title: Large Gastric Perforation Sealed by Splenic Lysis: Emphasis on Indirect Signs - A Rare Case Report.
abstract: BACKGROUND
  Gastric perforation is a life-threatening condition, requiring early and reliable discovery. The delay before surgical treatment is a strong determinant of poor outcome, associated complications and hospitalization costs. By using ultrasound and multi-detector computed tomography (MDCT) we can further evaluate undiagnosed cases of silent gastric perforations presenting with non-specific acute abdomen. Here we bring forth the role of a radiologist in cases of perforation which present with indirect signs involving the organs forming the stomach bed, like the spleen, pancreas and kidney.
  
  
  METHODS
  A 25-year-old male patient presented with an acute onset of severe upper abdominal pain radiating to the back and vomiting. MDCT of the abdomen was done which revealed atrophic pancreas with organized collection in the sub-capsular location indenting the superior pole of the left kidney. Spleen was not visualized. The most striking imaging finding in that case was destruction of the splenic parenchyma with protrusion of the remaining tissue into the stomach lumen. The hypothesis behind this was a cascade of events which started with gastric perforation, spillage of highly destructive gastric juice over the stomach bed and finally becoming silent with rapid sealing of the defect by the omentum and the spleen.
  
  
  CONCLUSIONS
  Acute abdomen is a diagnostic challenge to a clinician and radiologist with gastric perforation being a great mimicker of other urgent abdominal pathologies. To avoid a delayed diagnosis or a misdiagnosis, familiarity with typical and atypical imaging features is essential as in our case of splenic lysis. It acted as the 2(nd) policeman and provided a great clue to solve the diagnostic dilemma.
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Lalit
authors.initials: L
authors.lastname: Garg
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Mansi
authors.initials: M
authors.lastname: Jain
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Kishor
authors.initials: K
authors.lastname: Taori
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Ajinky
authors.initials: A
authors.lastname: Patil
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Anand
authors.initials: A
authors.lastname: Hatgaonkar
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Jawhar
authors.initials: J
authors.lastname: Rathod
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Swenil
authors.initials: S
authors.lastname: Shah
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Darshan
authors.initials: D
authors.lastname: Patwa
authors.affiliation: Department of Radiodiagnois, Government Medical College, Nagpur, India.
authors.forename: Akshat
authors.initials: A
authors.lastname: Kasat
keywords: Abdomen, Acute; Multidetector Computed Tomography; Pancreatitis; Peptic Ulcer Perforation; Spleen