The Peritoneal Cavity
Part I: Abdominal Sonography
Abdomen and Superficial Structures
Objectives
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=1492711166307051https://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 peritoneumhttps://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=1492711166307051https://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=1492621857645381http://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=1492621857645381http://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=1492712820198775https://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=1492713884772718https://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=1496860182066924https://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=1496860182066924http://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=1496860182066924http://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.jpghttp://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.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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 canalhttp://www.jultrasoundmed.org/content/25/9/1199/F18.large.jpghttp://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.
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=1492711166307051https://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 peritoneumhttps://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=1492711166307051https://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=1492621857645381http://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=1492621857645381http://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=1492712820198775https://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=1492713884772718https://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=1496860182066924https://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=1496860182066924http://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=1496860182066924http://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.jpghttp://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.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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
wallshttp://www.ultrasoundcases.info/files/Jpg/lbox_3430.jpghttp://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 canalhttp://www.jultrasoundmed.org/content/25/9/1199/F18.large.jpghttp://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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