Abstract
PurposeTo analyze the amount of free abdominal gas and ascites on computed tomography (CT) images relative to the location of a perforation.MethodsWe retrospectively included 172 consecutive patients (93:79 = m:f) with GIT perforation, who underwent abdominal surgery (ground truth for perforation location). The volume of free air and ascites were quantified on CT images by 4 radiologists and a semiautomated software. The relation of the perforation location (upper/lower GIT) and amount of free air and ascites was analyzed by the Mann–Whitney test. Furthermore, best volume cutoff for upper and lower GIT perforation, areas under the curve (AUC), and interreader volume agreement were assessed.ResultsThere was significantly more abdominal ascites with upper GIT perforation (333 ml, range 5 to 2000 ml) than with lower GIT perforation (100 ml, range 5 to 2000 ml, p = 0.022). The highest volume of free air was found with perforations of the stomach, descending colon and sigmoid colon. Significantly less free air was found with perforations of the small bowel and ascending colon compared to the aforementioned. An ascites volume > 333 ml was associated with an upper GIT perforation demonstrating an AUC of 0.63 ± 0.04.ConclusionUsing a two-step process based on the volumes of free air and free fluid can help localizing the site of perforation to the upper, middle or lower GI tract.Graphic abstract
Highlights
Breaching of the gastrointestinal (GI) tract wall can be due to ulcer disease, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, a foreign body or a neoplasm [1,2,3,4,5,6]
The clinical presentation varies; esophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations cause acute, severe abdominal pain, while colonic perforations tend to follow a slower course of progression with secondary bacterial peritonitis or localized abscesses
Our results demonstrate that both ascites and free air volumes are larger in upper gastrointestinal tract (GIT) perforations
Summary
Breaching of the gastrointestinal (GI) tract wall can be due to ulcer disease, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, a foreign body or a neoplasm [1,2,3,4,5,6]. Some studies have shown that as little as 1 ml of gas can be detected below the right hemidiaphragm on properly exposed erect chest radiographs [11]. Plain film radiography (erect chest and abdominal radiographs) is sensitive in only 50–70% of cases, and the site of perforation is almost never elucidated [12, 13]. When interpreting a right lateral decubitus image, gas within the stomach or colon may obscure small amounts of free air. Computed tomography (CT) is useful in detecting minute amounts of extraluminal gas [15, 16], the sensitivity of CT for free gas lies between 92 and 100% [17,18,19,20] A study of multidetector CT showed 86% accuracy in identifying the site of perforation [21]
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