Gastrointestinal perforation: ultrasonographic diagnosis

Abstract

Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women.

A case report of blunt gastric perforation treated with endoscopic clip closure

“…[3] Obviously, it is necessary to identify the location and severity of a perforation correctly in order to determine appropriate management. A thorough medical history and physical examination are critical and provide important clues for further examination.…”

Pneumothorax Causing Pneumoperitoneum: Role of Surgical Intervention

“…When there is a perforation of either the stomach, duodenum, or colon a CT with contrast is 100% sensitive and the diagnosis is fairly simple; however it is uncertain when it involves small bowel perforations [11]. …”

83-Year-Old Man With Chronic Kidney Disease, Fluid Overload, and Coronary Artery Disease Develops Altered Mental Status

“…Finally, patients with ascites may also show clear air bubbles, diagnostic of intraperitoneal air. 4 Indirect findings consistent with pneumoperitoneum include intraabdominal fluid collections and local ileus. In patients without pneumoperitoneum, "gut sliding" may be visualized.…”