Imaging Patients With Alimentary Tract

Perforation: Literature Review

Angela Faggian, MD, Daniela Berritto, MD, Francesca Iacobellis, MD,
Alfonso Reginelli, MD, Salvatore Cappabianca, MD, and Roberto Grassi, MD

Alimentary tract perforation is a frequent emergency condition. Imaging plays an important role
to make an accurate diagnosis, defining the presence, the level, and the cause of the
perforation, essential information to enable the most correct therapeutic choice. Plain
radiography is generally performed as the first choice. In case of a clinically suspected bowel
perforation, not detected on x-ray imaging, the contribution of computed tomography is
essential. Magnetic resonance is not yet widely used in diagnostic workup of patients with
acute abdominal pain, but it can be useful in the differential diagnosis of acute abdomen in
specific patients (pregnancy and pediatric patients).
Semin Ultrasound CT MRI ]:]]]-]]] C 2015 Elsevier Inc. All rights reserved.

Introduction useful in the differential diagnosis of acute abdomen in specific

patients (pregnancy and pediatric patients).13

A limentary tract perforation is one of the most frequent

reasons for admittance to emergency department. Imag-
ing plays an important role, in conjunction with clinical Clinical Features
information, to make a quick and accurate diagnosis, defining From a clinical point of view, clinical symptoms are variable
the presence, the level, and the cause of the perforation, because they are related to the cause and the site of the
essential information to enable the most correct therapeutic perforation. Neverthless, alimentary tract perforation is gen-
choice, thus improving patient outcome.1 Bowel perforation erally characterized by the appearance of an acute abdomen.14
can be caused by trauma (blunt or penetrating trauma, foreign In the beginning, pain is often localized in the suggested site
body ingestion, iatrogenic injury, or endoscopic procedures) of origin; it may move to a different site by the time the patient
or by nontraumatic inflammatory (peptic ulcers, enteritis, or is examined and, if not promptly treated, culminate in diffuse
Crohn’s disease), ischemic (mesenteric infarction, volvulus, and poorly localized abdominal pain.
intussusception, or vasculitis), and neoplastic conditions.2-8 Nausea, vomiting, fever, localized abscess formation, inflam-
Symptoms are variable and nonspecific, so imaging plays an matory mass, fistulas, and GI tract hemorrhage could be
important role for the diagnosis of alimentary tract perfora- present. On the contrary, rare complications are septicemia,
tion.9 In the diagnostic management of these patients, plain portal pyemia or pyogenic abscess, enterovascular fistulas, and
radiography is generally performed as the first choice. In case of even endocarditis.15-17
a clinically suspected bowel perforation, not detected on x-ray In some cases the clinical features may be nonspecific, for
imaging, the contribution of computed tomography (CT) is example in patients with covered perforation, those receiving
essential; in fact it has a sensitivity of 92% in detecting treatment with steroid drugs, or immunocompromised
perforations in the whole gastrointestinal (GI) tract.9-12 Mag- patients.14
netic resonance (MR) is not yet widely used in diagnostic
workup of patients with acute abdominal pain, but it can be
Conventional Radiography
Conventional radiography may be performed in the setting of
Institute of Radiology, Second University of Naples, Naples, Italy.
Address reprint requests to Angela Faggian, MD, Institute of Radiology, Second acute abdominal pain. Abdominal radiography, however, has a
University of Naples, P.za Miraglia 2, 80138 Naples, Italy. E-mail: angela. limited role in the evaluation of abdominal pain in adults.15,18
faggian@libero.it Although it has been shown to have high sensitivity (90%) for

http://dx.doi.org/10.1053/j.sult.2015.09.006 1
0887-2171/& 2015 Elsevier Inc. All rights reserved.
2 A. Faggian et al.

detecting intra-abdominal foreign bodies and moderate sensi- Direct findings of perforation and intraperitoneal free air are,
tivity for detecting bowel obstruction (49%), its low sensitivity on the upright thoracic film, the air in the subdiaphragmatic
for sources of abdominal pain and fever or abscess limit its role regions and, on the supine abdominal films, the outlining of
in this setting.19-23 For these reasons it remains the most various peritoneal reflections between the mesenteric folds.
frequently requested examination performed as initial imaging Indirect sign of perforation could be detected such as
in the assessment of patients who present with acute abdomi- translucent triangle, lucent liver, perihepatic gas collections,
nal pain and clinical suspicion of bowel obstruction to the Rigler’s sign, cupola sign, and football and cap of Doge signs. If
emergency department. It is widely available and cheap, and it bowel perforation is detected on x-ray examination, further
can be easily performed.13,24-27 imaging, before laparotomy, is useful to better evaluate the site
The diagnosis of bowel perforation is suggested by the and the etiology of perforation.24,32,33
detection of free intraperitoneal gas on the plain x-ray imaging.
Some authors report that specificity of plain x-ray imaging for
pneumoperitoneum ranges from 50%-70%14,15 and other Ultrasound
authors from 53%-89.2%,28 but the site of perforation is
Ultrasound (US) imaging could be executed as the first
almost never elucidated. Furthermore, in up to 49% of
examination in emergency and is particularly indicated in
patients, pneumoperitoneum or retroperitoneum could not
young patients and pregnant woman, patients in whom
be detected.29
radiation should be avoided.34 Nevertheless some authors
Esophageal perforation’s findings can be detected, on
assess that US imaging is more sensitive than plain radiography
posteroanterior and lateral plain chest radiographs, as indirect
in the diagnosis of pneumoperitoneum with a sensitivity of
signs and include pleural effusion, pneumomediastinum,
92% (vs 78% of plain abdominal film) and a negative
subcutaneous emphysema, hydrothorax, pneumothorax, and
predictive value of 39% (vs 20%), and the site of perforation
collapse of the lung.
is difficult to determine.13,14 On the contrary other authors
However, if the patient can swallow, a chest radiograph with
detected a lower sensitivity for the US (76% vs 92%).35 Linear
a water-soluble contrast medium could be executed, revealing
array transducers (10-12 MHz) could be preferred because
a contrast leak in most cases of esophageal perforation. Water-
they are more sensitive than convex transducers (2-5 MHz) in
soluble contrast should be used instead of barium contrast to
the detection of intraperitoneal free air owing to their size,
prevent barium-related inflammation of the mediastinum. If
shape, and resolution. US imaging findings in case of free
the initial contrast swallowing study result is negative and the
intraperitoneal air result from scattering of the US waves at the
clinical suspicion remains, imaging should be repeated after
interface of soft tissue and air, which is accompanied by
4-6 hours.29,30
reverberation of the waves between the transducer and the air.
Plain abdominal radiograph is generally performed in
Consequently there is an increased echogenicity of a peritoneal
upright and supine decubitus. In patients with critical illness,
stripe associated with multiple reflection artifacts and charac-
the supine decubitus is preferred, with anteroposterior and
teristic comet-tail appearance that can be changed by changing
lateral views of the abdomen and anteroposterior view of the
the patient’s position.36
thorax.27 Supine abdominal radiograph allows detection of
Indirect signs of bowel wall perforation detectable by US
moderate or large amounts of free intraperitoneal air. On the
imaging are presented by intraperitoneal free fluid or reduced
contrary, it is insensitive in detecting small amounts of free
intestinal peristalsis.37-40
intraperitoneal air, which could be interposed between the free
US shortcomings are operator dependence, poor coopera-
edge of the liver and the lateral wall of the peritoneal cavity and
tion of some patients due to the abdominal pain, and patients
may be detected by upright chest films or left lateral decubitus
with obesity or subcutaneous emphysema. Furthermore, US
abdominal films or both. In fact, upright posteroanterior chest
has low sensitivity in the detection of retropneumoperitoneum
radiograph is considered to be the most sensitive plain film for
revealing the presence of air around the duodenum and the
detecting pneumoperitoneum, and it may show as little as
head of the pancreas, especially ventral to the great abdominal
1 mL of free intraperitoneal air when meticulous radiographic
vessel leading to the picture of “vanishing” vessels.41-48
technique is used upright; however, because the x-ray beam is
centered on the middle part of the abdomen, and the exposure
is high, small amounts of free air can be obscured. Left lateral
decubitus radiograph of the abdomen can show small amounts
Computed Tomography
of free air if the heavy exposure does not compromise the In general, CT is the most diffuse modality in evaluating
detection. Upright posteroanterior chest radiograph is very nonpregnant patients with abdominal pain. CT has a very high
helpful because central x-ray beam penetrates air in the sensitivity in the diagnosis of GI tract perforation and in the
superior portion of the subdiaphragmatic recess along its long determination of the site of perforation, with an accuracy that
axis and usually does not burn out small amount of free air. may increase to 86%.
The upright lateral chest radiograph is more sensitive than the Moreover, the recent introduction of multiple detector
posteroanterior chest radiograph in detecting small amounts of computed tomography (MDCT) has allowed high-speed
pneumoperitoneum as the long axis of x-ray beam can show acquisition, thin slice collimation, and reformatting of
small air collection that may remain trapped anterior to the images in any plane with high spatial resolution, making this
liver.31 technique particularly suitable for the assessment of abdominal
Imaging patients with alimentary tract perforation 3

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