0:00

Here we have another contrast-enhanced CT scan

0:03

in a patient with abdominal pain, the liver looks

0:05

good here, but you notice something anterior

0:07

to the liver. Bringing on your lung windows.

0:11

See that there's indeed free air within the abdomen.

0:14

Lots of little dots of free air.

0:16

Now let's look back at the soft tissue window.

0:21

So we have a perforated viscous, and

0:22

we, we have a lot of choices here.

0:23

It could be from the stomach, it could be from the

0:25

colon, it could be from diverticulitis, it could be

0:27

from prior surgery, but we've excluded that by history.

0:30

Let's hope so.

0:31

This patient has quite a bit of ascites,

0:32

as well, so this is a problem for sure.

0:35

The liver is enhancing homogeneously, the spleen

0:38

looks good, but as you come down you notice that

0:40

the colon is quite dilated and fluid-filled as well.

0:43

And that surgery team, they are over your shoulder.

0:47

They want to know what is perforated, what is the

0:51

cause. They need to take this patient to surgery, and

0:54

um, determine what part of the bowel is perforated.

0:56

So you're going to play the odds.

0:58

That's how life is.

0:59

That's how we do things in radiology frequently.

1:01

And you'll notice that the stomach looks okay.

1:02

There aren't any bubbles of air near the stomach.

1:04

The colon is dilated and fluid-filled.

1:07

So you're going to put your money on colon

1:09

as your source of perforation, noticing

1:12

that the cecum looks pretty distended.

1:14

And that down near the cecum, there's just

1:16

tons of little tiny locules of free air.

1:19

Okay?

1:19

So the smallest little dots of air deep into

1:22

the mesentery seem to be around the cecum.

1:24

So I'm going to put my money on

1:26

the cecum as the location of perforation.

1:30

Let's look at this on coronal.

1:33

Again, free air, dilated colon.

1:37

Lots of little dots around the cecum, so I

1:40

would diagnose this as a cecal perforation.

1:45

Of the colon, and that would be my primary

1:48

diagnosis, but there could be some fun to come.

1:50

So take a look at this study a little

1:52

bit more, and then we'll move on to the

1:54

slides to explain further about this case.