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The British Journal of Radiology, 82 (2009), 162–171


Abdominal CT findings in small bowel perforation






and 2G GAYER,


Department of Diagnostic Imaging, Meir Medical Center, Kfar Saba and 2Department of Diagnostic Imaging, Assaf Harofe Medical Center, Zrifin, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel


ABSTRACT. Small bowel perforation is an emergent medical condition for which the diagnosis is usually not made clinically but by CT, a common imaging modality used for the diagnosis of acute abdomen. Direct CT features that suggest perforation include extraluminal air and oral contrast, which are often associated with secondary CT signs of bowel pathology. This pictorial review illustrates the CT findings of small bowel perforation caused by various clinical entities.

Received 24 October 2006 Revised 13 January 2007 Accepted 16 January 2007 DOI: 10.1259/bjr/78772574
’ 2009 The British Institute of Radiology

Small bowel (SB) perforation is an emergency medical situation that presents as an acute abdomen, and is only rarely diagnosed clinically. Nowadays, as CT is often the initial modality used to assess patients with acute abdomen, the radiologist may be the first to suggest such a diagnosis [1–5]. CT provides superb anatomical detail and diagnostic specificity by directly imaging the intestinal wall, detecting secondary signs of bowel disease within the surrounding mesentery and depicting even small amounts of extraluminal air or oral contrast leakage into the peritoneal cavity [4, 5]. The purpose of this article is to illustrate the CT features of a spectrum of SB perforation caused by different aetiologies.

CT technique
Our abdominal CT protocol for evaluating the acute abdomen includes the administration of both oral and intravenous contrast medium unless contraindications exist. The use of a multislice helical scanner with both axial images and multiplanar reformations allows for high-quality visualization of the entire abdomen (Figure 1) [3, 5]. Water-soluble contrast agents do not provoke an inflammatory reaction when leaking into the peritoneal cavity, as they are rapidly absorbed [4]. Assessment of bone and lung window settings, in addition to the routine abdominal window setting, serves as a useful complementary tool for detecting intra- or extra-luminal radio-opaque foreign bodies and free intra-abdominal air (Figure 2) [6].

its sensitivity is rather low (19–42%) [5]. Free intraperitoneal air (more clearly seen on a lung window setting) is another specific sign of perforation in the intact abdomen. CT is the most reliable imaging modality for detecting even small amounts of free air (Figure 3) [1–4]. Additional CT signs that may also indicate the site of the perforation include discontinuity of the bowel wall on an enhanced scan and focal thickening of the bowel wall adjacent to extraluminal gas bubbles with localized mesenteric fatty infiltration (Figures 4 and 5) [2,4–7]. The overall accuracy in diagnosing the site of the perforation is .80% [5]. Yeung et al [2] also found that the presence of air in both sides of the falciform ligament (Figure 6) may differentiate more certainly proximal from distal GIT perforation.

SB perforation can be caused by traumatic, inflammatory, ischaemic and neoplastic aetiologies. When assessing a patient with CT findings suggestive of such a perforation, the relevant clinical and laboratory data should be taken into consideration, together with the presence of additional CT findings, in order to establish its aetiology (Table 1).

Trauma and small bowel perforation
Blunt abdominal trauma

CT findings
Diagnostically, extraluminal oral contrast is a specific sign of gastrointestinal tract (GIT) perforation, although
Address correspondence to: R Zissin, Deptartment of Diagnostic Imaging, Meir Medical Center, Kfar Saba, 44281, Israel. E-mail:

SB injury following blunt trauma is an infrequent insult with a difficult and challenging clinical diagnosis. Abdominal CT plays an important role in its early detection, with overall sensitivity of 64%, specificity of 97% and accuracy of 82% [7]. Extraluminal oral contrast and free air in the peritoneum, in the absence of a pneumothorax or pneumomediastinum, or even a few tiny gas bubbles within the mesentery are specific but
The British Journal of Radiology, February 2009


However. (a) Axial contrast-enhanced CT at the lower abdomen and (b) coronal multiplanar reformation show mural thickening of an ileal segment (black arrows in (a)) with adjacent engorged mesenteric vessels (black arrows in (b)). and mesenteric infiltration are other important (and frequent) CT signs suggestive of bowel or mesenteric injury (Figure 4) [7. these are 163 Figure 1. as the FB is gradually impacted and the perforation is locally covered with fibrin. Free pneumoperitoneum is rare. and extraluminal gas bubbles (arrowheads). cause perforation. 5. transmural ileal perforation was found and resected. Most cases are accidental. imaging with a high index of suspicion plays an important role in the diagnosis. rectal and intravenous) has been introduced recently [9]. as most pass uneventfully in the stool. In contrast to blunt trauma. however. Penetrating abdominal trauma A high incidence of hollow visceral injury is seen in patients with thoracoabdominal penetrating injuries. (ii) blood on rectal examination or (iii) free fluid on FAST (focused assessment with sonography for trauma) examination. 10. some of which may be clinically occult at admission. At laparotomy. e. indicating perforation. Common CT findings include localized pneumoperitoneum and infiltrated fat near a thickened bowel segment. chicken bones and toothpicks may. having a sensitivity of 75%. Common sites of perforation include less fixed segments or those with acute angulations. the presence of free intraperitoneal air alone is not considered diagnostic of bowel injury following penetrating trauma. The most sensitive finding. and are commonly seen in children and elderly people. 11]. On contrast-enhanced CT. whereas bowel wall thickening with adjacent mesenteric contusion had a sensitivity of 42%. 8]. The most specific CT finding of bowel injury is leaking of oral contrast (Figure 7). Ingestion of a foreign body Ingested foreign bodies (FBs) rarely cause gastrointestinal perforation. or metallic FBs.g. As the clinical suspicion is low and the clinical presentation is nonspecific. The British Journal of Radiology. for haemodynamically stable patients without (i) signs of peritoneal irritation. A moderate to large volume of intraperitoneal fluid. 10. The use of CT for these patients is controversial. without visible signs of solid organ injury. Shanmuganathan et al [9] found that the sensitivity of this finding was only 19%. Ileal perforation in a patient with Crohn’s disease (CD).Pictorial review: Small bowel perforation — CT findings relatively insensitive signs of transmural SB injury (Figures 3 and 6) [8]. February 2009 . Histology revealed changes of active CD. hard or sharp objects such as fish bones. compatible with exacerbation of CD. as it can enter the peritoneal cavity by the bullet or the knife wound. mental retardation or those who abuse alcohol. found in 77% of cases. A small amount of free peritoneal fluid is also present. The definitive CT diagnosis is established by identifying the FB (Figures 2. In cases of calcified FBs. 11]. fish or chicken bones. the combination of bowel wall thickening and mural discontinuity is the most accurate indicator of bowel injury. 8 and 9) [3. triple contrast CT (oral. Long. it is important to know the number of wounds and the entry site(s). Intentional FB ingestion occurs in prisoners and those attempting suicide. When assessing the CT findings. as well as in patients with dentures. was a wound track extending up to the injured bowel. a specificity of 84% and an accuracy of 81% (Figure 4) [8]. such as the ileum and the ileocaecal and rectosigmoid segments [3.

A Osadchy and G Gayer Figure 2. white arrowhead). 164 The British Journal of Radiology. February 2009 . intraperitoneal air (arrows) and an ingested hyperdense foreign body (FB. (d) More cranially. (b) bone and (c) lung window settings demonstrates a thickened-wall ileal loop (thin arrow). Contrastenhanced CT at the lower abdomen on (a) abdominal. Small bowel (SB) perforation in a mentally retarded patient following ingestion of woody particles.R Zissin. additional non-perforating FBs are seen within the SB loops (arrows).

on (b) abdominal and (c) bone window settings. Figure 3. More cranially. Small bowel (SB) perforation caused by a chicken bone.Pictorial review: Small bowel perforation — CT findings Figure 4. (a) Contrast-enhanced CT at the lower abdomen shows extraluminal air (arrow) adjacent to a thickened ileal loop. Jejunal perforation following blunt abdominal trauma. an intraluminal hyperdense foreign body (arrow in (c)) is seen within the slightly dilated SB loop. The British Journal of Radiology. February 2009 165 . with some fluid and increased density within the adjacent mesentery (arrows in (b)). as well as mesenteric haematoma (thick arrow). Contrast-enhanced CT at the mid-abdomen on (a) abdominal and (b) lung window settings shows mural thickening of a small bowel segment (arrow) and two extraluminal gas bubbles (arrowheads) within the adjacent mesentery. Jejunal perforation following blunt abdominal trauma. Figure 5. Contrast-enhanced CT at the mid-abdomen shows the combination of small bowel wall thickening and mural discontinuity (thin arrows).

The British Journal of Radiology. February 2009 . portal vein gas and pneumoperitoneum. In cases of wooden FBs. Jejunal perforation following blunt abdominal trauma. e. Contrast-enhanced CT at the pelvis shows free peritoneal fluid and air (white arrows). seen on a lung window setting (Figure 9). caused by the laparoscopic instruments [12. Bowel inflammation Crohn’s disease Extraluminal air or oral contrast and a thickened wall SB loop. whereas fresh wood has high water content and a higher density (Figure 2). injury Endoscopic injury Retroperitoneal air with leakage of the oral contrast. as well as extraluminal oral contrast (black arrows). Strangulated small bowel Mural thickening with hypoenhancement or a lack of enhancement of SB loops. Ileal perforation following a penetrating abdominal trauma. Table 1. mainly during Extraluminal air or oral contrast and the SB tumour.R Zissin. often with multilayered enhancement. The SB is the most commonly affected site and the injury is usually discovered and treated during surgery. necessitating early CT imaging. a thickened wall jejunal segment (white arrow) and free gas bubbles within the adjacent mesentery are seen (black arrows). Demonstration of a FB. skewers and chopsticks. serious complications involving the GIT may occur. Contrast-enhanced CT at the upper abdomen on (a) abdominal and (b) lung window settings shows haemoperitoneum (arrows) and free air in both sides of the falciform ligament (arrowhead). Iatrogenic SB injury Intra-operative injury Laparoscopic surgery has now replaced many laparotomy procedures. Segmental bowel wall thickening with mural discontinuity. Free peritoneal fluid in the absence of a solid organ injury. A wound track trauma extending up to the injured bowel. with hypervascularity at its mesenteric side. A Osadchy and G Gayer Figure 6. Ingestion of a foreign body Segmental bowel wall thickening adjacent to extraluminal gas bubbles. Ischaemic Direct vascular occlusion Intravascular filling defect associated with the following findings. Unrecognized laparoscopyinduced bowel injury is associated with a high postoperative morbidity rate. pneumatosis intestinalis. (c) Slightly more caudally.g. Bowel wall thickening with adjacent mesenteric contusion. In reconstructive GIT surgery. blurred obstruction mesenteric vessels with localized mesenteric fluid. these have either low or high attenuation: dry wood has high air content. Spectrum of aetiologies of small bowel (SB) perforation and their hallmark CT features Type of pathology Characteristic CT features (in addition to the relevant clinical history) Traumatic Blunt abdominal trauma Extraluminal air or oral contrast. 13]. Rarely. Vasculitides Neoplasms Lymphoma. the finding of 166 Figure 7. Penetrating abdominal Extraluminal contrast. (FB) Iatrogenic Accidental intra-operative Leaking oral contrast in the presence of intact anastomosis. treatment more easily detected on a bone window setting (Figures 5 and 8).

February 2009 167 . Ileal perforation from an ingested fragment of a skewer. a fragment of a wood skewer was found. Figure 9. one loop with mural thickening (thick arrow in (a)). Small bowel (SB) perforation caused by a chicken bone. Contrast-enhanced CT at the lower abdomen on (a) abdominal and (b) bone window settings shows several slightly dilated SB loops within a post-operative ventral hernia.) The British Journal of Radiology. (Reprinted with permission from [11]. which is shown to be hyperdense. Contrast-enhanced CT at the lower abdomen shows an ill-defined inter-loop inhomogeneous abscess with a faint hypodense line (arrowhead). A small amount of mesenteric fluid (thin arrows in (a)) is seen. On laparotomy. (b) Longitudinal sonography at the level of (a) shows a hyperechoic line (arrows) embedded within a hypoechoic mass below the peritoneal stripe. probably caused by a foreign body (white arrow in (b)).Pictorial review: Small bowel perforation — CT findings Figure 8.

Free perforation. intraperitoneal. February 2009 . Duodenal perforation may be retroperitoneal or. rarely. (b) Repeat scanning. Endoscopic injury Perforation of the duodenum may occur during endoscopic procedures such as endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. (a) Non-contrast CT shows retroperitoneal extraluminal air (arrows) in the right anterior pararenal space. as its leakage is diagnostic of a duodenal perforation (Figure 11b) [6]. indicating a leak. Duodenal perforation during endoscopic ultrasound for a pancreatic mass. SB perforation may occur in a patient with known CD. although rare. The British Journal of Radiology. or may rarely be the first presentation of previously unknown inflammatory bowel disease. in the presence of an intact anastomotic site suggests diagnosis of accidental bowel injury (Figure 10). a small bowel loop injury was found and repaired. 168 Crohn’s disease and perforation The usual ileal-perforating complications of Crohn’s disease (CD) are often sealed off because of inter-loop adhesions. often presenting with typical findings of active CD (Figures 1 and 12) [14]. A Osadchy and G Gayer Figure 10.R Zissin. (a) Contrastenhanced CT at the level of the anastomosis (arrow) shows preserved perianastomotic fat. leading to phlegmon and abscess formation with localized peritonitis. extraluminal oral contrast. administration of oral contrast is indicated. Whenever a retroperitoneal perforation is detected. sometimes associated with intraperitoneal and even mediastinal air. CT helps to detect both the perforation and the unsuspected CD as its cause. air within the anterior pararenal space is demonstrated (Figure 11a). We recommend the use of non-contrast CT to verify any extraluminal contrast originating from the endoscopic procedure. In retroperitoneal perforation (either ductal or duodenal). (b) More caudally. Figure 11. in the right decubitus position. after administration of oral contrast demonstrates the leaking of contrast (arrows). with rapid development of peritonitis and sepsis. 15]. is a life-threatening complication reported in up to 3% of cases [14. Ileal perforation 5 days after an elective laparoscopic ileocolectomy for Crohn’s disease. On re-laparotomy. leakage of the oral contrast extending into the subcutaneous soft tissue (arrowhead) is seen.

Conclusions Figure 12. On laparotomy. i. February 2009 169 . indicative of a perforation. ileocolectomy was performed. marked pneumatosis intestinalis is seen (arrows). The CT findings suggestive of strangulation include intestinal wall thickening. characterized by inflammation and necrosis of small systemic blood vessels. including the visceral vessels of the GIT. 19]. with luminal narrowing and dilated vasa recta in the adjacent mesentery (arrows). pneumatosis intestinalis. presenting with an acute abdomen [4. SB neoplasm and perforation Primary or metastatic SB tumours are uncommon. Familiarity with the specific CT features of SB perforation. have been reported rarely as a cause of ischaemic intestinal perforation [16].e. the presence of extraluminal air or oral contrast in an intact abdomen coupled with additional CT findings. 17]. especially in patients with primary malignant lymphoma receiving chemotherapy and steroids (Figure 16). as well as intraperitoneal air (arrowhead). perforation of a SB neoplasm occurs. blurring of the mesenteric vessels with localized mesenteric fluid. (a) Contrast-enhanced CT at the lower abdomen shows mural thickening of the terminal ileum. Ileal perforation from previously unknown Crohn’s disease (CD). revealing CD with perforation. More specific findings of bowel infarction are lack of bowel wall enhancement. it can also occur in malignant stromal tumours of the SB [20]. Acute superior mesenteric artery thrombosis in a patient with end-stage renal disease. (b) More cranially. extraluminal gas bubbles (arrows) are seen. both the perforation and the cavitary tumour can be seen (Figure 16). on (b) abdominal and (c) lung window settings. gas in the portal vein or pneumoperitoneum (Figures 14 and 15) [16–18]. Figure 13. and have non-specific clinical manifestations.Pictorial review: Small bowel perforation — CT findings SB ischaemia and perforation The two most common aetiologies that cause vascular impairment of the SB wall leading to perforation are direct vascular occlusion (Figure 13) and strangulated SB obstruction (Figures 14 and 15) [16. (a) Contrast-enhanced CT at the upper abdomen shows intrahepatic portal vein gas (arrows). mural hypoperfusion. Various vasculitides. On CT. Prompt diagnosis and treatment is required for a strangulated bowel. Rarely. The British Journal of Radiology. and the clinical setting should lead to a rapid and accurate diagnosis. Perforation is most often related to SB lymphoma. findings suggestive of acute CD. Lower down. and free peritoneal fluid.

February 2009 . (a) Contrast-enhanced CT at the mid-abdomen shows a large post-operative hernia (arrowheads) and a smaller one. These findings were interpreted as gallstone ileus complicated by bowel perforation. (c) Slightly cranially to (b). (b) More caudally. Strangulated small bowel obstruction within a ventral hernia. At surgery. gallstone ileus with perforation of the distal ileum was confirmed. (b) At the pelvis. Strangulated obstruction caused by gallstone ileus. causing an obturation SB obstruction. (Reprinted with permission from [18]. 170 The British Journal of Radiology. a gallstone (black arrow) is impacted within a dilated small bowel (SB) loop. an ill-defined fluid collection with gas bubbles is seen within the bowel loop mesentery (black arrows).) Figure 15.R Zissin. (c) A coronal multiplanar reformation image shows the large lateral non-obstructed post-operative hernia (arrowheads) and the free peritoneal air (arrows). with an entrapped loop (arrow). (a) Contrast-enhanced CT at the upper abdomen shows gas within the intrahepatic bile ducts (arrows). more medially. A Osadchy and G Gayer Figure 14. free peritoneal fluid and gas bubbles (arrows) are seen.

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