Can you find the bubble? The clues of gastrointestinal perforation imaging to solve the trouble

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1 Can you find the bubble? The clues of gastrointestinal perforation imaging to solve the trouble Poster No.: C-1717 Congress: ECR 2015 Type: Educational Exhibit Authors: P. Solano Díaz, P. M. Leal Oliveira, S. Claret Loaiza, M. Prado Durán, A. Rodas Ocampo, M. Requena Santos, M. D. Sánchez Molinero; Málaga/ES Keywords: Acute, Contrast agent-intravenous, Computer ApplicationsGeneral, CT, Management, Emergency, Abdomen DOI: /ecr2015/C-1717 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 41

2 Learning objectives To learn the main imaging findings in order to carry out an accuracy diagnosis of gastrointestinal perforation by multidetector CT scan. To be able to correlate the perforation site with the place of the extraluminal gas. To know that not only the extraluminal bubbles are important clues in the diagnosis for acute abdomen but the indirect signs like intraperitoneal fluid, phlegmon or abscessed collections,too. Page 2 of 41

3 Background DEFINITION: Gastrointestinal tract perforation (GI perforation) is an emergent condition that requires prompt surgery. Diagnosis depends on imaging examinations, the correct localisation of its level and its causes. All these items supose essential to carry out an appropriate management and surgical planning. INTRODUCTION: There are several causes that develop a GI perforation: inflammatory disease, peptic ulcer disease, traumatic causes, iatrogenic factors and neoplasms. Fig. 1 on page 6 DIAGNOSIS: The clinical diagnosis of the site of GI tract perforation is difficult as the symptoms may be non-specific. The presence of free intraperitoneal gas (pneumoperitoneum) on a plain radiography usually indicates bowel perforation. Classically, radiologists could diagnose GI perforation through plain abdominal radiography with rates of sensitivity from 50-70%. However, in cases of early perforations with less than 1 ml of gas, this sensitivity decreases meanly, so the high clinical efficacy of computed tomographic examination in this field has been well recognized. The multidetector-row computed tomographic scanners (MDCT) is superior to single helical or conventional CT as it is able to provide rapid, high-volume coverage and diagnostic images even in patients unable to perform prolonged breath holds. However, Ultrasonography may be useful in notably children and pregnant women, who ionizing radiation should be highly restricted. However, it should not be considered definitive in excluding a pneumoperitoneum. MDCT showed 86% accuracy in predicting the site of perforation. Page 3 of 41

4 That is the reason why we can conclude that the gold standar imaging method is the MDCT. PERITONEAL ANATOMY: First of all, we shoul remember what peritoneum is and its anatomy details. The peritoneum is is the largest and most complexly arranged serous membrane in the body. There are to folds: parietal peritoneum, which lines the abdominal wall, and visceral peritoneum, that covers a viscus or an organ. Both types of peritoneum consist of a single layer of simple low-cuboidal epithelium called a mesothelium. A film of serous fluid separates the parietal and visceral layers and lubricates both peritoneal surfaces. The peritoneal cavity Fig. 2 on page 6 is a virtual space between the parietal peritoneum, which lines the abdominal wall, and the visceral peritoneum, which envelopes the abdominal organs. In men, the peritoneal cavity is closed, but in women, it communicates with the extraperitoneal pelvis exteriorly through the fallopian tubes, uterus, and vagina. Peritoneal ligaments, mesentery, and omentum divide the peritoneum into two compartments: the main region, called the greater sac, and another omental bursa, or lesser sac. # Peritoneal ligaments are double folds that support a structure within the peritoneal cavity, and these are mainly the omentum and the mesentery. Most abdominal ligaments arise from the ventral or dorsal mesentery. On one hand, the ventral part of the ventral mesentery becomes the falciform ligament and liver, and its dorsal part becomes the lesser omentum. On the other hand, the dorsal mesentery developes the ventral part ( gastrosplenic ligament ), and on the dorsal part becomes the splenorenal ligament, stomach, spleen, and pancreatic tail. Omentum is a mesentery or double layer of peritoneum that extends from the stomach and duodenal bulb to adjacent organs. Fig. 3 on page 7 Mesentery is a fold of membranous tissue that arises from the posterior wall of the peritoneal cavity and attaches to the intestinal tract, and it includes blood vessels, lymph nodes, nerves, and fat. Page 4 of 41

5 Mesentery allows the movement to the small bowell by ataching it to the retroperitoneum, however the retroperitoneal portions of the colon contain mesocolon. Transverse Mesocolon The transverse mesocolon is a peritoneal fold that attaches the transverse colon to the retroperitoneum and contains the middle colic vessels.this transverse mesocolon divides peritoneal cavity in two compartiments: supramesocolic space and inframesocolic space. Fig. 4 on page 8 The supramesocolic space is divided by the falciform ligament in two other spaces: Right and left supramesocolic spaces. Fig. 6 on page 10 The inframesocolic space: The right and left inframesocolic spaces are separated from the supramesocolic spaces by the transverse mesocolon and from the paracolic gutters laterally by the ascending or descending colon. Paracolic Spaces The paracolic gutters are located lateral to the peritoneal reflections of the left and right sides of the colon. The right paracolic gutter is larger than the left and communicates freely with the right subphrenic space. The right and left paracolic gutters communicate with the pelvic spaces, which in men, the most gravity-dependent site for fluid accumulation is the rectovesical space. In women, it is the retrouterine space (the pouch of Douglas). Retroperitoneal Spaces The retroperitoneum is divided into three distinct compartments: the posterior pararenal space, bounded by the posterior parietal peritoneum; the anterior pararenal space, bounded by the transversalis fascia; and the perirenal space, bounded by the perirenal fascia. Page 5 of 41

6 Images for this section: Fig. 1 Page 6 of 41

7 Fig. 2: Sagital imaging of peritoneal cavity. We can regard intraperitoneal and retroperitoneal organs The McGraw Hill Companies. Inc. Page 7 of 41

8 Fig. 3: -The lesser omentum, which is made of two contiguous components called the gastrohepatic and hepatoduodenal ligaments, attaches the stomach and duodenal bulb to the liver. - The greater omentum is attached to the stomach and hangs like an apron from the transverse colon Pearson Education.Inc. Page 8 of 41

9 Fig. 4: The transverse mesocolon divedes peritoneal cavitiy in supra and inframesocolic spaces.the latest is divided in left and right inframesocolic spaces, which is limited inferiorly by the attachment of the small bowel mesentery to the cecum. The larger left inframesocolic space communicates freely with the pelvis. However, this spaces and paracolic gutters are bounded by greater bowell, that is attached to retroperitoneum by ascending and descending colon. Page 9 of 41

10 Fig. 5 Page 10 of 41

11 Fig. 6: The right supramesocolic spaces include the right subphrenic (subdiaphragmatic) space, the Morison pouch (subhepatic or hepatorenal space), and the lesser sac (omental bursa). The left supramesocolic space is consists on the perihepatic, left subphrenic, and perisplenic spaces. The phrenocolic ligament is a relative but incomplete impediment to the spread of pathologic processes from the left para-colic gutter to the left subphrenic space. The left subphrenic space communicates with the left paracolic space. The right subphrenic space and the superior and inferior recesses of the lesser sac are separated by a peritoneal fold that contains the left gastric artery. Page 11 of 41

12 Findings and procedure details WHAT ARE THE CLUES TO DEPICT GI PERFORATION? As we writted upper, the presence of free intraperitoneal gas (pneumoperitoneum) on a plain radiography usually indicates bowel perforation. However, the rate of sensitivity of X-ray decreases mainly with les than 1 ml of gas. Then CT scan results quite useful. Fig. 7 on page 16. Fig. 8 on page 16 The MDCT provides a sensitivity of 89% by searching the following GI perforation signs: Direct signs: Extraluminal bubbles. Contrast fluid leaks Stop point at the intestinal wall. Indirect signs: Intraperitoneal fluids Abrupt wall thickening. Fig. 9 on page 17 Phlegmon, abscess. Foreign extraluminal bodies. Afterwards we will have to be able to indetify the perforation site according due to the peritoneal compartiments clasiffication: Supramesocolic, inframesocolic and retroperitoneum compartiments. Supramesocolic and inframesocolic are divided by transverse mesocolon (and colon) and pancreas. Therefore the organs implied in supramesocolic perforation will be stomach and duodenum. Fig. 10 on page 18 The inframesocolic perforation consists on small bowell and geater bowel, except retroperitoneal compartiment. The retroperitoneal perforation is caused because the second and third duodenum segments, ascending and descending colon and the medium third of the rectum. Supramesocolic perforations: Gastroduodenal perforation commonly occurs due to peptic ulcer disease, neoplasia and postoperative anastomotic leaks. In our institution Page 12 of 41

13 we had two cases of gastric and duodenal peptic ulcer and another case because of postoperative complications. -Penetrating ulcers of the anterior wall of the stomach or duodenum may perforate directly into the peritoneal cavity, whereas posterior stomach or duodenal ulcers often cause a walled-off or confined perforation. -Duodenal ulcers Fig. 11 on page 19 are often located on the anterior bulb of the duodenum and are, therefore, a common cause of peritonitis. In case of perforation of second or third duodenal portions and due, bubbles culd spread to the retroperitoneal space. The main supramesocolic signs of perforation are: Falciform ligament sign Fig. 13 on page 21 Tere ligament sign Gastroduodenal tiny bubble close to the bowell thickened wall Fig. 14 on page 22 Perigastroduodenal inflammatory changes (fluid). Fig. 15 on page 23 Inframesocolic perforations: -Small bowel perforations The incidence of small bowel perforation is low but can it develop from a variety of causes including ischemic or infectious enteritis, Crohn disease, intaked foreign bodies, bowel obstruction, volvulus, and intussusception, but also can became because of abdominal trauma iatrogenic injury, and postoperative leakage. Althought the amount of extraluminal air in small bowel perforation is small or absent, extraluminal air is detected in only approximately 50% of cases even with CT examination. We can see smal bubbles in the mesenteric folds and indirect findings. Perforation or leakage should be suspected with persistent or progressively increasing free air, specially on the point of the eigth day after surgery. -Large bowel perforations Perforations of the large bowel may occur in intraperitoneal or retroperitoneal spaces, depending on the perforated segment. They can be performed by, on one hand, malignant neoplasm, diverticulitis, spontaneous perforation, trauma, ischemia,(which are more frecuent in the left colon); and on the other hand, inflammatory lesions and iatrogenic causes,that become more frecuently in the right colon. Page 13 of 41

14 The cecum is predisposed to get perforated when the intraluminal pressure of the colon is increased:bowel obstruction and toxic megacolon. Therefore, rectum and sigmoid colon are the predominant sites of iatrogenic injuries. In cases of perforated diverticulitis, Fig. 16 on page 24 the amount of extraluminal air is usually small and perforation usually occurs into the retroperitoneal space because most diverticula of the colon are located in the retroperitoneum between Fig. 17 on page 25 the taenia mesocolica and libera and between the taenia mesocolica and omentalis. An speciall case is the intestinal pneumatosis, is defined as the presence of intramural gas at any location in the gastrointestinal tract. It constitutes not a radiological sign but a diagnosis too. It can be performed by several causes, although these were grouped into four major categories : -intestinal necrosis -mucosal disruption -increased mucosal permeability -lung diseases ( benign course). The intestinal pneumatosis may takes different appearance in images, this is, linear, curvilinear or bubbles. However, no relation was found between the morphological appearance of pneumatosis base entity and which facilitates its emergency. Portomesenteric gas Fig. 19 on page 27 can be showed because of the close realtion between intestinal mesenteryand the bowell with the intramural gas, Fig. 20 on page 28 as it can be drained by the mesenteric venous system to the porta vein. This radiologic finding leads to poor prognosis. Abdominal abscesses consist on well circunscribed fluid and purulent collections that present gas inside. Fig. 23 on page 31. The main causes are GI perforation, postoperative bacteremia and trauma. In plain radiography, fluid levels are observed to be oriented according to the position of the patient thought the sensitivity of radiography for abscesses air inside is between 70% and 80%. On CT scan we can see hypodense areas, that enhance after the intravenous administration of ioded contrasted solution. Page 14 of 41

15 The abscess can lead us to accurate diagnosis of GI perforation, althought we can not see the perforation gas. The retroperitoneal perforation is caused because the second and third duodenum segments, ascending and descending colon and the medium third of the rectum. Fig. 26 on page 34 Page 15 of 41

16 Images for this section: Fig. 7 Page 16 of 41

17 Fig. 8: AXIAL CT IMAGING: Tiny bubble close to the liver,the tere ligament sign. Fluid density in right perihepatic space. Duodenal perforation. Page 17 of 41

18 Fig. 9: AXIAL CT IMAGING: Perihepatic fluid next to the gastroduodenal perforation. CORONAL RECONSTRUCTION: Gastroduodenal thickening wall with tiny bubble. Page 18 of 41

19 Fig. 10: AXIAL CT IMAGING. Pictures in abdominal window show perihepatic fluid and small bubble in the supramesocolic space because of duodenal perforation at the posterior wall. Pictures on the right enhance the bubble close to the liver. Page 19 of 41

20 Fig. 11: CORONAL RECONSTRUCTION: This picture correlates with the fig.10. Duodenal perforation with small bubble in the supramesocolic space well contained close to the liver. Page 20 of 41

21 Fig. 12: PLAIN ABDOMINAL RADIOGRAPHY: Big neumoperitoneum over the liver shape that implies supramesocolic perforation. Page 21 of 41

22 Fig. 13: AXIAL CT IMAGING:FALCIFORM LIGAMENT SIGN. Lung window shows supramesocolic gas and falciform ligament that divides right and left suprahepatic spaces. On the right side we can see the locator imaging with central pneumoperitoneum. Page 22 of 41

23 Fig. 14: AXIAL CT IMAGING:supramesocolic perforation. The same case as 13 and 12 figs. Male. Accute abdominal pain. The white arrow show the thickening at the posterior wall of the stomach. The red arrows ahow the bubble close to the wall of the stomach. In the anterior abdominal wall there is too a pneumoperitoneum. Page 23 of 41

24 Fig. 15: AXIAL CT IMAGING. Caudal shapes from the gastric perforation with amount of fluid among the bowell, gutters and in the pelvic space. Page 24 of 41

25 Fig. 16: ACCUTE PERFORATED DIVERTICULITIS: White arrowheads show the bubbles next to the left colon and the pararenal fascia. Also there are fluid near to the inflammed colon. White arrows show the dierticula and the wall thickening of te left colon. Page 25 of 41

26 Fig. 17 Page 26 of 41

27 Fig. 18: INTESTINAL NEUMATOSIS. Page 27 of 41

28 Fig. 19: NEUMOBILIA. The biliar tree enhanced by the red arrow because of intestinal neumatosis. Hidatydic hepatic and calcified cysts. Page 28 of 41

29 Fig. 20: SIGMA NEUMATOSIS. This is the same case as fig.19. We can see the small bubbles located in the thickness of the sigma wall (red arrows). With blue arrow we can see the fluid colection indirect sign of perforation and inflammed sign. This patient died because of intestinal ischemia. Page 29 of 41

30 Fig. 21 Page 30 of 41

31 Fig. 22 Page 31 of 41

32 Fig. 23: Male, 54 years old.axial images CT scan with contrast enhancement. Chronic pancreatitis--> yellow arrows show pancreatic calcifications. Accute E pancreatitis, as we can see the purulent collections with enhanced ring close to the pancreatic tail. Bubbles in the lesser sac (white arrow)as the tere ligament sign because of the pancreatic-duodenal perforation. Page 32 of 41

33 Fig. 24: CORONAL RECONSTRUCTIONS E ACCUTE PANCREATITIS. Fluid in the pararenal fascia bound the perirenal left space (green arrow).there is also a collection n the left paracolic gutter. Chronic pancreatitis with calcifications inside (yelow arrow) and gas in the duodenal wall-> supramesocolic perforation due to the accute E pancreatitis above the chronic pacnreatitis. Page 33 of 41

34 Fig. 25: SUPRAMESOCOLIC AND RETROPERITONEAL PERFORATION.(1) Bubbles nexto to the liver. Falciform ligament sign. Perihepatic and perisplenic fluid. Page 34 of 41

35 Fig. 26: SUPRAMESOCOLIC AND RETROPERITONEAL PERFORATION.(2) Bubbles located next to the liver. Falciform ligament sign. Perihepatic and perisplenic fluid. Retroperitoneal bubble because of the duodenal origin of the perforation. Page 35 of 41

36 Fig. 28: SUPRAMESOCOLIC AND RETROPERITONEAL Perihepatic and perisplenic fluid. Right retroperitoneal bubbles. PERFORATION.(3) Page 36 of 41

37 Fig. 29: SUPRAMESOCOLIC AND RETROPERITONEAL PERFORATION.(4) Perihepatic and perisplenic fluid that follow both paracolic gutters and pelvis. Page 37 of 41

38 Fig. 30: RETROPERITONEAL SPACE. Patricia Solano Díaz Page 38 of 41

39 Conclusion The presence of extraluminal bubbles implies an important sign of gastrointestinal perforation which can also help us to find the perforation site. However, we should pay attention to other clues as lack of bubbles can also suggest perforation: contrast fluid leaks, stop point at the intestinal wall, intraperitoneal fluids, abrupt wall thickening, phlegmon, abscess or foreign extraluminal bodies. Therefore, the accurate and early diagnosis will suppose a correct and prompt surgical treatment. So radiologists play an important role in the GI perforation. Page 39 of 41

40 Images for this section: Fig. 31 Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang HK. Gastrointestinal Tract Perforation: MDCT Findings according to the Perforation Sites. Korean J Radiol 2009;10:63-70 Page 40 of 41

41 References 1. Singh JP, Steward MJ, Booth TC, Mukhtar H, Murray D. Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl 2010; 92: Furukawa A, M. Sakoda M, Yamasaki M, Kono N, Tanaka T, Nitta N, et al. Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging (2005) 30: Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang HK. Gastrointestinal Tract Perforation: MDCT Findings according to the Perforation Sites. Korean J Radiol 2009;10: Díaz Díaz NE, Forero Cuéllar OM, Ulloa Guerrero LH, Camargo Pedraza CB, Carrillo Bayona JA, Rivera AL. Gas extraluminal abdominal en imagen. Causas y significado clínico. Rev Colomb Radiol. 2008; 19(2): Cárdenas Rodríguez L, Martí de Gracia M, Santurio Gala N, Pérez Dueñas V, Salvatierra Arrieta L, Garzón Moll G. Utilidad de la tomografía computarizada multidetector para identificar la localización de las perforaciones gastrointestinales. Cir Esp ; 91(5) : Hainaux B, Agneessens E, Bertinotti R, De Maertelaer V, Rubesova E, Capelluto E, Moschopoulos C. Accuracy of MDCT in Predicting of Gastrointestinal Tract Perforation. AJR 2006; 187: Tirkes T, Sandrasegaran K, Patel AA, Hollar MA, Tejada JG, Tann M, et. al. Peritoneal and Retroperitoneal Anatomy and Its Relevance for CrossSectional Imaging. RadioGraphics 2012; 32: Page 41 of 41