Discussion

Based on the
All patients with clinical and/or
acute abdomen are radiologic and
initially submitted to sonographic
abdominal plain film findings, CT
and Ultrasonographic examination has
examination been performed.

12% of patients were taken to immediate surgery because of clinical

findings ; in the other 88 and 83.1% had an abdominal plain film
and UltraSonographic and 30% also a CT examination.
 Patients with gastro-duodenal
perforations represent 0,19%
of all those having a
conventional radiological
examination.

8,86% of all 0,93% Abdominal

plain 0,61% abdominal 1,34% Abdominal
emergency surgical
ultrasonographic CT
intervention films
 Based on experience

Abdominal plain film and Ultrasonographic allowed an accurate

66,2% diagnosis of perforations on the basis of evidence of direct and
indirect signs.

56,6% The abdominal plain film alone played an important role.

75,4% Diagnostic accuracy of Ultrasonographic and CT examinations

• In the group of 50 patients in which CT was performed, identification of
free air was possible in 24 cases only, because gastro-duodenal
perforation may not be associated to evidence of free air.

• Helical CT examination is usually more sensitive in the detection of free

air than the abdominal plain film, especially in the case of a small
amount of gas or small bubbles in a retroperitoneal site.

8 cases showed
that they were false negatives

In 14 patients in which the diagnosis

has been made by CT
6 cases CT examination was
performed after 16, 17 and 19 h
from the onset of symptoms, a lapse
of time sufficient to alter the negative
finding for perforation and
demonstrate the free air clearly.
In the literature some Authors have suggested the value and sensitivity of CT
in identifying perforations of the alimentary tract; others considered
conventional radiology poorly sensitive in some circumstances.

In such studies the upright postero-anterior chest radiograph has often been
used, because it has commonly been considered the most sensitive plain
film to detect pneumoperitoneum.

However, it has been reported that the sensitivity of CT versus the left lateral
decubitus radiograph and the postero-anterior chest radiograph has not yet
considered the most sensitive projection.
 Some authors have
suggested the use of oral But it is difficult to identify
contrast medium in CT a perforation in the axial
scanning and emphasised scans, if the lesion lies just
the advantage in detection near the anterior bowel
of duodenal injuries and
wall.
for its ability to identify
the site of the perforation

CT examination is considered more sensitive than abdominal plain film in

detection of peritoneal free air, but it cannot become the first step imaging
technique in a busy Emergency Department and in all patients with clinical
suspicion of gastrointestinal tract perforation, because of its costs and the
availability of the equipment
 Sensitivity of the plain films allowed a correct identification of a huge
percentage of patients with direct findings of perforations.

When the first plain film CT examination should be

is negative, it is more performed after a break of time
useful to repeat it after a of at least 6 h, to let the free air
few hours become more evident.

The decreased
Sonographic examination Identify the peristalsis
was not really useful to indirect findings
identify intraperitoneal free BUT of the The presence of
gas. perforation free fluid
between
intestinal loops
 • Ultrasonographic and CT examination it is not possible to
determine if the free intraperitoneal fluid is the result of a
peritoneal reaction or if it come from a perforated intestinal
loop.

Free peritoneal air could

be missing in the 35% of
gastroduodenal CT esxamination is able
perforations to identify free air in
120/146 patients

Some Authors attested that Abdominal plain films

combined methods of upright chest and US examinations are
radiography and ultrasonography Results
able to identify free air in
could increase the overall sensitivity 96/146 patients
in demonstrating free air
In the literature it has been reported that the amount of free peritoneal air is correlated
to the time passed from the perforation.

It depends on:

• The anatomical site

.
• The extension of the lesion
• The pre-existing gaseous content of the intestinal involved loop
• The mechanism of the perforation.

In presence of radiographic, sonographic and CT negative findings for perforations, it

is useful to wait at least 6 hours before to repeat the scanning, to let the free air become
more evident.