Jonathan M. Jacobs, MD •¿ Michael C. Hill, MB •¿ William M. Steinberg, MD
Peptic
Ulcer Disease:
The authors retrospectively describe the computed tomographic (CT) findings in 35 patients with peptic ulcer disease. Three of eight patients with gastritis or duodenitis had bowel-wall thickening. Ten of the remaining
27 patients
had CT evi
dence of ulcer perforation (n = 2) or penetration (n = 8), four cases of which were unsuspected clinically. Both patients with acute free perf o ration had pneumoperitoneum, and one showed free extravasation of orally administered contrast materi al. The precise site of perforation could not be established in either case with CT. The eight patients with ulcer penetration had CT evi dence of bowel-wall thickening (n = 3) and
inflammatory
changes
in
CT Evaluation'
C
OMPUTED tomography (CT) would be expected to be an in sensitive detector of mucosal ulcer ation; however, it might be useful in detecting perforation and penetra tion associated with peptic ulcer dis ease (PUD). In this study, we metro spectively reviewed the abdominal
CT findings
mouth
ministered
the pancreas (n = 4),
liver (n = 1), and lesser omentum (n = 1). Ulcer
craters
were
seen
in
only
two. The CT findings of penetration can mimic other disease processes. CT was not useful in detecting un complicated peptic ulcer disease.
mm was considered
70.1211
Gastrointestinal tract, CT,
•¿ Peptic
ulcer,
Peptic ulcer, diagnosis,
complications,
70.712.
70.1211
gastnitis
or duodenitis
with an upper
GI
good distention
I From
the
Departments
of
Radiology
(J.M.J.,
ten, 901 23rd St. NW, Washington, Received August 20, 1990; revision
DC 20037. requested
October 10; revision received November 9; ac cepted November 12. Address reprint requests
to M.C.H. C RSNA.
1991
fat
of a mass; (d) involve
orally administered con or both, in the penitoneal
tenmine how the diagnosis of PUD was made and why the abdominal CT scan was obtained. The patient's clinical pre sentation just before the CT scan was ob tamed was noted, along with the degree of clinical suspicion for perforation and The hematocnit,
white
blood
noted.
within
4
and opaci
al and air; and (d) patients who previous ly underwent gastric or small bowel resections that made identification of nor mal anatomy difficult were excluded from the study.
The abdominal
inflam
CT
fication of the stomach and duodenum af ten oral administration of contrast mateni
M.C.H.) and Gastnoentenology (W.M.S.), George Washington University Medical Cen
with
in the surrounding
cell count, and serum amylase level were
weeks of the diagnosis; (c) the CT scans had to be of a good diagnostic quality, demonstrating
on duodenum;
penetration
The medical chart of each patient Se lected for the study was reviewed to de
penetration.
as
ulcer patients only); (b) the abdominal scans had to have been obtained
ulcer
space on retropenitoneum.
The criteria
were classified
of
on extravasated tnast material,
series, esophagogastroduodenoscopy, or abdominal surgery, or a combination of these (patients with both an ulcer and
Radiology 1991; 178:745-748
in the
ment of adjacent organs such as the liven, biliary tract, and pancreas; (e) signs of acute free ulcer perforation with free air
(a) all patients had to have PUD or gastni proved
(c) signs
on the formation
medical records of all patients seen oven a 4-year period at the George Washington
tis on duodenitis
wall of the stomach
matory stranding
for inclusion in the study were as follows: Index terms:
abnormal
small bowel); (b) areas of ulceration with extension of the ulcer into or beyond the
of the computerized
Center.
un
and it was said to be thickened when it exceeded 7 mm; a thickness greaten than 3
AND METHODS
Medical
by drip infusion)
intravenously
duodenal-wall thickening (only the ante nor wall was measured in the stomach,
Patients with the diagnosis of PUD in cluding gastnitis on duodenitis were iden
University
was on the
Each CT scan was retrospectively re viewed for (a) focal or diffuse gastric- or
that should prompt the me
by review
the start of
less contnaindicated.
ferring physician to obtain an ab dorninal CT scan in patients with PUD.
tified
the patient
300 mL of 30% solution
in patients with PUD
MATERIALS
while
was also administered
adjacent soft tissues and organs (n 8), including
before
CT scanning table. lodinated contrast ma tenial (50 mL of 60% solution by bolus and
and correlated them with the clinical history, endoscopic and upper gas trointestinal (CI) series findings, and surgery when it was performed. Our aim was to determine (a) the spec trum of CT findings present in PUD patients and (b) the clinical signs on
symptoms
30—60minutes
the CT study, with the last cup being ad
CT scans were obtained
with a GE 9800 scanner (GE Medical Sys tems, Milwaukee) and contiguous 1-cm
thick sectioning from the bases of the lungs to the iliac crests. The upper CI tract was delineated with 900 mL of a di lute barium suspension administered by
RESULTS Of 755 patients identified
with the
diagnosis of PUD, only 59 (8%) un derwent abdominal CT scanning. Twenty-four patients were excluded from the study because the CT scans
were unavailable for review (n 9), had been obtained 4 weeks beyond the time of diagnosis (n 8), or were of poor diagnostic Also, four patients undergone gastric Abbreviations: peptic
GI
quality (n 1). had previously surgery, while two gastrointestinal, PUD
ulcer disease.
745
patients had malignant ulcers. Of the 35 patients who met the selection cmi tenia for the study, 18 men and 17 women ranged in age from 29 to 82 years (mean, 59 years). All had un demgone diagnostic esophagogastro duodenoscopy (n 25), an upper GI
series (n = 9), on surgery (n in 4 weeks
of the abdominal
6) with CT scan.
CT scanning was performed within week of diagnosis in 26 patients
1
(74%), 1—2weeks in four patients (12%), and 2—4weeks in five patients
(14%). The mean time between
diag
nosis and CT scanning was 6.2 days. Eight patients had gastritis on duo denitis, and three had CT evidence of focal antral wall thickening, includ ing one with inflammatory stranding in the adjacent pemiantmal fat. Twen ty-seven patients had ulcer disease. Fifteen had gastric ulcers, of which 12 were antral, two were in the body, and one was in the gastric cardia.
Twelve patients had duodenal
ulcers:
Nine were bulbam and three were postbulbam. Ulcer diameter, as deter mined with endoscopy, was stated in the records of 13 patients. The aver age diameter was 1.6 cm (mange, 0.5— 4.0 cm). Eleven of the 27 patients with PUD had findings at CT. Two patients had an acute free perforation of a gastric (n = 1) on duodenal (n = 1) ulcer. Eight patients had penetra tion on confined perforation of a gas tnic (n = 5) or duodenal (n 3) ulcer.
Of the remaining 17 patients with PUD, one showed evidence of bowel wall thickening. The 27 abdominal CT scans were obtained in the patients with ulcer disease to evaluate for penetration on perforation (n = 9), malignancy (n = 10), a declining hematocrit (n 4), abdominal pain (n 2), and various indications unrelated to PUD (n 2). Six of nine scans obtained to evaluate for perforation on penetration were positive. Four other CT scans ob tamed to exclude malignancy (n 2), evaluate nausea and vomiting (n 1), and evaluate abnormally elevated liven enzyme levels (n 1) showed evidence of penetration. Both of the patients with acute free perforation had acute abdominal pain of less than 2 days duration and abdominal rebound tenderness, while one had boandlike abdominal rigidity and hypotension. Two of the eight patients with CT evidence of penetration had guarding at abdomi nal examination, while none had boamdlike abdominal rigidity or me bound tenderness. The serum amy lase levels were not available for all patients.
746 •¿ Radiology
1.
2.
Figures 1, 2. (1) Acute free perforation of a prepylonic ulcer. There is free extravasation of orally administered contrast material (long arrow) between the liver (L) and right kidney (K) into Morison pouch. A small amount of fluid is seen in the penipyloric region (short arrows).
G = gallbladder, D
duodenum, S = stomach.(2) Acute free perforation of an anterior duo
denal wall ulcer. Free air (long arrow) is seen anterior to the left lobe of the liver (L), adja cent to the falciform ligament (F). Also note peniphepatic, pericaval, and pleural fluid (small
arrows). C = air in transverse colon, S
stomach, M = mass in upper pole of left kidney.
Among the four patients with pen etnation and CT evidence of peripan creatic inflammation, pancreatic phlegmon formation, on pancreatic pseudocyst formation, serum amylase levels were available in three pa tients and were abnormally elevated (mange, 507-1,970 lUlL). Serum amy lase levels, available for only six pa tients with uncomplicated PUD, were elevated in only one patient (222 IU/L) for reasons that were not clinically apparent. Only one of the two patients with an acute free pemfo nation had a leukocyte count elevated to 22,000/mm3 (22.0 X 109/L), and she was receiving steroid medication. Five of the eight patients with pene tration for whom data were available had leukocyte counts of between 10,000 and 15,000/mm3 (10.0-15.0 X 109/L). The remainder of the patients with perforation or penetration had leukocyte counts of less than 10,000/ mm3 (10.0 X 109/L).
DISCUSSION PUD refers to an ulceration of the mucous membrane of the esophagus, stomach, or duodenum produced by acid. Gastritis and duodenitis, non specific terms applied to inflamma tion of the gastric and duodenal mu cosa, have many causes, including PUD (1). Acute free perforation (occurring in 5%-10% of patients with PUD) represents extension of a peptic ulcer through the muscular and semosal layers of the GI tract, which forms a free communication between the bowel lumen and the adjacent penito neal space. In general, ulcers on the
Figure 3. Confined perforation of pyloric ulcer. A pyloric ulcer crater (white arrow) extends beyond the normal confines of the wall of the pylorus. G gallbladder, P pancreas, S = stomach.
anterior wall and curvatures freely perforate. Those located on the poste non wall penetrate into the sum rounding soft tissues unless they are on the posterior gastric wall, where they will freely perforate into the lessen sac (1). Posterior ulcers that in volve the adjacent soft tissue may have perforated but are referred to as posterior penetrations. If the base of such a penetrating ulcer lies in the adjacent soft tissue, then it is called a confined perforation (1). In patients who have undergone elective opera tion for PUD, 25%-31% have penetma tion with fibrous adhesions, while
23%-30% have a confined perforation (1). When evaluating patients for PUD, many clinicians perform either en doscopy or an upper GI series in the initial diagnostic wonkup. The mole of CT in evaluating these entities has until now been described only in the form of case reports (2—5).While we recognize that this study has a bias
March 1991
those of penetrating ulcers unless the base of the ulcer crater is seen to ex tend beyond the bowel wall. There was no significant difference be tween
the clinical
presentations
of
these two subgroups of penetration in our study, which probably reflects this study's
bias in that only patients
with continued symptoms under went CT scanning. The hematocnit is usually not significantly different in cases of ulcer penetration
a.
b.
Figure 4. (a, b) Endoscopically proved penetrating postbulbar duodenal ulcer. There is penetration into the pancreatic head with peripancreatic phiegmonous changes (large white arrow, b) around the head of the pancreas, which is enlarged and contains a pseudocyst (small black arrow).
No ulcer crater is seen. S
due to its retrospective nature and technique of patient selection, it does show that CT has no clinically
role in detecting
useful
uncomplicated
PUD, as 21 such patients
in this study
stomach,
C = gallbladder.
nation when CT showed the base of the ulcer crater extending into the adjacent head of the pancreas. The CT findings of ulcer penetration in cluded demonstration of an ulcer cra
had normal findings on abdominal CT scans. The CT scans had been ob tamed within 4 weeks of diagnosis, and 74% were obtained within 1 week. Although ulcers heal with
ten (n = 2), bowel
time, the complicated is capable of detecting
ic inflammatory changes (n 4), pan creatic head pseudocyst formation (n
ulcers that CT would not be
expected to heal completely
in the
short time between diagnosis scanning. Thus, this potential
and CT van
able should not have had a signifi cant impact on our findings. CT was helpful in detecting acute free perforation and penetration. Acute free ulcer perforations mea
= 3), and
wall thickening
inflammatory
(n
changes
the soft tissues and organs adjacent to the ulcer site (n 8). To be specific, these changes included penipancreat
= 1), formation
of a gastric
inflamma
tory mass (n 2), and inflammatory changes in the liven (n = 1) and lesser omentum (n = 1).
Madrazo et al have shown that the CT diagnosis of ulcer penetration can be made when a sinus tract contain ing extra-alimentary contrast mateni
com
show an increased level of serum am ylase or lipase, which when elevated
can help support the diagnosis of penetration (1). These values, avail able in only three such patients, were elevated. The CT scan was obtained because
in
when
pared with cases of uncomplicated ulcer disease (1). A slight leukocyto sis can occur and was observed in four of the eight patients with pene tration for whom data were available. It has been reported that only a small number of patients with posterior penetration into the pancreas will
of a clinical
suspicion
of ul
cempenetration or perforation in four of the eight patients with CT evi dence of ulcer penetration. In the me maining four patients with penetra tion, the scan was obtained for clini cal indications unrelated to PUD. This demonstrates that CT can be used to detect clinically unsuspected
penetrating ulcers. CT can provide valuable diagnostic information in the proper clinical setting. Patients who have rebound tenderness with no radiographic evi
al is identified or when the presence of an ectopic pocket of gas adjacent but extrinsic to an ulcer crater is demonstrated (2). However, ulcer
dence of free air might benefit from CT scanning. Although CT may show free air not detected with plain radio
craters are not always seen at CT and were detected in only two of eight
definition
is a clinical suspicion
ever, the site of perforation could not be precisely identified (Figs 1, 2).
patients with penetration (Fig 3). It is interesting that, in two patients, an tral ulcers 3—4cm in diameter were not seen at CT. CT can be useful in
This free air was best seen at CT by means of lung windows along the anterior aspect on undersurface of the left lobe of the liver and was seen on
venticulum from a large ulcer crater (2). Gastropancreatic fistulas due to penetrating ulcers can be detected at
verity
the plain radiographs
CT as evidenced
be given strong consideration.
sure 5 mm, on average, and are usual ly duodenal (72%), although the pre cise site may be difficult to locate at
surgery (1). The two patients with acute free perforations had CT evi dence of free extnavasation of orally administered contrast material or free intrapemitoneal air, or both; how
of only one pa
tient (6). Acute free perforation
was
helping
to distinguish
a duodenal
graphs,
di
by focal enlarge
ment of the pancreas
on the presence
clinically suspected in both patients, one of whom was receiving steroids, and both had rebound abdominal
of a fluid collection in or around the head of the pancreas, as seen in one
tenderness consistent with this diag nosis. None of the patients with pen
due to a penetrating
etrating PUD in this study had this clinical finding. Eight patients had penetrating peptic ulcers, four of which were sun gically
proved
confined
perforations.
Another patient was not operated on but proved to have a confined perfo Volume 178 •¿ Number 3
patient
with a pancreatic
pseudocyst
postbulbar
duo
denal ulcer (Fig 4). These CT find ings are indistinguishable from other causes of acute focal pancreatitis un less there is a clinical history of PUD
on a contrast medium—filled ulcer cra ten or fistulous
tract is seen.
The CT findings rations
of confined
are indistinguishable
pemfo from
it will probably
not allow
of the precise site of perfo
nation. CT is also useful
when
theme
of penetration,
such as when a patient experiences symptoms not normally associated with uncomplicated PUD on when
theme is a noticeable on pattern
change in the se
of the pain. If such a
patient had CT evidence of penetra tion, then surgical
treatment
would
Ulcer penetration can be misdiag nosed at CT, as the findings can sim ulate other disease processes such as
acute pancreatitis, a gastric wall mass, and a lesser omentum mass. These findings were seen in three of the four patients who had surgically
proved confined
perforations.
Two of
these patients had surgically proved lesser curvature gastric inflammatory masses, and in one, the process ex
tended via the lesser omentum and gastrohepatic recess into the liver, Radiology •¿ 747
producing multiple hepatic abscesses (Figs 5, 6). In both cases, the mistaken diagnosis of tumor was initially
made. Similarly, bowel-wall pseudocyst
and penipancreatic flammatory en clinical traluminal unless the siders the
findings
thickening, on phlegmon
such as pancreatic formation,
or soft-tissue in
changes can, in the prop setting, help define the ex extension of PUD. Thus, radiologist actively con diagnosis of PUD and is
aware of its CT manifestations, diagnosis missed.
of penetrating
the
PUD can be
a.
Bowel-wall thickening cannot be accurately assessed with CT unless there is adequate gastric on duodenal luminal distention with contrast ma temial or air, or both. This distention
can be optimally achieved by using gas granules for aimcontrast on by me scanning patients with additional oral contrast material (7). Scanning
b.
Figure
5.
Confined
attenuation
lesser
perforation
curvature
of a lesser curvature
mass
(arrows)
is seen
can, however,
perforation and penetration clinically unsuspected.
careful not to misdiagnose the anteni on wall of the stomach and adjacent
Acute free perforations can be di agnosed at CT when free intrapenito
inferior
finding of gastric- on duodenal-wall thickening at CT may be due to un denlying PUD, gastnitis, on duodeni tis, or a combination of these, and CT
neal aim or extravasation of oral con trast material, or both, are seen. In our limited experience with two pa tients, CT could not be used to deter mine the precise anatomic site of per fomation. The CT findings in cases of
cannot be used to distinguish be tween these entities unless there are other associated findings. The pres
penetration are varied and include bowel-wall thickening, inflammatory changes in the adjacent soft tissues
ence of bowel-wall thickening in three of eight patients with gastnitis or duodenitis is hard to explain, as these are mucosal diseases. It is possi ble that one on all three of these could have had a small associated ul cer that was not seen by means of an upper CI series or endoscopy.
and organs, and, uncommonly, cer crater. Confined perforation
The CT finding
thickening.
The
748 •¿ Radiology
be diagnosed
low recess
via
be used to detect ulcer that is
Figure 6. Confined perforation of a lesser curvature gastric ulcer. A mass (arrows) composed of inflammatory tissue is present along the lesser curvature of the stomach (5). L = liver,
SP = spleen.
an ul can
at CT only when the
base of the ulcer craten is seen ex tending outside the bowel wall. U
4.
Glick SN, Levine MS. Teplick 5K, Gasparai tis A. Splenic penetration by benign gas tnic ulcer: preoperative recognition with
5.
Joffe N, Antonioli
CT. Radiology
References 1.
of gastric- on duo
denal-wall thickening in the appro priate clinical setting is consistent with PUD, although CT could not be used to detect any abnormality in a large number of PUD patients. CT cannot help in distinguishing PUD from gastnitis or duodenitis in the ab sence of ulcer penetration on penfona
the gastrohepatic
tion. It is most useful when there is a clinical suggestion of gastric or duo denal perforation or penetration. It
the patient in the prone or decubitus
tip of the left lobe of the liv
into
the lesser omentum. S = stomach, L liver. (b) CT section at a higher level demonstrates a hepatic abscess (arrows) in the left lobe. S = stomach, L liver.
position with the area of interest up pemmost is also helpful. One must be
emas gastric-wall
gastric ulcer. (a) An irregular
extending
Pelot D, Hollander D. Complications of peptic ulcer disease. In: Benk JE, ed. Bockus gastroentenology. 4th ed. Philadelphia:
Saunders, 2.
Madrazo
RD. Sandier
Pearlbeng JL. Computed findings
in penetrating
MA,
tomognaphic peptic
ulcer.
Radi
ology 1984; 153:751-754. 3.
Hughes JJ, Blunck of gastropancreatic
DA.
Penetration
into
the spleen by benign gastric ulcers. Clin 6.
1985; 1155-1184. BL, Halpert
1987; 163:637-639.
7.
Radio! 1981; 32:177-181. Phatak MG, Frank SJ, Ellis JJ. Computed tomography of bowel perforation. Gas trointest Radio! 1984; 9:133-135.
Megibow AJ, Zerhouni
E, Hulnick DH, et
a!. Air contrast techniques tinal computed tomography. 145:418.
in gastrointes AJR 1985;
CE. CT demonstration fistula due to penetnat
ing gastric ulcer. J Comput Assist Tomogr 1987;11:709-711.
March 1991