritoneal fluid collections, its sensitivity and flow active bleeding [13, 18, 21].
specificity rates in diagnosing traumatic small The radiologist is asked not only to identify
bowel and colonic perforations are discouraging; the signs of trauma but also to provide an indica-
moreover, same way as the DPL, US is “blind” tion of the clinical significance of the detected
towards lesions of retroperitoneal tract of the lesions, focusing on conditions which, requiring
intestine because of its deep position [7, 15, 18]. immediate operative treatment, may change the
Abdominal radiograms may reveal antide- management of the ill patient [15, 20–22].
clivous air collections from a perforated hollow
viscus or signs of impaired canalization due to
the effects of BAT on the intestinal tract or the 10.5 CT Signs of Small Bowel
afferent blood vessels. In the era of multidetector and Colonic Traumatic
CT, however, the role of conventional radiogra- Perforations
phy is limited to particular situations, evaluated
case by case [14, 16, 18]. According to the kind and the degree of lesion,
the CT signs of traumatic intestinal perforation
are commonly divided into specific and nonspe-
10.4 Multidetector Computed cific [9, 15, 20, 23].
Tomography Direct visualization of a bowel wall discontinu-
ity and extraluminal spillage of enteric contents
Multidetector computed tomography (MDCT) (such as fluid, oral contrast material, solid ingests,
has been shown to be extremely accurate in diag- feces) represent the only specific signs of trau-
nosing small bowel and colonic perforations matic small bowel or colonic perforation. However,
from BAT, being the diagnostic test of choice in these signs are very uncommon [14, 22].
the hemodynamically stable and semi-stable Nonspecific signs of perforation include acute
patient [15, 18–21]. intestinal behaviors, extraluminal air collections,
The diagnostic accuracy of MDCT in the intraperitoneal free fluid, and infiltration of the
detection of traumatic bowel perforation has sig- mesentery.
nificantly increased in the last decade due to the Bowel wall discontinuity, extraluminal spill-
considerable availability of performing scanners age of enteric contents, and extraluminal air rep-
and the consequent reduction of motion artifacts resent signs of major lesion, while infiltration of
[2, 19, 21]. the mesentery and intraperitoneal fluid may be
In the era of MDCT, all exams must be per- associated with both minor and major lesions
formed with a high-resolution protocol, with [20, 23].
70 F. Iaselli et al.

Intramural hematoma, wall thickening, and seem to be diagnostically essential, especially in

abnormal bowel wall enhancement are ancillary conditions of limited bowel distension [3, 14].
signs, not directly addressing to perforation but
often coexisting with the abovementioned [20, 24].
10.5.2 Nonspecific CT Signs of Small
Bowel and Colonic Traumatic
10.5.1 Specific CT Signs of Small Perforation
Bowel and Colonic Traumatic
Perforation 10.5.2.1 Acute Intestinal Behaviors
Variations in tone, motility, shape, and location of the
10.5.1.1 Bowel Wall Discontinuity intestinal loops may represent the first hint of a small
or Transection of the Wall bowel or colonic perforation even in the absence of
with Focal Discontinuity small amounts of free fluid and air [9, 27].
of the Bowel Wall In most of the cases, reflex spastic ileus (RSI)
Although this sign is 100 % specific, its sensitiv- due to persistent contracture of the bowel with a
ity is low (approximately 7 %) [20, 24, 25] complete absence of intestinal gas is the first sign
because, in most of the cases, bowel perforation in order of appearance. When hypertonic spastic
is small and cannot be directly identified at CT reaction ends, the bowel loops relaxes and the
but only with a meticulous surgical exploration. tone decreases leading to reflex hypotonic ileus
(RHI) [23, 27].
10.5.1.2 Extraluminal Spillage RSI and RHI are characterized by an “intrinsic
of Enteric Contents evolutivity” and should not be considered as sep-
Similarly to the above-described sign, extralumi- arate entities, being possible the transition of
nal spillage of enteric contents is highly specific each of these in the other at any time in response
but is affected by low sensitivity values (12 %) to internal or external stimuli [28].
[24, 25] even if the study is conducted with previ-
ously oral contrast medium administration. 10.5.2.2 Intraperitoneal Fluid
In this regard, it should be noted that most of In most of the cases, intraperitoneal fluid may be
the evidences in the literature discourage the the only sign of a significant bowel injury at the
administration of oral contrast material before the first CT evaluation: pneumoperitoneum or retro-
execution of the CT exam as well as it is time- pneumoperitoneum, in fact, may not be visible
consuming (time required for its preparation, its immediately after the trauma, taking some hours
administration per os or using a nasoenteric probe, to appear (Fig. 10.1) [11, 24]. Management of
and its progression along the intestine may signifi- patients with intraperitoneal fluid as the sole find-
cantly affect the patient’s prognosis by retarding ing on CT scans includes laparotomy, diagnostic
the identification of traumatic injuries – e.g., active peritoneal lavage, or conservative management
bleeding – requiring urgent interventions) [20, 26]. with follow-up CT [14, 21].
Moreover, the administration of oral contrast Nonphysiologic amounts of free intraperito-
material in emergency patients with BAT does not neal fluid (>75 ml in minimally resuscitated

Fig. 10.1 A 24-year-old male patient admitted to the axial scan shows small amount of free fluid within the peri-
emergency department after a blunt abdominal trauma toneal cavity and absence of air. (d–f) Contrast-enhanced
(motor vehicle accident). (a) Plain film radiograph, upright follow-up CT study (wide window) performed 24 h later
view, shows scarce amount of air within the small bowel, depicts evidence of small amount of free air and fluid. The
with clear evidence of the psoas muscle’s outline consis- patient was sent to the operating room. At surgery, a trau-
tent with reflex spastic ileus. (b, c) Contrast-enhanced matic small bowel perforation was found
10 MDCT Imaging of Blunt Traumatic Bowel and Colonic Perforation 71

a b

c
f

e
72 F. Iaselli et al.

women of child bearing age, >25 ml in minimally

resuscitated adult males, and >25 ml in children)
without evidence for intraperitoneal solid organ
injury suggest occult hollow viscus injury [28].
The distribution of fluid collections may indi-
cate the injured structure [28]: while the hemoperi-
toneum from laceration of the liver or spleen is
classically distributed in the subphrenic spaces,
along the parieto-colic gutters and in the pelvis, in
the case of a mesenteric or intestinal injury, fluid is
more frequently observed among the loops and
within the mesenteric folds, forming typical polyg-
onal-shaped collections. In the case of a serosal
laceration, in fact, the blood spreads through the
mesenteric folds with a V-shaped morphology,
with the base corresponding to the loop and the
apex to the mesenteric root [23]. Fluid from lacera-
tion of a retroperitoneal hollow viscus tends to Fig. 10.2 Contrast-enhanced axial CT scan in a patient
with blunt thoracoabdominal trauma shows asymmetric
remain localized close to the site of injury [3, 29].
wall thickening of the medial aspect of the cecal wall
Origin of a peritoneal fluid may be also deduced associated with perivisceral soft tissue haziness. Note also
from its densitometric characteristics: a low-den- the presence of free air with a typical triangular appear-
sity collection (average values of density lower ance (arrows). CT findings consisting with cecal perfo-
rated hematoma, confirmed at surgery
than 20 HU, comparable to those of the bile inside
the gallbladder or of the urine in the bladder) sug-
gests the spillage of fluid from the intestine; a such as bowel wall thickening, abnormalities of
medium-density collection (>25 HU) is generally parietal enhancement, free peritoneal fluid, and
consisting largely of extravasated blood; a high- mesenteric infiltration may strengthen the diagnos-
density collection (>120 HU) is attributable to the tic suspicion (Fig. 10.2) [25].
extravasation of contrast medium from damaged Extraluminal air collection is subdivided into
vessels or to the spillage of oral contrast material free floating air (pneumoperitoneum and retro-
through bowel wall tears [28]. Notwithstanding peritoneum) and mottled air bubbles (air
these general assumptions, densitometric values entrapped within mesenteric layers).
do not have an absolute diagnostic value: a blood Free floating peritoneal air is typically localized
collection, for example, can appear with reduced right off of the anterior abdominal wall or along the
density because of decreased hematocrit or the anterior surface of the liver and spleen, being easily
admixture with other fluids of lesser density (e.g., identifiable even in small quantities [3, 23].
ascites, bile, urine) [20]. Mottled air bubbles indicate air nuclei confined
inside the mesenteric sheets, into the lumen of the
10.5.2.3 Extraluminal Air Collection mesenteric and portal veins, in the thickness of the
(Intraperitoneal, Mesenteric, intestinal wall, or right off of a gas-filled hollow
or Retroperitoneal) viscus. Their detection is more challenging and
Free extraluminal air represents a nonspecific but time-consuming, justifying the limited overall sen-
highly suggestive sign of intestinal injury from sitivity reported in the literature for free air at com-
BAT; when observed, even in the absence of spe- puted tomography (44–55 %) [23, 24]. In these
cific signs (interrupted intestinal wall, extraluminal cases, detection of the small air bubbles may be
spillage of enteric contents, intramural hematoma), difficult and time-consuming.
the diagnostic hypothesis bowel injury should Mottled air bubbles, especially if adjacent to a
always be sought [9, 24]. Coexistent ancillary signs bowel loop, have higher positive predictive value
10 MDCT Imaging of Blunt Traumatic Bowel and Colonic Perforation 73

10.5.3 Ancillary Signs

10.5.3.1 Intramural Hematoma

Intramural hematoma represents a specific find-
ing, difficult to detect in most of the cases, being
recognized only after a careful retrospective
analysis of the cases as an abnormal parietal
mass [25].
Identification is more frequent in duodenal
injuries (for its peculiar anatomical position, a
direct force may crush the viscus against the ver-
tebrae, as frequently happens in childhood trau-
mas from bicycle’s handlebars [5, 6] or in adults
in traumas from steering wheels), rare in colonic
lesions [10].
Fig. 10.3 Contrast-enhanced axial CT scan shows very
small gas bubbles (arrow heads) in the peritoneal cavity, Flexion-distraction fractures of L1–L2
consisting with traumatic perforation of the adjacent bowel (Chance fracture) have been reported in associa-
loop. This case outlines the importance of a careful assess- tion with duodenal intramural hematomas [10].
ment of the peritoneal cavity with a wide window setting
In the case of duodenal involvement, bowel
thickening may be observed in association with
for intestinal lesion than free floating peritoneal fluid in the anterior pararenal space, making it
air. This sign may suggest the location of bowel challenging to differentiate a wall hematoma
injury (Fig. 10.3) [4, 28]. from a traumatic duodenal perforation in the
A traumatic perforation of the duodenum and absence of a frank perforation. Only the detection
of the dorsal sides of the ascending and descend- of free air in the anterior pararenal space
ing colon causes a pneumoretroperitoneum: addresses the diagnosis of perforation of the duo-
extraluminal air extends through the fascial denum [10, 29].
planes and may dissect them, being so detectable Treatment is usually conservative: the
even at a great distance from the site of perfora- hematoma resolves spontaneously within 3
tion [10, 29]. weeks. In a limited percentage of cases, com-
In all patients with blunt trauma who have any plications are observed at a medium to long
CT finding that could potentially be associated with term, most often in the form of luminal steno-
a hollow viscus injury, images should be reviewed sis or obstruction [2].
with lung or bone window settings, in addition to
the routine soft tissue ones, in order to assess even 10.5.3.2 Segmental/Focal Bowel Wall
small amounts of free abdominal air [9, 23]. Thickening
Disproportionate circumferential thickening
10.5.2.4 Associated Mesenteric compared with the normal bowel segment and
Anomalies bowel wall thickness >3 mm is considered a
This minor CT sign of combined intestinal and nonspecific but significantly more sensitive
mesenteric traumatic injury, represented by striae sign of bowel traumatic injury compared to free
of inhomogeneous increase of the density of air and extravasated oral contrast medium,
mesenteric fat, is caused by small hemorrhages being appreciable in approximately 75 % of
within the mesentery. full-thickness lacerations [24, 28, 31]. The
Low specificity is reported for this finding, associated finding of intramural air makes
since it may be associated with both major and increases the specificity of wall thickening,
minor mesenteric lesions or bowel isolated making also likely the possibility of a full-
lesion [30]. thickness laceration [29].
74 F. Iaselli et al.

Avulsion of the meso, active contrast medium

extravasation, and mesenteric hematoma repre-
sent specific CT signs of mesenteric bowel injury.
Nonspecific signs include mesenteric infarction
and fluid collections [24, 30].

10.6.1 Mesenteric Avulsion

Peritoneal folds may be damaged at their inser-

tion on the loop. In CT a triangular-shaped col-
lection is observed, with the base oriented parallel
to the loop and apex facing towards the meso;
Fig. 10.4 Contrast-enhanced axial CT scan shows focal signs of loop sufferance from ischemia are gener-
hyper-enhancement of the distal ileum. This CT finding is
ally associated [30, 32].
nonspecific and requires clinical correlation

10.5.3.3 Abnormal Bowel Wall 10.6.2 Active Hemorrhagic

Enhancement Extravasation
Unequivocal focal abnormal enhancement
(decreased or increased) of a segment of the bowel Traumatic laceration of the meso associated with
is a highly suspicious finding often associated mesenteric vessel rupture leads to hemorrhage
with a significant injury especially if associated and subsequent necrosis of the intestine, deprived
with a pocket of fluid in the adjacent mesentery or of its vascular supply. The discontinuity of the
free fluid in the peritoneal cavity (Fig. 10.4) [20]. vessel wall is demonstrated by the appearance of
Vascular supply to a loop may be compro- a blush of contrast medium along the course of the
mised by traumatic intestinal or mesenteric vessel circumscribed by a halo of tenuous hyper-
lesions: consequent hypoperfusion can paradoxi- density, corresponding to the hematoma. This CT
cally manifest itself as increased wall enhance- sign is characterized by 100 % specificity [30],
ment in the early stages due to the passage of representing an absolute indication for urgent
molecules of the contrast medium through the operative treatment and frequently associating
more permeable damaged vascular endothelium. with major traumatic lesions of the bowel walls.
Bowel wall density may be evaluated compared
to that of the psoas muscle or of the contiguous
vessels [32]. Patchy, irregular areas of increased 10.6.3 Mesenteric Hematoma
impregnation of contrast medium represent a non-
specific sign of full-thickness laceration. Contained vascular lesions usually lead to the for-
Conversely, areas of decreased or absent bowel mation of mesenteric hematomas. In the absence
wall enhancement indicate traumatic bowel isch- of an active bleeding, the treatment of such enti-
emia due to mesenteric vascular laceration [20]. ties is conservative. However, large hematomas
may compress vascular structures leading to isch-
emic changes of the intestine [30, 32].
10.6 CT Signs of Major Primary CT density of a not-supplied hematoma is usu-
Mesenteric Injuries in BAT ally closer to that of soft tissues to that of the fluid,
being the blood in large part coagulated. Basal
Spectrum of primary mesenteric traumatic inju- scans may reveal a circumscribed, inhomoge-
ries includes conditions potentially associated neously hyperdense hematoma close to the site of
with bowel primary or secondary involvement. active blood extravasation “the sentinel clot sign.”
10 MDCT Imaging of Blunt Traumatic Bowel and Colonic Perforation 75

10.7 Pitfalls, Mimic, and Masks

• The administration of oral contrast material in

emergency patients with BAT represents a
potential source of pitfalls and misdiagnoses
[26, 32]: the spread of the iodine-based, endo-
venous contrast medium from an intraperito-
neal traumatic rupture of the bladder, for
example, may mimic the spillage of previ-
ously administered oral contrast material from
intestinal loops. Extraluminal oral contrast
material from injured bowel loops, then, may Fig. 10.5 Axial CT scan in a patient with severe blunt
mimic extravasated contrast medium from trauma (lung window) shows subcutaneous and pro-
peritoneal air tracking into the peritoneal cavity through a
ruptured vessels [33, 34]. diaphragmatic tear (arrow)
• Unsatisfactory specificity rates are reported
for intraperitoneal fluid as a sign of mesenteric
or intestinal lesion: its presence may be related
to other coexisting lesions (e.g., hepatic,
splenic). As already written, analysis of quali-
tative (e.g., density, locations) and quantitative
characteristics of fluid collections may help in
identifying the injured structure. As a general
rule, the presence of intraperitoneal fluid with-
out clear evidence of splenic or hepatic lesions
should always address towards the suspicion
of intestinal injury [29, 33, 34].
• In patients with history of BAT, before attrib-
uting with certainty the presence of free air in
the peritoneum to the trauma itself, it is neces-
Fig. 10.6 Contrast-enhanced axial CT scan shows dif-
sary to exclude other potential causes of pneu- fuse parietal thickening, fluid distension of the loops, and
moperitoneum: previous execution of a increased bowel wall enhancement secondary to profound
diagnostic peritoneal lavage, diffusion of air hypotension with hypoperfusion complex in a male
from the mediastinum, mechanical ventila- patient after blunt abdominal trauma: “shock bowel”
tion, pulmonary barotrauma, pneumothorax,
chest and diaphragmatic injury (Fig. 10.5), • “Shock bowel” represents a transient condition
provenience of the air from the apparatus source of false positivity for posttraumatic
female genital tract, and laceration of the peri- bowel wall thickening in patients with BAT:
toneal side of the bladder [34]. diffuse parietal thickening, fluid distension of
• The so-called pseudo-pneumoperitoneum (air the loops, and increased bowel wall enhance-
entrapped between the abdominal wall and the ment (Fig. 10.6) may be secondary to profound
parietal peritoneal layer) represents a diagnostic hypotension with hypoperfusion complex.
pitfall, mimicking true pneumoperitoneum [9]. Probably during hypoperfusion, vascular
• A non-circumferential parietal thickening, permeability increases with a preferential shift
limited to the declivous side of the loop, of blood flow to the mucosa [35]. The identifi-
should not be interpreted as a sign of intestinal cation of the hypoperfusion complex (flat infe-
traumatic injury, being only apparent, caused rior vena cava, increased enhancement of the
by the stratification of the intestinal contents adrenal glands, bowel, pancreatic and retro-
[24, 34]. peritoneal edema, “nutmeg liver” appearance,
76 F. Iaselli et al.

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Emergency radiology of the abdomen. Springer, ized tomography in the diagnosis of peritoneo-
Heidelberg, New York, Dordrecht, London intestinal lesions resulting from closed trauma.
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T, Brenneman F (2006) Evaluation of bowel and mesen- 30. Dowe MF, Shanmuganathan K, Mirvis SE, Steiner
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(1997) Blunt bowel and mesenteric injury: diagnostic 31. Macari M, Balthazar EJ (2001) CT of bowel wall
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26. Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy teric traumas. Semin Roentgenol 47(4):362–370
OH, Stevens MH (2004) Computed tomographic 33. Killeen KL, Shanmuganathan K, Poletti PA, Cooper
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 MDCT Imaging of Gastrointestinal
Tract Perforation Due to Foreign 11
Body Ingestion

Roberta Cianci, Valentina Bianco, Gianluigi Esposito,

Andrea Delli Pizzi, and Antonella Filippone

11.1 Etiology and Clinical drug abusers, in subjects who eat rapidly, and in
Scenario professionally exposed people (carpenters,
dressmakers, upholsterers). Subjects who wear
The ingestion of alimentary foreign bodies (FBs) dentures are particularly susceptible, because they
is relatively common, but most of them pass lack the sensitivity of the soft palate that is crucial
through the gastrointestinal (GI) tract unevent- for the recognition of small, sharp, or hard items
fully within 1 week [1], and perforation is rare, that may be included in the food bolus [1–3].
occurring in less than 1 % of patients [1, 2]. FBs Usually, nonmetallic dietary FB accidental
that complicate with perforation are usually ingestion is forgotten as it does not significantly
sharp, hard, pointed, or elongated; they can be impress patient’s memory. Moreover, there may
calcified (such as fish or chicken bones), metallic, be a considerable time lag of weeks or months
or wooden (such as toothpicks, skewers, chop- between the time of ingestion and the onset of
sticks) [2–5]. symptoms [1, 3].
Injury may occur anywhere from the mouth to FB perforation of the GI tract has a wide spec-
the anus, but the most common sites of perfora- trum of clinical presentations, which can be acute
tion include less fixed segments or those with or chronic. Patients occasionally present with
acute angulation, such as the ileum, the ileocecal, unusual or even bizarre manifestation, including
and rectosigmoid segments [2, 4]. hemorrhage, obstruction, and even ureteral colic
Voluntary ingestion of FBs is most common [1, 3].
among prisoners or in people who attempt suicide As the clinical suspicion is low and the clinical
[2]. In the majority, FB ingestion is unconscious presentation is varied and nonspecific, imaging
and/or accidental and is most common in the plays an important role in the diagnosis [4]. The
extremities of life (children and elderly), in prompt recognition of the presence, level, and
patients with mental disorders, in alcohol and cause of perforation is important for appropriate
patient management and surgical planning [6].

R. Cianci • V. Bianco • G. Esposito • A.D. Pizzi •

A. Filippone (*) 11.2 MDCT Technique
Section of Diagnostic Imaging,
Department of Neurosciences and Imaging,
“G. d’Annunzio” University, Via dei Vestini, The introduction of multidetector CT (MDCT)
Chieti 66100, Italy has allowed high-speed acquisition, thin slice
e-mail: [email protected]; [email protected]; collimation, and high spatial resolution, making
[email protected];
[email protected]; [email protected]
this technique particularly suitable for the

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 79

DOI 10.1007/978-3-319-08192-2_11, © Springer International Publishing Switzerland 2015
80 R. Cianci et al.

assessment of patients with abdominal pain from increases the sensitivity for detection of small
GI disease [7]. free air pockets [4, 6, 8].
We suggest to acquire data with a thin colli-
mation (≤1 mm) and to reconstruct the axial
images with a thickness of ≤3 mm. The use of 11.3 MDCT Findings
these parameters provides a better spatial resolu-
tion of both axial and reformatted images. The diagnosis of GI tract perforation on CT is
Intravenous contrast administration (300– generally based on identification of extraluminal
400 mgI/mL) is mandatory when not contraindi- leakage and consequent inflammatory reaction
cated, because it aids in depicting abnormalities around the perforation site [6]. Extraluminal air
of the GI wall and surroundings [4, 6, 8]. Usually is the major specific sign of GI tract perforation
a delay of 70 s after contrast injection provides a [4, 7, 9], and MDCT is the most reliable imaging
good quality enhancement of both bowel wall modality for detecting even small amounts of
and abdominal organs. free air [2, 4, 6–8, 10]. Rarely abundant free
The acquisition of non-enhanced phase should pneumoperitoneum occurs in the setting of GI
be recommended, mainly for less experienced tract perforation related to FB ingestion, espe-
radiologists, since the majority FBs appear as cially when small bowel is involved [5]. The pas-
hyperdense objects. sage of large amounts of intraluminal air into the
Although extraluminal leakage of oral con- peritoneal cavity is limited by the fact that the FB
trast material has been described as specific of GI produces a gradual erosion of the intestinal wall
perforation, the reported sensitivity of this sign is which results to being covered by fibrin, omen-
low, mainly in the presence of FBs [6, 7]. As a tum, or adjacent bowel loops [1, 3]. Therefore,
matter of fact, the extraluminal passage of the tiny bubbles of free air embedded in the omen-
oral contrast material may be precluded by tum and mesenteric folds or located along the
the rapid sealing of the perforation site and by the anterior aspect of the abdominal cavity should be
slow progression due to paralytic ileus, from carefully evaluated.
which these patients may suffer. Moreover, the So far, we described all the MDCT findings
major limit of positive oral contrast agent is to indicative of the presence of perforation. But
obscure subtle bowel wall changes or intralumi- since the management may depend on the loca-
nal high-density foreign objects [5, 7, 8]. tion of bowel defect, the next step is to identify
Therefore, in our opinion, oral contrast agent is the site of perforation. The first CT feature to this
not indicated in patients suspected of having a GI aim is the focal thickening of the GI wall (>8 mm
perforation from FBs. in stomach and duodenum, > 3 mm in jejunum
The use of reformatted images, such as multi- and ileum, >5 mm in colon and rectum) in close
planar (MPR) and thin-slab maximum intensity proximity to extraluminal air bubbles, with adja-
projection (MIP), is advocated since it may cent regional mesenteric fat stranding [2, 7, 9].
increase the diagnostic confidence. As a matter of In other cases, localized perienteric gas or
fact, these images are very useful when the orien- fluid collections and abscesses lying on the per-
tation of an FB with respect to the axial CT scan forated bowel wall represent an indirect clue of
affects the perception of the viewer [1, 5]. site perforation. Therefore, we recommend to
Furthermore, scrolling MPR may help to recog- carefully assess both axial and reformatted
nize and follow the bowel loops along their images for detection of localized interloop col-
course. In this way it is possible to increase the lections of extraluminal gas or fluid.
detection rate of subtle findings, such as small Sometimes the site of perforation may be
extraluminal fluid or air collections, adjacent to specified by the direct visualization of disconti-
the bowel wall. nuity of the GI wall, which appears as a low-
Assessment of lung window setting in addi- attenuating cleft. Although MPR may be useful
tion to the standard abdominal window setting to identify the focal defect on the GI wall when
11 MDCT Imaging of Gastrointestinal Tract Perforation Due to Foreign Body Ingestion 81

axial images are indeterminate, this finding is not appreciate their morphology and edges. Also in
commonly detected, owing to the small size of presence of less radiodense FB, such as fish bones,
the lesion [2, 7, 8]. CT provides good contrast resolution, showing a
When the perforation or directly the FB itself thin and linear hyperdensity [10] (Fig. 11.1).
causes a local inflammatory reaction which To be able to detect the FB, the radiologist has
involves the adjacent loops, the main finding is an to keep in mind that besides an intraluminal or
occlusive pattern. In these cases, the recognition partial extraluminal location (Fig. 11.2) at the
of obstruction level may indicate the perforation level of the perforated loop, it may lie free in the
site [1, 2]. peritoneal cavity passing through the bowel wall.
Ultimately, a definitive CT diagnosis is estab- It means that we can find the FB far from the per-
lished by identifying the FB. Calcified and metal- foration site [3, 5].
lic FBs are easily detected on CT, and the use of a We have to underline that, unfortunately, non-
bone window setting [4, 10] allows to better calcified wooden FBs, e.g., toothpicks, skewers,

a b

c d

Fig. 11.1 Surgically confirmed right colon perforation thickening of the right colon wall with surrounding
caused by a salted codfish bone in a 56-year-old woman fat stranding (open arrow in c), and an endoluminal
complaining with vague abdominal pain. Contrast- linear hyperdense structure indicative of foreign body
enhanced images (a–c: axial views, d: coronal thin-slab (arrow in c), better appreciable on MIP reconstruction
MIP) show tiny free air bubbles (arrowheads in a and b), (arrow in d)
82 R. Cianci et al.

a b

c d

Fig. 11.2 Sigmoid colon perforation caused by a chicken foreign body through the sigmoid colon wall (arrows in a
bone in an 84-year-old woman with Alzheimer disease. and b). These findings were confirmed by surgery (c, d:
CT images (a: coronal MIP; b: sagittal oblique MIP) show Courtesy of Prof. Felice Mucilli, Department of
free air bubbles (open arrowheads in a and b) and a local- Biomedical Sciences, “G. d’Annunzio” University of
ized abscess (arrowheads in a and b) with a hyperdense Chieti, Italy)
11 MDCT Imaging of Gastrointestinal Tract Perforation Due to Foreign Body Ingestion 83

a b

c d

Fig. 11.3 An 81-year-old man presenting at the emer- These findings were indicative of small bowel obstruction
gency department with acute abdominal pain and leuko- caused by the abdominal hernia, complicated with perfo-
cytosis. Contrast-enhanced images (a, b: axial views, c: ration. At surgery, a fragment of a wood skewer
sagittal MPR) demonstrate dilated fluid filled small bowel (d: Courtesy of Prof. Felice Mucilli, Department of
loops and a postoperative ventral hernia including a small Biomedical Sciences, “G. d’Annunzio” University of
bowel loop that shows mural thickening (arrows in a and c) Chieti, Italy) was found within the perforated loop. The
with adjacent mesenteric fat stranding (asterisk in c) and foreign body was not detectable on MDCT examination
localized air/fluid collections (arrowhead in a and b). owing to its nature

and chopsticks, may be missed even at an accu- tively show air and water components, which are
rate inspection, owing to their isoattenuating hardly distinguishable from the normal GI tract
appearance. Dry and fresh wood may respec- content (Fig. 11.3).
84 R. Cianci et al.

Conclusions 3. Goh BK, Chow PK, Quah HM et al (2006) Perforation

of the gastrointestinal tract secondary to ingestion of
In conclusion, GI tract perforation caused by
foreign bodies. World J Surg 30(3):372–377
FB is rarely clinically suspected, owing to the 4. Zissin R, Hertz M, Osadchy A et al (2008) Abdominal
frequent lack of awareness of ingestion [9]. The CT findings in nontraumatic colorectal perforation.
diagnosis should always be considered at CT, Eur J Radiol 65(1):125–132
5. Hines J, Rosenblat J, Duncan DR et al (2013)
particularly in the elderly patients, when other
Perforation of the mesenteric small bowel: etiologies
causes of abdominal pain have been excluded. and CT findings. Emerg Radiol 20(2):155–161
The accurate MDCT image analysis 6. Furukawa A, Sakoda M, Yamasaki M et al (2005)
performed with a high index of suspicion Gastrointestinal tract perforation: CT diagnosis of
presence, site, and cause. Abdom Imaging 30(5):
allows to identify subtle findings and to
524–534
achieve the correct diagnosis, with obvious 7. Hainaux B, Agneessens E, Bertinotti R et al (2006)
advantage for patient’s prognosis. Accuracy of MDCT in predicting site of gastrointesti-
nal tract perforation. AJR Am J Roentgenol 187(5):
1179–1183
8. Kim SH, Shin SS, Jeong YY et al (2009)
References Gastrointestinal tract perforation: MDCT findings
according to the perforation sites. Korean J Radiol
1. Goh BK, Tan YM, Lin SE et al (2006) CT in the preop- 10(1):63–70
erative diagnosis of fish bone perforation of the gastro- 9. Yeung KW, Chang MS, Hsiao CP, Huang JF (2004)
intestinal tract. AJR Am J Roentgenol 187(3):710–714 CT evaluation of gastrointestinal tract perforation.
2. Coulier B, Tancredi MH, Ramboux A (2004) Spiral Clin Imaging 28(5):329–333
CT and multidetector-row CT diagnosis of perfora- 10. Zissin R, Osadchy A, Gayer G (2009) Abdominal CT
tion of the small intestine caused by ingested foreign findings in small bowel perforation. Br J Radiol
bodies. Eur Radiol 14(10):1918–1925 82(974):162–171
 Pneumoretroperitoneum: Imaging
Findings 12
Antonio Pinto, Carlo Muzj, and Giuseppe Ruggiero

12.1 Introduction Perforation of the duodenum caused by blunt

trauma to the abdomen is now being encountered
Pneumoretroperitoneum is defined by the pres- as an automobile lap belt deceleration injury. In
ence of free air within the retroperitoneal space. duodenal injuries, mural hematoma, laceration,
The retroperitoneum is the compartmentalized or complete transection of the duodenum is usu-
space bounded anteriorly by the posterior parietal ally encountered, attributable to the following
peritoneum and posteriorly by the transversalis mechanisms: (1) tearing during deceleration, (2)
fascia. It extends from the diaphragm superiorly crushing between the abdominal wall and the
to the pelvic brim inferiorly [1]. spine, and (3) blowout [3].
Most often, air is seen surrounding the kid- Rupture usually occurs at the junction of the
neys and overlying the contour of the iliopsoas second and third portions, which are retroperito-
muscles. Free air can accumulate in the retroperi- neal, resulting in a local accumulation of gas in
toneal space after perforation of a retroperitoneal the right perirenal or anterior pararenal space;
bowel segment, or air can spread below the dia- multiple perforations are possible, and there may
phragm from a pneumomediastinum. be accompanying traumatic pancreatitis.
Duodenal perforation may also be secondary to
leukemia and penetrating foreign body. Severe
12.2 Etiology pelvic fractures, dislodging bony fragments, can
perforate the rectum, allowing intestinal gas to
Common causes of pneumoretroperitoneum are migrate into the retroperitoneal spaces. Rectal
reported in Table 12.1. perforations can also result from iatrogenic pro-
Duodenal perforation is an acute illness whose cedures, infection, or colorectal cancer. Self-
major causes are peptic ulcer disease, endoscopic induced colorectal perforations are rare and can
complication of endoscopic retrograde cholangi-
opancreatography or sphincterotomy, and blunt Table 12.1 Common causes of pneumoretroperitoneum
abdominal trauma [2].
Penetrating trauma
Blunt traumatic rupture of the duodenum
Pelvic trauma with perforation of the rectum
A. Pinto (*) • C. Muzj • G. Ruggiero Postoperative
Department of Radiology, Post-diagnostic procedure
“A. Cardarelli” Hospital, Spontaneous colon perforation
Via Cardarelli 9, Naples I-80131, Italy
Extension from pneumomediastinum
e-mail: [email protected]; [email protected];
[email protected] Gas-containing retroperitoneal abscess

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 85

DOI 10.1007/978-3-319-08192-2_12, © Springer International Publishing Switzerland 2015
86 A. Pinto et al.

result from foreign body or accidental

impalement. Distinction between injuries to the
intraperitoneal and extraperitoneal segments of
the rectum is an important consideration in
patients with rectal injury given the differences in
their subsequent management. The anterior and
lateral sidewalls of the upper two-thirds of the
rectum are covered with peritoneum, and injuries
to these segments are considered intraperitoneal.
The distal one-third of the rectum circumferen-
tially and the upper two-thirds of the rectum pos-
teriorly are not covered with peritoneum and are
considered extraperitoneal [4].
Spontaneous pneumoretroperitoneum is com-
monly a consequence of perforations of colonic
diverticula or carcinomas. The thorax and the
extraperitoneal spaces communicate directly
through the mediastinum posteriorly and, to a
lesser extent, across small midline openings in Fig. 12.1 Supine abdominal radiography showing retro-
the diaphragm anteriorly. Thus, any cause of peritoneal air (arrow) dissecting around the right kidney
pneumomediastinum may also determine the
presence of pneumoretroperitoneum.
Other causes of pneumoretroperitoneum include differentiate retroperitoneal from intraperitoneal
superinfected necrotizing pancreatitis, necrotizing air: retroperitoneal air is usually crescentic, with
fasciitis, abscess formation, percutaneous biopsy, curvilinear upper and lower borders. Free air
epidural anesthesia, extracorporeal shock-wave lith- rises to the peak of the diaphragmatic dome,
otripsy, and hydrogen peroxide wound irrigation [1]. whereas retroperitoneal air is usually positioned
Pneumoretroperitoneum following endo- more inferiorly. Retroperitoneal air generally
scopic procedures is extensive, however, because accumulates either medially or laterally rather
of the high pressure gradient generated and the than directly beneath the apex of the diaphrag-
large volume of air insufflated; it is thus some- matic leaf [8].
times associated with pneumoperitoneum and Supine abdominal radiographs can show areas
pneumothorax [5]. Pneumoretroperitoneum can of mottled air or collection of air in the left or
be also a possible finding of bowel infarction [6]. right upper quadrant (Fig. 12.1), indicating pneu-
moretroperitoneum, with lack of left psoas mus-
cle shadow, suggesting potentially retroperitoneal
12.3 Pneumoretroperitoneum: illness [9]. Similar findings can be observed on
Plain Abdominal Film and CT scout CT images (Fig. 12.2).
Findings While confirming the presence of a perforation
is critical, clinical management and surgical tech-
Conventional radiography is commonly the ini- nique also depend on localizing the perforation
tial imaging examination performed in the diag- site. Multidetector-row computed tomography
nostic workup of patients who present with acute (MDCT) is accurate in detecting the site of perfora-
abdominal pain to the emergency department. tion. If the gas is isolated to the extraperitoneum, a
Conventional radiography includes supine and retroperitoneal perforation is more likely, including
upright conventional abdominal radiography and the second or third segments of the duodenum,
upright chest radiography [7]. On plain film, ascending colon (Fig. 12.3), descending colon
beneath the diaphragm, it is often difficult to (Fig. 12.4), or distal third of the rectum [10].
12 Pneumoretroperitoneum: Imaging Findings 87

a b

Fig. 12.2 Scout CT images (a, AP view; b, lateral view) demonstrating the presence of pneumoperitoneum and
retropneumoperitoneum

a distal duodenal perforation. Sensitive, though

less-specific findings overlap with perforations
elsewhere and include focal bowel wall thicken-
ing, perigastric or periduodenal fluid, and adja-
cent mesenteric fat stranding. Perforation of the
descending duodenum is confined to the right
anterior pararenal space, but less often the perire-
nal space is breached and air may dissect into it.
Perforated diverticulitis represents the most
serious complication of diverticular disease and
can occur at any site along the colon. MDCT has
a high sensitivity for detecting complications
(Fig. 12.5) secondary to diverticulitis including
abscess formation and focal contained perfora-
tions. Contained perforations present as small
Fig. 12.3 Contrast-enhanced MDCT shows right pneu-
extraluminal pockets of gas. Less often, diffuse
moretroperitoneum caused by ascending colon perfora- pneumoperitoneum and even retroperitoneal and
tion. Pneumoperitoneum is also evident mediastinal gas can occur via subperitoneal com-
munications [11]. MDCT is very useful in order
As the duodenum distal to the bulb is retroperi- to demonstrate the presence of pneumoperito-
toneal, extraluminal gas in the right anterior para- neum associated with pneumoretroperitoneum
renal space is a reliable CT finding for diagnosing and pneumomediastinum (Fig. 12.6).
88 A. Pinto et al.

a b

Fig. 12.4 Contrast-enhanced MDCT (a, coronal reconstruction; b, sagittal reconstruction) shows left pneumoretroperi-
toneum caused by descending colon perforation. Small amount of pneumoperitoneum (b, arrows) is also evident

a b

Fig. 12.5 Contrast-enhanced MDCT (a) demonstrating adjacent to the sigmoid wall due to perforated sigmoid colon
pericolic fat stranding, small peritoneal fluid, diverticular diverticulitis. A more cranial image shows the presence of
outpouching, and multiple extraluminal collections of air pneumoretroperitoneum and pneumoperitoneum (b)
12 Pneumoretroperitoneum: Imaging Findings 89

a b

Fig. 12.6 Contrast-enhanced MDCT (a, sagittal reconstruction; b, coronal reconstruction) shows the presence of mas-
sive pneumoperitoneum associated with pneumoretroperitoneum and pneumomediastinum

Typically, rectal perforations are bilateral and gastrointestinal tract is frequently involved.
displace the properitoneal fat lines on both sides [8]. While such air is not in itself dangerous,
prompt recognition of its origin is essential as
Conclusions serious septic conditions may be involved.
The importance of discerning between pneu- MDCT is an excellent resource in detecting
moperitoneum and pneumoretroperitoneum the presence of pneumoretroperitoneum.
on plain abdominal films cannot be minimized
because retroperitoneal air differs markedly
from pneumoperitoneum in etiology, clinical References
course, and patient’s treatment.
Besides the awareness of intraperitoneal 1. Goenka AH, Shah SN, Remer EM (2012) Imaging of the
free air signs, radiologists should take a care- retroperitoneum. Radiol Clin North Am 50:333–355
2. Yagan N, Auh YH, Fisher A (2009) Extension of air
ful look at the particularly retroperitoneal into the right perirenal space after duodenal
radiolucency during abdominal radiographic perforation: CT findings. Radiology 250:740–748
evaluation in cases with high index of suspi- 3. Motateanu M, Mirescu D, Schwieger A-F et al (1992)
cion for retroperitoneal infection or bowel Computed tomography of retroperitoneal duodenal rup-
ture in blunt abdominal trauma. Eur J Radiol 15:163–165
perforation. 4. LeBedis CA, Anderson SW, Soto JA (2012) CT imag-
Recognition of pneumoretroperitoneum is ing of blunt traumatic bowel and mesenteric injuries.
important since rupture of a segment of the Radiol Clin North Am 50:123–136
90 A. Pinto et al.

5. Pretre R, Robert J, Mirescu D et al (1993) 9. Wang YC, Lin CM, Chen SK (2010) Intraperitoneal
Pathophysiology, recognition and management of versus retroperitoneal air signs in abdominal radio-
pneumoretroperitoneum. Br J Surg 80:1138–1140 graphs. Am J Emerg Med 28:109–110
6. Grassi R, Pinto A, Rossi G (2000) Isolated pneumor- 10. Ghekiere O, Lesnik A, Hoa D et al (2007) Value of com-
etroperitoneum secondary to acute bowel infarction. puted tomography in the diagnosis of the cause of non-
Clin Radiol 55:321–323 traumatic gastrointestinal tract perforation. J Comput
7. Stoker J, van Randen A, Laméris W et al (2009) Assist Tomogr 31:169–176
Imaging patients with acute abdominal pain. Radiology 11. Oliphant M, Berne AS, Meyers MA (1996) The sub-
253:31–46 peritoneal space of the abdomen and pelvis: planes of
8. Baker SR (1990) Plain film radiology of the perito- continuity. AJR Am J Roentgenol 167:1433–1439
neal and retroperitoneal spaces. In: Baker SR (ed) The
abdominal plain film. Appleton & Lange, Norwalk/
San Mateo, pp 71–125
 Imaging of Gastrointestinal Tract
Perforation in the Pediatric Patient 13
Cecilia Lanza, Elisabetta Panfili,
and Andrea Giovagnoni

There are multiple etiologies of gastrointestinal 13.1 Suggestive Signs

perforation in children. It occurs most frequently of Perforation
in the newborn. The most common causes of per-
foration include necrotizing enterocolitis (NEC), The presence of pneumoperitoneum on the
gastric perforation, Hirschsprung’s disease, abdominal radiograph is widely accepted as an
meconium ileus, imperforate anus, and neonatal absolute indication for perforation; free air can
small left colon syndrome. Other causes of intes- be seen above the liver in upright films or below
tinal perforation are intussusception, volvulus/ the anterior abdominal wall on supine lateral
malrotation, appendicitis, inflammatory bowel abdominal radiograph with horizontal beam.
disease, and foreign object. Various radiological descriptions are used for
Diagnosis requires a combination of clinical, specific distribution of free intraperitoneal gas,
laboratory, and radiological findings. such as the Rigler sign (gas outlining both sides
The radiological criteria evaluated as predic- of the bowel), football sign (oval–shaped perito-
tors of perforation are pneumoperitoneum, intes- neal gas, Fig. 13.1), increased lucency in the
tinal distension, peritoneal fluid, air fluid levels, right upper quadrant (gas accumulating anterior
pneumatosis intestinalis, and gas in the portal to the liver), and triangle sign (triangular gas
venous system. pocket between the three loops of bowel,
Fig. 13.2). Although conventional radiography is
a common method for detecting small amount of
intraperitoneal free air [1, 2], imaging may not
C. Lanza (*) • A. Giovagnoni detect pneumoperitoneum or retroperitoneum in
Dipartimento di Scienze Radiologiche, up to 49 % of patients [3]. Intestinal distention is
SOD Radiologia Pediatrica e Specialistica, the most frequently encountered radiological
Azienda Ospedaliero-Universitaria Ospedali Riuniti
di Ancona, Via Conca, 71, Ancona 60126, Italy
sign especially in patients with necrotizing
e-mail: [email protected]; enterocolitis, Hirschsprung’s disease, volvulus,
[email protected] and meconium ileus. In patients with small-
E. Panfili bowel obstruction, supine views show dilation of
Dipartimento di Scienze Radiologiche, multiple loops of small bowel, with a paucity of
Scuola di Specializzazione in Radiodiagnostica, air in the large bowel. Those with large-bowel
Università Politecnica delle Marche,
Azienda Ospedaliero-Universitaria Ospedali Riuniti
obstruction may have dilation of the colon, with
di Ancona, Via Conca, 71, Ancona 60126, Italy decompressed small bowel in the setting of a
e-mail: [email protected] competent ileocecal valve.

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 91

DOI 10.1007/978-3-319-08192-2_13, © Springer International Publishing Switzerland 2015
92 C. Lanza et al.

Fig. 13.3 Multiple air fluid levels and bowel parietal

thickening in intussusception

Fig. 13.1 The radiography shows both football sign, as

oval-shaped peritoneal gas, and Rigler sign (arrow) enteritis or enterocolitis, except when the gas has
been introduced accidentally through an indwell-
ing umbilical catheter.
Upright or cross-table lateral radiograph films
may show laddering air fluid levels. These
findings, in conjunction with a lack of air and
stool in the distal colon and rectum, are highly
suggestive of mechanical intestinal obstruction
(Fig. 13.3).
In some cases of perforation of hollow vis-
cera, the clinical and plain film findings may be
inconclusive. In such circumstances, examina-
tion with contrast material may be indicated. The
site of perforation may be demonstrated if extrav-
asation of contrast medium occurs.
If a perforation is suspected, barium is contra-
Fig. 13.2 Triangle sign: triangular gas pockets between
loops of bowel (arrows) are seen in small amount of peri- indicated, and water-soluble agents should be
toneal gas used [4, 5].
Therefore, the use of Gastrografin, which con-
Another suggestive sign of perforation is peritoneal tains a wetting agent, was used when looking
fluid that is associated with high mortality rate. for a gastrointestinal perforation. However,
Gas in the intestinal wall and portal venous Gastrografin may cause dehydration secondary to
system in infant is invariably associated with the hyperosmolarity. Recently Iopamidol has been
13 Imaging of Gastrointestinal Tract Perforation in the Pediatric Patient 93

preferred to Gastrografin for its lower osmotic

pressure, with the same rate of success.

13.2 US Examination

Ultrasound may be particularly useful in chil-

dren where radiation burden should be limited.
Ultrasonography could be useful as an initial
diagnostic test to determine, in various cases, the
presence and, sometimes, the cause of the pneu-
moperitoneum. Ultrasound has lower sensitivity
than radiography (76 % vs. 92 %, respectively)
and should be used in selected cases only (clini-
cal conditions preventing radiographs from
being performed correctly, persisting clinical
suspicion with negative or questionable radio-
graphic findings, the exclusion of other acute
abdominal conditions) [6].
The main sonographic sign of perforation is Fig. 13.4 Intestinal distension in NEC may mimic Rigler
free intraperitoneal air, resulting in an increased sign (see Figure), due to air inside two near intestinal
echogenicity of a peritoneal stripe associated loops with near bowel walls
with multiple reflection artifacts and characteris-
tic comet-tail appearance. It is best detected using
linear probes in the right upper quadrant between both clinically and radiologically. NEC is considered
the anterior abdominal wall, in the prehepatic primarily a pathology related to prematurity. Over
space. 90 % of cases occur in preterm infants [7]. NEC can
Direct sign of perforation may be detectable, develop in any portion of the gastrointestinal tract,
particularly if they are associated with other with the small bowel and proximal large bowel
sonographic abnormalities, called indirect signs, being most frequently affected [8, 9]. NEC diagno-
like thickened bowel loop and air bubbles in sis requires a combination of clinical, laboratory,
ascitic fluid or, in a localized fluid collection, and radiological findings.
bowel thickened wall associated with decreased Early diagnosis is critical to the institution of
bowel motility or ileus. proper therapy in premature infants with necro-
Nevertheless, this exam has its own pitfalls. It tizing enterocolitis. In order to make the early
is strongly operator dependant; some machines diagnosis of NEC, plain abdominal radiographs
have low-quality images that may not able to must be taken of all premature infants with
detect intraperitoneal free air; furthermore, chil- abdominal distension, vomiting, apneic spells,
dren are uncooperative; sonography is also diffi- jaundice, or bloody stools. If the radiographs are
cult in patients with subcutaneous emphysema. negative, but symptoms continue, they should be
repeated.
Radiological signs play an important part in
13.2.1 Necrotizing Enterocolitis making the diagnosis of NEC. [10]. Intestinal
distension (Fig. 13.4) is the most frequently
Necrotizing enterocolitis (NEC) is an often fatal encountered radiological sign in patients with
inflammatory disease involving the intestinal tract NEC (55–100 % of cases) [8, 11].
of premature infants in which intestinal perforation Previous studies have reported the presence of
is common. The condition may mimic obstruction radiological signs suggestive of peritoneal fluid
94 C. Lanza et al.

Fig. 13.5 Intramural gas (arrows) in severe pneumatosis

in NEC Fig. 13.6 Pneumatosis intestinalis, seen as lucency
inside the bowel wall and bubbly appearance of bowel
(arrow), and gas in the portal venous system (arrowheads)
in 11 % of cases and have shown a higher inci- in a case of necrotizing enterocolitis
dence of patient mortality in these patients.
Common radiographic features included Direct sign, such as localized gas collections
increased intraluminal gas and fluid, a “bubbly” related to bowel perforations, may be detectable,
or “frothy” appearance to the bowel, intramural particularly if they are associated with other
gas (Fig. 13.5), hepatic portal venous gas, and sonographic abnormalities, called indirect signs
pneumoperitoneum. Gas in the wall of the intes- (thickened bowel loop and air bubbles in ascitic
tine, mesentery and retroperitoneum, and portal fluid or, in a localized fluid collection, bowel
vein gas are the most important and useful radio- thickened wall associated with decreased bowel
graphic features (Fig. 13.6). Neither is pathogno- motility or ileus).
monic; both features have been observed in
patients afflicted with such entities as
Hirshsprung’s disease, imperforate anus, meco- 13.2.2 Gastric Pneumatosis
nium ileus, small-bowel atresia, and following in Infancy
surgical repair of coarctation of the aorta. Portal
vein gas can be introduced inadvertently through Gastric pneumatosis in infancy (defined as gas
umbilical vein catheters. The sonographic within the wall of the stomach) may be easily
appearance of free intraperitoneal air results in an detected by radiography. It presents as a fine
increased echogenicity of a peritoneal stripe lucent stripe conforming to the contour of the
associated with multiple reflection artifacts and stomach and enveloping any intraluminal gas and
characteristic comet-tail appearance that can be fluid content. The finding, though quite rare, is of
changed by changing the patient’s position. almost clinical importance.
13 Imaging of Gastrointestinal Tract Perforation in the Pediatric Patient 95

Fig. 13.7 Hirschsprung’s disease: radiography shows confirms narrowing segment of aganglionic rectum. The
dilated large bowel without evidence of gas in rectum; arrow indicates transition zone.
fluoroscopic examination with contrast medium enema

In infancy, isolated gastric pneumatosis has Hirschsprung’s disease (Fig. 13.7). Most of the
been seen very rarely in gastric outlet obstruc- perforations reported in the literature were in the
tion. It has also been reported in neonatal necro- proximal colon (68 %), appendix (1 8 %), or dis-
tizing enterocolitis, in association with intestinal tal small bowel (6 %). In utero perforation pro-
pneumatosis or after perinatal stress though it ducing meconium peritonitis has also been
may rarely be isolated. described [15, 18]. The mechanism of perfora-
Thus, radiographic detection of gastric pneu- tion appears to be directly related to increased
matosis indicates serious underlying disease, and intraluminal pressure from distal obstruction.
determination of its cause will depend on the Long segment or total colonic aganglionosis
associated clinical findings. accounted for 61 % of documented cases of
Hirschsprung’s disease that presented with bowel
perforation. Appendiceal and ileal perforation
13.2.3 Hirschsprung’s Disease were particularly associated with long-segment
disease.
Hirschsprung’s disease is a major differential Perforation in these cases is in aganglionic
consideration in a neonate or young infant with bowel, and blind colostomy at the site of perfora-
radiographic evidence of distal bowel obstruction tion or in the transverse or sigmoid colon is an
and clinical signs of abdominal distension, vom- inappropriate treatment.
iting, constipation, failure to pass meconium, and
failure to thrive [12–15]. Aganglionosis is the
most common cause of large-bowel obstruction 13.2.4 Meconium Ileus
in the young infant [16, 17], and therefore colonic
or appendiceal perforation, especially in the Meconium abnormalities are at the origin of a
young infant, should raise the suspicion of series of neonatal intestinal obstructions,
96 C. Lanza et al.

characterized by a wide spectrum of severity, from incidence ranges between 1:3,300 and 1:5,000
the benign meconium plug syndrome to the com- live births. They vary in severity from mild anal
plicated meconium peritonitis and perforation. stenosis to complete caudal regression. These
These relatively frequent and benign conditions disorders usually require surgical intervention
need prompt recognition to exclude other forms of in the neonatal period and postoperative follow-
neonatal intestinal obstruction; among them meco- up to obtain and maintain fecal and urinary con-
nium ileus is frequently associated to severe pre- tinence. Diagnostic and therapeutic delays
maturity and low birth weight. It results from in the management of ARM may lead to compli-
combination of highly viscid meconium in the cations such as sepsis, aspiration, abdominal
colon or terminal ileum and poor intestinal motil- distension, colonic perforation, respiratory
ity, resulting in mechanical bowel obstruction. embarrassment, electrolyte imbalance, and even
Clinical signs of delayed meconium passage death.
included gastric residual volumes, abdominal Colonic perforation due to ARM may not be
distension, and bilious residua. Perforated cases avoided completely; however, early diagnosis is
may be confused with NEC which is excluded by essential in assuring better outcomes with surgi-
clinical history, no signs of sepsis, lab signs miss- cal management. Spontaneous perforation of the
ing, abdominal signs missing, and typical radio- colon is estimated to occur in 2 % of neonates
logical signs missing. with ARM, and the incidence rises to 9.5 % when
Management of meconium obstruction syn- the diagnosis is delayed [23, 24].
drome included plain radiography that reveals evi-
dence of a mechanical obstruction and enema.
Plain abdominal film shows distended small-bowel 13.2.6 Small Left Colon Syndrome
loops without air fluid levels or pneumatosis. These
findings are enough to make diagnosis and exclude Intestinal perforation can occur as a complication
other forms of intestinal obstruction, mainly NEC. of the neonatal small left colon syndrome, a con-
Once the obstruction occurred, the risk of per- dition producing signs and symptoms of low
foration becomes higher and is estimated around colonic obstruction.
30 %. Radiographic examination of the abdomen
A softening enema with low osmotic pressure shows multiple dilated small-bowel loops and
ionic X-ray contrast medium, is the first option sometimes visualization of dilated ascending and
whenever overt perforation was not present. The transverse portions of the colon.
contrast medium leads to a propulsive hyperac- This syndrome is a benign condition in which
tive gastrointestinal motility and is diagnostic contrast enema examination is curative by stimu-
and therapeutic; however, it is not recommended lating meconium evacuation. Contrast enema
for hemodynamically unstable patients [19, 20]. study demonstrates a characteristic pattern of a
Success rate is estimated around 80 % and is small left colon to the level of the splenic flexure
strictly time dependent [21, 22]. Where enema where a sharp transition zone exists with the
has to be performed, fluoroscopy is essential to proximal colon being dilated. This study should
document contrast medium passing ileocecal be done immediately in newborns who develop
valve and mixing with intestinal content, to get clinical findings of colon obstruction or fail to
an effective clinical result. pass significant meconium within 24–48 h. This
aggressive approach hopefully should reduce the
incidence of intestinal perforation as a complica-
13.2.5 Imperforate Anus tion of the neonatal small left colon syndrome.
Repeat contrast enema examinations may occa-
Anorectal malformations (ARM) are common sionally be necessary to relieve the obstructive
anomalies observed in neonates. The reported signs in these babies.
13 Imaging of Gastrointestinal Tract Perforation in the Pediatric Patient 97

13.2.7 Intussusception

Intussusception occurs when a portion of the

digestive tract becomes telescoped into the adja-
cent bowel segment. It generally occurs in chil-
dren between 6 months and 2 years of age. The
vast majority are ileocolic [25–27].
Intussusceptions are the second most common
cause of acute intestinal obstructions in children.
Once they are diagnosed, they should be treated
as early as possible. Though their exact causes
are not known in most of the cases, swollen
Payer’s patches, enlarged lymph nodes, polyps,
Meckel’s diverticulum, and duplication cysts
have been suggested as few of the common etio-
logical factors [28, 29].
The classic triad of intermittent abdominal pain
or irritable crying, a palpable mass, and red currant Fig. 13.8 Intussusception: contrast enema shows the
jelly stools is reported to have a positive predictive “coiled spring” (arrow) appearance of bowel at the site of
value of 93 % for intussusceptions [30, 31]. the obstruction
Ultrasonography is a very useful investigation
that can be used for the diagnosis. The absence of foration, shock, or peritonitis, when other
blood flow in the lesion on color Doppler study attempts at reduction fail, or when a pathologic
correlates significantly with the high incidence of lead point is suspected [34, 35].
the complications and irreducibility [28, 29, 32].
On the ultrasound image the intussusceptions
is a complex structure due to the amount of mes- 13.2.8 Malrotation/Volvulus
entery [33]. The intussusceptions (the receiving
loop) contain the folded intussuscepted (the donor Malrotation/volvulus is a congenital abnormal
loop), which has two components: the entering position of the bowel within the peritoneal cavity
limb and returning limbs. Ultrasound obtained at and usually involves both the small and the large
the apex shows a hyperechoic outer ring separated bowel [36].
from a hypoechoic center by a thin hyper echoic Malrotation is accompanied by abnormal
ring, which likely represents the opposed serous bowel fixation by mesenteric bands or absence of
surface of the intussuscepted. Ultrasound obtained fixation of portions of the bowel, leading to
near the apex shows multiple concentric rings increased risks of bowel obstruction, acute or
with a hypoechoic ring surrounding a hyperechoic chronic volvulus, and bowel necrosis. Malrotation
ring, which surrounds another hypoechoic ring. occurs in approximately 1 in 500 births [37] and
US scan obtained at the base shows the central is usually diagnosed in newborns and young
limb of the intussusception eccentrically sur- infants.
rounded by the hyperechoic mesentery that show The classic clinical manifestation of malrota-
the crescent in doughnut sign. tion in newborns is bilious vomiting with or
Contrast medium or gas enemas have been without abdominal distention associated with
widely used to reduce uncomplicated intussus- either duodenal obstructive bands or midgut vol-
ceptions, but 10–30 % of patients eventually vulus [38]. Midgut volvulus is a life-threatening
require surgery (Fig. 13.8). Surgery is definitely condition in which the small-bowel or proximal
indicated when patients present with signs of per- colon twists around the superior mesenteric artery
98 C. Lanza et al.

Fig. 13.9 Malrotation in Ladd’s bands: evidence of gastric distention on radiography; fluoroscopic examination with
contrast medium shows right-sided duodenal-jejunal junction

(SMA) and it commonly presents during the first by shortening hospitalization. Ultrasound is con-
year of life [39]. The diagnosis of midgut volvu- sidered to be the imaging test of choice in children.
lus in infants is facilitated by direct sonographic Experienced ultrasonographers can achieve sensi-
visualization of the twisted bowel loop. Normally, tivities of 85–90 % and specificities of 95–100 % in
the superior mesenteric vein is on the right side of acute appendicitis. On longitudinal images, the
the artery. In malrotation, we evaluated on ultra- inflamed, non-perforated appendix appears as a
sound image the “whirlpool sign” on the axial fluid-filled, uncompressible, blind-ending tubular
scan, formed by the mesenteric vein that is on the structure. The maximal appendix diameter, from
left side of the artery. The diagnosis is made with outside wall to outside wall, is greater than 6 mm.
an upper gastrointestinal contrast study (UGI) that On the axial image, we evaluated a “target sign”
demonstrates the right-sided position of the duo- characterized by a fluid-filled center and sur-
denal-jejunal junction or evidence of a midgut rounded by an echogenic mucosa and submucosa
volvulus (Fig. 13.9). Treatment requires surgical and hypoechoic muscularis. US features of perfo-
laparotomy and detorsion or lysis of Ladd’s bands ration include loss of the echogenic submucosal
(Ladd procedure). layer and presence of a loculated periappendicular
or pelvic fluid collection or abscess.
In early inflammation, color flow may be
13.2.9 Appendicitis absent or limited to the appendicular tip. Color
Doppler findings of appendicular perforation
Appendicitis is the most common condition requir- include hyperemia in the periappendicular soft
ing an emergency abdominal operation in child- tissues or within a well-defined abscess.
hood [40]. Despite the relatively high incidence of Sometimes, when peritonitis with paralytic
this common emergency, it remains a difficult diag- ileus is suspected, plain film is useful, and one of
nosis for clinicians. Early diagnosis of appendicitis the earliest radiographic sign of perforation on
in infant and children can prevent perforation and radiographic film is dilated transverse colon sign
postoperative complications and can decrease costs associated with emptiness of the ascending colon.
13 Imaging of Gastrointestinal Tract Perforation in the Pediatric Patient 99

It is believed to result from a combination of par- Computed tomography (CT) as a cross-

alytic ileus of the transverse colon and spasm of sectional imaging method overcomes this and
the ascending colon. may be helpful in the acute situation, for plan-
This point can be used to differentiate normal ning surgery, especially in the evaluation of stric-
transverse colon gas accumulations from those ture or obstruction. The major disadvantage of
seen in perforated appendicitis. In the normal CT is the large amount of radiation exposure
individual, the ascending colon usually contains [44].
gas and/or fecal material. Thus, especially in children, techniques using
ionizing radiation should be avoided if possible
[45]. MR enterography has definitely advantages
13.2.10 Inflammatory Bowel including the detection and assessment of dis-
Disease ease activity of the entire gut and the ability to
evaluate extraluminal disease and is therefore
During the course of the disease, most patients becoming the standard assessment of the small
with inflammatory bowel disease (IBD) may bowel in many centers. However, there is no
eventually develop a stricturing or a perforating consensus about the technique, and there is no
complication, and a significant number of patients approved standard protocol for the evaluation of
with both Crohn’s disease and ulcerative colitis IBD using MRI.
will undergo surgery.
A young age at onset or pediatric presentation
is an important risk factor for developing compli- 13.2.11 Ingestion of Foreign
cated disease behavior and even disease exten- Objects
sion [41, 42].
The radiation-free ultrasound performed Children have a natural tendency to explore
with adequate technique and experience by the objects with their mouths; this can result in the
sonographer should be used as initial imaging swallowing of foreign objects. Many cases of
method to describe the extension and grading ingestion of foreign bodies are noted in children
of the inflammation and to appreciate extraint- between 6 months and 3 years of age [46].
estinal findings (lymph node enlargement, Although the ingested foreign bodies are com-
abscesses). mon and alerting problems of childhood, most of
Plain radiography is reserved for acute dis- them pass the alimentary tract without any sequel.
eases like obstruction or perforation. Findings are However, some foreign bodies cause obstruction
nonspecific and can include large-bowel dilation or perforation of the gastrointestinal tract, requir-
and small-bowel distension. In the acute abdomen, ing surgical intervention. Sharp materials such as
the toxic megacolon or obstruction can be sus- fish bones, chicken bones, and needles in contrast
pected. These cases have to be followed in order may cause complications up to 35 % of the cases,
to detect possible bowel perforation. Contrast such as peritonitis, abscess formation, inflamma-
enema can be helpful for the evaluation of the tory mass formation, obstruction, fistulae, and
extension of the disease; moreover, it is helpful to hemorrhage [47, 48].
rule out or prove stenosis. Upper gastrointestinal Perforation occurs in less than 1 % of inges-
series with small-bowel barium follow-through tion of a foreign body. The most common sites of
has been the cornerstone of small-bowel imaging intestinal foreign body perforation are the ileoce-
in the past [43]. cal and rectosigmoid regions.
The more sensitive enteroclysma was consid- Non-radioopaque foreign bodies are espe-
ered the gold standard but both methods suffer cially difficult to detect on plain radiographs of
from one further major disadvantage: its very the abdomen. When foreign object swallowing is
limited information regarding the extraluminal suspected, an immediate radiographic evaluation
mesenteric extension of the disease. is recommended. This evaluation would include a
100 C. Lanza et al.

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guided hydrostatic reduction of childhood intussus- perforation of the appendix into the bladder. Pediatr
ception: technique and demonstration. Radiographics Surg Int 15(1):66–67
20:1818 48. Karacay S, Topçu K, Sözübir S et al (2013) A rare
33. Del Pozo G, Albillos JC (1999) Intussusception in complication of an ingested foreign body: gallblad-
children-current concept in diagnosis and enema der perforation. Case Rep Gastrointest Med 2013:
reduction. Radiographics 19:299–319 672572
34. Ksia A, Mosbahi S, Brahim MB et al (2013) Recurrent 49. Kunizaki M, Kusano H, Azuma K et al (2009)
intussusception in children and infants. Afr J Paediatr Cholecystitis caused by a fish bone. Am J Surg 198(2):
Surg 10:299–301 e20–e22
 Imaging of Gastrointestinal Tract
Perforation in the Elderly Patient 14
Alfonso Reginelli, Anna Russo, Duilia Maresca,
Fabrizio Urraro, Giuseppina Fabozzi,
Francesco Stanzione, Alfredo D’Andrea,
Ciro Martiniello, and Luca Brunese

14.1 Introduction bowel disease. The contents of these organs are

then able to spill over into the abdominal cavity.
Gastrointestinal perforation is a medical emer- A hole in gastrointestinal system can lead to
gency that requires immediate medical care. The peritonitis.
condition is life-threatening. Chances of recovery Intestinal perforation is an emergency medical
improve with an early diagnosis and treatment [1]. situation presented as an acute abdomen, and it is
Gastrointestinal perforation (GP) occurs when only rarely diagnosed clinically. CT is often the
a hole forms all the way through the stomach, initial modality used to assess patients with acute
small intestine, and large intestine. It might be abdomen, the radiologist may be the first to sug-
caused by a number of different diseases, includ- gest such a diagnosis [2–6]. CT provides superb
ing foreign bodies, colon cancer, diverticulitis, anatomical detail and diagnostic specificity by
ischaemia, Degos’ syndrome, and inflammatory directly imaging of the intestinal wall, detecting
secondary signs of bowel disease within the sur-
rounding mesentery and depicting even small
A. Reginelli (*) • F. Urraro amounts of extraluminal air or oral contrast leak-
Department of Internal and Experimental Medicine, age into the peritoneal cavity [5, 6].
Magrassi-Lanzara, Institute of Radiology,
Second University of Naples,
Computed tomography allows to identify the
Piazza Miraglia, Naples 80100, Italy site of gastrointestinal perforations and to deter-
e-mail: [email protected]; [email protected] mine the most predictive signs in this diagnosis.
A. Russo • D. Maresca • G. Fabozzi • A. D’Andrea Typically, simple standing chest radiography,
C. Martiniello including the diaphragm, is the first imaging test
Department of Radiology, S. G. Moscati Hospital, that is done in order to identify the presence of
Via Gramsci, Aversa 81134, Italy
e-mail: [email protected];
extraluminal gas, although, sometimes, it is dif-
[email protected]; [email protected]; ficult to establish the diagnosis because the
[email protected] symptoms are non-specific and pneumoperito-
F. Stanzione neum is only observed on 30–59 % of simple
General, and Emergency Surgery, Metabolic Care, radiographs [7–9]. Recent studies reveal poor
Clinic Pineta Grande, Castel Volturno, Caserta, Italy sensitivity of plain radiography for the detection
e-mail: [email protected]
of free air, especially in patients with jejuno-ileal
L. Brunese or colonic perforation. Several studies have dem-
Department of Medicine and Health Sciences,
University of Molise,
onstrated that computed tomography (CT) is the
Contrada Tappino, Campobasso, Italy best technique for detecting free intraperitoneal
e-mail: [email protected] air and for the diagnosis of GI perforation.

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 103

DOI 10.1007/978-3-319-08192-2_14, © Springer International Publishing Switzerland 2015
104 A. Reginelli et al.

Typical signs to be assessed on CT are: thickening of the bowel wall adjacent to

1. Extravasation of oral contrast extraluminal gas bubbles, streaky density within
2. Intestinal wall focal defects the mesentery ‘dirty fat’ sign, and focal collec-
3. Free air in the supramesocolic compartment tion of extraluminal faecal matter ‘dirty mass’
4. Free air in the inframesocolic compartment were considered indirect finding of perforation
5. Free air in supra- and inframesocolic [3, 5, 11] (Fig. 14.1).
compartments The overall accuracy in diagnosing the site of
6. Gas bubbles adjacent to the intestinal wall the perforation is 80 % [6]. Yeung et al. [3] also
7. Localised extraluminal fluid found that the presence of air in both sides of the
8. Segmental wall thickening (>3 mm) falciform ligament may differentiate more cer-
9. Perivisceral fat stranding ‘dirty fat sign’ tainly proximal from distal GIT perforation.
10. Focal collection of extraluminal faecal mat-
ter ‘dirty mass’
11. Abscesses 14.2 Foreign Bodies
12. Sagittal and coronal MPR to view the focal
wall defect Generally, the ingestion of foreign bodies occurs
Signs 1, 2, and 11 were considered direct involuntarily while eating; meat boluses are the
signs, meaning that they are signs that indicate most common foreign bodies ingested in Western
where there is a discontinuity in the GI. The countries and fish bones in oriental countries
remainder were indirect signs of the location of [12–14]. However, in 1 % of cases, it causes com-
the GI perforation: some indicate the distribution plications such as acute abdomen due to intesti-
of the extraluminal gas (signs 3, 4, 5, and 6,) and nal perforation [13]. In some cases, it can cause
others indicate inflammatory changes (signs 8, 9, severe complications and even death; in the USA,
and 10) that help estimate the affected GI 1,500 people die annually from foreign body
segment. ingestion [15].
CT protocol for evaluating the acute abdomen Bowel perforation by a foreign body is less
includes the administration of intravenous con- common, as the majority of foreign bodies
trast or both oral contrasts. The use of a multislice uneventfully pass to the faeces and only 1 % of
helical scanner with both axial images and multi- them (the sharper and more elongated objects)
planar reformations allows for high-quality visu- will perforate the gastrointestinal tract, usually at
alisation of the entire abdomen [4, 6]. the level of the ileum [4, 16]. The complications
Water-soluble contrast agents do not provoke an of foreign bodies ingestion with perforation
inflammatory reaction when leaking into the include the formation of localised abdominal
peritoneal cavity, as they are rapidly absorbed abscesses, colorectal, colovesical and enterovas-
[5]. Assessment of bone and lung window set- cular fistulas, inflammatory masses or omental
tings, in addition to the routine abdominal win- pseudotumors, pyemia, and endocarditis [4, 17].
dow setting, serves as a useful complementary In the early patients this condition is more fre-
tool for detecting intra- or extraluminal radio- quent because of persistent two predisposing risk
opaque foreign bodies and free intra-abdominal factors for foreign body ingestion: comorbid con-
air [10]. dition and the use of dentures, because they
Diagnostically, extraluminal oral contrast is a reduce the sensitivity of the palate [13, 14].
specific sign of gastrointestinal tract (GIT) perfo- The intestinal tract, where perforations by for-
rations (more clearly seen on a lung window set- eign bodies are most frequent, includes the ileo-
ting). CT is the most reliable imaging modality cecal and rectosigmoid regions, because the
for detecting even small amounts of free air [3–6]. intestinal lumen narrows and the digestive tract is
Additional CT signs, which may also indicate the angulated in these sites. Sites where impaction is
site of the perforation, include discontinuity of most likely include zones with adhesions, areas
the bowel wall on an enhanced scan and focal containing a diverticular process, or surgical
14 Imaging of Gastrointestinal Tract Perforation in the Elderly Patient 105

a b

c d

Fig. 14.1 Abdominal CT scan. CT image shows even the bowel wall adjacent to extraluminal gas bubbles
small amounts of free air (a–d). Additional CT shows the (c, white arrows) and streaky density within the mesentery
site of the perforation (a, white circle), focal thickening of (d, white arrow) ‘dirty fat’ sign (b, white arrow)

anastomoses [13, 14]. Treatment consists of omentum or adjacent loops and limiting the
surgery (from primary suture to rectosigmoid amount of gas or fluid in the peritoneal cavity
resection with colostomy, removal of the foreign [18]. The use of US makes it possible to identify
body, and abdominal cavity lavage) and foreign bodies, even non-radio-opaque bodies
antibiotics. such as fish bones and toothpicks, based on their
The patient presented at the emergency depart- high reflectivity and variable posterior shadow-
ment with diffuse abdominal pain with peritoneal ing [4, 19]. MDCT is currently considered the
irritation and vomiting of 24 h duration. method of choice for the evaluation of patients
Laboratory tests showed generally leukocytosis with acute abdominal pain and the depiction of
and increased C-reactive protein. The supine foreign bodies due to MDCT’s ability to generate
plain abdominal radiograph demonstrated signs high-resolution, thin-collimation, multiplanar
of small-bowel obstruction but do not always reconstructions, which allow the GI tract to be
shows a radio-opaque foreign body or pneumo- examined in all projections.
peritoneum. This finding is not surprising Abdominal CT showed generally a foreign
because, for example, fish bones have variable body in the small bowel, with pneumoperito-
radio-opacity depending on the fish species; neum and fluid within the abdominal cavity
in general, the foreign bodies are minimally (Fig. 14.2).
radio-opaque and can rarely be detected on plain
films, especially if they are masse by coexistent
inflammatory tissue, fluid, or abscesses [18]. 14.3 Colorectal Cancer
Moreover, signs of pneumoperitoneum are not
usually observed in plain films because impac- Colorectal cancer (CRC) is the most common
tion of the foreign body into the intestinal wall is cancer and is also an increasing trend [20, 21].
gradual, allowing the perforation site to seal with Computed tomography (CT) has played an
106 A. Reginelli et al.

a b

c d

Fig. 14.2 Plain films sign shows gas in the peritoneal body in the small bowel with gas and fluid within the
cavity (a, black arrows). Abdominal CT confirms abdominal cavity (c, d, white circle)
pneumoperitoneum (b, white arrow) and shows a foreign

important role in the preoperative staging and and abscess formation, the clinical picture can
postoperative surveillance of colon cancer. The closely resemble complicated diverticulitis,
recent advances in CT technology provide greater whether on clinical examination or on radiologi-
accuracy for the preoperative staging of colorec- cal imaging such as computed tomography (CT)
tal cancer. The findings associated with adeno- scans. Patients typically present fever, abdominal
carcinoma of the colorectum generally include pain and leukocytosis, and CT scans show a peri-
asymmetric bowel wall thickening with contrast colic or intra-abdominal abscess.
enhancement or the presence of a soft-tissue Bowel obstruction is the most commonly
mass that frequently leads to luminal narrowing observed complication of colon cancer. Left-
or obstruction. sided colon malignancies are more prone to
Common presenting symptoms of CRC obstruct the colon lumen than are the right-sided
include abdominal pain, change in bowel habits, malignancies. This is because the diameter of the
rectal bleeding, anaemia, and weight loss [22]. A left colon is smaller than that of the right colon.
less frequent presentation is perforation and CT is a sensitive imaging modality for detecting
abscess formation, which is usually intraperito- bowel obstruction, and the multiplanar recon-
neal, but may occasionally be located in extra- struction images can provide additional informa-
peritoneal spaces. With contained perforation tion on the transition point in problematic cases [1].
14 Imaging of Gastrointestinal Tract Perforation in the Elderly Patient 107

Identifying the transitional zones and an obstruct- the presumptive diagnosis of perforated
ing lesion on CT, and these usually appear as diverticular disease. All patients who present
irregular circumferential thickening of the colon, with complicated ‘diverticular disease’ and intra-
is important to differentiate this entity from other abdominal abscess especially those that do not
benign conditions such as adynamic ileus, respond to conservative treatment should be
colonic pseudoobstruction, and stercoral colitis, offered surgery with resection of the involved
and all these maladies can present with colonic colon and removal of the abscess for histological
dilatation. evaluation (Fig. 14.3).
Perforation in association with a colonic
tumour is uncommon as a primary presentation,
with incidences ranging from 2.6 % [4] to 10 % 14.4 Diverticulitis
[23]. Perforation of the colon can be diagnosed
by CT with the demonstration of a focal defect in Diverticular disease has become more prevalent
the colon wall that may be accompanied by a in Western countries [29, 30]. About 10–25 % of
fluid-density abscess, free air, or stranding of the individuals with diverticulosis will develop
pericolic fat. Abscess formation occurs in 0.3– symptomatic diverticulitis, and of these, 15 %
0.4 % of colonic carcinomas and it is the second will develop significant complications, such as
most common complication of perforated lesions. perforation [31]. Although the absolute preva-
Abscesses commonly remain localised in the lence of perforated diverticulitis complicated by
paracolic region or may develop into a pelvic generalised peritonitis is low, its importance lies
abscess, but they can also track along various tis- in the significant postoperative mortality, ranging
sue planes and have been reported to present as a from 4 to 26 % regardless of the surgical strategy
flank abscess, psoas abscess, or even a subcuta- selected [31, 32]. Optimal treatment strategies
neous abscess on the trunk [24]. The location of are based on disease severity as classified by
perforation associated with colonic cancers is Hinchey [33]. The usual management of diver-
most commonly at the tumour site and is due to ticulitis is based on patients symptomatology as
locally invasive disease causing a breach of integ- well as CT scan results. Simple diverticulitis can
rity of the colonic wall. Perforations can also be treated with bowel rest and intravenous antibi-
occur proximally to an obstructing primary otics. Complicated diverticulitis is classified
lesion, for example, a perforated caecum second- using the Hinchey classification, and manage-
ary to a closed loop obstruction with a competent ment strategies depend on the classification.
ileocecal valve in an obstructed carcinoma of the Hinchey III and IV diverticulitis are indications
sigmoid or descending colon [25, 26]. The loca- for laparotomy, washout, and resection of the
tion of the tumour is also a factor in the likeli- affected colon.
hood of perforation and abscess formation. In the Today, a conservative treatment with antibi-
right and transverse colon, perforations present otics (and abscess drainage) is advocated for
twice as commonly as peritonitis compared to Hinchey 1 and 2 [34]. Patients presenting with
abscesses. On the other hand, abscess formation perforated diverticulitis with generalised perito-
is more common than free perforation in the left nitis (Hinchey 3 and 4) should undergo emer-
colon, and the sigmoid and rectosigmoid are the gency surgical treatment. Laparoscopic
most frequent locations [23, 27]. It is well docu- peritoneal lavage without resection of the
mented that perforated colonic carcinoma has a affected bowel segment in patients with puru-
lower 5-year survival rate, in comparison to the lent peritonitis (Hinchey 3) appears to diminish
uncomplicated colonic cancer undergoing elec- the morbidity and improve outcome, whereas
tive resection [28]. It is important that the diagno- acute resection should be performer in patients
sis of perforated colonic carcinoma is considered with gross faecal peritonitis (Hinchey stage 4).
as a differential diagnosis whenever a patient The combination of free air and intra-abdominal
presents with an intra-abdominal abscess with fluid seen on the CT scan correlated well with
108 A. Reginelli et al.

a b

c d

Fig. 14.3 Abdominal CT shows pneumoperitoneum (a, Caudal to colon wall thickening, there are colon wall
b, white arrows) with liver focal lesion (b, white circle). defect with adjacent peritoneal free fluid and gas
Axial CT scan shows irregular thickening of descending (c, arrow). Free perforation was surgically confirmed
colon (c, arrow) and pericolic fat stranding (d, arrow).

a b

Fig. 14.4 Abdominal CT scan (a, b). The combination of free air (arrow) and intra-abdominal fluid (circle) seen on
the CT scan correlated well with Hinchey 3 and 4 perforated diverticulitis
14 Imaging of Gastrointestinal Tract Perforation in the Elderly Patient 109

Hinchey 3 and 4 perforated diverticulitis, and 14.5 Ischaemia

these are the main findings the radiologists used
to for the CT based diagnosis of Hinchey 3 or 4 The two most common aetiologies that cause
(Fig. 14.4). Preoperative differentiation between vascular impairment of the SB wall leading to
Hinchey stage 3 and 4 is not very important, as perforation are direct vascular occlusion and
both need emergency surgical treatment. strangulated SB obstruction [38]. Various vascu-
Nevertheless, it could be useful in deciding on litides, characterised by inflammation and necro-
the surgical approach. In case of purulent perito- sis of small systemic blood vessels, including the
nitis (Hinchey 3), laparoscopic peritoneal lavage visceral vessels of the GIT, have been reported
and drainage without resection of the affected rarely as a cause of ischaemic intestinal perfora-
bowel segment has shown excellent results. In tion [39]. Prompt diagnosis and treatment is
case of faecal peritonitis, laparotomy is recom- required for a strangulated bowel. The CT find-
mended for resection of the affected bowel ings suggestive of strangulation include intestinal
segment. wall thickening, mural hypoperfusion, blurring
The preoperative differentiation between of the mesenteric vessels with localised mesen-
Hinchey 3 and Hinchey 4 is not possible with CT teric fluid, and free peritoneal fluid (Fig. 14.5).
scanning. Today, computed tomography is the More specific findings of bowel infarction are
modality of choice in the assessment and man- lack of bowel wall enhancement, pneumatosis
agement of diverticulitis with its high sensitivity intestinalis, gas in the portal vein, or pneumoperi-
and specificity [35, 36]. With CT-guided percuta- toneum [38–40].
neous abscess drainage (PCD), it has also become Moreover, elderly patient often have underly-
an important therapeutic modality. In recent ing pathologies, such as chronic cardiovascular
years, CT scanning has become the imaging and pulmonary disease, diabetes, malignancies,
modality of choice to determine the extent of the diverticula, abdominal aortic aneurism, peptic
disease and surgeons tend to rely more frequently ulcer disease, and biliary tract disease.
on the CT findings to decide upon further treat- They usually take multiple medications, and
ment [37]. they often are unable to explain their symptoms

a b

Fig. 14.5 CT scan detects a target appearance of the represented by mural thickening of the involved segments,
ischaemic bowel with an inner hyperdense ring due to peritoneal fluid, and mesenteric engorgement (a, circle). In
mucosal hypervascularity, a middle hypodense edematous late-stage venous thrombosis, absence of mural enhance-
submucosa, and a normal or slightly thickened muscularis ment and the presence of fluid and gas may be evident in the
propria. If the vascular impairment persists, CT findings are sub-peritoneal or peritoneal space (b, arrows)
110 A. Reginelli et al.

clearly because of an impaired sensorium. within 2–3 years. Medical treatments such as
Although SBO and mesenteric ischaemia are antiplatelet drugs have been given, but there is
well-known and common conditions, the diagno- not definite effective treatment. The gastrointesti-
sis and the choice of the correct treatment still nal tract is affected in 50 % of patients with sys-
pose challenges for those working in emergency temic Degos’ syndrome. Other systems such as
clinical settings. Clinicians must take into the central nervous system and renal system can
account atypical presentations and the many clin- also be affected, as demonstrated by the cases
ical differentials. Once they have established the described by McFarland et al. and Schade et al.
diagnosis, they need to decide whether, how, and Both the patients described by Kohlmeier and
when to intervene. Degos in 1941 and 1942 died from bowel perfo-
Mesenteric ischaemia leading to bowel infarc- ration Kim et al. described a case of Degos’ syn-
tion is a relatively common catastrophic occur- drome with gastrointestinal involvement in a
rence in the elderly. In this condition the diagnosis 59-year-old woman, with a history of multiple
may be difficult, but time is of the essence for skin lesions and small-bowel perforation treated
survival, because the prognosis is poor, and the by surgery [45]. The patient developed gener-
treatment is almost inconsequential if performed alised abdominal pain, and explorative laparot-
too late. Acute mesenteric ischaemia is a syn- omy revealed multifocal ischaemic changes in
drome in which inadequate blood flow through the small bowel with perforations. A case of
the mesenteric circulation causes ischaemia and Degos’ syndrome described by González
eventual gangrene of the bowel wall. The aetiol- Valverde et al. presented with acute abdominal
ogy could be arterial or venous; the arterial dis- pain due to intestinal perforation and multiple
ease can be subdivided into nonocclusive and serosal maculae on the intestine; Degos’ syn-
occlusive ischaemia. Diagnostic imaging plays drome was not diagnosed until a few erythema-
the main role in detecting the degree and severity tous skin lesions were discovered. The CT
of intestinal ischaemia and in assessing for evi- findings in a 40-year-old woman with Degos’
dence of infarction. syndrome were described by Amaravadi et al.
They included extensive ascites, nodular thicken-
ing of the omentum, small-bowel wall thicken-
14.6 Degos’ Syndrome ing, gross pneumoperitoneum with small-bowel
perforations, and intraluminal haemorrhage into
Kohlmeier described malignant atrophic papulo- a loop of infarcted jejunum. The serial CT images
sis in his article ‘Multiple Hautrekrosen bei can demonstrate the sites of perforation, perito-
Thromboangiitis obliterans’ in 1941 [41]; this neal enhancement, and nodular omentum, of
same disease entity was described by Degos in which the features are not specific for Degos’
1942. Degos’ syndrome is an occlusive small- syndrome. The nodular omentum may resemble
vessel vasculopathy which causes tissue infarct other conditions such as peritoneal carcinomato-
[42], but its aetiology is unknown and it affects sis. The patent mesenteric vessels and absence of
all ages. Degos’ syndrome has a benign cutane- atherosclerosis excluded that there was mesen-
ous form and a fatal systemic form [43]. Skin teric artery and vein occlusion.
lesions may manifest as erythematous papules Tiny pockets of pneumatosis intestinalis were
which heal to leave scars with white atrophic noted in the ileum and ascending colon during the
centres. Light microscopy findings of skin lesions first and third admissions. The pneumatosis was a
may demonstrate wedge-shaped zones of necro- bubble-like configuration, but without associated
sis extending from the epidermis to the reticular portovenous gas. Pneumatosis intestinalis was pre-
dermis, thickened vessel walls, and thromboses viously regarded as a sign of transmural necrosis,
[44]. Gastrointestinal lesions may show identical but it can also be due to different non-ischaemic
histological findings, and complications such as causes such as chronic obstructive pulmonary dis-
bowel perforation and peritonitis are often fatal ease, connective tissue diseases or infectious
14 Imaging of Gastrointestinal Tract Perforation in the Elderly Patient 111

enterocolitis, none of which are necessarily was suggested by Crohn (1965) [49]. No perfora-
associated with unfavourable outcomes. tions have been reported in the series of acute
Pneumatosis intestinalis was previously regarded ileitis reported by Atwell and colleagues (1965)
as a sign of transmural necrosis, but it can also be [50], Schofield (1965) [51].
due to different non-ischaemic causes such as CT helps to detect both the perforation and the
chronic obstructive pulmonary disease, connective unsuspected CD as its cause, often presenting
tissue diseases, or infectious enterocolitis, none of with typical findings of active CD.
which are necessarily associated with unfavour-
able outcomes. Kernagis et al. suggested that iso-
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 Imaging of Gastrointestinal
Tract Perforation in the Oncologic 15
Patients

Luigia Romano, Sonia Fulciniti, Massimo Silva,

Riccardo Granata, and Giuseppe Ruggiero

15.1 Introduction factors because it is frequently associated with a

severe septic status. It has been reported to occur
Gastrointestinal tract cancer can occur with many in 3–10 % of colorectal carcinoma, and it is an
complications. Perforation, obstruction, bleed- emergency condition that requires immediate
ing, and invasion of the adjacent organs and surgical management [2].
structures are the main complications associated Perforation may occur because of the tumor’s
with gastrointestinal tumors [1]. lack of desmoplastic response and rapid growth
One of the most severe complications has with insufficient blood supply, or it could depend
been represented by perforation. on rapid necrosis due to chemotherapy.
Perforation is one of the gastrointestinal tract It is generally due to two main conditions that
tumor complications with the worse prognostic are frequently associated and are represented by
tumor necrosis and ischemia. The necrotic degen-
eration determined by the rapid tumoral growth
L. Romano (*)
under a limited blood supply can determine the
Department of Radiology, “A. Cardarelli” Hospital,
Via Manzoni n° 213, Naples 80123, Italy tumoral perforation. Furthermore, the vascular
e-mail: [email protected] occlusion by tumor cells and the increasing endo-
S. Fulciniti luminal hollow viscus pressure contribute to
Department of Radiology, “A. Cardarelli” Hospital, intestinal cancer perforation. Rarely the perfora-
Via Cupa Costa Brancaccio, n°12, tion occurs distantly from the primary tumor; in
Naples 80131, Italy
this case, it could depend on the mucin produc-
e-mail: [email protected]
tion by the tumor associated with the obstructive
M. Silva
condition with a high pressure of the intestinal
Department of Radiology, “A. Cardarelli” Hospital,
Via Diaz, n° 108, Portici (Naples) 80025, Italy lumen.
e-mail: [email protected] The gastrointestinal perforation has two poor
R. Granata prognostic factors represented by the develop-
Second University of Naples-Italy, ment of a severe septic status and the spillage of
Via Quattro Giornate n°15, cancer cells inside the peritoneal cavity with a
Giugliano in Campania-Naples 80014, Italy
high rate of metastatic site diffusion.
e-mail: [email protected]
In case of a perforated rectal tumor, CT can
G. Ruggiero
demonstrate the involvement of soft surround-
Department of Radiology, “A. Cardarelli” Hospital,
Via Sigmund Freud n°63, Naples 80131, Italy ing tissues represented by subcutaneous cellulitis
e-mail: [email protected] and myositis associated with gas dissection

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 115

DOI 10.1007/978-3-319-08192-2_15, © Springer International Publishing Switzerland 2015
116 L. Romano et al.

composed of multiple air bubbles. Deep fluid misinterpreted as other frequent abdominal
collections may coexist in the pelvic and retro- emergency conditions such as obstruction, intes-
peritoneal infected spaces. tinal ischemia, and peritonitis.
The fluid collections are generally distributed Patients with abdominal pain and an acute
in the perirectal and perineal planes, ischiorectal presentation of the gastrointestinal cancer
fossa, scrotum, thighs, buttocks, abdominal wall, undergo contrast medium emergency CT of the
and retroperitoneum. This kind of rectal cancer abdomen. In fact for acutely ill patients, CT is
perforation associated with adjacent soft tissue often the only study required, providing crucial
gas dissection is called Fourier gangrene. information for accurate diagnosis of gastrointes-
In patients affected by cancer treated with tinal tract neoplasms and associated complica-
monoclonal antibody-tyrosine kinase inhibitors, tions [4].
a perforation of gastrointestinal tract can occur as
a complication of the chemotherapeutic protocol.
Monoclonal antibodies are tyrosine kinase 15.3 MDCT Protocol Design
inhibitors targeting the vascular endothelial Consideration
growth factor (VEGF) receptor and are used
widely in the treatment of various neoplasms, The MDCT protocol described is designed for a
demonstrating an improved selected antitumoral 64-row scanner, and images are acquired at 0.625
efficacy [3]. collimation, with reconstruction axial slice of
Particularly bevacizumab has been utilized for 2.5 mm., pitch of 0.984, and gantry rotation time
the treatment of advanced colorectal cancer, and of 0.5 s.
it is under investigation for the treatment of other The abdominal volumetric scan begins at the
kinds of neoplasms. Unfortunately these new level of the diaphragmatic dome and ends at the
agents have severe collateral effects as gastroin- pubic symphysis.
testinal perforation, gastrointestinal fistula, and For gastrointestinal tract evaluation, the use of
arterial thrombosis. thin sections, high-volume, rapid-bolus scanning
VEGF inhibition can damage the capillary technique with state-of-the-art CT technology is
bed of the intestinal wall, thus reducing the important in differentiating intestinal and abdom-
threshold for the development of microperfora- inal findings.
tion, pneumatosis intestinalis, or frank perfora- Preliminary unenhanced abdominal CT is
tion. Up to the stage of the development of obtained to detect free air bubbles into the perito-
pneumatosis intestinalis, the patient can be man- neal cavity or in fluid collections, hemoperito-
aged successfully by stopping anti-angiogenic neum, and preexisting hyperattenuating material
therapy associated with fasting and parenteral in the bowel wall and lumen such as suture materi-
nutrition. In case of perforation the patient has to als, blood clots, or retained contrast material (c.m).
be treated surgically to prevent sever peritonitis Intravenous administration of contrast
and septic status. medium is mandatory for discovering gastroin-
testinal cancer.
Intravenous injection of a volume of 100–
15.2 Computed Tomography 120 ml of iodine contrast material is generally
necessary for evaluating enhancement alteration
Computed tomography (CT) is increasingly of the bowel wall and mesenteric fold.
being used as a screening modality for patients For better viewing the enhancement alteration
with symptoms of acute abdomen and has of the gastrointestinal wall, contrast agents with
become the preferred small bowel imaging higher concentration of iodine (400 mg./ml) and
modality for assessing intestinal disorders. high injection rates (at least 3–4 ml/s.) are pre-
Early symptoms of gastrointestinal tumor ferred and are followed by a 30–50 ml saline
perforation are often nonspecific and could be chaser, also injected at a rate of 3–4 ml/s.
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 117

After the abdominal pre-contrast scan, the

automated bolus tracking is used to time the
beginning of the c.m. acquisition during the arte-
rial phase. The bolus tracking requires precise
placement of the region-of-interest (ROI) cursor
in the abdominal aorta lumen. The image acquisi-
tion is triggered at an attenuation threshold of
150 UH.
The c.m. arterial phase is mandatory to detect
arterial supply and arterial enhancement of
hypervascularized gastrointestinal stromal
tumors (GISTs) and their distant metastasis. It is
also mandatory for evaluating ischemic changes
of the intestinal wall that could be associated Fig. 15.1 Axial post-contrast medium CT scan shows
with cancer. the ascending colon thickening (white arrows) and sur-
rounded by a pericolic fat inflammation associated with
The scan delay for the next portal-venous
dense fluid and air bubbles (white arrow heads). Fluid
phase is 70 s. The portal phase acquisition gives film and air bubbles spread also into the abdominal wall
maximum bowel wall and primary tumor attenu- (black arrow head)
ation and distant metastasis attenuation, and it is
useful in evaluating other intestinal cancer-
associated findings, as mesenteric fold spreading, diffusion to adjacent fat planes, structures, organs,
presence of a fistula through adjacent hollow vis- lymph nodes, and distant regions.
cus wall, and venous mesenteric drainage neo- A variety of radiological findings that depend
plastic obstruction. It is useful also for evaluating on the development of peritoneal and mesenteric
the CT findings associated with tumor perfora- fold inflammation and fluid collection associated
tion, as generalized peritonitis and septic fluid with gastrointestinal tumor perforation some-
collections. times can hide the underlying primary cancer and
In selected cases, oral administration or enema can be misinterpreted as an infectious disease [5]
of iodine contrast material (c.m.) could be useful, (Fig. 15.1).
especially for demonstrating cancer fistulization.
Sagittal and coronal MIP reformatted images
are useful for localizing the pathological segment 15.5 Stomach Cancer
of the bowel within the abdomen and evaluating
the map of the distribution of air bubbles, abdom- The most frequent CT finding of stomach cancer
inal cavity and peritoneal fold inflammation, and is represented by a focal or diffuse gastric wall
fluid collections. thickening, with a dishomogeneous post-contrast
medium wall attenuation, particularly of the ade-
nocarcinoma type (Fig. 15.2). Other CT signs are
15.4 CT Findings of Primary outer and inner lobulated irregular margins,
Gastrointestinal Cancer ulceration, and narrowing of the lumen with
obstruction and secondary proximal gastrectasia.
CT is unable to determine whether a neoplasm is The areas of dishomogeneous post-contrast
localized to the mucosa or infiltrates the muscula- enhancement are due to tumoral tissue inhomo-
ris layer. CT staging of the primary tumor is based geneity for edema, necrosis, or hemorrhage [6].
on the evaluation of an irregular thickness or The tumor could invade surrounding organs
mass of the gastrointestinal wall, with a dishomo- and structures as the diaphragmatic muscle, pan-
geneous post-contrast medium wall attenuation, creas, spleen, left lobe of the liver, transverse
with the presence or absence of the neoplastic mesocolon, and small and greater omentum.
118 L. Romano et al.

Fig. 15.2 Axial post-contrast medium CT scan shows

pneumoperitoneum (white arrow heads) and a focal gas-
tric wall thickening, with a dishomogeneous post-contrast Fig. 15.3 Coronal post-contrast medium CT scan shows
medium wall attenuation (white arrows), representing a the narrowing of the stomach body lumen (white arrows)
stomach cancer. The perforation of the lesion has been with secondary proximal gastrectasia. There is an open
demonstrated by adjacent multiple air bubble spread peritoneal perforation, with fluid and free air bubbles dif-
within the small omentum (black arrows) fused around the gastric walls, inside the small omentum,
and in the right subphrenic space (white arrow heads)

When the greater omentum is diffusely infil-

trated, an “omental cake” may be recognized at high-resolution axial CT slices can demonstrate
CT scan as an extensive dishomogeneous thick- in some cases a direct discontinuity of the gastric
ened soft tissue mass, separating the colon and neoplasm. In open peritoneal perforation, an
the small bowel from the anterior abdominal wall. amount of fluid and free air bubbles is diffused
Metastasis could be evidenced at the liver, principally around the gastric walls, in the sub-
adrenal glands, lymph nodes, ovaries, and perito- phrenic left space, and inside the umbilical fis-
neal cavity. sure of the liver and the small omentum
Gastric lymphoma can occur as a part of a (Fig. 15.3).
generalized lymphomatous process or, in 10 % of
cases, could be represented by an isolated pri-
mary gastric localization [7]. 15.6 Small Intestinal Cancer
The lymphomatous process generally spreads
submucosally, determining an irregular diffuse Tumors of the small intestine are uncommon,
inhomogeneous and hypodense smooth thicken- accounting for no more than 6 % of all gastrointes-
ing of the gastric wall greater than 1 cm. involv- tinal apparatus neoplasms, and are frequently rep-
ing more than half of the circumference of the resented by annular, aneurysmally dilated or
stomach. The inner and outer margins of the lym- ulcerated mass, associated with thickening or
phoma are frequently waved; the perigastric flat retractive desmoplastic reaction of the adjacent
planes are generally obliterated by the tumor mesenteric fold. An endoluminal mass with a
invasion. Associated diffuse bulky lymphadenop- dishomogeneous post-contrast medium wall atten-
athies indicate a disseminated disease. uation can be visualized. The evidence of ulcer-
The perforation of gastric carcinoma and lym- ation is indicative of adenocarcinoma. Other CT
phoma is a rare condition with an incidence of signs are ulceration, necrotic areas, inner undu-
0.4–0.6 % [8]. lated margins, irregular outer profiles, and narrow-
It generally occurs in elderly patients with a ing and obstruction of the lumen (Fig. 15.4). The
locally ulcerated advanced tumor. The use of thin perforation occurs in sites of the small intestine
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 119

Fig. 15.4 Axial post-contrast medium CT scan shows a

small bowel ulcerated mass (white arrow head), associ-
ated with narrowing of the lumen and retractive desmo-
plastic reaction with irregular outer profiles of the adjacent
mesenteric fold in which there are multiple air bubbles
(black arrows)

where an intramural infiltration by neoplastic cells

has developed and has been followed by tumor
necrosis. Perforation of a bowel metastasis can
occur also after chemotherapy due to the cellular Fig. 15.5 Coronal post-contrast medium CT scan shows
a very large dishomogeneous ileal mass (black arrows),
necrotic effect produced by the drug [9].
associated with a thin fistula (white arrow) communicat-
ing with a mesenterial abscess (white arrow heads)

15.7 Small Intestinal Lymphoma

Small intestinal involvement of a lymphoma is

one of the crucial points in the course of the
pathology. The perforation or fistulization of this
kind of localization can occur at any site including
the duodenum, jejunum, and ileum [10] (Fig. 15.5).
Free intestinal perforation may occur both
spontaneously and after chemotherapy, and it is
due to tumor necrosis (Fig. 15.6). The diagnosis
is often delayed because this kind of pathology
has been frequently treated with cortisone that
can reduce significantly abdominal acute Fig. 15.6 Axial post-contrast medium CT scan shows a
symptoms. very large small intestinal mass (black arrows), in which
If the perforation involves a small intestinal there is a necrotic area (white arrow head)
lymphoma, it is possible that in the peritoneal
cavity there will be the presence only of free fluid mucosal ulceration, the depth of which increased
without air. The peritoneal fluid can be evidenced gradually with the depth and degree of lymphoma
by ultrasonography, but the site of the intestinal cell infiltration, until eventually with the increase
lymphoma could be better visualized by com- in intraluminal pressure (Fig. 15.7a, b).
puted tomography. If the lymphoma is located in the mesenteric
The bowel wall can get ruptured due to the fold, it can invade and obstruct the adjacent bowel
mechanical action of the bowel that resulted in loops leading to their perforation in the abdominal
120 L. Romano et al.

a b

Fig. 15.7 (a) Axial post-contrast medium CT scan shows (white arrow head) communicating with the retroperito-
a very large dishomogeneous mass (white arrows in a and neal space. (b) After oral administration of contrast
small arrow in b) of the abdominal left flank, involving an medium, the intestinal fistula is clearly demonstrated
ileal loop and the adjacent mesenteric fold in which there (two white arrows), with extravasation of c.m. into the left
is an ulcerated area associated with a long posterior fistula anterior pararenal space (white arrow head)

a b

Fig. 15.8 (a) Axial post-contrast medium CT scan shows image shows the involved bowel loops (black arrows) and
a large lymphoma located into the mesenteric fold (white their perforation with air bubbles into the adjacent mesen-
arrow heads) that invades and obstructs the adjacent teric fold (white arrow) and into the abdominal cavity
bowel loops (white arrow). (b) Coronal reconstruction CT (black arrow head)

cavity (Fig. 15.8a, b) or to their fistulization in an 15.8 Small Intestinal Metastasis

adjacent structure, as the excretory renal system
or psoas muscle [11] (Fig. 15.9a, b). Solitary or multiple metastases spread in the small
The steroid treatment itself can induce ulcer- intestinal wall is much less common, although
ation, tumor necrosis, and perforation of the small bowel involvement in the late stage of
intestinal bowel loop lymphoma. abdominal carcinomatosis is frequently observed.
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 121

a b

Fig. 15.9 (a) Axial post-contrast medium CT scan shows (b) Sagittal reconstruction CT image better shows the per-
an obstructed small intestinal loop (white arrows) perfo- forated bowel loop (white arrows) with the development
rated into the psoas muscle fascia (white arrow head). of a muscle abscess (white arrow head)

When metastatic lesions of the small intestine

cause symptoms, the usual presentation is that of
either complete or incomplete bowel obstruction,
intestinal bleeding due to ulceration and erosion,
and more rarely intestinal perforation [12].
Perforation of a bowel metastasis can occur
also after chemotherapy due to the cellular
necrotic effect produced by the drug [9]
(Fig. 15.10).
The most frequent histologic types that can
determine hematogenous metastasis into the
intestinal wall are oat cell, epidermoid, giant cell
carcinomas, and melanomas. The primary tumor
generally has an abdominal or pelvic cancer ori-
gin as colon, uterine, and ovarian cancer or extra-
abdominal origin as pulmonary cancer, breast
cancer, and melanoma [13].

Fig. 15.10 Post-contrast medium CT coronal recon- 15.9 Colorectal Cancer

struction shows a large mesenterial mass (thin white
arrows) with a large necrotic area and irregular borders The ascending and descending colon tumors
(white arrow heads) involving the duodenum (black
can be readily assessed because of their fixed
arrow head). The necrotic mass perforation has been
demonstrated by the presence of air and fluid into the peri- retroperitoneal locations. Tumors localized in
toneal cavity (white arrow) the flexures and transverse colon are less
122 L. Romano et al.

frequently well evidenced by CT, for their

position, retained fecal material, incomplete
distension of the wall, peristaltic activity, and
respiratory excursions.
The most frequent CT finding of colon cancer
is represented by a focal thickening of the wall
greater than 6 mm with a dishomogeneous post-
contrast medium wall attenuation, frequently
narrowing the intestinal lumen (Fig. 15.11).
Particularly in the adenocarcinoma type, an
endoluminal polypoid mass with a dishomoge-
neous post-contrast medium wall attenuation can
be visualized. Other CT signs are ulceration,
necrotic areas, inner undulated margins, irregular
Fig. 15.11 Post contrast medium axial reconstruction outer profiles, stenosis, and obstruction of the
shows a focal thickening of the sigmoid colon wall with a lumen (Fig. 15.12a, b).
dishomogeneous post-contrast medium wall attenuation
narrowing the intestinal lumen (white arrows), with
The rectum and rectosigmoid tract are easily
mechanical obstruction of the proximal intestinal loops evaluated by CT because of the fixed position in
(white arrow heads) the pelvic cavity.

a b

Fig. 15.12 (a) Sagittal reconstruction post-contrast fluid (white arrow heads). (b) Coronal reconstruction
medium CT image shows a neoplastic mass of the cecum post-contrast medium CT image shows a mechanical
pouch with inner undulated margins and irregular outer obstruction of the proximal ileal loops (white arrow
profiles (white arrows, a and b), surrounded by peritoneal heads) with the lumen filled with fluid and air bubbles
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 123

Extracolon tumor spread is suggested by loss

tissue fat planes between the large intestine and
the surrounding structures as the seminal vesi-
cles, prostate, bladder, uterus, ovaries, ureters,
and muscles as the iliac, levator ani, obturator
internus, piriformis, and coccygeal. Rectum and
rectosigmoid tumor can invade bones as the
sacrum and coccyx.
In selected cases it is possible to evidence a
discontinuity of the colorectal cancer wall, with
associated findings of open perforation or cov-
ered perforation (Fig. 15.13). In open perfora-
tion, an amount of dense fluid and free air bubbles
Fig. 15.13 Axial post-contrast media CT scan shows a
focal thickening of the wall of the right flexure of the
is located principally in the subphrenic spaces,
colon with a dishomogeneous post-contrast medium around the liver and the gastric walls, along the
wall attenuation narrowing the intestinal lumen (black mesenteric folds, and in the peritoneal recesses of
arrows). The neoplastic stenosis has been complicated the pelvic cavity.
both with a covered perforation due to the development
of a pericolic abscess (white arrows) and open
The cover perforation with the development of
perforation with free air bubbles around the abscess an abscess has been demonstrated by a low-
wall (white arrow heads) and into the peritoneal cavity density unilocular or multilocular collection with
(black arrow heads) air-fluid level or air bubbles (Fig. 15.14a, b),

a b

Fig. 15.14 (a) Axial post-contrast medium CT scan been complicated with an abdominal wall fistula and
shows the cover perforation of the ascending colon cancer development of a subcutaneous fat abscess (black arrows).
(white arrow head) with the development of an abscess, (b) Sagittal reconstruction CT image shows the paracolic
demonstrated by a low-density multilocular collection internal (white arrow head) and subcutaneous external
with air bubbles (white arrows), associated with inflamed abscesses (white arrows). The infection has spread also
surrounding fat tissue. The multiloculated abscess has inside the muscle fasciae (black arrows)
124 L. Romano et al.

associated with an increased peripheral density

of the infiltrated or inflamed surrounding fat tis-
sue. It is generally associated with a limited
amount of free peritoneal fluid mainly localized
in the vesical-rectal pouch.
Associated metastasis could be evidenced at
the liver, adrenal glands, local lymph nodes, and
peritoneal cavity. Additional findings are fre-
quently represented by omental cake diffused
distant lymph nodes.

15.10 CT Findings of Associated Fig. 15.15 Axial post-contrast medium CT scan shows a
Intestinal Obstruction metastatic tissue that involves the transverse colon and
adjacent ileal bowel loop (white arrows) with intestinal
Abnormal accumulation of gas and fluid in the perforation and spread of air bubbles and enteric fluid into
the mesenteric fold (white arrow head)
distended intestinal tract occurs in the mechani-
cal obstruction of both the small and large bowels
affected by cancer (Figs. 15.11 and 15.12a, b). 15.11 Primary Tumors
The distended intestinal loops contain air-fluid and Metastasis of Small
levels and are located proximal to the site of the Bowel Perforation
neoplastic obstruction. During the acute phase of
the mechanical obstruction, peristalsis become Primary tumors and metastasis of the small
hyperactive with thickened plicae mucosae as the bowel intestine can determine various compli-
intestine attempts to work against the site of cations as obstruction, bleeding, malabsorption,
occlusion. When the obstruction lasts for a long and perforation.
time and is persistent, the intestine becomes Mural replacement by metastatic tissue occurs
atonic and plicae mucosae disappear. after hematogenous or lymphatic spread of can-
At the level of the small intestine, the occlu- cer cells. The spontaneous necrosis or the induced
sion can determine an accumulation of small necrosis by chemotherapy can lead to metastasis
droplets of gas within the recesses between the perforation (Fig. 15.15). Also the increased lumi-
valvulae conniventes, producing a series of small nal pressure due to the obstructed bowel loop or
air bubbles referred to as the “string of pearls.” the embolization procedure performed for
If the site of neoplastic mechanical obstruction occluding the arterial supply to stop the severe
is the colon, a competent ileocecal valve prevents bleeding of a metastasis can lead to the perfora-
the reflux of gas and fluid in the lumen of the small tion [15].
intestine, resulting in a “closing loop” obstruction
of the colon. The wall of the cecum, being thinner
and weaker than the wall of the remainder portions 15.12 Gastrointestinal Stromal
of the colon, distends more rapidly and to a greater Tumor (GIST) Perforation
degree. Therefore the rupture of the obstructed
colon most likely occurs at the cecum level. Gastrointestinal stromal tumors (GISTs) are the
If the ileocecal valve is incompetent, allowing most common mesenchymal tumors of the
gas and fluid to reflux into the lumen of the small gastrointestinal tract and are 2.5 % of all
intestine, the tear of the cecum is not probable. gastrointestinal tumors [16]. The stomach is the
The high pressure in the intestinal lumen most common site accounting for 50–70 % of
caused by occlusion can lead to a hypoperfusion GISTs, the small intestine for 25–30 %, and the
of the intestinal wall with consequent ischemia colon-rectum for 5 % [17]. They are well-
and infarction [14]. circumscribed masses that range in size from
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 125

several millimeters to 30 cm and do not have a Extensive necrosis and fistula development
true capsula. They are frequently inhomoge- may occur determining the growth of a cavity
neous with hyperdense areas that depend on a inside the tumoral tissue and bleeding. An
significant arterial blood supply, with focal air-fluid level can occur in these lesions with the
areas of hemorrhage, necrosis, calcifications, formation of a fistula between an adjacent bowel
cystic degeneration, and cavitations that can loop and the primary tumor.
communicate with the intestinal lumen, the
abdominal cavity, or both. Extension into the
adjacent small bowel mesentery and encase- 15.13 Colon Cancer Perforation
ment of noncontiguous segments of the small
intestine, colon, bladder, ureter, and abdominal The perforation of colon neoplasms can occur in
wall can occur [18]. 2.5–10 % of cases [21].
They involve the muscularis propria of the Michowitz et al. [22] have proposed the fol-
intestinal wall and have the propensity for outer lowing classification of perforated colon cancer:
growth, projecting into the abdominal cavity. 1. Free perforation with leakage of the enteric
The most common GISTs have an exophytic fluid into the abdominal cavity
growth pattern and are shown by a mass located 2. Covered perforation with local abscess
outside the gastrointestinal tract of origin development
(Fig. 15.16). 3. Perforation into adjacent structures or organs
Obstruction of the intestine occurs very rarely, or development of a fistula
whereas the most frequent complication is hem- Perforation of colon cancer has been reported
orrhage [19]. to be a poor prognostic condition because it is
GIST spontaneous perforation is a rare condi- evaluated as a sign of advanced disease and asso-
tion and can be due to the bleeding of the mass ciated with two risks. The first is the diagnosis of
and capsula rupture that lead to a severe hemo- the cancer itself and the second the septic compli-
peritoneum rather than pneumoperitoneum [20]. cation that is joined with the perforation, the
tumor dissemination, and consequent high rate of
recurrence for the peritoneal seeding [23]
(Fig. 15.17).

Fig. 15.16 Post-contrast medium CT coronal recon-

struction shows a large hypervascularized and perforated Fig. 15.17 Axial post-contrast medium CT scan shows
gastrointestinal stromal tumor (GIST) involving the wall the irregular thickening and narrowing of the cecum
of a jejunal loop (white arrows) with air bubbles spread (white arrows) surrounded by a pericolic fat inflammation
into the adjacent mesenteric fold (white arrow heads) associated with free air bubbles (white arrow heads)
126 L. Romano et al.

Particularly if there is a competent ileocecal The tumor perforation could depend on the
valve, the presence of the tumor can lead to an necrotic degeneration of the neoplastic tissue,
obstruction complicated with a significant dilata- next colonization of the necrotic fluid by enteric
tion of the lumen producing a closed-loop colon bacteria, and then fistulization of the necrotic and
occlusion that can be complicated by the perfora- inflamed wall in the peritoneal cavity. It could
tion of the intestinal wall. depend also on the neoplastic occlusion of the
Perforation and penetration of the intestinal lumen, dilatation of the proximal colon, and sec-
tumor in the pericolic fat can lead to a pericolic ondary perforation of the thin distended wall.
abscess that could be the early presentation of the As consequence of a perforated colon cancer,
tumor. an adjacent localized air-fluid collection can
Abscess development occurs in 0.3–0.4 % of occur, associated with pericolic folds and fat
colonic carcinoma, and it is the second most inflammation or a peritoneal open spreading with
common complication of perforative lesions evidence of air bubbles and dense fluid in all peri-
[24]. toneal recesses and pouches [29].
One of the most common presenting condi- Especially open peritonitis can cause spread-
tions of colonic abscess is the development of an ing of primary cancer cells into the abdominal
anterior abdominal wall frequently determined cavity with peritoneal seeding. Afterward a peri-
by a transverse colon fistulized tumor. It is not toneal carcinosis can develop.
rare that the tumor can determine an adhesion The pericolic abscess can occur as a conse-
with a solid organ capsula. Colon flexure carci- quence of the perforation or direct tumor invasion
noma can involve the liver or the spleen that of the surrounding structures [30].
could become the presenting site of abscesses The most frequent localization is represented by
[25]. the pelvic peritoneal cavity and the paracolic
Retroperitoneal perforation of ascending and recesses. From the first site, the infectious dense
descending colon cancer can involve the fat fluid can spread into other spaces with the develop-
planes of the retroperitoneum, the posterior wall ment of new abdominal collections. The diaphrag-
muscles, and the subcutaneous fat. The most fre- matic aspiration movement can facilitate the
quent complication of these abscesses is repre- development of a right subphrenic fluid collection.
sented by the entero-cutaneus fistula (16.7 %) In rare cases ascending or descending colon
[26] (Fig. 15.14a, b). tumor can develop a posterior perforation or a fis-
Abscess development occurs in 0.3–4 % of tula in the retroperitoneal iliac cavity. The inflam-
cases of colon cancer and is the second most mation can distribute along fascial and muscle
common presentation of this type of tumor [27]. planes, especially the iliopsoas muscle, and can
Tumor growth can contribute to abscess devel- spread up to the groin and the inferior limb [31].
opment due to the presence of bacteria in the In these cases, the diagnosis of primary colon
bowel content. Suppuration of the intestinal con- cancer is very difficult.
tent can lead also to more rare infectious collec- Another difficult differential diagnosis is rep-
tions as muscle, anterior abdominal wall, resented by the primary colon cancer stranding
retroperitoneal, perirenal, and periappendicular the adjacent fat tissue and inflammatory condi-
abscesses [28]. tions as diverticulitis and appendicitis. In some
The application of a drainage catheter into the cases colonic perforation can depend also on an
fluid collection, when it is achievable by CT or underlying pathology as diverticulitis. Sigmoidal
ultrasound guide, is the best preliminary treat- diverticulitis could be associated with a chronic
ment for reducing patient toxemia. The next inflammatory thickening of the wall of the
diverting colostomy followed by the resection of affected loop, so it is difficult for making a diag-
the affected colon tumor portion can definitely nosis of a perforated colon cancer associated
remove the source of the sepsis. with diverticulitis.
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 127

Marked asymmetric intestinal wall thickness During the ischemic phase, the colon wall
with loss of stratified contrast attenuation that proximal to the obstructed loop is thickened
regard a segmental colon loop could be evaluated due to intramural edema and hyperemia, and
as colon cancer, whereas the presence of strati- this finding is similar to nonspecific colitis
fied enhancement is an important sign of benig- [34].
nant inflammatory pathologies [32]. Another Ischemia that occurs proximally to a colon
finding in favor of colon cancer is represented by carcinoma has an incidence of 1–7 % [35].
a sudden transitional loop from a normal thin
wall to a thickened segmental wall, associated
with pericolic fat stranding and lymph nodes. 15.15 Colon Cancer Complicated
The overlap in the radiological appearances of with Ischemia
the perforated colon cancer often complicates the and Perforation
differential diagnosis of a pericolic infiltration with
a cover perforation with an inflammatory abscess The main site of ischemic alteration in colon can-
that could depend on appendicitis or diverticulitis. cer is the segment contiguous with the primary
tumor. In a minority of cases, the ischemic site is
located in a noncontiguous colon segment (skip
15.14 Obstructing Colon Cancer zone).
Complicated Colon ischemia with transmural edema can
with Perforation appear on CT axial images as a smooth, annular
wall thickening with a layered pattern enhance-
The effect of obstruction of colorectal carcinoma ment proximal to a dishomogeneous tissue of
complicated with perforation influences signifi- irregular thickness of a fungine mass that repre-
cantly the outcome. The consequences of the per- sents the colon neoplasm [36].
foration are represented by the tumor cells spread The CT appearance of the ischemic segment is
into the peritoneal cavity and the development of a concentrically thickened wall with a target dou-
abdominal abscesses and/or peritonitis. ble halo sign, due to the mucosal congestion and
The perforation can depend directly on the ulceration and submucosal hemorrhage.
tumor necrosis or can occur proximally to the Obstructive ischemia, mucosal ulceration, sub-
cancer site for ischemic or marked dilatation of mucosal edema, and hemorrhage determine the
the proximal bowel loop. most frequent CT findings that are represented by
The perforation of the tumor occurs at the colon wall thickening.
immediate localization of the primary cancer, Especially ischemic colitis that can develop
whereas the perforation proximal to the tumor proximally to a colonic cancer can be compli-
occurs at least 2 cm proximal to the cancer site. cated with bowel perforation.
An obstructing colon cancer can increase The colon is particularly involved in colonic
strongly the endoluminal pressure of the proxi- ischemia when the tumor arises in two critical
mal loops. If the ileocecal valve is efficient, there areas: at the junction between the superior and
is not any decompression of the dilated lumen, inferior mesenteric artery, proximally the splenic
and the consequent severe dilatation of the colon flexure, and between the inferior mesenteric
lumen can lead to the collapse of the submucosal artery and the hypogastric artery, proximally the
vascular plexus, with consequent ischemia and rectosigmoid segmental tract.
perforation of the wall. This severe complication The bowel lumen dilatation for a rectosigmoi-
can lead to a pericolic abscess if the perforation is dal cancer has a significant role in the develop-
covered by surrounding mesenteric folds or to ment of ischemia, because distended bowel
open peritoneal perforation complicated with lumen may produce local hemodynamic altera-
stercoraceous peritonitis [33]. tions and vascular supply insufficiency [37].
128 L. Romano et al.

15.16 CT Findings of Associated

Peritonitis

Bacterial peritonitis usually results from gastro-

intestinal tumor perforation complicated with
seeding of the peritoneal cavity with multiple
enteric bacteria. In its early stage peritonitis is
manifested by a thickened peritoneum due to
edema associated with exudative free fluid. These
findings could be generalized or localized [38].
CT can demonstrate loculated ascites, omental
or mesenteric thickness, and ectopic air bubbles
that generally surround the perforation site and
are distributed in both supramesocolic and
Fig. 15.18 Axial post-contrast medium CT scan shows a
inframesocolic compartments.
perforated rectal cancer (white arrows) surrounded by
free air bubbles spread into the perirectal and left iliac fat
planes (black arrows)
15.17 Rectal Cancer Perforation:
Fourier Gangrene
where it is fenestrated. The fenestrated fascia
Fourier gangrene is defined as a polymicrobial may allow the perirectal infection to distribute
necrotizing fasciitis of the perineal, perirectal, or into the scrotum (Fig. 15.19a, b). The connection
genital area. Soft tissue gas represents the prod- of the Colles fascia with Scarpa fascia allows the
uct of anaerobic bacteria metabolism. infection to spread to the buttocks, the thighs, and
In elderly, debilitating, alcoholic, and diabetic the abdominal wall (Fig. 15.20).
patients, a Fourier gangrene could be a severe Furthermore the infection may spread above
complication of rectal tumors. The gangrene is the urogenital diaphragm into the perivesical
due to the leakage of intestinal content along the space and then into the retroperitoneal space.
perirectal or ischiorectal fossa with the formation The characteristic CT appearance of Fourier
of an anaerobic infection (Fig. 15.18). gangrene is of soft tissue thickening, fat strand-
The pathogenesis of Fourier gangrene is due ing of the surrounding tissue, and diffuse devel-
to soft tissue necrosis based on infectious celluli- opment of air bubbles.
tis, myositis, and fasciitis associated with subcu- CT can demonstrate the perirectal infection
taneous vessel thrombosis with endoarteritis and adjacent to the rectal tumor and the distribution of
disruption and necrosis of the overlying dermal infectious subcutaneous cellulitis and myositis
and epidermal tissue. associated with gas dissection composed of mul-
Anatomically the perineum is divided into two tiple air bubbles. Deep fluid collections may coex-
triangles with an anterior urogenital area and a ist in pelvic and retroperitoneal infected spaces.
posterior anorectal area. The two areas are The fluid collections are generally distributed
divided by the imaginary line connecting the in the perirectal and perineal planes, ischiorectal
ischial tuberosities. fossa, scrotum, thighs, buttocks, abdominal wall,
The superficial perineal fascia, or Colles fas- and retroperitoneum [39].
cia, is fixed laterally to the pubic branches and is The testis and epididymis are spared from the
in relation with the bulbocavernous muscle, infection and are of normal size and structure.
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 129

a b

Fig. 15.19 Axial (a) and sagittal (b) post-contrast medium CT images show Fourier gangrene with multiple air bub-
bles spread into the scrotum (black arrows)

15.18 Bowel Perforation

Associated
with Chemotherapy

Monoclonal antibodies are tyrosine kinase inhibi-

tors targeting the vascular endothelial growth fac-
tor (VEGF) receptors and are used widely in the
treatment of various neoplasms, demonstrating
an improved selected antitumoral efficacy [3].
Vascular endothelial growth factor-targeted
therapies (VEGF) including bevacizumab, suni-
tinib, and sorafenib can give intestinal toxicity,
especially bowel loop perforation, gastrointesti-
nal fistula, and arterial thrombosis. Time expo-
sure to the drug may induce chronic damage to
the intestinal microvasculature due to VEGF
inhibitors.
Multifactorial causes could determine these
complications, as the compromise of intestinal
wall consistency, interruption of intestinal wall
Fig. 15.20 Coronal reconstruction CT scan shows
Fourier gangrene with multiple air bubbles spread into the determined by the necrosis of superficial micro-
subcutaneous fat of the abdominal wall (white arrows) metastasis, ischemia due to peripheral mesenterial
130 L. Romano et al.

a b

Fig. 15.21 Axial (a) and sagittal (b) post-contrast sal hyperemia (white arrows). The ischemia has been
medium CT images show an ischemic ileal bowel loop complicated with a cover perforation represented by a sur-
with a thickening of the wall due to edema and submuco- rounding large air-fluid collection (white arrow heads)

arteries thrombosis, and dehiscence of surgical presence of colon diverticulitis, or bowel obstruc-
intestinal sutures [40]. tion associated with intestinal cancer. Particularly
Thromboembolic events could occur in 3 % of the presence of peritoneal carcinomatosis com-
cases [41]. plicated with intestinal poor canalization is a pre-
The venous and especially arterial vessels are disposing factor to bowel wall perforation during
at thrombotic risk, and it is due to the VEGF VEGF inhibitor treatment, for the increasing
inhibitors with the progressive loss of the vascu- lumen pressure with multiple ischemic sites
lar protection by the endothelial cells. along the wall of the intestinal loop [43].
The disruption of the endothelial vascular Particularly bevacizumab has been utilized for
layer of the arterial wall induces platelet aggrega- the treatment of advanced colorectal cancer, and
tion and then thrombosis of the lumen [42]. it is under investigation for the treatment of other
Gastrointestinal perforation, determined by a kinds of neoplasms.
direct effect of the drug on the intestinal wall or Bevacizumab is known to be associated with
by the intestinal necrosis induced by the arterial intestinal perforation in 0.5–1.7 % of patients
thrombosis, has been paid particular attention with colon cancer [44].
nowadays and has an overall risk of 5.4 % and a Bevacizumab could limit the blood flow to the
specific risk for colorectal cancer of 2.4 %. splanchnic vasculature by thrombosis or vaso-
One of the reasons of bowel perforation constrictions, which can be responsible for poor
could be represented by the necrosis of the ulcer healing inducing bowel perforation.
tumor up to the serosal layer predisposing the The drug can modify the endothelial cells of
wall to the development of perforation. Also the vascular submucosal plexus of the intestinal
the thrombosis of intestinal mesenteric vessels wall leading to thrombosis, ischemia, and perfo-
and the resulting ischemia can lead to bowel ration [45] (Fig. 15.21a, b).
wall perforation. Pneumatosis intestinalis is another condition
Other gastrointestinal-related risk factors that that could be determined by bevacizumab che-
can lead to intestinal perforation during VEGF motherapy. It is a pathologic condition repre-
inhibitor treatment have been represented by the sented by an infiltration of air bubbles into the
site of the intestinal colorectal anastomosis, wall of the intestinal loops.
15 Imaging of Gastrointestinal Tract Perforation in the Oncologic Patients 131

Every pathology that could determine chronic 2. Kelley WE, Brown PW, Lawrence W et al (1981)
Penetrating obstructing and perforating carcinomas of
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 Role of Multidetector Row
Computed Tomography in the 16
Diagnosis of Acute Peritonitis Due
to Gastrointestinal Perforation

Vittorio Miele and Barbara Sessa

16.1 Introduction 16.2 Peritonitis from

Gastrointestinal
Peritonitis can be defined as an inflammatory Tract Perforation
process of the peritoneal space caused by numer-
ous sources, generally by an infectious agent as From proximal to distal the gastrointestinal tract is
bacteria, fungi and virus or by irritant agents as composed of the stomach, duodenum, jejunum,
talc, drugs or foreign bodies [1]. ileum, appendix, colon, and peritonealized rectum.
The inflammatory process could be localized A break of the integrity of the intestinal wall
with the formation of abscesses or diffuse; on the causes intra-abdominal contamination resulting
basis of the pathogenesis, it could be classified as in a secondary peritonitis, localized with abscess
primary, secondary or tertiary peritonitis. formation or diffuse [1].
Primary peritonitis is generally caused by an The type and degree of peritoneal contamina-
extraperitoneal source, frequently from hae- tion depends on the site and duration of the patho-
matogenous dissemination in patients with cir- logical process and on the physiologic state of the
rhosis or in children who have nephrosis. patient, including the time of the last meal, other
Secondary peritonitis is caused by an infec- coexistent diseases and the presence or absence of
tion by the resident flora of the gastrointestinal a bowel obstruction with bacterial overgrowth.
tract resulting from a break of the integrity of the Microbiological contamination depends on
intestinal tract or the urogenital system or solid the anatomic site of perforation increasing from
organs; it could be classified as acute peritonitis proximal to distal.
by perforation, postoperative peritonitis or post- The stomach and duodenum have the lowest
traumatic peritonitis [2]. number of microorganism per cubic centime-
Mortality of secondary peritonitis is still tre of luminal contents (less than 103 organisms
30–50 % despite advances in pharmacological per gram) for the presence of acidic, biliary and
and resuscitation therapy and surgical and imag- pancreatic secretions which produce a hostile
ing technique [1, 3]. local milieu. They are yeast, aerobic bacteria
(predominantly Staphylococci, Streptococci and
Haemophilus species) and anaerobic bacteria
(predominantly Bacteroides, Veillonella and
V. Miele (*) • B. Sessa Bifidobacterium species).
Cardiovascular and Emergency Radiology
Gastric and duodenal perforation pro-
Department, S. Camillo Hospital,
C.ne Gianicolense 87, Rome 00152, Italy duce a highly acute pain due to a rapid chemi-
e-mail: [email protected]; [email protected] cal peritonitis, often followed by a systemic

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 133

DOI 10.1007/978-3-319-08192-2_16, © Springer International Publishing Switzerland 2015
134 V. Miele and B. Sessa

inflammatory response syndrome (SIRS) with a bones, fish bones, razor blades and toothpicks
rapid clinical deterioration and a progress to an [6, 7] and is more frequently localized in the
infected peritonitis and sepsis. small intestine and colon.
The small bowel and colon contain a relatively Other causes are penetrating trauma and
neutral environment. endoscopy/iatrogenic perforation for invasive
The proximal jejunum contains 104 organisms diagnostic and therapeutic medical proce-
per gram of luminal contents to 107 organisms dures as upper endoscopy, colonoscopy, inter-
per gram in the terminal ileum. ventional radiologic-guided tissue biopsy and
The frequency of aerobes progressively fluid drainage, laparoscopy, etc.
increases along the small bowel with the major 2. Extrinsic obstruction, caused by benign
percentage of Gram-negative in the terminal or malignant neoplasms or by non-
ileum. gastrointestinal tumours located adjacent to
The highest percentage of microorganism per the compressed segment of bowel.
gram (1012) is present in the colon, with an abrupt 3. Other causes are surgical adhesions, malrota-
change of the microfloral load and composition tion, volvulus or herniation. These conditions
between the terminal ileum and the colon. In fact produce perforation especially when they
in this tract, anaerobes outnumber aerobes by up occur as a closed-loop obstruction; in these
to 1,000-fold, with a prevalence of Bacteroides, cases, there was a progressive increase in
Bifidobacterium, Eubacterium, Clostridium, venous congestion followed by arterial stasis,
Lactobacillus and Fusobacterium; also a limited necrosis and loss of mural integrity [8, 9].
variety of Gram-positive anaerobes are present 4. Intrinsic gastrointestinal obstruction, more
[4, 5]. frequently in cases of appendicitis and diver-
Colonic perforations cause a neutral, nonero- ticulitis, but also from the gastrointestinal
sive environment and may present with a slower tract for intraluminal neoplasms, phytobe-
clinical progression, without immediate pain. But zoars, ischaemic strictures and Crohn
they produce a secondary bacterial peritonitis disease.
which progressively leads to purulent or faecal 5. Direct loss of gastrointestinal wall integrity
peritonitis or localized intra-abdominal abscess especially for peptic ulcer perforation but also
formation [5]. from neoplastic growth or from adjuvant or
neoadjuvant therapy [10].
6. Gastrointestinal ischaemia especially in
16.3 Major Causes elderly and critically ill patients.
of Gastrointestinal Tract 7. Infection from Clostridium difficile,
Perforation and Related Salmonella typhi, Mycobacterium tuberculo-
Peritonitis sis and cytomegalovirus [11].

Common causes of peritonitis include appendici-

tis, diverticulitis, perforated gastrointestinal 16.4 Imaging of Gastrointestinal
ulcer, perforated carcinoma, acute cholecystitis, Perforation and Related
acute pancreatitis, and abdominal surgery. Peritonitis
Gastrointestinal perforation with lack of gas-
trointestinal wall integrity causes acute peritoni- The diagnosis of gastrointestinal perforation is
tis for the release of intraluminal contents into the generally based on the identification of extralu-
normally sterile peritoneal cavity. minal leakage and consequent inflammatory
The more frequent causes of gastrointestinal reaction which is around the perforated site or
perforation are: diffuse (peritonitis).
1. Penetrating foreign body. Plain radiography has been the first imaging
It results from the ingestion of sharp, step in patients with suspected GI perforation for
pointed or jagged objects such as chicken the detection of free air outside the gut lumen.
16 Role of Multidetector Row Computed Tomography in the Diagnosis of Acute 135

The reported sensitivity in the identification When gas is located in the retroperitoneum, it
of extraluminal air on plain radiography is generally tends to remain confined in the retro-
50–70 % [12]. peritoneal space without a free spread in the peri-
CT is the diagnostic modality of choice in toneal space.
diagnosing GI tract perforation [13]. When gas is located bilaterally into the ante-
It can depict the presence of a small amount of rior and/or posterior pararenal spaces, it gener-
intra- and extraperitoneal air but also the site of ally originates in the pelvis; gas in the anterior
perforation, cause and associated complications pararenal space is generally produced by duode-
such as phlegmon, abscess and peritonitis. nal or ascending colon perforations, whereas gas
The diagnosis of alimentary tract perforations in the left anterior pararenal space indicates
is based on direct findings as focal bowel wall descending or sigmoid colon perforations.
discontinuity, extraluminal gas and extraluminal Rectal perforation causes bilateral pneumoret-
enteric contrast (when administrated); indirect roperitoneum [17].
signs of GI perforation and related peritonitis When it is depicted as intraperitoneal and
include segmental bowel wall thickening, abnor- extraperitoneal air, generally the source of perfo-
mal bowel wall enhancement, perivisceral fat ration is an extraperitoneal structure [17].
stranding, or fluid and abscess.
It is important for the clinical management
and surgical approach of the identification of the 16.4.1 Oral Contrast Administration
site of GI perforation; CT is accurate in detect-
ing the site of perforation in about 85 % of cases In case of suspected gastrointestinal perforation,
[13, 14]. an oral contrast should be administrated during
The site of perforation can be evaluated by CT exam, consisting in a dilute water soluble
CT signs as (a) discontinuation of the GI wall, iodinated solution.
(b) the site of luminal contrast medium leak- When an extravasation of ingested contrast
age, (c) the level of bowel obstruction and (d) material was depicted, it must be considered a
abrupt GI wall thickening with or without an specific direct sign of bowel perforation with a
associated phlegmon, inflammatory mass or high specificity in the diagnosis of the perfora-
abscess [15]. tion site.
On the basis of location of extraluminal air, it The sensitivity of extravasation of oral con-
could be possible to presume the site of perfora- trast material varies from 19 to 42 % [13] due to
tion: air in the lesser sac is commonly due to pos- the rapid sealing of perforation sites and the
terior perforation of the stomach or duodenum or supine position during the CT exam so that the
less commonly from the rupture of the lower absence of visible extravasation does not exclude
oesophagus or transverse colon. When perfora- a perforation.
tion is in the duodenal bulb or stomach, free air is
confined in the intrahepatic fissure or the liga-
mentum teres. Air in the mesenteric folds is gen- 16.5 Perforation of the Stomach/
erally depicted in the perforation of the colon and Duodenum
small bowel.
Pneumoretroperitoneum is found in the perfo- Peptic ulcer disease remains the most common
ration of the extraperitoneal gastrointestinal cause of gastroduodenal perforation [14], most
tracts as the duodenum (descending and horizon- commonly from the gastric antrum or duodenal
tal portions), ascending and descending colon bulb.
and rectum [16]. Other causes of stomach or duodenum
Also three-fourths of the diverticulum is perforation are traumatic injuries, especially in
located in the extraperitoneum, and so perfora- the descending and horizontal portions of the
tion of the sigmoid diverticula also can produce a duodenum, mostly by blunt trauma in children
pneumoretroperitoneum. and by penetrating trauma in adults, with
136 V. Miele and B. Sessa

a b

c d

Fig. 16.1 Contrast-enhanced axial scans (a-d). Ulcer of lesser sac, in the intrahepatic fissure (green arrow), peri-
the anterior bulb of the duodenum (red arrow), perforated portal free gas (yellow arrows) and free air in the perito-
in the peritoneal cavity. Signs of peritonitis are air in the neal cavity (blue star)

pneumoretroperitoneum in the anterior pararenal cially in the lesser sac and in the intrahepatic fis-
space [18]. Rarely malignant tumours at advanced sure of the ligamentum teres (Fig. 16.1).
stage can produce a gastric perforation (reported The most significant sign to distinguish upper
incidence of 0.4–6 %) [19]. from lower GI tract perforation is the periportal
Reported perforation rates for diagnostic and free gas for the anatomical relationship between
therapeutic procedures such as esophagogastro- the portal tract and the gastric antrum or duode-
duodenoscopy and endoscopic retrograde chol- nal bulb (Fig. 16.1).
angiopancreatography are 0.03–0.3 % [20], A distal duodenal perforation produces
especially of the oesophagus, followed by the extraluminal air in the right anterior pararenal
duodenum, jejunum and stomach. space because of the retroperitoneal position of
CT direct signs of gastroduodenal perforation the duodenum distal to the bulb (Fig. 16.2).
are extraluminal air with gas bubbles in close Other CT signs about the perforated wall are
proximity to the discontinuity in the gastrointes- wall thickening and wall focal enhancement.
tinal wall, focal wall defect and leakage of lumi- The stomach and duodenum contain acidic,
nal contrast when administrated. biliary and pancreatic secretions so that gastric
Ulcers of the anterior wall of the stomach and and duodenal perforation produce a rapid chemi-
duodenum may perforate directly into the perito- cal peritonitis which can be followed by a sys-
neal cavity, whereas posterior stomach and duo- temic inflammatory response syndrome (SIRS)
denum wall defect often caused a confined with a possible progress to an infected peritonitis
peritonitis. Generally ulcers are located on the and sepsis.
anterior bulb of the duodenum and produce, CT signs of peritonitis due to gastrointestinal
therefore, a peritoneal peritonitis with air espe- perforation are increased fat density adjacent to
16 Role of Multidetector Row Computed Tomography in the Diagnosis of Acute 137

a b

Fig. 16.2 Ulcer in the III portion of the duodenum. (a, b) Axial scans, (c) coronal reconstruction shows a wall defect
in the III portion of the duodenum (white arrow) with an inflammatory collection in the retroperitoneal space (blue star)

the site of wall defect, perigastroduodenal fluid, The amount of extraluminal air in these cases is
stranding and gas bubbles in close proximity to small or absent, and it is depicted only in 50 % of CT
the site of perforation and fluid between the duo- performed in patients with small bowel perforation.
denum and pancreatic head (Fig. 16.2). When present free air is depicted in the
mesenteric folds.
Indirect signs of small bowel perforation and
16.6 Small Bowel Perforation related peritonitis are an increased attenuation of
small bowel mesenteric fat, free fluid in the mes-
The incidence of small bowel perforation is low, enteric folds or leaking of intestinal contents into
but it can be produced by a variety of causes the interloop spaces.
including ischaemic or bacterial enteritis, Crohn Crohn disease is a common small bowel
disease, diverticulitis, ingested foreign bodies, inflammatory condition but can rarely lead to free
bowel obstruction, volvulus and intussuscep- perforation, from the colon (1.6 %) or small
tions [21]. bowel (0.7 %) [22].
138 V. Miele and B. Sessa

a b

Fig. 16.3 Localized peritonitis. (a) Unenhanced axial a toothpick (red arrows) close to an ileal loop, at the site
scan, (b) enhanced axial scan and (c) coronal MPR recon- of perforation. An inflammatory reaction of the mesen-
struction depicted an extraluminal ingested foreign body, teric fat around the foreign body is also present

Small bowel perforation could be a complica- 16.7 Appendix Perforation

tion of wall ischaemia with transmural necrosis,
leading to peritonitis. CT has a high sensitivity and specificity
Also penetrating abdominal trauma can pro- for diagnosing acute appendicitis ranging from
duce small bowel perforation; in these cases 94 to 98 % [24]. Unfortunately detecting
abdominal CT has a sensitivity of 64 % and appendiceal perforation is not so simple in CT
accuracy of 82 % in detecting the site of perfora- especially in early stage; rupture of the appen-
tion even in the absence of the free air but dix, in fact, can be a localized process, and the
especially with the help of indirect signs as infil- amount of extraluminal air is usually small or
tration of the mesentery and/or intraperitoneal absent (no more than 1 or 2 ml) because acute
fluid [23]. appendicitis is typically initiated by luminal
Small bowel perforation can also result from obstruction.
GI lymphoma, GISTs or metastasis. CT reaches a sensitivity and specificity of
Fish bones and chicken bones are the most 95 % in the diagnosis of perforated appendicitis
common ingested foreign bodies to cause perfo- when it presents a combination of these five
ration (Fig. 16.3). findings: (1) extraluminal air, (2) extraluminal
16 Role of Multidetector Row Computed Tomography in the Diagnosis of Acute 139

a b

Fig. 16.4 Peritonitis due to mesoceliac perforated appen- on the top with free air (red arrow) and inflammatory
dicitis. (a, b) Axial scans, (c) coronal MPR reconstruc- reaction of the perivisceral fat
tion: a long mesoceliac appendicitis (blue star) perforated

appendicolith, (3) abscess, (4) phlegmon and (5) Inflammatory lesions and penetrating trauma
defect in enhancing the appendiceal wall [24] are frequently observed in the right colon,
(Figs. 16.4 and 16.5). whereas malignant neoplasm, spontaneous
The signs of peritonitis as periappendiceal perforation, diverticulitis, blunt trauma and isch-
stranding and fluid can be detected in the perfo- aemia are generally detected in the left colon
rated but also in non-perforated appendicitis. [21]; perforation of cecum can occur when the
intraluminal pressure of the colon is increased, as
in the case of bowel obstruction or in malignant
16.8 Colon Perforation tumour (Fig. 16.6).
Iatrogenic injuries produce perforations espe-
Malignant neoplasm and diverticulitis are the cially of the rectum and sigmoid colon.
major causes of large bowel perforation, fol- Perforation of the large bowel may occur in
lowed by trauma, ischaemia, inflammatory intraperitoneal or extraperitoneal space depend-
lesions and iatrogenic causes. ing on the perforated portion.
140 V. Miele and B. Sessa

a b

c d

Fig. 16.5 Peritonitis due to gangrenous perforated forated appendicitis with extraluminal bubbles and
appendicitis. (a, b) Axial scans, (c) sagittal reconstruc- extraluminal appendicoliths (red arrow); also a perivis-
tion, (d) coronal reconstruction detects a gangrenous per- ceral abscess is present (blue star)
16 Role of Multidetector Row Computed Tomography in the Diagnosis of Acute 141

a b

c d

Fig. 16.6 Peritonitis due to perforation of the cecum neo- thickening with an ileum-cecum-colon intussusception
plasm with intussusception. (a, b) Axial scans, (c, d) cor- and wall perforation with gas bubbles (red arrow) and an
onal reconstruction shows a pathological cecum wall increased attenuation in mesenteric fat
142 V. Miele and B. Sessa

a b

Fig. 16.7 Peritonitis due to perforated sigmoid diverticulitis. (a, b) Axial scans, (c) MPR coronal reconstruction.
Perforation of a sigmoid diverticula with an obturatory space abscess containing free bubbles (red arrows)

Gas only in the pelvis suggests a colon perfo- retroperitoneal space, often in the anterior parare-
ration; diverticula perforation may produce extra- nal space.
peritoneal or intraperitoneal free bubbles In case of perforated colorectal neoplasm
(Figs. 16.7 and 16.8) because most colon diver- without large bowel obstruction, the amount of
ticula are located in the retroperitoneum between extraluminal air is usually small.
the taenia mesocolica and taenia libera and CT findings of colonic perforation and peritoni-
between the taenia mesocolica and taenia omen- tis are free air, dirty mass, dirty fat sign, extralumi-
talis [17]. nal fluid collection, bowel wall thickening around
A large amount of free air is seen in the perfo- the perforated site and interruption of colonic wall.
ration for complicated large bowel obstruction A dirty mass is a focal collection of extralumi-
and iatrogenic procedure; colonoscopic perfora- nal faecal matter containing small air bubbles
tion of the posterior walls of the sigmoid, ascend- (Fig. 16.9). The dirty fat sign is a diffuse increase
ing and descending colon causes free gas in the in attenuation of mesenteric fat [25].
16 Role of Multidetector Row Computed Tomography in the Diagnosis of Acute 143

a b

c d

Fig. 16.8 Peritonitis due to perforation of sigmoid diverticula. (a, b) Axial scans, (c) sagittal scan and (d) coronal scans
show a sigmoid diverticulitis with perivisceral phlegmon and free bubbles (red arrows)
144 V. Miele and B. Sessa

a b

c d

Fig. 16.9 Faecal peritonitis due to perforation of the posterior wall of the ascending colon (red arrow) pro-
ascending colon. (a, b) Axial scans, (c) sagittal recon- duces an extraluminal faecal matter containing small air
struction and (d) coronal reconstruction. A leakage of the bubbles (dirty mass) (blue star)

Acute colon perforation may produce a faecal References

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G et al (eds) Geriatric imaging. Springer, Berlin/
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 Abdominal Compartment
Syndrome and Gastrointestinal 17
Tract Perforation

Ciro Acampora, Rosa Ignarra, and Antonio Pinto

17.1 Introduction performed at the bedside with the intravesical

pressure measurements and is based on clinical
The term abdominal compartment syndrome was findings, with the pulmonary, renal, and cardio-
primarily used by Kron et al. [1] in the early vascular systems being most adversely affected by
1980s to depict the physiologic effects of intra- the acute rise in the intra-abdominal pressure [8].
abdominal hypertension complicating a ruptured
aortic aneurysm surgery. However, the majority
of our knowledge about this disease has evolved 17.2 Definitions
over the past few years [2, 3].
Abdominal compartment syndrome can involve Usually, a compartment syndrome represents a
both nonsurgical and surgical patients, either pathological situation with an increased pressure
preoperatively or postoperatively. Abdominal in a confined anatomical space that negatively
compartment syndrome is most commonly diag- affects the circulation and threatens the function
nosed in patients sustaining abdominal or pelvic and viability of the tissues therein [7]. Such a
trauma or suffering from intra-abdominal hemor- syndrome may occur within any enclosed space
rhagic diseases. Less common etiologic factors that is subject to distension. The typical example
include retroperitoneal hematoma or edema, is an extremity compartment syndrome following
bowel obstruction, ascites, and necrotizing pan- trauma to the major inflow or outflow vessels of
creatitis [2]. Although the incidence of abdominal the lower limb. Abdominal compartment syn-
compartment syndrome ranged between 5 and drome occurs when there is an acute increase in
15 % of trauma patients [4], an increased intra- the intra-abdominal pressure above physiological
abdominal pressure (18 mmHg) was observed in limits [7].
up to 41 % of surgical patients [5]. In 2004, a consensus conference was con-
Abdominal compartment syndrome occurs vened by the World Society of the Abdominal
when there is an acute rise in the intra-abdominal Compartment Syndrome (WSACS) consisting of
pressure above physiological limits [6, 7]. The European, Australasian, and North American
diagnosis of this syndrome is generally rapidly surgical, trauma, and medical critical care spe-
cialists. Recognizing the lack of accepted defini-
tions, the WSACS tasked these specialists to
C. Acampora • R. Ignarra • A. Pinto (*) create evidence-based definitions for “intra-
Department of Radiology, “A. Cardarelli” Hospital,
abdominal hypertension” (IAH) and “abdominal
Via Cardarelli 9, Naples I-80131, Italy
e-mail: [email protected]; [email protected]; compartment syndrome” (ACS) [9]. The intra-
[email protected] abdominal pressure (IAP) is the steady-state

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 147

DOI 10.1007/978-3-319-08192-2_17, © Springer International Publishing Switzerland 2015
148 C. Acampora et al.

pressure concealed within the abdominal cavity: 17.3 Etiology and Pathophysiology
the normal IAP is approximately 5–7 mmHg in
critically ill adults. The intra-abdominal pressure Any abnormality that elevates the pressure within
can be measured using various direct and indirect the abdominal cavity can result in intra-abdominal
techniques. Direct measurement requires place- hypertension. Spontaneous causes include mas-
ment of an intraperitoneal catheter connected to sive ascites, intra-abdominal abscess, ileus, intes-
an external pressure transducer or saline manom- tinal obstruction, ruptured aortic aneurysm,
eter. Indirect measurements are more practical in tension pneumoperitoneum, acute pancreatitis,
clinical situations: the most common technique pregnancy, chronic ambulatory peritoneal dialy-
used in clinical practice is the measurement of sis, and mesenteric venous thrombosis [15–19].
the urinary bladder pressure. After instilling Nevertheless, blunt abdominal trauma with
50–100 mL of liquid into the bladder through an intra-abdominal bleeding from splenic, hepatic,
indwelling transurethral catheter and clamping and mesenteric injuries is the most common
the distal tubing, pressure measurements can be cause of intra-abdominal hypertension [2, 20].
obtained by attaching a manometer or bedside Postoperative and iatrogenic causes include
monitor to a needle inserted in the specimen col- hemorrhage (intraperitoneal or retroperitoneal),
lection port of the catheter. With the patient in visceral edema, acute gastric dilatation, abdomi-
supine position, the symphysis pubis is used as nal closure under tension, abdominal packing,
the zero point for monitor calibration [10–12]. and reduction of large peritoneal or diaphrag-
IAH is defined as a sustained or repeated patho- matic hernias. Posttraumatic elevations of the
logic elevation of IAP ≥12 mmHg. ACS is intra-abdominal pressure typically occur as a
defined as a sustained IAP >20 mmHg (with or result of hemorrhage or postresuscitation vis-
without an abdominal perfusion pressure ceral edema [11].
<60 mmHg) that is associated with new organ If ACS is allowed to develop, the resultant
dysfunction/failure. pathophysiology is extensive and system-wide.
ACS may be further classified as either pri- As initially described 80 years ago, rising IAP
mary, secondary, or recurrent based upon the increases the intrathoracic pressure through
duration and etiology of the patient’s IAH [13]. cephalad deviation of the diaphragm [21].
Primary, or “surgical,” ACS is characterized by An increased intrathoracic pressure notably
IAH of relatively short duration occurring as a reduces venous return, resulting in reduced car-
result of an intra-abdominal etiology such as diac output [22]. IAP is transmitted to the thorax
abdominal trauma, ruptured abdominal aortic both directly and through cephalad deviation of
aneurysm, hemoperitoneum, acute pancreatitis, the diaphragm. This significantly increases the
secondary peritonitis, retroperitoneal hemor- intrathoracic pressure, resulting in extrinsic com-
rhage, or liver transplantation. Primary ACS is pression of the pulmonary parenchyma and
therefore defined as a condition associated with development of pulmonary dysfunction [23].
injury or disease in the abdominopelvic region IAH-induced atelectasis has been demonstrated
that frequently requires early surgical or inter- to cause an increase in the rate of pulmonary
ventional radiological intervention. Secondary, infection [24]. Beyond the heart, lungs, and kid-
or “medical,” ACS is characterized by IAH that neys, almost every other organ system is impacted
develops as a result of an extra-abdominal in the critically ill patient with IAH, even if these
etiology such as sepsis, capillary leak, major effects are not clinically obvious. Of all the organ
burns, or other conditions requiring massive fluid systems, the gut appears to be one of the most
resuscitation. It is most commonly encountered sensitive to elevations in IAP.
in medical or burn patients [14]. Recurrent ACS In addition to reducing arterial blood flow,
represents a redevelopment of ACS symptoms IAP compresses thin-walled mesenteric veins,
following resolution of an earlier episode of promoting venous hypertension and intestinal
either primary or secondary ACS. edema. Visceral swelling further increases IAP,
17 Abdominal Compartment Syndrome and Gastrointestinal Tract Perforation 149

initiating a vicious cycle which results in worsen- diagnosis of abdominal compartment syndrome
ing malperfusion, bowel ischemia, decreased is complicated by the fact that these patients have
intramucosal pH, feeding intolerance, systemic many other explanations for renal or pulmo-
metabolic acidosis, and significantly increased nary failure. Sepsis, acute respiratory distress
patient mortality [25]. syndrome, hypovolemic shock, and multiorgan
Abdominal compartment syndrome caused by failure syndrome are frequently seen in patients
perforated peptic ulcer is rare owing to early who are also at risk of abdominal compartment
diagnosis and management. Delayed recognition syndrome. In some patients, these diverse and
of perforated peptic ulcer with pneumoperito- potentially lethal conditions may coexist [28].
neum, bowel distension, and decreased abdomi-
nal wall compliance can make up a vicious circle
and lead to ACS [16]. The perforated peptic ulcer 17.5 Radiologic Findings
results in pneumoperitoneum and bowel disten-
sion. The progressive increase of the intra- Although ACS is diagnosed clinically, a number
abdominal pressure with obstruction of lymph of computed tomography (CT) features have
and venous return can result in diffuse lymph- been described to aid the diagnosis of IAH and
edema of the abdominal wall. The increasing ACS. Pickhardt et al. [8] described several CT
intra-abdominal pressure with abdominal tam- features associated with ACS in four patients
ponade compromises the blood circulation with with clinically proven abdominal compartment
initial presentations of a distended abdomen, syndrome, which included compression of the
edema of the lower legs, and cyanosis with dete- inferior vena cava (Fig. 17.1), round belly sign
rioration of function of the intra-abdominal (Figs. 17.1 and 17.2) (abdominal distension indi-
organs. Emergent laparotomy is indicated in this cated by a tense or rounded morphology on axial
clinical setting [16]. CT, with a relative increase in the anteroposterior
Tension pneumoperitoneum is an unusual abdominal diameter compared with the trans-
event. In trauma intraperitoneal air is observed in verse diameter)), renal and other solid abdominal
elective and emergency surgery and, most com-
monly, is due to a leak from a gastrointestinal
anastomosis or perforation. Tension pneumoperi-
toneum can be associated with positive-pressure
ventilation, pneumothorax, spontaneous gastro-
intestinal perforation, and other more rare syn-
dromes. In each situation, early recognition and
treatment of abdominal hypertension is critical to
the care of the patient [17].

17.4 Clinical Diagnosis

Findings suggestive of abdominal compartment

syndrome include a tensely distended abdomen;
increased peak airway pressure; difficulty in
maintaining ventilation, with hypoxia and Fig. 17.1 A 51-year-old woman presenting with dyspnea
hypercarbia; increasing creatinine; and oliguria after a liver transplant. Axial CT image shows free intra-
[26]. However, most patients with abdominal peritoneal liquid (black arrow), the collapsed inferior
vena cava (arrowhead), and the “round belly sign” (blue
compartment syndrome are in intensive care
arrow). The intravesical pressure was 21 mmHg. The
units, and clinical examination is usually not occurrence of abdominal compartment syndrome is about
sensitive for diagnosing this entity [27]. The 30 % after liver transplantation
150 C. Acampora et al.

Fig. 17.2 A 19-year-old man with acute abdominal pain.

Axial contrast-enhanced CT image shows massive dilata-
tion of colic loops over spread by fecal material (toxic
megacolon). The “round belly sign” and bilateral renal
displacement and compression are evident. The patient
underwent colectomy

visceral compression (Fig. 17.3) or displacement

(Fig. 17.2), bowel wall thickening with enhance-
ment (Fig. 17.4), and bilateral inguinal herniation.
Epelman et al. [29] evaluated the preoperative
abdominal CT scans of three children with proven
ACS to identify signs of elevated IAP. Findings
common to these patients included narrowing of
the inferior vena cava, direct renal compression
or displacement, bowel wall thickening with Fig. 17.3 An 84-year-old woman with colonic perfora-
enhancement, and a rounded appearance of the tion. Multidetector-row computed tomography (sagittal
abdomen. Other investigators described elevation reconstruction) with intravenous contrast medium show-
of the diaphragm (Fig. 17.4) in association with ing pneumoperitoneum with compression of the intra-
abdominal viscera
IAH [30]. Al-Bahrani et al. [31] evaluated the
abdominal CT examination performed in 24 criti-
cally ill patients and affirmed that the presence of neither sensitive nor likely specific for abdominal
the round belly sign and the bowel wall thicken- compartment syndrome. However, when a combi-
ing with enhancement on CT images of critically nation of these findings is present in the appropriate
ill surgical patients should alert clinicians to the clinical setting or if the signs are seen to worsen
possibility of the presence of IAH and ACS. on sequential imaging studies, the radiologist
It is important to recognize that the CT exami- should raise the possibility of abdominal compart-
nation should be viewed as an adjunct toward the ment syndrome [27, 32]. Identifying patients with
recognition of IAH, but not as a substitute to the IAH and/or ACS at earlier stages could potentially
measurement of the intravesical pressure in at-risk improve the outcome of these patients by early
patients. Individual CT signs such as elevated hemi- radiological drainage of large fluid collections and/
diaphragm, flattened inferior vena cava and renal or surgical intervention with abdominal decom-
veins, and increased bowel wall enhancement are pression (laparotomy).
17 Abdominal Compartment Syndrome and Gastrointestinal Tract Perforation 151

a b

Fig. 17.4 A 19-year-old man (the same patient of vated left diaphragm and free intraperitoneal air and liquid
Fig. 17.2) with sudden hypotension, tachycardia, and and (b) bowel wall thickening. The intravesical pressure
respiratory failure after colectomy due to toxic megaco- was 20 mmHg. The patient underwent emergency abdom-
lon. Axial contrast-enhanced CT images show (a) an ele- inal laparotomy but died due to severe heart failure

Conclusions 3. Biffl WL, Moore EE, Burch JM et al (2001) Secondary

ACS has tremendous relevance in the practice abdominal compartment syndrome is a highly lethal
event. Am J Surg 182:645–648
of surgery and the care of critically ill patients 4. Ertel W, Oberholzer A, Platz A et al (2000) Incidence
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multiple organ systems. ACS has been identi- patients with severe abdominal and/or pelvic trauma.
Crit Care Med 28:1747–1753
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mortality among critically ill surgical, medi- abdominal hypertension is an independent cause of post-
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 Index

A Colorectal surgery, 65
Abdomen, emergency CT, 116 Compartment syndrome, 147
Abdominal carcinomatosis, 120 Compression of inferior vena cava, 149
Abdominal cavity, 148 Computed tomography (CT), 37, 38, 42, 43, 57, 58,
Abdominal compartment syndrome (ACS), 147 135–138, 142, 149
primary, 148 signs of traumatic intestinal perforation, 69
secondary, 148 Conventional radiograph, 38
Abdominal radiograms, 69 Conventional radiography, 10, 86
Abnormal bowel wall enhancement, 74 Cover perforation, 123
Abscess(es), 34, 80 Crohn’s disease, 111
Active hemorrhagic extravasation, 74 Cupola sign, 13
Acute abdomen, 1, 5, 61
Acute abdominal conditions, 42
Acute appendicitis, 45 D
Acute diverticulitis perforation, 53–59 Degos’ syndrome, 110–111
Acute intestinal behaviors, 69 Diagnostic peritoneal lavage (DPL), 68
Alimentary tract perforation, 1, 4, 5 Dirty fat density, 33
Anastomotic leaks/leakage, 34, 65 Distended abdomen, 149
Anterior superior oval sign, 12 Diverticular abscess, 54
Appendicitis, 91, 98–99 Diverticular disease, 107–109
Appendicolith, 46 Diverticular fistulisation, 53, 54, 56
Appendicular fat, 47 Doge cap sign, 12
Appendix, 47 Dolphin sign, 12
Duodenal perforation, 85

B
Blunt abdominal trauma (BAT), 67, 68, 70, 72, 75 E
Bowel perforation, 1–4, 41 Emergency department, 35
Bowel wall Esophageal perforation, 23, 24
discontinuity, 62, 69 Extrahepatic ligamentum teres sign, 12
thickening, 62 Extraluminal air, 72
bubbles, 80
collections, 69
C Extraluminal gas, 62
Cardiac output, 148 Extraluminal spillage of enteric contents, 69
Catarrhal appendicitis, 46
Colonic tumors, 62
Colon neoplasm, 127 F
perforation, 125 Falciform ligament sign, 12
Colonoscopic perforation, 64 Fat stranding, 135
Colon wall thickening, 127 Fish/chicken bones, 79, 81
Colorectal cancer, 105–107 Fissure for ligamentum teres sign, 12
wall discontinue, 123 Fluid collections, 65
Colorectal perforation, 61 Focal bowel wall thickening, 32

L. Romano, A. Pinto (eds.), Imaging of Alimentary Tract Perforation, 153

DOI 10.1007/978-3-319-08192-2, © Springer International Publishing Switzerland 2015
154 Index

Focal radiolucency, 13 M
Football sign, 13 Mackler’s triad, 25
Foreign bodies (FBs), 79, 104–105 Maximum intensity projection (MIP), 80
Free air, 9, 85, 134–139, 142 MDCT. See Multidetector computed tomography
Free extraluminal air, 31 (MDCT)
Free intestinal perforation, 119 Mediastinitis, 23, 26
Medium contrast, 47
Mesenteric avulsion, 74
G Mesenteric fat stranding, 80
Gangrenous appendicitis, 46 Mesenteric hematoma, 74
Gas microbubbles in the bowel wall, 131 Mesenteric infiltration, 69
Gastric ulcer, 9 Mesoappendix sign, 13
Gastroduodenal perforation, 29 Micro-pneumoperitoneum, 38
Gastrointestinal fistula, 129 Multidetector computed tomography (MDCT), 31, 45,
Gastrointestinal stromal tumor (GIST), 124 62, 69, 79, 86
spontaneous perforation, 125 Multiplanar reconstructions (MPR), 31, 47, 80
Gastrointestinal (GI) tract, 79 Multiple organ systems, 151
tumor complications, 115
Gastrointestinal tumor perforation, 117
N
Necrotic degeneration, neoplastic tissue, 126
H Necrotizing enterocolitis (NEC), 91, 93–95
Hepatic edge sign, 12 Neoplastic obstruction, 124
Hirschsprung’s disease, 91, 95 Nontraumatic colorectal perforation, 61
Hyperlucent liver sign, 11
Hypertonic spastic, 70
Hypoperfusion complex, 75 O
Obstruction, 81
Oral contrast material, 75
I
Iatrogenic causes, 9
Increased intra-abdominal pressure, 151 P
Inferior vena cava, compression of, 149 Pain, 30
Inflammation, 47 Patient outcome, 150
Inflammatory bowel disease (IBD), 65 Pelvic fractures, 85
Intestinal and abdominal findings, 116 Peptic ulcer disease, 33
Intestinal disease, 18, 19 Perforated colon cancer, 126
Intestinal perforation, 91, 93, 96 Perforated diverticulitis, 87
Intestinal tract, 15, 17, 18, 20 Perforated peptic ulcer, 149
Intestinal wall, interruption of, 129 Perforation, 15, 16, 18–20, 37, 38, 40, 42, 43, 46,
Intra-abdominal pressure, 147 68, 79, 80, 133–144
Intramural hematomas, 68, 73 of gastric carcinoma and lymphoma, 118
Intraperitoneal fluid, 70 Peripheral mesenterial microvascular occlusion, 131
Intraperitoneal free fluid, 69 Perirectal infection adjacent the rectal tumor, 128
Intravenous contrast, 43 Peritonitis, 10, 30, 126, 133–144
Intravesical pressure, 147 Phlegmonous appendicitis, 46
Intussusception, 91, 92, 97 Plain abdominal films, 30
Inverted V sign, 12 Plain film, 37
Ischaemia, 43, 109–110 Pneumomediastinum, 87
Ischaemic alteration in colon cancer, 127 Pneumoperitoneum, 2–4, 9, 15, 16, 18, 30, 42, 62, 72,
Ischaemic changes of the intestinal wall, 117 87, 125, 149
Pneumoretroperitoneum, 32, 85
Primary ACS, 148
L Pseudo-pneumoperitoneum, 75
Laparotomy, 45
Left-sided anterior superior oval sign, 13
Lower gastrointestinal tract, 41 R
Luminal contrast studies, 34 Radiograph/radiography, conventional, 10, 38, 86
Lymphoma, 43 Rectal contrast, 43
Index 155

Rectal perforations, 85 Traumatic causes, 9

Reflex hypotonic ileus (RHI), 70 Traumatic intestinal perforation, 69
Retrocecal appendicitis, 46 specific and nonspecific signs of, 69
Retroperitoneum, 72, 85 Traumatic perforations, 67
Retropneumoperitoneum, 56 Triangle sign, 11
Rigler sign, 10 Tumoral perforation, 115
Round belly sign, 149 Tumor necrosis, 115

S U
Secondary ACS, 148 Ulcer disease, 29
Shock bowel, 75 Ultrasonography, 15, 20, 69
Sigmoid perforation, 62 Urachus sign, 12
Small bowel, 37 Urinary bladder pressure, 148
Small intestinal lynphoma, 119
Small intestine, 37
Spontaneous causes, 9 V
Spontaneous gastrointestinal perforation, 149 VEGF inhibitors, 131
Spontaneous pneumoretroperitoneum, 86 Vermiform appendix, 45
Stercoraceous mass, 63 Visible gallbladder, 12
Stercoral perforation, 63
Stomach cancer, 117
Sub-cecal appendicitis, 46 W
Subphrenic radiolucency, 13 Wall rupture, 32
Supine abdominal radiographs, 10, 86 Wall thickening, 73

T
Tension pneumoperitoneum, 148, 149
Transverse mesocolon and root of small bowel
mesentery signs, 13