关键词: 十二指肠后壁穿孔, 胆囊周围积液, 超声, 影像学检查, 消化道穿孔

Abstract:

Objective To analyze the imaging performance and clinical diagnosis and treatment process of one patient with peri-gallbladder fluid caused by the posterior duodenal perforation primarily diagnosed by ultrasound， and to provide the clinical diagnostic evidence for this disease. Methods The clinical data， laboratory examination， gastroscope performance， and imaging performance of one patient with peri-gallbladder fluid caused by the posterior duodenal perforation was collected. The process of diagnosis and treatment was recorded and followed up. The related literatures were reviewed to analyze the clinical characteristics and imaging performances of the posterior duodenal perforation. Results The patient was a 50-year-old male who had constant dull pain in the upper right abdomen for over 20 d， without obvious cause and intensified after meals， accompanied by radiculalgia in the right waist and back.The ultrasonic examination at a local hospital showed an occupying lesion in the gallbladder， and the patient came to our hospital for the further diagnosis and treatment. On the day of admission， the ultrasound examination showed poor fasting gallbladder filling， continuous and uniformly thickened gallbladder wall.The multiple strong echoes were observed in the gallbladder cavity， and the chaotic distributed hypoechoic and anechoic areas could be seen around the gallbladder， extending to the back of the duodenal bulb， and connected with the bulb by a narrow strip of gaseous shadow. The ultrasound results showed that there was perforation of the posterior wall of the duodenal bulb， leading to pericholecystic fluid accumulation， with poor gallbladder filling due to compression， and chronic inflammation of the gallbladder wall associated with gallstones. The enhanced computed tomography （CT） results clearly showed the perforation site in the posterior wall of the duodenal bulb， and the CT conclusion was consistent with the ultrasound conclusion. The gastroscope results showed a large deep ulcer on the posterior wall of the duodenal bulb， and it confirmed to be diagnosed as the peri-gallbladder fluid caused by ulcer perforation. A gastric tube and jejunal nutrition tube were inserted， and the symptomatic treatments such as anti-inflammation， analgesia， and acid suppression were carried out. The ultrasound reexamination within 3 months of treatment showed the peri-gallbladder fluid was gradually decreased and the gallbladder cavity was gradually filled.Since the patient’s gallbladder inflammation symptoms persisted，the cholecystectomy was performed， and it was pathologically diagnosed as chronic cholecystitis complicated with gallstones. Conclusion The posterior duodenal perforation is often misdiagnosed or missed due to atypical clinical manifestations.The imaging examination can assist in early clinical diagnosis. When the presence of abdominal gas does not interfere with observation， the ultrasound can serve as the first choice and effective method for the diagnosis of gastrointestinal perforation.

Key words: Posterior duodenal perforation, Peri-gallbladder fluid, Ultrasound, Radiographic examination, Gastrointestinal perforation