Presentation
Fell down stairs 4 days ago fracturing C1. Now has RUQ pain and rising CRP (400).
Patient Data
Large right perinephric collection of fluid, gas locules and soft-tissue attenuation. Gas locules outline the posterior surface of the second part of the duodenum. There is a fluid filled track through the posterior duodenal wall.
Radiodense body posterior to the duodenal perforation.
Small right renal cyst, otherwise normal right nephrogram and symmetrical renal enhancement.
Inflammation extends into the right ascending mesocolon, the right paracolic gutter, abdominal wall and overlying subcutaneous fat.
Oral contrast medium
The CT scan was repeated with oral contrast medium and confirms duodenal perforation communicating with the right perirenal space.
Case Discussion
Stress and alcohol abuse are risk factors for duodenal ulcer in this case.
The distribution of the collection is explained by the anatomy. The anterior right pararenal space is also the mesocolon, bounded posteriorly by the anterior renal fascia. This sometimes inserts into the posterior wall of the duodenum connecting the posterior duodenum directly to the perirenal space.
The radiodense foreign body was a mystery and we initially thought this could have been a bone fragment. The collection progressively resolved following CT-guided percutaneous drainage and on follow-up CT the foreign material appeared to disintegrate and then disappear. Perhaps it was due to ingested tablets?
Emphysematous pyelonephritis was not considered as a differential diagnosis due to the normal appearance of the right kidney.
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