G a s t r o i n t e s t i n a l I m a g i n g • C l i n i c a l Pe r s p e c t i ve Kuzmich et al. Sonography of Peptic Ulcer

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Gastrointestinal Imaging Clinical Perspective

Perforated Pyloroduodenal Peptic Ulcer and Sonography Siarhei Kuzmich1,2 Chris J. Harvey 1 Daniel T. M. Fascia1 Tatsiana Kuzmich 3 Deena Neriman 4 Rizwan Basit 4 Kai Lee Tan5

OBJECTIVE. The purpose of this article is to illustrate the spectrum of sonographic findings in perforated pyloroduodenal peptic ulcer and discuss the potential role of sonography in the diagnosis. CONCLUSION. Although sonography is not the first-line investigation of choice in suspected perforated peptic ulcer, understanding of the characteristic appearances seen during general abdominal sonography may aid the reader in the diagnosis of this important and sometimes overlooked cause of nonspecific abdominal pain. This may shorten time to the diagnosis and ultimate surgical management.

Kuzmich S, Harvey CJ, Fascia DTM, et al.

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Keywords: peptic ulcer, peptic ulcer perforation, sonography DOI:10.2214/AJR.11.8292 Received November 27, 2011; accepted after revision March 19, 2012. 1 Department of Imaging, Hammersmith Hospital, London, United Kingdom. 2

Present address: Department of Radiology, Newham University Hospital, Glen Rd, London, United Kingdom E13 8SL. Address correspondence to S. Kuzmich ([email protected]).

3 Department of Imaging, North Middlesex University Hospital, London, United Kingdom. 4 Department of Radiology, Guy’s and St Thomas’ Hospitals, London, United Kingdom. 5 Department of Radiology, Newham University Hospital, London, United Kingdom.

WEB This is a Web exclusive article. AJR 2012; 199:W587–W594 0361–803X/12/1995–W587 © American Roentgen Ray Society

erforated peptic ulcer remains a potentially life-threatening condition associated with high morbidity and mortality, and outcomes are worse in the elderly and when the diagnosis is delayed for more than 12 hours after the onset of symptoms [1–3]. By contrast, improved medications for peptic ulcer disease (PUD) and advent of treatment to eradicate one of its major causes, Helicobacter pylori infection, have led to a steady decline in the incidence of uncomplicated PUD in recent years [1, 4], which, combined with the decreasing use of upper gastrointestinal fluoroscopy, makes establishing the correct diagnosis more challenging for the radiologist. Usually, the clinical diagnosis is made with relative ease when patients with perforated peptic ulcer have an acute abdominal presentation accompanied by clinical signs of peritonitis and free intraperitoneal air on radiographs. However, the clinical presentation of perforated peptic ulcer is variable and is related to many factors, including the time between perforation and presentation, size of perforation, spontaneous self-sealing, and extent of intraabdominal soiling with gastroduodenal contents. It also depends on whether there is a known preexistent diagnosis of PUD, which is often lacking because peptic perforation commonly occurs in patients with hitherto silent ulceration, particularly in those taking nonsteroidal antiinflammatory drugs or aspirin [5].

Furthermore, the symptoms and signs of perforation may be obscure, delayed, or nonspecific in elderly or immunocompromised patients and in those taking steroids. Relatively frequently, an acute perforation rapidly seals itself before anything other than a small amount of air and fluid has leaked into the peritoneal cavity leading to relatively minor perforation symptoms [4]. Perforated peptic ulcer can mimic acute pancreatitis, cholecystitis, or appendicitis when gastroduodenal contents track down the right paracolic gutter causing pain in the right iliac fossa. These atypical presentations can be misleading. A recent study has shown that perforated peptic ulcer is not initially considered in the differential diagnosis in up to 20% of proven cases [1]. In patients with equivocal or nonspecific clinical and radiographic findings, CT allows accurate detection of very small amounts of free intraperitoneal air. Detection of ancillary signs, such as fluid collections, inflammation, and thickened gastric or duodenal wall, offers a clear diagnostic advantage over radiography, making CT the current imaging modality of choice in suspected perforated peptic ulcer [6– 9]. Radiologic identification of the perforation site is important because it may influence patient management. For example, laparoscopic closure may be considered over laparotomy depending on the site and size of the perforated peptic ulcer and extent of intraabdominal soiling. Surgical closure is usually necessary when the perforation is still leaking at the time

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Kuzmich et al. rapidly localize into a walled-off pocket. A duodenal perforation is often contained by apposition to the undersurface of the medial segment of the left hepatic lobe between the gallbladder and falciform ligament [19]. Spontaneous self-sealing by the greater omentum is very common, with half of the perforated duodenal ulcers estimated to be sealed at the time of admission [10]. Subacute and chronic nonsealed perforations into a walled-off pocket have been described [14].

of diagnosis, whereas nonoperative treatment may be considered in self-sealed perforated duodenal ulcers with minimal contamination of the peritoneal cavity [10]. Although CT is often successful at showing the site of perforation [7, 8], direct visualization of a relatively small perforation defect with CT is less frequently achieved [9]. Sonography does not typically play a role in either first-line investigation or management workup of perforated peptic ulcer, and it is not our intention to suggest that it should do so. However, we believe that an understanding of the constellation of appearances of peptic perforation seen during general abdominal sonography will aid the reader in the diagnosis of perforated peptic ulcer as the true cause of abdominal symptoms when this condition is not suspected clinically. In our experience, this large patient group typically includes referrals for acute appendicitis, cholecystitis, pancreatitis, pyelonephritis, and other conditions for which sonography may be the initial test performed. Similar to other observers, we have found that perforated peptic ulcer generates recognizable sonographic appearances [11–16]. Likewise, our experience suggests that the site of perforation and even presence of an active leak can be identified during real-time sonographic observation. This article stems from our experience in sonographic diagnosis of perforated peptic ulcer of the pyloroduodenal region in 12 patients encountered at our institution between June 2009 and October 2011. In each case, the diagnosis of perforated peptic ulcer was initially overlooked and was discovered through so-

nographic examination. The patients were eight men and four women (mean age, 52 years; age range, 29–75 years). Nine of the patients presented within 24 hours of the onset of nonlocalizing abdominal pain, whereas the other three attended the emergency department between 24 and 48 hours from the onset of symptoms. Ten of the 12 patients underwent erect chest radiography on admission, which was unrevealing. None of the patients had a history of PUD. Because appendicitis, cholecystitis, biliary colic, and pyelonephritis were major considerations, abdominal sonography was the initial crosssectional radiologic examination performed in all cases. This article will discuss a range of sonographic appearances with examples of surgically proven cases. Perforated Ulcer Morphology An ulcer is a focal full-thickness erosion of the mucosa that may extend into the submucosa and muscularis propria. The majority of gastric ulcers are found along the lesser curve near the pylorus, whereas duodenal ulcers overwhelmingly occur in the anterior wall of the duodenal bulb—usually within 3 cm of the pylorus [17]. The most common perforation sites are the duodenal bulb (35– 65%), pylorus and prepyloric antrum (20– 45%), and gastric body (5–15%) [1, 18]. Erosion through the anterior duodenal wall commonly results in perforation into the peritoneal cavity. Ulcers perforating into the lesser sac, retroperitoneum, and other organs, although not rare, are less common. Acute intraperitoneal perforation may be contained by preexisting adhesions to the liver or may

Sonographic Considerations Technique A standard abdominal survey is performed with the patient supine. A 2.5-5.0–MHz curvilinear or 6-12–MHz linear transducer is used as required. In selected cases, particularly when sonographic findings are unanticipated inflammatory change and complex free fluid in the right abdomen or epigastrium, consideration may be given to sonographic techniques that aid in detection of pneumoperitoneum. If free intraperitoneal gas is noted sonographically, particularly in the perihepatic spaces and epigastrium, the area of the distal stomach and duodenal bulb may be given detailed analysis with sonography as will be discussed later. Administration of oral fluid might improve gastric visualization and show a leak through a perforation. However, we did not use hydrosonography for any of our cases. This technique may be of limited use in practice because perforated peptic ulcer is usually encountered when it is not expected. Furthermore, sonography is not chosen if perforated peptic ulcer is a major consideration.

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Fig. 1—Appearance of lung gas and pneumoperitoneum. Insets show position of transducer. A, Healthy 34-year-old man. Right intercostal sonogram with 6-MHz transducer depicts echogenic line of lung gas (black arrowheads) above diaphragm (asterisk). Echogenic stripe of liver capsule (white arrowheads) and thin stripe of parietal peritoneum (white arrow) on undersurface of diaphragm can usually be seen, as in this individual. B, 29-year-old man with perforated anterior duodenal bulb ulcer and small pneumoperitoneum. Right intercostal sonogram shows bright echogenic line of free air (arrow) on liver surface (arrowheads) with posterior comet-tail artifact. C, Drawing corresponds to right intercostal sonogram and shows difference between lung gas and free intraperitoneal gas. Highly reflective shadowing band of lung gas (black arrowheads) glides with breath-related movements (open black arrow and open white arrow) in and out of costophrenic recess above diaphragm (asterisk). In contrast, free air (solid black arrow) is seen stretching on liver surface (white arrowheads) underneath peritoneal stripe (solid white arrow) and diaphragm.

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Sonography of Peptic Ulcer Indirect Signs of Perforation Pneumoperitoneum—Perforated peptic ulcer is the most common cause of substantial free intraperitoneal gas outside the postoperative state [17]. In gastroduodenal perforation, free intraperitoneal air tends to accumu-

late around the liver, duodenum, and stomach. By contrast, free extraluminal gas produced by a perforated bowel diverticulum or, less commonly, the appendix is rarely found in the epigastrium [7, 8]. Other causes, such as pneumatosis intestinalis, foreign body perforation,

and certain chest conditions, are less common. Pneumoperitoneum may develop in a variety of nonsurgical conditions and after diagnostic and therapeutic procedures [20]. Sonography can be an accurate method for the detection of pneumoperitoneum when

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Fig. 2—43-year-old woman with anterior duodenal bulb peptic perforation, pneumoperitoneum, and free fluid. Insets show position of transducer. A, Intercostal sonogram with 6-MHz transducer shows free fluid (F) anterior to liver (L) and pocket of air (arrow) as echogenic focus in peritoneal stripe (white arrowheads). Note ring-down artifact (black arrowheads) from free gas. B, Transverse epigastric sonogram with 2.5-MHz transducer depicts pocket of shadowing gas (arrow) adjacent to gallbladder (GB) and porta hepatis (asterisk) under posterior surface of liver (L). C, Right intercostal sonogram with 2.5-MHz transducer shows free fluid (F) in hepatorenal space and dependent echogenic shadowing stripe of free air (arrow) outlining liver (L) anterior to right kidney (RK). Note lack of typical reverberation or ring-down artifacts from free gas when low-frequency transducer is used.

Fig. 3—Appearance of pneumoperitoneum and bowel gas. Insets show position of transducer. A, Schematic drawing shows common locations of free gas (arrows) in epigastrium. Free air is seen as focally increased echogenicity on anterior liver surface or peritoneal stripe (white arrowheads). Stripe of transversalis fascia (black arrowhead) may be seen lying superficially to peritoneal line. B, 34-year-old man with perforated anterior prepyloric ulcer and pneumoperitoneum. Parasagittal epigastric sonogram with 10-MHz transducer shows free gas (arrow) as highly echogenic line in peritoneal stripe (arrowheads) with distal “ring-down” artifact underneath abdominal wall (asterisk). C and D, Healthy 32-year-old man. Parasagittal epigastric sonograms with 10-MHz transducer depict bowel gas (curved arrows) lying deep in relation to normal peritoneal stripe (white arrowheads) and at some distance from it underneath abdominal wall (asterisk). Note transversalis fascia line (black arrowheads) overlying peritoneal stripe.

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Kuzmich et al. careful technique is used [21–23]. Even a tiny bubble of free gas can be recognized on sonography because of its exclusive ability to produce distinctive bright echoes and artifacts [24]. Nonetheless, failure to reveal pneumoperitoneum is a well-known weakness of this modality and is related to the patient’s body habitus, ultrasound equipment, skill of the sonographer, and identification of the findings, which may be subtle. Free air is often easiest to detect sonograph­ ically in the perihepatic spaces. The survey is initiated by inspecting the anterior liver surface with the transducer scanning over the intercostal spaces. The aerated lung is noted as a highly reflective shadowing band that glides with breathrelated movements in and out of the costophrenic recess, above the diaphragm (Fig. 1A). Small quantities of free gas appear as strongly echogenic foci on the liver surface producing ringdown or comet-tail artifact (Fig. 1B). A useful differentiating feature between lung gas and subdiaphragmatic gas is found by observing the position of the gas in relation to the diaphragm (Fig. 1). In the presence of free fluid, free gas

gravitates to the undersurface of the diaphragm where it may be recognized (Fig. 2A). Free gas may be found layering against the posterior liver surface in the hepatorenal space and gallbladder fossa, near the porta hepatis (Fig. 2). Accumulation of free gas in the fissure for the ligamentum teres has also been reported [25]. As with radiographic techniques, the patient can be placed in the left lateral decubitus position. This technique, however, may be time-consuming because the gas takes time to rise. The same issue is present when imaging with radiography. Another potential limitation of this method is that small quantities of free gas may not rise at all when trapped underneath the left liver or settled among fibrin strands in thick fluid. Free air can also be detected underneath the anterior abdominal wall, usually in the epigastrium, where it often accumulates while the patient remains supine. This may be achieved by careful analysis of the undersurface of the abdominal wall with a 6-12–MHz linear array transducer. The parietal peritoneum is noted as a thin echogenic line on the

undersurface of the abdominal wall [26] (Fig. 3). Free gas layering underneath the parietal peritoneum is visualized as foci or lines of increased echogenicity in the peritoneal stripe with or without posterior reverberation or ring-down artifacts [21] (Fig. 3B). Bowel gas is also seen as highly echogenic foci or lines. However, in contrast to free air, intraluminal gas lies deep in relation to the peritoneal stripe and at some distance from it (Fig. 3C). Care should be taken not to mistake bowel gas with pneumoperitoneum when a thin-walled aperistaltic bowel loop lies against the abdominal wall. In such case, bowel gas may lie very close to the peritoneal stripe, which may be confusing. Confident differentiation can be made when a normal peritoneal stripe is visualized and it overlies the line of the bowel gas as Muradali et al. [21] have shown in animal and human studies. Another helpful distinguishing feature can be found by observing a small gap between the stripes of bowel gas and peritoneum (Fig. 3D). This subtle gap, in our experience, is usually evident on close inspection owing to the pres-

Fig. 4—57-year-old man with surgically confirmed retroperitoneal perforation of peptic ulcer located in posterior wall of second part of duodenum. Oblique epigastric sonogram with 3.5-MHz curvilinear probe angled from epigastrium toward right kidney shows thick-walled gallbladder (GB) and pockets of retroperitoneal free gas (arrows) lying posterior to thickened second and third parts of duodenum (arrowheads) and to right of inferior vena cava (IVC). Although ulcer crater was not visualized on this study, perforated duodenal ulcer was suspected on basis of presence of thickened duodenum and free gas in adjacent right anterior pararenal space. Insets show position of transducer.

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Fig. 5—Appearance of fluid collections in perforated peptic ulcer. Insets show position of transducer. A, 56-year-old man with perforated anterior antral ulcer. Parasagittal epigastric sonogram with 3.5-MHz probe shows complex fluid (F) containing thick echogenic component with small bright particles of free gas (arrows) underneath abdominal wall (asterisk). B, 75-year-old man with perforated anterior prepyloric ulcer. Right intercostal sonogram shows several bubbles of free gas (black arrows) trapped in complex fluid with echogenic debris anterior to liver and dependent gas pocket (open arrow) with comet-tail artifact.

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Sonography of Peptic Ulcer Fig. 6—Appearance of normal pylorus and proximal duodenum. Insets show position of transducer. A, Healthy 38-year-old woman. Oblique epigastric sonogram with 5-MHz probe angled through left liver (L) shows fluid-filled duodenal bulb (arrowheads) continuous with pylorus (arrow) and prepyloric antrum (A) proximally and second portion of duodenum (D2) distally. B, Healthy 50-year-old man. Right oblique subcostal sonogram with transducer angled through right liver (L) depicts cross-section of second portion of duodenum (arrowheads) lying alongside pancreatic head (P) and anteromedially to right kidney (RK).

ence of the bowel wall between the peritoneal stripe and intraluminal gas, although the bowel wall itself may not be clearly seen. Extraluminal gas—Extraluminal gas bubbles are often found collecting close to the site of gastrointestinal tract perforation [7–9]. As recognized on CT, localized extraluminal gas pooling against the posterior surface of the left hepatic lobe, in our experience, is frequently seen close to the perforated peptic ulcer in the gastroduodenal region. The presence of a few bubbles of periduodenal gas may be the first sign of ulcer perforation [14, 27]. Detection of free gas in the right pararenal or perirenal space will usually point to the possibility of perforation of the second portion of the duodenum [28]. Likewise, sonographic discovery of retroperitoneal gas collecting anterior to the right kidney and near the duodenum may raise the suspicion of perforated peptic ulcer (Fig. 4), although other causes, such as perforated duodenal diverticulum, iatrogenic duodenal perforation, and emphysematous pyelonephritis, should also be considered [28, 29]. When a large amount of air has accumulated in the right perirenal space, the right kidney may be obscured on sonography [30, 31]. Thickening and increased echogenicity of the right anterior extrarenal tissues associated with perforated duodenal ulcer have also been reported [32]. Fluid collections—Fluid collections may be seen at the site of perforation and around the liver or may track into the right paracolic gutter. Free fluid in the setting of peptic perforation is seldom simple on close inspection. Mobile strands, fibrinous strings, trapped pockets of air, and floating bubbles of gas visualized as highly reflective particles are often observed [11, 14, 16, 33, 34] (Fig. 5).

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Distal Stomach and Duodenal Bulb Normal appearances—Much of the mid and distal parts of the stomach, pylorus, and duodenal bulb can be visualized when scanning from the epigastrium. The proximal stomach is usually a blind area for sonography unless it is filled with fluid and purposeful positioning techniques are used to displace the intraluminal gas [27, 35]. Liberal transducer angulations from different positions in the epigastrium may be used to obtain 3D information. Views through the liver permit maximal visualization. The gastric wall, like elsewhere in the gastrointestinal tract, is visualized as a five-layered struc-

ture when imaged under optimal conditions, although basic identification of three main layers of serosa, muscularis, and mucosa will usually suffice [36]. The prepyloric antrum and pylorus are recognized by noting the reduction in caliber of the stomach in cross-sections and relative thickening of the hypoechoic muscularis propria. A loop of thick pyloric muscle denotes the pyloric ring. In contrast to the pylorus, the duodenal bulb muscularis propria is much thinner and the layers of the duodenal wall are less identifiable, although peristaltic waves with fluid and gas bubbles passing through the duodenal lumen will usually aid identification (Fig. 6). The remaining

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Fig. 7—34-year-old previously healthy woman with nonspecific epigastric pain of 2 weeks duration. Insets show position of transducer. A, Epigastric sonogram with 3.5-MHz curvilinear transducer angled through left liver margin (L) depicts echogenic line (open arrow) suggesting ulceration within thickened anterior wall of duodenal bulb (arrowheads) just distal to pylorus (black arrow) and pyloric antrum (A). Second part of duodenum (D2) is seen looping around head of pancreas (P). B, Sonogram with same view as in A but using 6-MHz transducer shows same echogenic gas pocket (open arrow) retained within focally thickened anterior bulbar wall (white arrowheads), which resembles profile “mound of edema” signs seen on barium studies. Posterior bulbar wall (black arrowheads) lying adjacent to pancreatic head (P), pylorus (solid arrow), and prepyloric antrum (A) are shown. Active peptic ulceration in anterior duodenal bulb was confirmed at endoscopy.

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Kuzmich et al.

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Fig. 8—Sonographic appearance of perforated peptic ulcer in three different patients. Insets show position of transducer. A, 52-year-old man with perforated ulcer in anterior duodenal bulb. Epigastric sonogram using 6-MHz transducer reveals ulcer crater seen as pocket of gas (open arrow) in thickened wall of pyloroduodenal region (white arrowheads) distal to antrum (A) and linear track of gas (black arrow) connecting ulcer crater to extraluminal gas bubbles (black arrowheads) that are pooling underneath liver margin (L). Gallbladder (GB) lying next to duodenal bulb is noted. B, 52-year-old man with perforated anterior pyloric ulcer. Sagittal epigastric sonogram with 5-MHz transducer angled through liver (L) depicts cross-section of pylorus (arrowheads) and pocket of gas (arrow) extending through thickened pyloric wall and beyond its outline. C, 33-year-old man with perforated peptic ulcer located in anterior gastric antrum. Sagittal epigastric sonogram though left liver margin (L) shows cross-section of gastric antrum (arrowheads) and echogenic gas pocket (open arrow) extending through anterior wall. Note pocket of free air (white arrow) underneath abdominal wall (asterisk).

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Fig. 9—42-year-old woman with leaking peptic perforation in anterior duodenal bulb. Insets show position of transducer. A–D, Sagittal epigastric sonograms from cine loop at different time intervals show spillage of gas bubbles through anterior wall perforation (open arrow). Propagation of echogenic gas particles from lumen through anterior wall defect into surrounding free fluid was obvious during dynamic observation. Pool of gas bubbles (solid arrow) is seen underneath liver (L) next to pyloroduodenal area, which is visualized in cross-sections (arrowheads, A and B).

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Sonography of Peptic Ulcer duodenum is more difficult to visualize, unless the patient is slender (Fig. 6B). Ulcer and ulceration site—Since the initial reports of diagnostic sonography of the abdomen, reports have been published on successful detection of peptic ulcers by sonography. Several observers have consistently reported the sonographic appearance of active peptic ulceration as focal thickening of the gastroduodenal wall containing an echogenic focus or line [12, 37–39]. Similarly, our experience suggests that ultrasound can be used to identify active ulceration when the ulcer crater erodes deep into the muscularis propria layer and when some inflammatory change around the lesion is present. The main finding that points to the location of the active lesion, in our experience, is usually asymmetric thickening of the gastric or duodenal wall. When an ulcer crater contains a pocket of gas, it can be visualized as a sharply defined highly reflective focus or line within the thickened wall (Fig. 7). The hallmark for sonographic identification is the constant shape and size of such a gas pocket throughout the examination. Interestingly, the appearance of an ulcer visualized in sonographic cross-sections bears a resemblance to the “ulcer niche” and profile “mound of edema” signs seen on barium studies. Depending on the depth of ulceration, the crater gas pocket may be seen tracking peripherally toward the serosa, where there is often evidence of echogenic inflammatory change in the adjacent fat. Extension of the gas track into an adjacent organ together with surrounding inflammatory change may suggest a penetrating ulcer [14, 40, 41]. Direct Signs of Perforation When an ulcer perforates, it erodes a hole through the whole thickness of the duodenal or gastric wall. The sonographic display of the perforated site relies on visualization of an ulcer crater and a bright linear track of gas bubbles extending through the wall beyond its outline [16, 34] (Fig. 8). On the outside of the wall, the bright gas track may be seen to be in continuity with the gas bubbles that are pooling in the adjacent subhepatic space (Fig. 8A). We have noted that, depending on the presence of free fluid around the perforated site, two sonographic configurations may be observed. When present, anechoic free fluid outlines the perforation seen as a focal cleft or defect on the outside surface of the wall. Real-time inspection may reveal apparent propagation of the gas bubbles from the lu-

men through the wall defect into surrounding fluid (Fig. 9). This observation may indicate active spillage and, in our experience, is associated with leaking perforation [34]. Another configuration is seen when free fluid is absent (Fig. 8). In this case, perforation may be visualized as a linear gas pattern tracking through the full thickness of the wall. The lack of free fluid may indicate self-sealing [15]. Accurate sonographic differentiation of the duodenal bulb from the pylorus and antrum may be problematic in the setting of perforation. However, the preoperative localization of the anterior perforation within the juxtapyloric area does not influence management and is clinically unimportant. Conclusion Peptic ulcer perforation generates recognizable sonographic appearances. These may include both indirect and direct signs, which may be subtle. Detection of indirect signs, such as pneumoperitoneum or localized extraluminal gas and fluid, particularly when there is pooling around the liver close to the thickened duodenal bulb or distal stomach, may lead the radiologist to suspect a perforated ulcer. Direct visualization of the perforated ulcer may be achieved with vigilant sonographic technique. Familiarity with the characteristic sonographic appearances of peptic ulcer perforation may allow the early diagnosis during examination for abdominal symptoms. This may facilitate correct management planning and a prompt operative procedure. References 1. Thorsen K, Glomsaker TB, von Meer A, Soreide K, Soreide JA. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg 2011; 15:1329–1335 2. Møller MH, Adamsen S, Thomsen RW, Møller AM. Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review. Scand J Gastroenterol 2010; 45:785–805 3. Svanes C, Lie RT, Svanes K, Lie SA, Soreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg 1994; 220:168–175 4. Lui FY, Davis KA. Gastroduodenal perforation: maximal or minimal intervention? Scand J Surg 2010; 99:73–77 5. Pounder R. Silent peptic ulceration: deadly silence or golden silence? Gastroenterology 1989; 96:626–631 6. Baker SR. Imaging of pneumoperitoneum. Abdom Imaging 1996; 21:413–414 7. Maniatis V, Chryssikopoulos H, Roussakis A, et al. Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging

2000; 25:373–379 8. Hainaux B, Agneessens E, Bertinotti R, et al. Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR 2006; 187:1179–1183 9. Ongolo-Zogo P, Borson O, Garcia P, Gruner L, Valette PJ. Acute gastroduodenal peptic ulcer perforation: contrast-enhanced and thin-section helical CT findings in 10 patients. Abdom Imaging 1999; 24:329–332 10. Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg 1998; 133:1166–1171 11. Puylaert JB. Ultrasound of acute GI tract conditions. Eur Radiol 2001; 11:1867–1877 12. Garcia Santos JM. Direct sonographic signs of acute duodenal ulcer. Abdom Imaging 1999; 24:226–227 13. Lee DH, Lim JH, Ko YT, Yoon Y. Sonographic detection of pneumoperitoneum in patients with acute abdomen. AJR 1990; 154:107–109 14. Ranschaert E, Rigauts H. Confined gastric perforation: ultrasound and computed tomographic diagnosis. Abdom Imaging 1993; 18:318–319 15. Fujii Y, Asato M, Taniguchi N, et al. Sonographic diagnosis and successful nonoperative management of sealed perforated duodenal ulcer. J Clin Ultrasound 2003; 31:55–58 16. Tsai KC, Wang HP, Huang GT, Wang SM. Preoperative sonographic diagnosis of sealed-off perforated gastric ulcer. J Clin Ultrasound 1998; 26:269–271 17. Mindelzun RE, McCort JJ. Acute abdomen. In: Margulis AR, Burhenne HJ, eds. Alimentary tract radiology, 3rd ed. St. Louis, MO: Mosby, 1983:391–480 18. Naesgaard JM, Edwin B, Reiertsen O, Trondsen E, Faerden AE, Rosseland AR. Laparoscopic and open operation in patients with perforated peptic ulcer. Eur J Surg 1999; 165:209–214 19. Taylor H. Peptic ulcer perforation treated without operation. Lancet 1946; 248:441–444 20. Miller RE, Becker GJ, Slabaugh RD. Nonsurgical pneumoperitoneum. Gastrointest Radiol 1981; 6:73–74 21. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-Simpson D. A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe. AJR 1999; 173:1257–1262 22. Braccini G, Lamacchia M, Boraschi P, et al. Ultrasound versus plain film in the detection of pneumo­ peritoneum. Abdom Imaging 1996; 21:404–412 23. Chen SC, Yen ZS, Wang HP, Lin FY, Hsu CY, Chen WJ. Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum. Br J Surg 2002; 89:351–354 24. Wilson SR, Burns PN, Wilkinson LM, Simpson DH, Muradali D. Gas at abdominal US: appearance, relevance, and analysis of artifacts. Radiology 1999; 210:113–123

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