Author's Response to Reviews Luigi Camera ([email protected]) a Perforated Duodenal Ulcer Presenting with a Subphrenic Abscess Detected by Plain Abdominal Films and Confirmed by Mdct: a Case Report

Introduction: Peptic ulcer disease is still the major cause of gastro-intestinal perforation despite major improvements in both diagnostic and therapeutic strategies. While the diagnosis of a perforated ulcer is straightforward in typical cases, its clinical onset may be subtle because of co-morbidites and/or concurrent therapies. Case presentation: We report a case of a 53-year-old Caucasian male with a history of chronic myeloid leukaemia in maintainance therapy (100 mg/die) with Imatinib (Glivec) who was found to have a subphrenic abscess resulting from a perforated duodenal ulcer which had been clinically overlooked. The patient was febrile (38,5° C) with abdominal tenderness and hypoactive bowel sounds. In the upright abdominal film a huge air-fluid level could be appreciated in the right subphrenic space. In the supine film the extra-luminal air appear to extend to the subhepatic space and the hepato-duodenal fossa. At contrast-enhanced multi-detector CT a right subphrenic abscess was clearly depicted. The huge air-fluid collection extended from the subphrenic to the sub-hepatic anterior space. After oral administration of 500 cc of 3% diluted Diatrizoate Meglumine (Gastrografin) an extra-luminal leakage of the water-soluble iodinated contrast media could then be appreciated as a result a perforated duodenal ulcer. At surgery, the abscess was drained and extensive adhesiolysis had to be performed to expose the duodenal bulb where the ulcer was first identified by methylen blue administration and then sutured. Conclusion: While subphrenic abscesses are well known complications of perforated gastric or duodenal ulcer, they have nowadays become rare thanks to the advances in both diagnostic and therapeutic management of peptic ulcer disease. However, when this latter is not clinically suspected, the contribution of imaging may be substantial.