Ultrasound Pictures “Ultrasound Perforated Ulcer”

Clinical manifestations Perforated Ulcer: Acute-onset pain with muscular guarding, hematemesis, and a tarry stool.

Diagnosis Perforated Ulcer :

x History: Known ulcer disease
x Sonography: Free air; excludes other causes of pain
x Endoscopy: Demonstrates the ulcer
x Radiography:
– Abdominal radiograph: Free air
– Chest radiograph: Air crescent below the diaphragm leaflets

Sonographic findings Perforated Ulcer:

x Free air in the abdomen:
– Small amounts of air collect below the abdominal wall in the supine patient
(appearing sonographically as a continuous echogenic band with an incomplete acoustic shadow).
– When the upper body is slightly elevated, larger amounts of air collect below
the diaphragm leaflets.

Ultrasound Pictures Perforated Ulcer A, Ultrasound Pictures Perforated Ulcer B

a, b Free air in the abdomen following a perforation. a Echogenic band
over the liver. b Free air in left lateral decubitus.

ULTRASOUND PICTURES Free air following a perforation: echogenic band over the liver, associated with an incomplete acoustic shadow. The air over the liver is seen even more clearly when the
patient is scanned in left lateral decubitus. Arrows: Reverberations. RLL = right liver lobe

– In left lateral decubitus, air echoes appear superimposed over the echo pattern of the liver.
x Wall thickening can sometimes be detected at the ulcer site.

Accuracy of sonographic diagnosis Perforated Ulcer: As little as 1 mL of free air can be detected, and 10 mL cannot be missed. Sonography shows definite evidence for the presence of a perforation. The site of the perforation is demonstrated by endoscopy.