Clinical picture Sonographic diagnosis of peptic ulcer perforation

A 54-year-old man visited our emergency department with severe upper abdominal pain. Physical examination revealed muscle guarding and rebound tenderness. Emergent sonography revealed marked thickening of the duodenal wall and a linear hyperechoic band involving the entire wall of the duodenal bulb (Figure 1, arrow). Small hyperechoic spots were found continuously moving from the band towards the abdominal cavity with formation of free air (Figure 2). A perforated duodenal ulcer with active air leakage was suspected. A chest X-ray revealed a small amount of subphrenic free air suggestive of hollow organ perforation (Figure 3). The patient underwent successful surgical repair of the perforated ulcer. Peptic ulcer diseases are common, and perforation is one of its most serious complications. Patients are usually diagnosed by medical history, physical examination and detection of subphrenic free air on plain chest X-ray. Although sonography is useful as a first-line diagnostic tool for acute abdomen in the emergency department, it is less helpful in the diagnosis of peptic ulcer perforation. Sonographic findings suggestive of peptic ulcer perforation include the presence of ascites, intraperitoneal free air and a linear echogenic band