Pediatric Gastric Perforation

Etiology:
— Placement of a nasogastric tube
— Placement of a gastrostomy or gastrojejunostomy tube
— Use of indomethacin to close a patent ductus arteriosus
Imaging CXR upright: Air beneath the diaphragm
Imaging AXR upright: Air beneath the diaphragm
Imaging AXR left lateral decubitus: Air above the liver (air between abdominal wall and liver)
Imaging 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
Imaging 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: When you see massive amounts of free air consider spontaneous gastric perforation
Note: A nasogastric tube tip that projects over the pelvis should be suspected of not being in the stomach
Note: In inflamed abdomen (due to perforation) pneumoperitoneum may be loculated and not be classically seen on upright and decubitus and cross-table lateral views and may appear as fixed air collection that does not appear to conform to bowel
DDX:
Complications:
Treatment:
Clinical:

Radiology Cases of Gastric Perforation

AXR of gastric perforation from nasogastric tube placement — Supine AXR (left) shows a large amount of air within the abdomen and air outlining both sides of bowel wall (Rigler’s sign) in the right lower quadrant. Supine AXR taken later after pulling back of the nasogastric tube out of the stomach shows visualization of the falciform ligament over the spine (American football sign)

AXR of gastric perforation from nasogastric tube placement — Supine AXR (above) shows increased lucency throughout the central abdomen and left lateral decubitus AXR (below) shows air between the abdominal wall and the liver. On both views the tip of the nasogastric tube projects inferior to the gas-filled stomach.

AXR of gastric perforation from nasogastric tube placement — Supine and left lateral decubitus AXR (left) show a nasogastric tube with its tip deep in the pelvis without evidence of free air. Supine AXR taken after pulling the nasogastric tube back into the stomach (above right) shows increased lucency throughout the central abdomen and left lateral decubitus AXR taken at same time (below right) shows air between the abdominal wall and the liver.

Surgery Cases of Gastric Perforation

Surgical image of gastric perforation — Surgical image shows the surgical forceps in the center of the image delineating the size of the hole in the antrum of the stomach.