Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis
Tóm tắt
Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented. • Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs
• Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis
• CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs
• Currently the commonest complication, haemorrhage may be treated with transarterial embolisation
• Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation
Tài liệu tham khảo
Fashner J, Gitu AC (2015) Diagnosis and treatment of peptic ulcer disease and H. Pylori infection. Am Fam Physician 91:236–242
Uyanikoglu A, Danalioglu A, Akyuz F et al (2012) Etiological factors of duodenal and gastric ulcers. Turk J Gastroenterol 23:99–103
Lee D, Park MH, Shin BS et al (2016) Multidetector CT diagnosis of non-traumatic gastroduodenal perforation. J Med Imaging Radiat Oncol 60:182–186
Kumar A, Muir MT, Cohn SM et al (2012) The etiology of pneumoperitoneum in the 21st century. J Trauma Acute Care Surg 73:542–548
Allen BC, Tirman P, Tobben JP et al (2015) Gastroduodenal ulcers on CT: forgotten, but not gone. Abdom Imaging 40:19–25
Guniganti P, Bradenham CH, Raptis C et al (2015) CT of gastric emergencies. Radiographics 35:1909–1921
Kitchin DR, Lubner MG, Menias CO et al (2015) MDCT diagnosis of gastroduodenal ulcers: key imaging features with endoscopic correlation. Abdom Imaging 40:360–384
Lau JY, Sung J, Hill C et al (2011) Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 84:102–113
Ba-Ssalamah A, Prokop M, Uffmann M et al (2003) Dedicated Multidetector CT of the stomach: spectrum of diseases. Radiographics 23:625–644
Tonolini M, Vella A, Bonzini M (2016) Forgotten but not disappeared: CT diagnosis of uncomplicated peptic ulcer {Online}. EuroRAD case 13835: URL: http://www.eurorad.org/case.php?id=13835. doi: 10.1594/EURORAD/CASE.13835
McNeeley MF, Lalwani N, Dhakshina Moorthy G et al (2014) Multimodality imaging of diseases of the duodenum. Abdom Imaging 39:1330–1349
Jayaraman MV, Mayo-Smith WW, Movson JS et al (2001) CT of the duodenum: an overlooked segment gets its due. Radiographics 21 Spec No:S147–S160
Zissin R, Osadchy A, Gayer G et al (2002) Pictorial review. CT of duodenal pathology. Br J Radiol 75:78–84
Heller MT, Haarer KA, Itri JN et al (2014) Duodenum: MDCT of acute conditions. Clin Radiol 69:e48–e55
Lee CW, Sarosi GA Jr (2011) Emergency ulcer surgery. Surg Clin North Am 91:1001–1013
Satoh K, Yoshino J, Akamatsu T et al (2016) Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol 51:177–194
Laursen SB, Jakobsen M, Nielsen MM et al (2015) Transcatheter arterial embolization is the first-line therapy of choice in peptic ulcer bleeding not responding to endoscopic therapy. Scand J Gastroenterol 50:264–271
Tonolini M, Vella A (2016) Peptic duodenal stricture causing gastric outlet obstruction: CT diagnosis with endoscopic correlation {Online}. EuroRAD URL: http://www.eurorad.org/case.php?id=13857. doi: 10.1594/EURORAD/CASE.13857
Millet I, Doyon FC, Pages E et al (2015) CT of gastro-duodenal obstruction. Abdom Imaging 40:3265–3273
Kimmins MH, Billingham RP (2001) Duodenal Crohn’s disease. Tech Coloproctol 5:9–12
Tonolini M (2017) Pancreatic abscess, a rare complication of peptic ulcer disease {Online}. EuroRAD URL: http://www.eurorad.org/case.php?id=14507. doi: 10.1594/EURORAD/CASE.14507
Tonolini M (2013) Spontaneous pneumobilia revealing choledocho-duodenal fistula: a rare complication of peptic ulcer disease. J Emerg Trauma Shock 6:146–147
Sadatomo A, Koinuma K, Zuiki T et al (2013) Retroperitoneal abscess associated with a perforated duodenal ulcer. Clin J Gastroenterol 6:373–377
Yoshida H, Onda M, Tajiri T et al (1999) A case of abscess caused by a penetrating duodenal ulcer. Hepato-Gastroenterology 46:2379–2381
Jaballah S, Sabri Y, Karim S (2001) Choledochoduodenal fistula due to duodenal peptic ulcer. Dig Dis Sci 46:2475–2479
Shimono T, Nishimura K, Hayakawa K (1998) CT imaging of biliary enteric fistula. Abdom Imaging 23:172–176
Xi B, Jia JJ, Lin BY et al (2016) Peptic ulcers accompanied with gastrointestinal bleeding, pylorus obstruction and cholangitis secondary to choledochoduodenal fistula: a case report. Oncol Lett 11:481–483
Hoppenstein JM, Medoza CB Jr, Watne AL (1971) Choledochoduodenal fistula due to perforating duodenal ulcer disease. Ann Surg 173:145–147