CASE 13835 Published on 08.07.2016

Forgotten but not disappeared: CT diagnosis of uncomplicated peptic ulcer


Abdominal imaging

Case Type

Clinical Cases


Tonolini Massimo, M.D.; Vella Adriana, M.D.; Bonzini Miriam, M.D.

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74
20157 Milan, Italy;

54 years, male

Area of Interest Stomach (incl. Oesophagus) ; Imaging Technique CT, CT-Quantitative
Clinical History
A middle-aged obese man with history of cigarette smoking suffered from nausea, vomiting, epigastric pain radiating to the back. A previous similar episode was attributed to reflux oesophagitis.
Physically, tender abdomen at deep palpation without peritonism was noted. Laboratory signs were consistent with systemic inflammation (14.000/mmc leukocytes, C-reactive protein 34 mg/l).
Imaging Findings
Requested to investigate severe, recurrent abdominal pain, urgent multidetector CT (Fig. 1) with multiplanar image viewing showed asymmetric hypoenhancing mural thickening of the pylorus and proximal duodenal bulb with mucosal enhancement, spared anterior aspect, and 2-cm roundish posterior outpouching filled by fluid and air. Associated findings included inflammatory-type stranding of surrounding fat and sub-centimetre regional lymphadenopathies.
Upper digestive endoscopy confirmed corresponding post-pyloric dorsal peptic ulcer with peripheral hyperaemia and negative biopsy findings for neoplasia. On further questioning, the patient admitted discontinuation of antacids and H2-blocker medications, use of nonsteroidal anti-inflammatory drugs to relieve chronic low back pain. Retrospectively, oedematous mural thickening with mucosal hyperenhancement at the posterior and superior aspects of the pylorus and proximal duodenal bulb was already visible on CT-angiography (Fig. 2) obtained 3 months earlier to rule out acute aortic diseases, without ulcer crater and perivisceral inflammation.
The patient ultimately did well on proton-pump inhibitors and anti-Helicobacter pylori therapy.
Peptic ulcers (PUs) correspond to defects in the digestive tract mucosa which extend through the muscularis mucosa. Despite the declining incidence after introduction of effective medications and of Helicobacter pylori (HP) eradication, peptic disease represents a major health issue reaching a 1-1.5% prevalence in some countries. Risk factors include smoking, obesity, nonsteroidal anti-inflammatory drugs use including low-dose aspirin. Among PUs, gastric ulcers prevail after 50 years of age whereas the more prevalent duodenal ulcers generally occur in younger patients. Uncomplicated PUs manifest with dyspepsia, bloating, early satiety or nausea, and sometimes present acutely with nonspecific abdominal pain, usually in the epigastrium. Complications include bleeding, perforation and obstruction in descending order of frequency [1-4].
PUs account for 10-20% of patients with unexplained abdominal pain presenting to emergency department (ED). Endoscopy is the mainstay diagnostic technique, but is invasive, often unfeasible or unavailable in ED. Conversely, multidetector CT is increasingly used to rapidly assess abdominal complaints and identify complications requiring hospitalization or surgery, and therefore usually represents the initial investigation performed in patients with unsuspected PU. Unfortunately, the stomach and duodenum are intrinsically difficult to evaluate on CT because of peristalsis, non-distended lumen or retained enteric content. Albeit uncomplicated PUs are generally missed, appropriate CT interpretation using multiplanar image reconstruction significantly improves the diagnostic power and confidence. Therefore, the aware radiologist may be the first to suspect PU and suggest endoscopy, thus preventing diagnostic delay and possible development of complications. Direct signs of gastric or duodenal ulcer include disruption of the normal mucosal enhancement corresponding to erosion through the muscularis mucosa, and luminal outpouching representing the ulcer crater through and beyond the gastroduodenal wall. However, 54% of gastroduodenal ulcers remain occult on CT, particularly those located in the duodenum and measuring less than 1.5 cm. Indirect signs which should be searched for include: low-attenuation mural thickening from submucosal oedema, generally asymmetric close to the ulceration site; diffuse or localised mucosal hyperenhancement from underlying gastritis or duodenitis; perivisceral fat inflammatory changes, and regional adenopathy [5, 6].
The commonest differential diagnoses include malignant ulcers, heralded by soft-tissue wall thickening, and secondary periduodenal inflammation from acute pancreatitis. Furthermore, CT may detect complications represented by active intraluminal bleeding, pneumoperitoneum, periduodenal air/fluid collections from contained perforation, and stomach overdistension from gastric outlet obstruction [5-10].
Uncomplicated PUs are treated conservatively with nasogastric tube, intravenous fluids and HP triple therapy [2, 4].
Differential Diagnosis List
Duodenal bulb ulcer from nonsteroidal anti-inflammatory drug abuse.
Duodenitis in acute pancreatitis
Groove pancreatitis
(Inflamed) duodenal diverticulum
Zollinger-Ellison syndrome
Crohn’s disease
Bleeding ulcer
Free ulcer perforation
Contained ulcer perforation
Peptic gastric outlet obstruction
Malignant gastroduodenal ulcer
Final Diagnosis
Duodenal bulb ulcer from nonsteroidal anti-inflammatory drug abuse.
Case information
DOI: 10.1594/EURORAD/CASE.13835
ISSN: 1563-4086