Background: Gastrointestinal perforations are a frequent cause of acute abdominal symptomatology for patients in the emergency department. The aim of this study was to investigate the findings of multidetector-row computed tomography of gastrointestinal perforations and analyze the impact of any imaging signs on the presurgical identification of the perforation site. Methods: We retrospectively reviewed emergency MDCT findings of 93 patients submitted to surgery for gastrointestinal perforation at two different institutions. Two radiologists separately reviewed the emergency MDCT examinations performed on each patient, before and after knowing the surgical diagnosis of the perforation site. A list of findings was considered. Positive predictive values were estimated for each finding with respect to each perforation site, and correspondence analysis (CA) was used to investigate the relationship between the findings and each of the perforation types. Results: We did not find inframesocolic free air in sigmoid colorectal perforations, and in rare cases, only supramesocolic free fluid in gastroduodenal perforations was found. A high PPV of perivisceral fat stranding due to colonic perforation and general distension of upstream loops and collapse of downstream loops were evident in most patients. Conclusions: Our data could offer additional information on the perforation site in the case of doubtful findings to support surgeons, especially in planning a laparoscopic approach.