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The Peritoneal Cavity Part I: Abdominal Sonography Abdomen and Superficial Structures Objectives Identify the potential spaces of the peritoneum and the organs and/or ligaments that divide them on diagram.Identify Identify the potential spaces of the peritoneum on sonogram.Identify State the organs located in the peritoneum.State Explain the role greater omentum and mesentery play in limiting the extent of pathology.Explain Recognize the sonographic appearance of benign and malignant changes seen in the peritoneum. Recognize Analyze sonographic images of the peritoneum for pathology.Analyze THE PERITONEUM The Peritoneum is the serous membrane lining the walls of the abdominal cavity. It covers the abdominal viscera. • The peritoneum that covers the abdominal organs is known as the visceral peritoneum. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj0u-yHjbHTAhXC7SYKHaDWCncQjRwIBw&url=https://www.slideshare.net/VischaMarvidiantika/23-peritoneum&psig=AFQjCNGbFIGVxjEL18_Xt51SusKpth5meg&ust=1492711166307051 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj0u-yHjbHTAhXC7SYKHaDWCncQjRwIBw&url=https://www.slideshare.net/VischaMarvidiantika/23-peritoneum&psig=AFQjCNGbFIGVxjEL18_Xt51SusKpth5meg&ust=1492711166307051 The peritoneum that lines the abdominal cavity is known as the parietal peritoneum https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj0u-yHjbHTAhXC7SYKHaDWCncQjRwIBw&url=https://www.slideshare.net/VischaMarvidiantika/23-peritoneum&psig=AFQjCNGbFIGVxjEL18_Xt51SusKpth5meg&ust=1492711166307051 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj0u-yHjbHTAhXC7SYKHaDWCncQjRwIBw&url=https://www.slideshare.net/VischaMarvidiantika/23-peritoneum&psig=AFQjCNGbFIGVxjEL18_Xt51SusKpth5meg&ust=1492711166307051 Layers • The outer layer: parietal peritoneum • The inner layer: visceral peritoneum Parietal peritoneum is attached to the abdominal wall. Visceral peritoneum is wrapped around the internal organs that are located inside the abdominal cavity. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves. Peritoneal cavity • The peritoneal cavity is a potential space between the parietal and visceral peritoneum. • Contains peritoneal fluid having (water, electrolytes, leukocytes and antibodies) Peritoneal cavity The fluid functions are: It acts as a lubricant, enabling free movement of the abdominal viscera. The antibodies fight infection. Peritoneal cavity Ordinarily, the peritoneal cavity is only of capillary thinness; however, it is referred to as a potential space because excess fluid can accumulate in the peritoneal cavity resulting in the clinical condition of ascites. • The peritoneal cavity forms a completely closed sac in the male; in the female there is a communication with the retroperitoneal cavity through the uterine tubes, uterus, and vagina. Subdivisions of the Peritoneal Cavity The peritoneal cavity can be divided into the greater and lesser peritoneal sacs. http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwjm1Z_uv67TAhXBTCYKHaFlC80QjRwIBw&url=http://teachmeanatomy.info/abdomen/areas/peritoneal-cavity/&psig=AFQjCNFOWGcRHFrehP4clyqHD5V73Ef7wg&ust=1492621857645381 http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwjm1Z_uv67TAhXBTCYKHaFlC80QjRwIBw&url=http://teachmeanatomy.info/abdomen/areas/peritoneal-cavity/&psig=AFQjCNFOWGcRHFrehP4clyqHD5V73Ef7wg&ust=1492621857645381 Subdivisions of the Peritoneal Cavity The greater sac comprises the majority of the peritoneal cavity. Greater sac The Greater Sac Divided into two compartments by the mesentery of the transverse colon . • The supracolic compartment • The infracolic compartment The Greater Sac The supracolic compartment lies above the transverse mesocolon and contains the stomach , liver and spleen. The Greater Sac The infracolic compartment lies below the transverse mesocolon and contains the small intestine, ascending and descending colon. The infracolic compartment is further divided into left and right infracolic spaces by the mesentery of the small intestine. The Greater Sac The supracolic and infracolic compartments are connected by the paracolic gutters Subdivisions of the Peritoneal Cavity The lesser sac (also known as the omental bursa) is smaller and lies posterior to the stomach and lesser omentum. http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwjm1Z_uv67TAhXBTCYKHaFlC80QjRwIBw&url=http://teachmeanatomy.info/abdomen/areas/peritoneal-cavity/&psig=AFQjCNFOWGcRHFrehP4clyqHD5V73Ef7wg&ust=1492621857645381 http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwjm1Z_uv67TAhXBTCYKHaFlC80QjRwIBw&url=http://teachmeanatomy.info/abdomen/areas/peritoneal-cavity/&psig=AFQjCNFOWGcRHFrehP4clyqHD5V73Ef7wg&ust=1492621857645381 Lesser Sac (Omental Bursa) The omental bursa allows the stomach to move freely against the structures posterior and inferior to it. Lesser Sac (Omental Bursa) Lesser Sac (Omental Bursa) The omental bursa is connected with the greater sac through an opening in the omental bursa, the epiploic foramen. Lesser Sac (Omental Bursa) The epiploic foramen is situated posterior to the free edge of the lesser omentum (the hepatoduoden al ligament). Omental Foramen(epiploic foramen) OMENTUM The omentum is made up of two layers of fatty tissues and both supports and covers the organs and intestines found in this area of the body. OMENTUM There are two parts of the omentum: • the greater omentum • the lesser omentum. OMENTUM The omentum is responsible for storing fat deposits and connecting the intestines and stomach to the liver respectively. OMENTUM Hangs in front of the stomach and intestine It is an apron-like flap of tissue which hangs from the underside of the stomach and aids circulation in the abdomen The greater omentum is given off from the greater curvature of the stomach, forms a large sheet that lies over the intestines. Contains blood vessels, nerves, and other structures between these layers. Functions of the greater omentum The functions of the greater omentum are: • Fat deposition, having varying amounts of adipose tissue. • Infection and wound isolation; It may also physically limit the spread of intraperitoneal infections. Greater Omentum Lesser omentum Also known as the gastrohepatic omentum or small omentum. A double layer structure located from the beginning of the duodenum and stomach’s lesser curvature to the liver. Lesser Omentum The term mesentery is often used to refer to a double layer of visceral peritoneum Mesentery Attaches the small intestine and much of the large intestine to the posterior abdominal wall. Mesentery vs omentum Mesentery is the support tissue that the intestine is rooted into, and the omentum is a fatty blanket that hangs down in front of all of the intestines. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwiz0KLdkrHTAhVH4CYKHWc4DwcQjRwIBw&url=https://www.pinterest.com/pin/397090892129861390/&psig=AFQjCNF_ed0PM3ZtdEwD1hMIl5AWjzMIZA&ust=1492712820198775 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwiz0KLdkrHTAhVH4CYKHWc4DwcQjRwIBw&url=https://www.pinterest.com/pin/397090892129861390/&psig=AFQjCNF_ed0PM3ZtdEwD1hMIl5AWjzMIZA&ust=1492712820198775 Retroperitoneal Organs and Vascular Structures • Retroperitoneal organs and vascular structures remain posterior to the cavity and are covered anteriorly with peritoneum: • Urinary system • Aorta • Inferior vena cava • Colon • Pancreas • Uterus • Bladder. Potential spaces of the peritoneum • Left anterior subphrenic space • Right subphrenic space • Left posterior suprahepatic space • Hepatorenal space also known Morrison pouch or space • Omental bursa • Right and left paracolic gutters • Vesicorectal space • Rectouterine space also known as posterior cul de sac or pouch of Douglas or rectovaginal pouch • Uterovesicle space also known uterovesicle pouch or anterior cul de sac • Space of Retzius also called prevesicle or retropubis space Subphrenic spaces The subphrenic spaces are recesses in the greater sac of the abdominal cavity between the anterior diaphragmatic surface of the liver and diaphragm. Subphrenic spaces They are separated into left and right subphrenic spaces by the falciform ligament of the liver. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjf0ZjmlrHTAhWKwiYKHe8bD-oQjRwIBw&url=https://rjjaramillo.wordpress.com/2013/06/01/trauma-fast-exam/&psig=AFQjCNH_Pp1Wn0nQxxtMidcDvM2XrOBirA&ust=1492713884772718 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjf0ZjmlrHTAhWKwiYKHe8bD-oQjRwIBw&url=https://rjjaramillo.wordpress.com/2013/06/01/trauma-fast-exam/&psig=AFQjCNH_Pp1Wn0nQxxtMidcDvM2XrOBirA&ust=1492713884772718 Subphrenic abscesses Subphrenic abscesses generally occur as a result of accumulation of pus in the left or right suphrenic spaces as consequence of peritonitis. They are more common in the right side due to increased frequency of appendicitis and rupture of duodenal ulcer. Hepatorenal Space Also referred to as Morrison Pouch This peritoneal potential space is created by the peritoneum, reflecting from the liver over the right kidney and right posterior peritoneal wall. When the patient is in a supine position this space is most gravity-dependent potential space of the abdominal cavity, collecting fluid from the supracolic area and the lesser sac. https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjv7NX37KnUAhVF2SYKHSNSATIQjRwIBw&url=https://en.wikipedia.org/wiki/Focused_assessment_with_sonography_for_trauma&psig=AFQjCNHQ40iojOglOLxRxa26c7lQDky4EA&ust=1496860182066924 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjv7NX37KnUAhVF2SYKHSNSATIQjRwIBw&url=https://en.wikipedia.org/wiki/Focused_assessment_with_sonography_for_trauma&psig=AFQjCNHQ40iojOglOLxRxa26c7lQDky4EA&ust=1496860182066924 http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjS2uLt7KnUAhWEZiYKHQbjCZwQjRwIBw&url=http://www.ultrasoundpaedia.com/fast-scan/&psig=AFQjCNHQ40iojOglOLxRxa26c7lQDky4EA&ust=1496860182066924 http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjS2uLt7KnUAhWEZiYKHQbjCZwQjRwIBw&url=http://www.ultrasoundpaedia.com/fast-scan/&psig=AFQjCNHQ40iojOglOLxRxa26c7lQDky4EA&ust=1496860182066924 Right and Left Paracolic Gutters Potential spaces found along the lateral ascending and descending colon that conducts fluid between the supracolic compartment of the abdomen and infracolic compartment of the inferior abdomen and pelvis. Important determining the extension of disease. Vesicouterine pouch Known as Anterior cul-de-sac. Located anterior to fundus between uterus and bladder 49 Rectouterine pouch Known as Posterior cul-de-sac or Pouch of Douglas. Located posterior to uterine body and cervix, between uterus and rectum. 50 Rectouterine pouch When the female is in a supine position this space is the most gravity dependent. Retropubic space Also known as Space of Retzius or prevesicle space. Located between bladder and symphysis pubis 52 Vesicorectal space Potential space in males Potential space created by the peritoneal reflection over the rectum and posterior bladder wall Pathologies of the peritoneal cavity • Ascites • Peritoneal abscess • Hemoperitoneum • Hematoma • Pseudomyxoma peritonei • Fluid collections (seroma, Lymphocele, biloma and urinoma) • Peritoneal masses Ascites refers to an accumulation of excess fluid in the peritoneal cavity. It can occur in conjunction with infection and peritonitis, however it is more commonly caused by portal hypertension secondary to cirrhosis of the liver. http://teachmeanatomy.info/wp-content/uploads/Ascites.jpg http://teachmeanatomy.info/wp-content/uploads/Ascites.jpg Other causes include: • malignancies of the GI tract • malnutrition • heart failure • mechanical injuries which result in internal bleeding. http://teachmeanatomy.info/wp-content/uploads/Ascites.jpg http://teachmeanatomy.info/wp-content/uploads/Ascites.jpg Patients present with : • distended abdomen • discomfort • nausea • dyspnea. Ascites Ascites the excessive accumulation of serous fluid in the peritoneal cavity. Causes of ascites: • Cirrhosis (most Common) • Congestive heart failure • Cancer • Tuberculosis • Peritonitis Ascites Gallbladder thickening is usually seen with ascites Ascites The mechanism that produces ascites are complex and incompletely understood. Two mechanism that produce ascites are: • Low serum osmotic pressure (protein loss). • High portal venous pressure. Ascites Ascites is commonly found • Inferior aspect of the Right lobe of the liver • Morrison pouch • Pelvic cul de sac • Paracolic gutter Ascites • Ascites can be treated successfully with Transjugular intrahepatic portal systemic shunt which lower portal pressure. This shunt is place using jugular access and it is place between the RHV and the RPV) Ascites • Benign ascites is indicated by freely floating bowel . • With malignant ascites , the bowel loop is tethered to the posterior abdominal wall surrounded by complex or loculated fluid collection. Causes of ascites include: • An abdominal injury • An abdominal infection (peritonitis) • Scarring of the liver tissue (cirrhosis) • Liver failure • Cancer Ascites Loculated Ascites Exudative Ascites Paracentesis is a procedure to remove fluid that has collected in the abdomen (peritoneal fluid). The fluid buildup is called ascites. Paracentesis can relieve abdominal pressure and pain, improve kidney and intestinal function and help patients overcome difficulty breathing. It may also be performed to check for liver cancer or other types of cancer. For the procedure, the patient’s belly is cleaned and a local anesthetic is administered to numb the area. A long, thin needle is then carefully inserted into the belly. The excess fluid is extracted through the hollow needle. In some cases, doctors use ultrasound to show where the fluid is in the belly. • Localized fluid collections in the abdominal wall may due by: • Seroma • Abscesses • Hematomas Fluid Collections Seroma A seroma is an accumulation of fluid in a tissue or organ that can occur after surgery, or sometimes after an injury such as blunt trauma. The fluid, called serum, leaks out of nearby damaged blood and lymphatic vessels. Cells are typically present in the fluid, which is normally clear. Seroma Seromas can occur after a number of different types of surgeries, especially those that are extensive or involve significant tissue disruption. These include hernia repairs, significant plastic surgeries such as breast augmentation or reconstruction, abdominoplasties (tummy tucks), and surgeries performed for breast cancer. Seroma formation may be associated with an increased risk of infection and breakdown of the surgical site. Seroma: abdominal wall seroma after splenectomy Abscess An abdominal abscess is a pocket of infected fluid and pus located inside the belly (abdominal cavity). This type of abscess can be located near or inside the liver, pancreas, kidneys or other organs. There can be one or more abscesses. Round image with hypoechoic contents (A) with thick and irregular walls http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg Abscess There can be one or more abscesses. The most reliable finding in patients with abscess are: •Fever •Increased white blood cell count Round image with hypoechoic contents (A) with thick and irregular walls http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg • An abscess may form in an area of the body from different causes: inflammatory bowel disease (Crohn’s disease) • trauma • surgery • intestinal perforation. The main symptoms of an abscess are pain and fever. Abscess Typically an abscess is a complex mass(solid and cystic) . Debris, septation and gas can be seen within the abscess . • Gas within the abscess typically produce reverberation (come-tail) artifact. • Can show acoustic enhancement depending of the cystic component. Round image with hypoechoic contents (A) with thick and irregular walls http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg http://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpg ABSCESS Peritoneal Abscess Culdocentesis involves the extraction of fluid from the rectouterine pouch (pouch of Douglas) through a needle inserted through the posterior fornix of the vagina. It can be used to extract fluid from the peritoneal cavity or to drain a pelvic abscess in the rectouterine pouch. A Percutaneous Abscess Drainage is a procedure performed by a doctor to remove or drain a contained collection of infected fluid (abscess) from an area of the body such as the chest, abdomen, or pelvis. During the procedure, a doctor places a thin needle into the fluid collection using x-ray guidance such as Computed Tomography (CT) scanning. Usually, a drainage tube is left in place to drain the abscess fluid. On occasion, the fluid collection may need to be drained in the operating room. Hemoperitoneum Hemoperitoneum is the presence of blood within the peritoneal cavity. Hemoperitoneum Etiology • penetrating or non-penetrating abdominal trauma (often with associated organ injury) • ruptured ectopic pregnancy • Ovarian cyst rupture • Aneurysm or pseudo aneurysm rupture • neoplasm rupture • acute hemorrhagic pancreatitis • iatrogenic • spontaneous bleeding, especially patients with coagulopathy or on anticoagulant therapy (uncommon ) • Uterine rupture Ultrasound non-specific appearance of intra-peritoneal free fluid may be hypo-, iso- or hyper-echoic commonly will demonstrated fluid-fluid levels with mixed internal echogenicity Hemoperitoneum – Female Pelvis Hematomas Collection of blood which is usually confined to an organ, tissue or space. A decrease of hematocrit level indicated the presence of hematoma Hematocrit is the volume of the red blood cells found in 100 ml of blood. Blood spillage outside the circulatory system will result in decreased hematocrit levels. HEMATOMA Hematomas The ultrasound appearance of hematomas is **variable and depends on the age of the collection. Pseudomyxoma Peritonei This pathology is caused by metastasis or rupture of a mucinous cystadenocarcinoma of the ovary or mucinous tumor of the appendix. This is also referred as malignant ascites. The peritoneal cavity is filled with mucinous material and gelatinous ascites. Pseudomyxoma Peritonei Biloma Bilomas are extrahepatic collections of extravasated bile. They are caused by: • abdominal trauma • gallbladder disease • biliary surgery Bilomas are predominantly cystic masses located in the right upper quadrant. Biloma Urinoma • Is a collection of urine which is located outside of the kidney or bladder. • Urinomas are most common caused by renal trauma, renal surgery or from an obstructing lesion. • Most common associated with renal transplantation and posterior urethral valve obstruction • Sonographically appears similar to a lymphocele. Lymphocele Lymphocele is caused by **leakage of lymph from a renal allograft or by surgical disruption of the lymphatic channels. Is not common see internal echoes in lymphocele Lymphocele is complications of: • Renal transplantation • Gynecologic surgery • Vascular surgery • Urogenical surgery Peritoneal Masses • Mesenteric cyst • Mesenteric adenopathy • Peritoneal mesothelioma • Peritoneal implants and omental caking • Mesenteric Cyst The majority originate from the small bowel mesentery. It is benign Peritoneal serous secretion present. Mesenteric Lymphadenopathy Peritoneal Mesothelioma Relative rare primary malignant tumor of the peritoneum . Associated to asbestos exposure Peritoneal Implants They are associated with peritoneal metastases Omental Caking Thickening of the greater omentum due to malignant infiltration. Indicative of peritoneal metastases also known as peritoneal carcinomatosis. *Associated to primary cancers of ovary, stomach or colon. Peritoneal masses Endometriosis Lymphadenopathy Undescendent testis Lipoma of the of the Spermatic Cord and Inguinal Canal inguinal canal http://www.jultrasoundmed.org/content/25/9/1199/F18.large.jpg http://www.jultrasoundmed.org/content/25/9/1199/F18.large.jpg LIPOMA OF THE INGUINAL CANAL References • Kawamura, D. M., & Lunsford, B. M. (2012). Diagnostic medical sonography. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

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