Duodenal Perforation

  • Etiology: placement of a feeding tube, placement of a gastrojejunostomy tube, use of indomethacin to close a patent ductus arteriosus, blunt trauma
  • AXR left lateral decubitus: air above the liver (air between abdominal wall and liver)
  • AXR cross-table lateral: for small amounts of free air see tell-tale triangle sign of air between bowel loops, for large amounts of free air see air superiorly between abdominal wall and viscera
  • AXR supine: overall increased lucency of abdomen, American football sign of falciform ligament, inverted Y of umbilical artery ligaments, Rigler’s sign (see air outlining both sides of bowel wall)
  • Note: in inflamed abdomen (due to perforation) pneumoperitoneum may be loculated and not be classically seen on upright / decubitus / cross-table lateral views, may appear as fixed air collection that does not appear to conform to bowel

Cases of Duodenal Perforation

AXR of pneumoperitoneum due to malposition of gastrojejunostomy tube outside of bowel
Supine AXR (above) shows the tip of the gastrojejunostomy tube extending deep into the pelvis. Left lateral decubitus AXR (below) shows air between the abdominal wall and the liver.
AXR and gastrojejunostomy tube injection of pneumoperitoneum due to malposition of the gastrojejunostomy tube outside of the bowel
Supine (above left) and left lateral decubitus (above right) AXR show no evidence of air between the abdominal wall and the liver but on the decubitus view several concerning air bubbles project over the liver and appear extra-lumenal. The gastrojejunostomy tube was exchanged for a gastrostomy tube and AP image from a gastrostomy tube injection with water soluble contrast (below) shows contrast extravasating inferiorly out of the duodenum at the junction of the second and third parts of the duodenum.
Surgical image of duodenal perforation
Surgical image shows the forceps within a hole in the fourth portion of the duodenum.