Grassi Roberto, Romano Stefania, Pinto Antonio, Romano Luigia
Department "Magrassi-Lanzara", Second University, 80138 Naples, Italy.
Eur J Radiol. 2004 Apr;50(1):30-6. doi: 10.1016/j.ejrad.2003.11.012.
Gastro-duodenal perforations may be suspected in patients with history of ulceration, who present with acute pain and abdominal wall rigidity, but radiological findings in these cases may be unable to confirm a clinical diagnosis. The aim of our study was to report our experience in the diagnosis of gastro-duodenal perforation by conventional radiography, US and CT examinations.
We retrospectively reviewed medical records of 166 consecutive patients who presented in the last 2 years to our institutions with symptoms of acute abdomen and submitted to surgery at the Emergency Unit of the "A.Cardarelli" Hospital of Naples with a surgical finding of perforated gastro-duodenal ulcer. The evidence of free intraperitoneal air on abdominal plain film was considered as a direct or suggestive finding of perforation. Evidence of intraperitoneal free fluid and/or reduced intestinal peristalsis at sonographic examination were considered indirect signs of gastro-duodenal perforation. Evidence of free peritoneal gas at CT was considered as a direct evidence of gastro-duodenal perforation.
Twenty patients underwent immediate surgery with no preoperative imaging evaluation, in 10 of them the site of perforation was found in a juxta-pyloric region and in the others at level of duodenum. In 146 patients submitted to serial radiological investigations before surgery, the site of perforation was in 56 (38.3%) duodenal, in 52 (35.6%) juxta-pyloric, in 28 (19.1%) gastric and in 10 (6.8%) pyloric. The cause of perforation was in all cases gastric or duodenal ulceration, in seven cases involving pancreatic parenchyma. In 110 (75.4%) patients with direct findings of perforation, in 94 cases (85.5%) the correct diagnosis was established on abdominal plain film, in two (1.8%) with radiographic and sonographic examinations and in 14 (12.7%) on CT findings. In 36 (24,6%) patients with no direct findings of perforation, only 24 (16,4%) of them showed indirect findings of perforation. In other 12 patients no direct or indirect finding of free peritoneal air was detected.
Our experience documents that in 146 gastroduodenal perforations the free peritoneal air was not evident in 12 cases and in 66% of these patients the presence of intraperitoneal fluid could be the only sign of perforation. If free peritoneal air was detected with conventional radiography, other investigations were not indicated. In the absence of direct or indirect findings of pneumoperitoneum, US examination could help to confirm intestinal paresis and the evidence of intraperitoneal free fluid. Helical CT examination was useless before at least 6h from the onset of symptomatology, because in the absence of direct or indirect findings of penumoperitoneum at abdominal plain film and sonograpy, CT could not demonstrate any additional diagnostic information.
有溃疡病史且出现急性疼痛和腹壁强直的患者可能会被怀疑存在胃十二指肠穿孔，但这些病例的影像学检查结果可能无法确诊临床诊断。我们研究的目的是报告我们在通过传统X线摄影、超声和CT检查诊断胃十二指肠穿孔方面的经验。
我们回顾性分析了过去两年内在我们机构就诊并因急性腹痛症状在那不勒斯“A. 卡雷利”医院急诊科接受手术且手术发现为胃十二指肠溃疡穿孔的166例连续患者的病历。腹部平片上腹腔内游离气体的证据被视为穿孔的直接或提示性发现。超声检查时腹腔内游离液体和/或肠蠕动减弱的证据被视为胃十二指肠穿孔的间接征象。CT检查时腹腔内游离气体的证据被视为胃十二指肠穿孔的直接证据。
20例患者未进行术前影像学评估即立即接受手术，其中10例穿孔部位位于幽门旁区域，其余位于十二指肠水平。在146例术前接受系列影像学检查的患者中，穿孔部位在十二指肠的有56例（38.3%），幽门旁的有52例（35.6%），胃的有28例（19.1%），幽门的有10例（6.8%）。穿孔原因在所有病例中均为胃或十二指肠溃疡，7例累及胰腺实质。在110例（75.4%）有穿孔直接征象的患者中，94例（85.5%）通过腹部平片确诊，2例（1.8%）通过X线摄影和超声检查确诊，14例（12.7%）通过CT检查确诊。在36例（24.6%）无穿孔直接征象的患者中，只有24例（16.4%）显示有穿孔的间接征象。另外12例患者未检测到腹腔内游离气体的直接或间接征象。
我们的经验表明，在146例胃十二指肠穿孔病例中，12例未发现腹腔内游离气体，其中66%的患者腹腔内液体的存在可能是穿孔的唯一征象。如果通过传统X线摄影检测到腹腔内游离气体，则无需进行其他检查。在没有气腹的直接或间接征象时，超声检查有助于确认肠麻痹和腹腔内游离液体的证据。螺旋CT检查在症状出现后至少6小时前无用，因为在腹部平片和超声检查未发现气腹的直接或间接征象时，CT无法显示任何额外的诊断信息。
