CTICasesPneumoperitoneum from Perforated Peptic Ulcer and Amiodarone Toxicity
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Imaging findings
A PE protocol CT showed diffuse ground glass opacity and reticulation, some bronchial dilatation, and architectural distortion in the lungs, initially mislabeled as edema. Small pleural effusions were also present. The gastric antrum and pylorus appeared thickened with an abnormal crater and other ulcers. Subsequent radiographs revealed free air with a Rigler sign, which was confirmed as a large volume of pneumoperitoneum on repeat CT. The chronic lung findings remained unchanged over time.
Key takeaways
Perforated peptic ulcer disease can cause pneumoperitoneum, which, if subtle, may be overlooked or misattributed (e.g., to colonic interposition). CT findings of gastric wall thickening and ulcers are key indicators. Chronic lung changes, such as ground glass opacity and reticulation, in a patient on high-dose amiodarone, are highly suggestive of amiodarone toxicity, distinguishable from acute edema by architectural distortion and lack of septal thickening. In critically ill patients, it is vital to prioritize and identify acute catastrophic findings like pneumoperitoneum amidst chronic or less urgent issues.
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