What is the role of radiography in the diagnosis of intestinal perforation?

Updated: Jul 24, 2020
  • Author: Samy A Azer, MD, PhD, MPH; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Erect radiographs of the chest are recognized as the most appropriate first-line investigation when a perforated peptic ulcer is considered likely. [15] However, in approximately 30% of patients, no free gas can be identified. Thus, an erect posteroanterior chest radiograph is not sufficiently sensitive to rule out pneumoperitoneum in patients presenting with upper abdominal pain.

Plain supine and erect radiographs of the abdomen are the most common first steps in the diagnostic imaging evaluation of patients presenting with medical history and/or clinical signs suggestive of bowel perforation. Findings suggestive of perforation include the following:

  • Free air trapped in the subdiaphragmatic locations - If the quantity of free air is great enough, its presence can be visualized on the supine radiograph of the abdomen, allowing clear definition of the inner and outer surface of the wall of the bowel
  • Visible falciform ligament - The ligament may appear as an oblique structure extending from the right upper quadrant toward the umbilicus, particularly when large quantities of gas are present on either side of the ligament
  • Air-fluid level - This is indicated by the presence of hydropneumoperitoneum or pyopneumoperitoneum on erect radiographs of the abdomen

Water-soluble radiologic contrast media administered orally or through a nasogastric tube can be used as an adjunct diagnostic tool to detect any intraperitoneal leak.

The perforation has sealed at presentation in approximately 50% of patients. For those who favor a nonoperative approach, contrast radiology is routine in the management of these patients.

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