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Table 2 Presenting symptoms, imaging and clinical considerations in relation to site and causes of small bowel and appendiceal perforation

From: Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Site Presentation CT findings Causes Cause specific findings Considerations
Small bowel Non-specific, abrupt sudden-onset pain, vomiting, anorexia, nausea, sepsis, peritonitis IP gas (minimal/absent), oral contrast leakage, mural defect, wall thickening, poor/inhomogeneous mural enhancement, mesenteric fluid, fat stranding, extraluminal faecal material Trauma Pneumoperitoneum not diagnostic in penetrating trauma, wound track extending to intestinal segment. History of trauma
IIschemia Decreased/absent bowel enhancement, pneumatosis intestinalis, gas/thrombi within mesenteric/portal vessels Mechanical obstruction, large vessel occlusion, venous outflow obstruction, vasculitis, sepsis, congestive heart failure, acute MI, hypovolemic shock
Inflammatory Phlegmon/abscess formation Typhoid fever, HIV, tuberculosis, hookworms
IBD Phlegmon/abscess formation, lengthy bowel wall thickenning, sinus tracts, fistulas Crohn's disease
Tumour Circumferential wall thickening aneurysmal luminal dilatation multifocal bowel involvement lymphadenopathy hepatosplenomegaly heterogeneous mass Commonly lymphoma adenocarcinoma malignant GISTs metastases
Diverticulae Inflamed diverticulum Meckel's diverticulum
Foreign body Foreign body,
may be located distal to perforation site
Common in ileocaecal area Avoid oral contrast
Iatrogenic persistent/progressively increasing free gas and/or ascites, oral contrast leakage Laparoscopic surgery, anastomotic leakage, endoscopic procedures. Pneumoperitoneum normal < 2 weeks post laparoscopy
Appendix Long standing abdominal pain, fever, muscle guarding Periappendiceal/IP gas, appendiceal wall defect, phlegmon/abscess, fat stranding, free fluid Inflammation Extraluminal appendicolith  
Tumour Luminal diameter > 1.3 cm,
mural calcifications, pseudomyxoma peritonei, mass, enhancing wall nodularity
  1. IP intraperitoneal perforation, MI myocardial infarction, HIV human immunodeficiency virus, IBD inflammatory bowel disease, GIST gastrointestinal stromal tumour