The British Journal of Radiology, 82 (2009), 162171

PICTORIAL REVIEW

Abdominal CT findings in small bowel perforation

1

R ZISSIN,

MD,

A OSADCHY,

MD

and 2G GAYER,

MD

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 [15]. 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 (1942%) [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) [14]. 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) [2,47]. 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.

Aetiology
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: zisinrivka@clalit.org.il

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
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Pictorial review: Small bowel perforation CT findings

relatively insensitive signs of transmural SB injury (Figures 3 and 6) [8]. On contrast-enhanced CT, the combination of bowel wall thickening and mural discontinuity is the most accurate indicator of bowel injury, having a sensitivity of 75%, a specificity of 84% and an accuracy of 81% (Figure 4) [8]. A moderate to large volume of intraperitoneal fluid, without visible signs of solid organ injury, and mesenteric infiltration are other important (and frequent) CT signs suggestive of bowel or mesenteric injury (Figure 4) [7, 8].

Penetrating abdominal trauma

A high incidence of hollow visceral injury is seen in patients with thoracoabdominal penetrating injuries, some of which may be clinically occult at admission. The use of CT for these patients is controversial. However, for haemodynamically stable patients without (i) signs of peritoneal irritation, (ii) blood on rectal examination or (iii) free fluid on FAST (focused assessment with sonography for trauma) examination, triple contrast CT (oral, rectal and intravenous) has been introduced recently [9]. When assessing the CT findings, it is important to know the number of wounds and the entry site(s). In contrast to blunt trauma, the presence of free intraperitoneal air alone is not considered diagnostic of bowel injury following penetrating trauma, as it can enter the peritoneal cavity by the bullet or the knife wound. The most specific CT finding of bowel injury is leaking of oral contrast (Figure 7). Shanmuganathan et al [9] found that the sensitivity of this finding was only 19%, whereas bowel wall thickening with adjacent mesenteric contusion had a sensitivity of 42%. The most sensitive finding, found in 77% of cases, was a wound track extending up to the injured bowel.

Ingestion of a foreign body

Ingested foreign bodies (FBs) rarely cause gastrointestinal perforation, as most pass uneventfully in the stool. Long, hard or sharp objects such as fish bones, chicken bones and toothpicks may, however, cause perforation. Most cases are accidental, and are commonly seen in children and elderly people, as well as in patients with dentures, mental retardation or those who abuse alcohol. Intentional FB ingestion occurs in prisoners and those attempting suicide. Common sites of perforation include less fixed segments or those with acute angulations, such as the ileum and the ileocaecal and rectosigmoid segments [3, 10, 11]. As the clinical suspicion is low and the clinical presentation is nonspecific, imaging with a high index of suspicion plays an important role in the diagnosis. Free pneumoperitoneum is rare, as the FB is gradually impacted and the perforation is locally covered with fibrin. Common CT findings include localized pneumoperitoneum and infiltrated fat near a thickened bowel segment. The definitive CT diagnosis is established by identifying the FB (Figures 2, 5, 8 and 9) [3, 10, 11]. In cases of calcified FBs, e.g. fish or chicken bones, or metallic FBs, these are
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Figure 1. Ileal perforation in a patient with Crohns disease

(CD). (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)), compatible with exacerbation of CD, and extraluminal gas bubbles (arrowheads), indicating perforation. A small amount of free peritoneal fluid is also present. At laparotomy, transmural ileal perforation was found and resected. Histology revealed changes of active CD.

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

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Figure 4. Jejunal perforation following blunt abdominal

trauma. Contrast-enhanced CT at the mid-abdomen shows the combination of small bowel wall thickening and mural discontinuity (thin arrows), as well as mesenteric haematoma (thick arrow).

Figure 3. Jejunal perforation following blunt abdominal

trauma. 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.

Figure 5. Small bowel (SB) perforation caused by a chicken bone. (a) Contrast-enhanced CT at the lower abdomen shows
extraluminal air (arrow) adjacent to a thickened ileal loop. More cranially, on (b) abdominal and (c) bone window settings, an intraluminal hyperdense foreign body (arrow in (c)) is seen within the slightly dilated SB loop, with some fluid and increased density within the adjacent mesentery (arrows in (b)).

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Figure 6. Jejunal perforation following blunt abdominal trauma. 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). (c) Slightly more caudally, a thickened wall jejunal segment (white arrow) and free gas bubbles within the adjacent mesentery are seen (black arrows).

Table 1. 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. Segmental bowel wall thickening with mural discontinuity. Free peritoneal fluid in the absence of a solid organ injury. Penetrating abdominal Extraluminal contrast. Bowel wall thickening with adjacent mesenteric contusion. A wound track trauma extending up to the injured bowel. Ingestion of a foreign body Segmental bowel wall thickening adjacent to extraluminal gas bubbles. Demonstration of a FB. (FB) Iatrogenic Accidental intra-operative Leaking oral contrast in the presence of intact anastomosis. injury Endoscopic injury Retroperitoneal air with leakage of the oral contrast. Bowel inflammation Crohns disease Extraluminal air or oral contrast and a thickened wall SB loop, often with multilayered enhancement, with hypervascularity at its mesenteric side. Ischaemic Direct vascular occlusion Intravascular filling defect associated with the following findings. Strangulated small bowel Mural thickening with hypoenhancement or a lack of enhancement of SB loops, blurred obstruction mesenteric vessels with localized mesenteric fluid, pneumatosis intestinalis, portal vein gas and pneumoperitoneum. Vasculitides Neoplasms Lymphoma, mainly during Extraluminal air or oral contrast and the SB tumour. treatment

more easily detected on a bone window setting (Figures 5 and 8). In cases of wooden FBs, e.g. skewers and chopsticks, these have either low or high attenuation: dry wood has high air content, seen on a lung window setting (Figure 9), whereas fresh wood has high water content and a higher density (Figure 2).

Iatrogenic SB injury Intra-operative injury Laparoscopic surgery has now replaced many laparotomy procedures. Rarely, serious complications involving the GIT may occur, caused by the laparoscopic instruments [12, 13]. The SB is the most commonly affected site and the injury is usually discovered and treated during surgery. Unrecognized laparoscopyinduced bowel injury is associated with a high postoperative morbidity rate, necessitating early CT imaging. In reconstructive GIT surgery, the finding of
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Figure 7. Ileal perforation following a penetrating abdominal trauma. Contrast-enhanced CT at the pelvis shows free peritoneal fluid and air (white arrows), as well as extraluminal oral contrast (black arrows). The British Journal of Radiology, February 2009

Pictorial review: Small bowel perforation CT findings

Figure 8. 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, one loop with mural thickening (thick arrow in (a)). A small amount of mesenteric fluid (thin arrows in (a)) is seen, probably caused by a foreign body (white arrow in (b)), which is shown to be hyperdense.

Figure 9. Ileal perforation from an ingested fragment of a skewer. Contrast-enhanced CT at the lower abdomen shows an ill-defined inter-loop inhomogeneous abscess with a faint hypodense line (arrowhead). (b) Longitudinal sonography at the level of (a) shows a hyperechoic line (arrows) embedded within a hypoechoic mass below the peritoneal stripe. On laparotomy, a fragment of a wood skewer was found. (Reprinted with permission from [11].)

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Figure 10. Ileal perforation 5 days after an elective laparoscopic ileocolectomy for Crohns disease. (a) Contrastenhanced CT at the level of the anastomosis (arrow) shows preserved perianastomotic fat. (b) More caudally, leakage of the oral contrast extending into the subcutaneous soft tissue (arrowhead) is seen. On re-laparotomy, a small bowel loop injury was found and repaired.

Figure 11. Duodenal perforation during endoscopic ultrasound for a pancreatic mass. (a) Non-contrast CT shows retroperitoneal extraluminal air (arrows) in the right anterior pararenal space. (b) Repeat scanning, in the right decubitus position, after administration of oral contrast demonstrates the leaking of contrast (arrows).

extraluminal oral contrast, indicating a leak, in the presence of an intact anastomotic site suggests diagnosis of accidental bowel injury (Figure 10).

Whenever a retroperitoneal perforation is detected, administration of oral contrast is indicated, as its leakage is diagnostic of a duodenal perforation (Figure 11b) [6].

Endoscopic injury Perforation of the duodenum may occur during endoscopic procedures such as endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. Duodenal perforation may be retroperitoneal or, rarely, intraperitoneal, with rapid development of peritonitis and sepsis. In retroperitoneal perforation (either ductal or duodenal), air within the anterior pararenal space is demonstrated (Figure 11a), sometimes associated with intraperitoneal and even mediastinal air. We recommend the use of non-contrast CT to verify any extraluminal contrast originating from the endoscopic procedure.
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Crohns disease and perforation

The usual ileal-perforating complications of Crohns disease (CD) are often sealed off because of inter-loop adhesions, leading to phlegmon and abscess formation with localized peritonitis. Free perforation, although rare, is a life-threatening complication reported in up to 3% of cases [14, 15]. SB perforation may occur in a patient with known CD, or may rarely be the first presentation of previously unknown inflammatory bowel disease. CT helps to detect both the perforation and the unsuspected CD as its cause, often presenting with typical findings of active CD (Figures 1 and 12) [14].
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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, 17]. Various vasculitides, characterized by inflammation and necrosis of small systemic blood vessels, including the visceral vessels of the GIT, have been reported rarely as a cause of ischaemic intestinal perforation [16]. Prompt diagnosis and treatment is required for a strangulated bowel. The CT findings suggestive of strangulation include intestinal wall thickening, mural hypoperfusion, blurring of the mesenteric vessels with localized mesenteric fluid, and free peritoneal fluid. More specific findings of bowel infarction are lack of bowel wall enhancement, pneumatosis intestinalis, gas in the portal vein or pneumoperitoneum (Figures 14 and 15) [1618].

SB neoplasm and perforation

Primary or metastatic SB tumours are uncommon, and have non-specific clinical manifestations. Rarely, perforation of a SB neoplasm occurs, presenting with an acute abdomen [4, 19]. Perforation is most often related to SB lymphoma, especially in patients with primary malignant lymphoma receiving chemotherapy and steroids (Figure 16); it can also occur in malignant stromal tumours of the SB [20]. On CT, both the perforation and the cavitary tumour can be seen (Figure 16).

Conclusions
Figure 12. Ileal perforation from previously unknown
Crohns disease (CD). (a) Contrast-enhanced CT at the lower abdomen shows mural thickening of the terminal ileum, with luminal narrowing and dilated vasa recta in the adjacent mesentery (arrows), findings suggestive of acute CD. (b) More cranially, extraluminal gas bubbles (arrows) are seen, indicative of a perforation. On laparotomy, ileocolectomy was performed, revealing CD with perforation.

Familiarity with the specific CT features of SB perforation, i.e. the presence of extraluminal air or oral contrast in an intact abdomen coupled with additional CT findings, and the clinical setting should lead to a rapid and accurate diagnosis.

Figure 13. Acute superior mesenteric artery thrombosis in a patient with end-stage renal disease. (a) Contrast-enhanced CT at the upper abdomen shows intrahepatic portal vein gas (arrows). Lower down, on (b) abdominal and (c) lung window settings, marked pneumatosis intestinalis is seen (arrows), as well as intraperitoneal air (arrowhead). The British Journal of Radiology, February 2009 169

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Figure 14. Strangulated obstruction caused by gallstone ileus. (a) Contrast-enhanced CT at the upper abdomen shows gas within the intrahepatic bile ducts (arrows). (b) At the pelvis, a gallstone (black arrow) is impacted within a dilated small bowel (SB) loop, causing an obturation SB obstruction. (c) Slightly cranially to (b), an ill-defined fluid collection with gas bubbles is seen within the bowel loop mesentery (black arrows). These findings were interpreted as gallstone ileus complicated by bowel perforation. At surgery, gallstone ileus with perforation of the distal ileum was confirmed. (Reprinted with permission from [18].)

Figure 15. Strangulated small bowel obstruction within a ventral hernia. (a) Contrast-enhanced CT at the mid-abdomen shows a large post-operative hernia (arrowheads) and a smaller one, more medially, with an entrapped loop (arrow). (b) More caudally, free peritoneal fluid and gas bubbles (arrows) are seen. (c) A coronal multiplanar reformation image shows the large lateral non-obstructed post-operative hernia (arrowheads) and the free peritoneal air (arrows).

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Figure 16. Ileal perforation in a patient with non-Hodgkins lymphoma following chemotherapy. (a) Contrast-enhanced CT at the upper abdomen shows intraperitoneal gas bubbles (arrows). (b) At the pelvis, a thick-walled annular lesion with aneurismal luminal dilatation of an ileal loop (black arrows) is seen with mural perforation (white arrow).

Acknowledgments
We gratefully acknowledge Marjorie Hertz, MD, for her assistance in the preparation of the manuscript.

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