Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Abstract

Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis. Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations. The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.

Spontaneous Rectal Perforation in a Patient with SARS–CoV-2 Infection

“…CT is the most valuable imaging technique for identifying the presence, site, and cause of bowel perforation, with an overall accuracy ranging from 82% to 90% [15]. The imaging diagnosis of bowel perforation almost always relies on the detection of free extraluminal air.…”

“…In addition, focal bowel wall discontinuity, sometimes associated with wall thickening and increased attenuation of the surrounding fat, the so-called "fat stranding", could be seen. However, the perforation site is visible only in few cases, more often in the upper gastrointestinal tract than in the lower one [15,16].…”

“…Lack of bowel wall enhancement, pneumatosis intestinalis, and portomesenteric gas are suggestive of underlying bowel ischemia [15][16][17][18].…”

Multiple spontaneous jejunal and ileal perforations: a diagnostic challenge

“…In the Western countries, trauma forms the leading cause, followed by closed loop obstructions, malignancy, jejunal diverticula and tumours. 2 Less common causes of small bowel perforations include Crohn's disease, ischaemia, iatrogenic manipulations, and drugs such as potassium chloride and steroids. 2 The underlying cause for the small bowel perforations can often be diagnosed; however, there are instances when the diagnosis proves elusive to be arrived at.…”

“…2 Less common causes of small bowel perforations include Crohn's disease, ischaemia, iatrogenic manipulations, and drugs such as potassium chloride and steroids. 2 The underlying cause for the small bowel perforations can often be diagnosed; however, there are instances when the diagnosis proves elusive to be arrived at. Pneumoperitoneum is present in only 50 % of the cases and if the clinical signs are subtle, there may be delay in diagnosis which can be life threatening.…”