Q: To diagnose perforated peptic ulcer disease PUD), if water soluble oral contrast is given 

 A) Patient should be rotated 360 degrees and placed on the right side 
B) Patient should be rotated 360 degrees and placed on the left side 
C) Patient should be rotated 180 degrees and placed on the right side 
D) Patient should be rotated 180 degrees and placed on the left side 
E) KUB should be obtained 30 minutes after oral contrast in lordotic position 


 Answer: A

In this era of rapid CT scan, many old previous techniques have been forgotten, but they are cost effective, or at least academically should be known to a physician. In perforated PUD, free air in KUB is very diagnostic but it may be missing in one fifth of the cases. One other technique to confirm perforated PUD is to find  leakage of water soluble oral contrast. After administrating water soluble oral contrast, patient should be rotated 360 degrees and placed on the right side to fill the antrum and duodenum, and to document leakage.


References:

1. Wong CH, Chow PK. Posterior perforation of gastric ulcer. Dig Dis Sci 2004; 49:1882. 

2. Grassi R, Romano S, Pinto A, Romano L. Gastro-duodenal perforations: conventional plain film, US and CT findings in 166 consecutive patients. Eur J Radiol 2004; 50:30. 

3. Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg 1998; 133:1166.