0:00

Okay, so here is our patient.

0:02

This is their chest X-ray.

0:03

You can see that there's free

0:04

air underneath the diaphragm.

0:06

Um, and this is a 43-year-old individual.

0:08

So I have to say in medicine and in radiology,

0:11

we are always gambling in the reading

0:13

room on what's the most likely diagnosis.

0:16

You know, this is snake eyes, not the best.

0:17

In general, you want to just think to yourself,

0:19

what's the probability of your location?

0:21

We know that this person has free air.

0:23

They have a perforated viscus,

0:24

they've come in with abdominal pain.

0:26

We usually say the line is at 55 years old, patients

0:28

younger than 55 are more likely to have upper tract

0:31

perforations from ulcer disease of the stomach

0:34

or duodenum, as opposed to people over 55 who are

0:37

more likely to come in with diverticular ruptures

0:40

from diverticulitis and with free air from that.

0:43

Okay, so perforated, duodenal

0:45

ulcers have multiple causes.

0:47

Um, I think the most common cause is usually NSAID use,

0:50

high-dose NSAIDs for, um, pain relief and the like.

0:53

H. pylori infection is being treated more frequently

0:56

and pretty aggressively, so not quite as common.

0:59

Obviously, we're all stressed, so who knows?

1:01

Smoking, a big cause of ulcers.

1:03

You'll see smoking cause marginal ulcers.

1:05

Definitely your gastric bypass patients.

1:07

Um, they'll come in with those.

1:08

That's unfortunate.

1:09

Alcohol and cancers of the stomach can sometimes cause.

1:13

Large malignant ulcers.

1:14

So you always want to think to yourself, oh,

1:16

do I see any signs that could be cancer?

1:18

Could it be a malignant ulcer?

1:19

Look for lymphadenopathy, especially any gastrohepatic,

1:21

hepatic lymphadenopathy, anything that's abnormal,

1:24

because those cases can be very concerning.

1:27

But most of our ulcers that we

1:28

see are probably from NSAIDs.

1:30

Our surgeons will go in, do a Graham patch.

1:32

That's basically where you

1:33

take your omentum and you just.

1:35

Stick it on top of the hole and

1:36

hope that it blocks itself off.

1:38

And they usually do.

1:39

So they do pretty well.

1:40

And then the patients are treated

1:41

for their underlying disease.

1:43

So upper tract perforation causing

1:46

significant upper midline abdominal pain

1:48

from duodenal and/or gastric ulcers.

1:51

Many causes for that.

1:52

Definitely more common your younger populations,

1:55

but we do see them in all comers, especially

1:57

patients who are taking high-dose NSAIDs.