Abdominal Exam 3 - Peritoneum/Retroperitoneum

What are extraperitoneal hematomas?

*Acute or chronic collections of blood lying either in the rectus muscle or between the muscle and its sheath.* Occur as the result of direct trauma, pregnancy, cardiovascular and degenerative muscle diseases, surgical injury, anticoagulation therapy, steroids, or extreme exercise.

What does hypofunction of adrenal cortical hormones cause? symptoms?

*Addison's Disease* - hypotension - weakness/fatigue/weightloss - *bronzing of skin*

What is the most common malignancy of the adrenal glands in childhood?

*Adrenal Neuroblastoma* - poor prognosis

What are the sex hormones secreted by the adrenal glands?

*Androgens* *Estrogens*

What are Glucocorticoids and what are the primary ones(2)?

*Carbohydrate metabolism* and diminish allergic response *Cortisone and Hydrocortisone*

What are the two endocrine glands that make up the adrenals?

*Cortex* *Medulla*

What syndrome does oversecretion of ACTH cause?

*Cushings Syndrome*

What is produced in the medulla of the adrenal glands? what do they do?

*Epinephrine* elevate/decrease BP *Norepinephrine* vasoconstriction/dilation *together promote breakdown of glycogen into glucose to increase blood sugar*

What is the "sandwich sign"? what does it indicate?

*Lymphoma* enlarged lymph nodes or masses encasing the SMA on both sides

How is the peritoneum different in males and females?

*Males*: peritoneum forms a closed cavity *Females*: alleged communication outside peritoneum through uterine tubes, uterus and vagina; *however*, complex linings of the uterus and fallopian tubes close off any potential spaces to prevent air from entering

Signs of pathology in the paraaortic lymph nodes are (3)?

*Mantle* of nodes in paraspinal location *floating* or anteriorly displaced aorta *Mesenteric sandwich sign* anterior and posterior node masses surrounding mesenteric vessels

What are mineral corticoids and what is the primary one?

*Regulate electrolyte metabolism* *Aldosterone* is primary - secreted by cortex of adrenals

The cortex secretes (3):

*Steroid hormones* 1. Mineralcorticoids 2. Glucocorticoids 3. Sex hormones

What are the "gutters" of the peritoneal cavity? why should you always look there

*The lateral flanks and the pelvis* There could be pathological collections of fluid

What is the sonographic findings of an abdominal abscess?

*Variable depending on length of time and space available* Many appear predominantly fluid-filled with irregular borders - also can be complex with debris floating within the cystic mass -may show a more solid pattern - may be gas containing

The LEFT adrenal gland is what shape?

*Varies, but usually *semilunar* in shape and extends along medial border of left kidney

What does overproduction of sex hormones cause?

*Women:* adrenal tumors in women promote secondary masculine characteristics *Prebubertal males*: accelerate adult masculine development

When scanning an abdominal abscess you should also look at surrounding:

*bowel* careful analysis of bowel patterns and peristalsis to separate bowel from abscess collection

What is a biloma abscess? why do they occur

*extrahepatic loculated collections of bile* rupture of biliary tree due to medical treatment (iatrogenic), trauma or spontaneous rupture

What are the two sections of the peritoneal cavity and how do they communicate?

*greater sac* and *lesser sac* they communicate through a small opening - *epiploic foramen*

Where is the gastrosplenic ligament? how does it divide the left subhepatic space

*lt lateral extension of the greater omentum* connects abdominal wall to splenic hilum *forms portion of left lateral border of lesser sac*

What suspends the small intestine, transverse colon and sigmoid colon from the posterior abdominal wall?

*mesentery*: small intestine *Transverse mesocolon*: transverse colon *Sigmoid mesocolon*: Sigmoid colon

What is the 'gutter' of the pelvis?

*pouch of Douglass*

What lines the bare area of the liver?

*right superior and inferior coronary ligaments*

What does lymphoma of the omentum and mesentery look like on ultrasound?

*sandwich sign* Lobulated, confluent, hypoechoic mass surrounds a centrally positioned echogenic area

What are signs of Adrenal Neuroblastoma in childhood?

*usually asymptomatic* - can spontaneously regress before 1 y/o - Palpable abdominal mass

What is the function of the greater omentum?

- *adheres* to diseased organs - *walls off* infected fluid from the body - *Vascular structure* Brings masses of blood phagocytes to areas it adheres to

What are sonographic findings of a urinoma?

- Cystic masses most often oriented inferomedially, with upward and lateral displacement of the lower pole of the kidney along with medial displacement of the ureter. - Usually anechoic or contain low-level echoes

How does Adrenogenital Syndrome affect men and women?

- Masculizing effect on adult women - Prubuescent boys will have signs of masculine development

What are sonographic findings of abdominal cysts?

- Mesenteric and omental cysts may be uniloculated or multiloculated with smooth walls and thin internal septations. - Internal echoes are correlated with fat globules, debris, superimposed hemorrhage, or infection.

What makes up the Perihepatic spaces?

-*Right subhepatic space*: rt bare area to falciform ligament -*Morison's Pouch* *Left subhepatic space*: *Lesser Sac*

What are the 3 subdivisions of the retroperitoneum?

1. Anterior pararenal space 2. Perirenal space 3. Posterior pararenal space

What are types of lesions occur on the superficial abdominal wall (5)? most common?

1. Inflammatory lesions 2. Hematomas 3. Neoplasms 4. Hernias 5. *Post-surgical lesions* most common

What are 5 pathways bacteria can enter the liver to cause an abscess?

1. Portal system 2. Ascending cholangitis of CBD 3. Hepatic artery secondary to bacteremia 4. direct extension of an infection 5. implantation of bacteria after trauma to abdominal wall

What are the 4 origins of abdominal cysts?

1. embryologic 2. traumatic or acquired 3. neoplastic 4. Infective/degenerative *its important to determine the origin of the mass*

What is size are the adrenal glands?

3-6 cm long 3-6 mm thick 2-4 cm wide

Are mets of the adrenal glands common?

4th most common mets site

What is the lesser omentum?

A double layer of peritoneum that extend from the liver to the lesser curvature of the stomach.

What stimulates release of sex hormones in adrenals?

ACTH from the pituitary negative feedback loop

What is Adrenogenital Syndrome?

AKA *Adrenal Virilism* - Result from excessive secretion of sex hormones and adrenal androgens - caused by a tumor or hyperplasia of adrenals - *In newborn, there may be ambiguous genitalia*

What is the most common primary adrenal tumor?

Adrenal adenoma

What organs are in the Perirenal space?

Adrenal glands Kidneys Ureters Great Vessels

Where are adrenal glands located?

Anterior, medial and superior to the kidneys

Where is the retroperitoneal space?

Area between the posterior portion of the parietal peritoneum and the posterior abdominal wall muscles Extends from diaphragm to pelvis

What is a red flag for a extraperitoneal hematoma?

Asymmetry between rectus sheath muscles

What lines the visceral side of the abdominal muscles (2 names)?

Bandlike vertical fibrous groove called *linea semilunaris or Spigelian fascia*

Whats in the posterior pararenal space?

Blood lymphnodes

What is a urinoma? where are the located?

Encapsulated collection of urine which is located outside of the kidney or bladder

What is Cushing's Syndrome? signs and symptoms?

Excessive secretion of cortisol due to adrenal hyperplasia or tumor - truncal obesity and thin extremities - Buffalo hump - Moon face - Hypertension - irrehular menes - psychiatric disturbances *can cause masculizing affect on women*

When scanning peritoneal fluid or abscess, what are some techniques?

Have them move and see where the fluid goes: decubitus, prone, sitting up

Compared to the kidneys, how does the size differ in infancy and adulthood?

Infant: 1/3 size of kidney Adult: 1/13 size of kidney

The _______ acts as a _______ for the stomach, suspending it from the liver

Lesser omentum, sling

What are 3 neoplasms of abdominal wall?

Lipomas Desmoid tumors (beign fibrous neoplasm) Mets

What type of malignant neoplasms are most common in the peritoneum?

Lymphoma and Secondary (mets) neoplasms

Mesentery masses are more likely to be malignant if they're found near the __________

Mesentery masses are more likely to be malignant if they're found near the *mesentery root area*

Mesentery masses that are primary are usually _______ . and _______ neoplasms are more frequent

Mesentery masses that are primary are usually *benign*. and *secondary* neoplasms are more frequent

What are sonographic findings of peritoneal mets?

Nodular, sheetlike, irregular configuration - multiple small nodules - larger masses obliterate the line and adhere to bowel loops

Omental masses are usually ______ neoplasms and _____ are malignant

Omental masses are usually *secondary* neoplasms and *1/3* are malignant

What organs are in the anterior pararenal space?

Pancreas Duodenum Ascending and TV colon

What does the peritoneal cavity consist of (4)?

Peritoneal ligaments and folds that connect viscera and abdominopelvic walls includes: *Lesser and greater omentum* *mesenteries* *ligaments* *multiple fluid spaces*

What can cause hypersecretion of epinephrine and norepinephrine?

Pheochromocytoma

How can you distinguish a Pleural from a Subdiaphragmatic fluid collection?

Plueral fluid tends to distriute posteromedially in the chest

What are differential diagnosis for a lesser-sac abscess?

Pseudocyst, pancreatic abscess, gastric outlet obstruction and ascites

What muscle lines the posterior pararenal space? what else is found here?

Psoas muscle blood and lymphnodes embedded in fat are found here

What is are the most common adrenal carcinomas?

RARE May be hyperfunctional or nonfunction

What is Inflammatory or Malignant ascites?

Sonographic characteristics to suggest inflammatory or malignant processes, such as: - fine or coarse internal echoes - loculation - unusual distribution of bowel loops - thickening of interfaces between fluid and neighboring structures

What is the vascular supply to the adrenal glands?

Suprarenal branch of the *Inferior phrenic, Aorta, Renal artery* Sing vein from hilum of each glads drains into IVC *LEFT* drains into Left renal vein

What is a key factor in determining location of abdominal wall mass?

Symmetry of rectus sheath muscles

What are differentials to Adrenal Neuroblastoma?

WIlms tumor Hepatoblastoma

What is a urachal cyst?

Where only a part of the allantois does not fuse completely, leaving a fluid filled cavity between the bladder and the umbilicus.

DO men or women get adrenal cysts?

Women 3:1, still uncommon

What is the greater omentum?

a large apron-like fold of visceral peritoneum that hangs down from the stomach

What is ascites?

accumulation of fluid in the peritoneal cavity

What is peritonitis?

acute inflammation of the peritoneum. abscess or multiple abscess formation

What part of the liver is most difficult to visualize?

bare area of the liver

What is an abscess?

cavity formed by necrosis with solid tissue or circuscribed collection of purulent material (pus)

What is a lymphocele?

collection of fluid that occurs after surgery in the pelvis, retroperitoneum or recess cavities can look complex or cystic

Peritoneal masses tend to be:

complex with infiltrative patterns

If a Adrenal Neuroblastoma is suspected, a sonographer should also:

evaluate retroperitoneum and liver to rule out mets

What is a sign of an abscess? lab findings?

fever of unknown origin, tenderness and/or swelling Labs: - *normal liver function test* - *Leukocytosis* (inceased WBC) - *generalized sepsis*

What does ultrasound rule out in the retroperitoneum?

fluid collection, hematoma, urinoma, or ascitic fluid

If there is a tumor of the adrenals, it often pushes against the _______ _________

great vessels

What is Addison's disease? causes?

hormone deficiency caused by atrophy of the adrenal cortex - Autoimmune - TB - Inflammation - Primary neoplasm - Mets

What is a sign on ultrasound that there is pathology of the adrenal glands?

hyperechoic and/or rounded

Where is the presacral space?

in retroperitoneum, lies between rectum and fascia covering the sacrum and posterior pelvic floor muscles

What does an aldosterone insufficiency cause?

increased exceretion of sodium, chloride and water into urine - reduces blood volume

How can you tell if a abscess is subcapsular?

it conforms to the shape of the organ

the left adrenal gland is more __________ to the kidney

medial

What is another name for the lesser sac?

omental bursa

What mets to peritoneum?

ovaries, stomach and colon multiple lesions

What type of abscess can be located in the lesser sac

pancreatic abscess

What is a clue to sonographers that a abscess is filled with gas?

scattered air reflectors densely echogenic mass with or without acoustic shadowing and otherwise increased through-transmission

How does the lesser sac and greater sac communicate?

small vertical opening called the *Epiploic Foramen*

What is peritoneum?

smooth membrane that lines the entire abdominal cavity and reflected over contained organs *Visceral peritoneum*: lines abdominal organs (not always completely) *Parietal peritoneum* lines the walls of the cavity

The right adrenal gland is more _________ to the kidney

superior

What causes adrenal hemorrhage?

trauma traumatic birth - most common

The RIGHT adrenal gland is what shape?

varies but usually *triangular* and caps the upper pole of the right kidney

Where are abdominal masses usually found?

within or along the peritoneum, mesentery or omentum