Peritoneum

lymphoceles are the development of lymph-containing fluid collections caused by ...

- *leakage of lymph* (from renal allograft) - *surgical disruptions* (of lymphatic channels) - *surgical complications* (renal transplants, gyn, vas. or urological surgery)

causes of Ascites

- CHF - liver disease - nephrotic syndromes - infections - malignancy - trauma

which vessels/organs are included in the anterior pararenal space?

- IVC/ aorta - pancreas -splenic & hepatic vessels - duodenum - ascending & descending colon - SMA/SMV

lymphoma sono appearance

- an anechoic to hypoechoic mass contain a central echogenic focus - seen throughout peritoneum, especially around the great vessels and organ hilums - "sandwich" or "mantle"

small collections of ascites can be found:

- around the inferior/posterior to the right love of the liver (*morrison's pouch*) - superior portion of the right flank - pelvic cul de sac

causes of retroperitoneal fibrosis

- connective tissue disease - systemic vasculitis due to AIDS - drug related - tumor induced - trauma - surgery - response to aortic aneurysm growth

retroperitoneal fibrosis sono appearance

- envelopes structure rather than displacing them! - hypoechoic midline mass

what is the clinical sign (triad) of intraperitoneal abscess?

- fever - pain - leukocytosis (high WBC)

the next sites for ascitic collections are located:

- in the parabolic gutters - lateral and anterior to the liver

the Perirenal space includes what organs?

- kidneys - adrenal glands - proximal ureter

what are differential diagnosis of lymphocele?

- located ascites - urinoma - hematoma - abscess

mesothelioma sono appearance

- mantle or sheet like thickening of the omentum - anterior surface of the mass generally conforms to the contour of the abdominal cavity, while the posterior deeper surfaces appear lobulated - hypoechoic, containing scattered small, echogenic foci

ascites sono appearance

- may have debris - possible GB wall thickening

Pseudomyxoma peritonei causes

- metastasis or rupture of a cystadenocarcinoma of the ovary - mutinous tumor of the appendix

metastatic implants of peritoneum sono appearance

- minute to extensive - if massive, caused the omentum to become a plate like mass appearing as relatively anechoic band of tissue beneath the abd. wall - hemorrhagic ascites may be present

pseudomyxoma peritonei sono appearance

- multiple hypoechoic or multicystic masses throughout the peritoneum and mesentery due to tumor implants - if ascites is present, it is massive in volume and may be echogenic as a result of the gelatinous content of the fluid

what is in the posterior pararenal space?

- no organs - psoas muscle - quadratus lumborum

the retroperitoneum is divided into the:

- perirenal spacew - anterior pararenal space - posterior pararenal space

Lymphocele sono appearance

- predominantly anechoic - may contain septations and debris

symptoms of peritonitis

- severe pain w. possible rebound tenderness - fever, chills - nausea, vomiting

mesenteric & omental cyst sono appearance

- single or multiple - thin walled - may have debris and septations - may be calcified

intraperitoneal asbcess' are usually the result of :

- trauma - surgery - infection in other body areas

symptoms for peritoneal mesothelioma

- weight loss - abdominal swelling and pain - bowel obstruction

intraperitoneal abscess sono appearance

- well defined - thick wall - debris - septations - gas

Mesothelioma occurs predominantly...

- with prior exposure to asbestos - usually Middle Aged men

what are the 2 other functions of the peritoneum , besides holding the viscera in position?

1. *secrete serous fluid* -- lubricates the surfaces of the peritoneum and facilitates free movement between he viscera 2. *help to resist infection* -- contains injury/infection; attempting to localize and wall it off

folds of peritoneum form ligaments which various organs are suspended within the peritoneal cavity. what are the 3 ligaments?

1. falciform ligament 2. coronary ligament 3. triangular ligament

what are the 2 parts of the mesocolon?

1. transverse mesocolon - attaches transverse colon to posterior abdominal wall 2. sigmoid mesocolon - attaches sigmoid colon to posterior abdominal wall

the greater omentum is ___ layers of peritoneum that hangs from the greater curvature of the stomach and loops down in front of the intestines, draping like an apron and attaches the _______ colon

4 transverse

paracolic gutters: ___ important paracolic gutters are formed by the arrangements of the ________ and _______

4! ascending and descending colons (lateral to ascending, medial to ascending, medial to descending & lateral to descending)

Malignant ascites may be associated with?

Bowels that are matted posteriorly to abdominal wall

the opening between the greater and lesser omentum is called...

Foramen of Winslow (Epiploic/ Omental Foramen)

retroperitoneal fibrosis rarely extends superior to the level of the _______ , and may extend inferiorly to the dome of the _______

L2 bladder

what is the most common location for free fluid ?

Morrison's pouch (posterior sub hepatic space/ hepatorenal space)

what are the retroperitoneal organs?

S - suprarenal *adrenal* gland A - aorta/IVC D - duodenum P - pancreas (except tail) U - ureters C - colon K - kidneys E - esophagus R - rectum

what is the mnemonic for retroperitoneal organs?

SAD PUCKER

peri-vessel lymphoma is typically seen as lymphomatous nodules anterior and posterior to the ________

SMA

intraperitoneal abscess

a collection of bacteria, necrotic tissue, and WBC's, located in any of the spaces of the peritoneal cavity

lymphocele

a collection of lymphatic fluid

lymphoma

a general term applied to malignancies affecting lymphoid tissues

the parietal peritoneum is the outer layer that is attached to the _____________

abdominal wall

the greater omentum contains large quantities of ___________ tissue, which may serve as an insulating/protective layer

adipose

posterior sub hepatic space is _____ to the right kidney

anterior

the falciform ligament extends from the umbilicus to the diaphragm and attaches the liver to the _________

anterior abdominal wall

what is the sub hepatic space divided into?

anterior and posterior spaces

retroperitoneal fibrosis is associated with _______ ________ ________

bilateral ureteral obstruction

with _____________, ascites is caused by increased pressure n the portal vein (portal HTN)

chronic liver disease (transudate!)

pseudomyxoma peritonei

condition can be described as a filling of the peritoneal cavity with *mucinous material and gelatinous ascites*

retroperitoneal fibrosis

dense fibrous tissue proliferation confined to the paravertebral region

the greater sac (general sac) is the largest compartment covering the entire width of the abdomen and extending from the ________ to the _____

diaphragm pelvis

ascites

excessive accumulation of serous fluid in the peritoneal cavity

_________ are caused by fluid that has escaped out of the blood vessels and has been deposited in the tissues or on tissue surfaces

exudates

the suphrenic space is inferior to the diaphragm and divided into right and left spaces by the _________ ligament

falciform

peritoneum contains what things?

fat, blood, vessels, lymphatics, and nerves

Benign ascites may be associated with?

floating bowel and mesentery

the anterior sub hepatic space is in the region of the ________

gallbladder

the peritoneal cavity is divided into several pouches or compartments that are created by peritoneal folds. what are the names of the sacs?

greater sac (general sac) lesser sac

the subphrenic space is created by the folding of the peritoneum in the _______ region

hepatic

the posterior sub hepatic space is also called _________ and ________

hepatorenal space Morrison's pouch

Exudates are characterized by _____ protein, ______ WBC, and ______ pH

high WBC high protein low pH

mesothelioma tumors are _____________

highly malignant (fatal within a year)

the major function of the peritoneum is to ...

hold the viscera in position by its folds

the sub hepatic space is located ________ to the liver

inferior

peritonitis

inflammation of the peritoneum

the presence of _____________ within the collection is more consistent with abscess/hematoma than with a lymphocele

internal echoes

the lesser sac is the small compartment lying behind the stomach, it is a diverticulum from the greater sac between the stomach and the pancreas. the lesser sac lies between the _________ and _______

lesser and greater omenta

where is the most common region of pancreatic pseudocyst

lesser sac

peritonitis is a potentially __________ condition

life-threatening (requires immediate medical attention)

__________ attach to the liver, spleen, stomach, kidneys, bladder and uterus to the peritoneum

ligaments

the right anterior subprenic space is anterior to the ________

liver

Transudates are characterized by ____ WBC, ____ protein, and ____ pH

low WBC low protein (hypoalbuminemia) high pH

the ______________ connect portions of the intestine with the posterior abdominal wall to the peritoneum

mesenteries

____________: double sheet of peritoneum suspending jejunum and ileum from the posterior abdominal wall, it fans out to encircle the small bowel loops

mesentery (proper)

mesenteries are folds of peritoneum that unite the abdominal wall with the intestines, that carry blood vessels, nerves, and lymphatics to organs. what are the two types of mesenteries ?

mesentery (proper) & mesocolon

_____________: surrounds parts of the colon and attaches it to the posterior abdominal wall

mesocolon

the _______ attach to the stomach to the peritoneum

omenta

the visceral peritoneum is the inner layer that is wrapped around the internal _________ located inside the abdominal cavity

organs (ex. glissons capsule around liver)

metastatic implants of the peritoneum can originate from a wide variety fo primary causes, mostly _______ of from the _______

ovarian GI tract

_______periteoneum: the outer layer

parietal

"sandwich" or "mantle" sign is the presence of __________

peri-vessel lymphoma

________: the potential space between the visceral and parietal layers of the peritoneum

peritoneal cavity

the space between the parietal and visceral peritoneum is called the _________

peritoneal cavity

the retroperitoneum is located ...

posterior to the parietal peritoneum

posterior sub hepatic space is located ___________ to the liver

posterior/inferior

between the two layers of peritoneum, there is a __________ between them

potential space *PERITONEAL CAVITY*

mental and mesenteric cysts

rare cysts that ares from the omentum or mesentery

Mesothelioma

rare neoplasm arising from the serous membranes line the pleural, pericardial, and peritoneal compartments

the perirenal space is separated from the pararenal spaces by the ____________

renal fascia (Gerota's fascia)

the right posterior subphrenic space lies posterior to the __________ lobe of the liver

right

the peritoneum is a __________ membrane

serous

the peritoneal cavity contains __________

serous fluid

the peritoneal cavity is filled with a small amount of....

slipper serous fluid (50 ml), allowing the two ayers to slide freely over each other

the left subphrenic space (anterior and posterior) is inferior to the diaphragm and anterior and posterior to the ________

spleen

folds of omen are attached to the _________

stomach

the lesser omentum is attached to the lesser curvature of the _______ and the _______

stomach and the liver

the potential space under the diaphragm is called the _______ space

subphrenic

which part of the pancreas is not retroperitoneal?

tail

any substance passing through a membrane or being pushed out through a tissue is a ________

transudate

what are the two major types that ascites can be subdivided into?

transudate and exudate

how many layers of peritoneum are there?

two

____________ peritoneum: the inner layer

visceral