Presentation
Right lower quadrant pain. Sudden onset. ?Appendicitis.
Patient Data
Large amount of simple looking free fluid and free gas within the peritoneum. The appearances are in keeping with a perforated hollow viscus.
Although the appendix is difficult to identify, there are no appendicoliths in the pelvis.
There is also thickening of the peritoneal reflections and generalized fat stranding in keeping with peritonitis.
Bibasal consolidation.
Case Discussion
The subsequent operative note said "...Findings: D1 1.5 cm anterior perforation with free small bowel content and pus throughout abdomen, perihepatic area, right paracolic gutter, and pelvis (aprox. 2L) ... Procedure: Laparoscopic repair of perforated duodenum, primary suture repair with omental patch and washout..."
The case highlights how non-feculent free fluid and a large amount of intraperitoneal free air point towards and upper GI perforation rather than a lower GI perforation.
The keyed axial image suggests D1 perforation based on the impression of a mural defect seen along the lateral wall.
Incidentally, the CT scan is low quality due to off centering artifact (the couch was positioned too low by the radiographer).
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