Abdominal Wall and Fluid Collections and Hernia

Pyogenic Hepatic Abscess

- Fever, hepatomegaly, leukocytosis, possible abn LFTs, RUQ pain, complex cysts with thick walls, debris/septations/gas, Air; dirty shadow or ring-down

R/O in Chest

--R/o pleural effusion or chest mass

Etiology of Ascites

-90% due to cirrhosis, neoplasm, CHF, TB, hypoalbuminemia, pancreatic: pancreatitis or pseudocyst development, pyogenic peritonitis, Metabolic, inflammatory, collagen-vascular, trauma, renal failure, nephrotic syndrome; damage to urinary tract

Rectus Sheath Hematoma

-Abd pain, palp abd mass, discoloration of skin in area of hematoma, decreased hematocrit

S&S of Rectus Sheath Hematoma

-Abd pain, palp abd mass, discoloration of skin in area of hematoma, decreased hematocrit

Types of Abscesses

-Acute, chronic, pyogenic;non, abdominal site, renal, IBD

Spleen hematoma

-Acute: Complex or hypo, Middle: Echogenic (clot) or isoechoic, Later stages: anechoic or hypo, Chronic: complex or calcified walls

Retroperitoneum

-Adrenals, Kidneys, ureters, aorta, IVC -Area btwn parietal and posterior abdominal wall -Ant pararenal space, perirenal space (within gerota's fascia), posterior pararenal space

US of Ascites

-Anechoic regions in peritoneal cavity, free moving fluid, floating bowel loops, check all 4 quadrants -Dependent areas; inferior tip of RLL (Morrison's pouch), SUP Rt flank, CDS, paracolic cutters, lat and ant to liver

Paraumbilical Hernia

-Bowel herniates thru rectus adominus muscle and linea alba

Spigelian Hernia

-Bowel protrudes into a weakened area in the lower one-fourth of rectus muscle; midline of abdomen and between umbilicus and symphysis pubis, lateral wall herniation

Incisional Hernia

-Bowel protrudes into surgical incision site, silent CT, Subcostal, Midline vertical, lower abdominal Pfannensteil incision (bikini cut)

Umbilical Hernia

-Bowel protrudes into the umbilicus , medial margin of rectus abdominus

Linea Alba Hernia/Anterior Abdominal Wall/Epigastric hernia

-Bowel protrudes thru fascia of linea alba; midline of abdomen

Hernia

-Break in abdomen wall allowing bowel loops to protrude where no muscle present, point of weakness -Herniated extraperitoneal fat

Hematoma's

-Collection of clotted or unclotted blood due to leakage from blood vessels, confined to organ, tissue or space

Pseudomyxoma Peritonei

-Collection of mucinous material and gelatinous ascites which fills peritoneal cavity. Semi-solid mass, Associated with adhesions caused matted bowel loops -Etiology: METS, tumor implants on peritoneum, rupture of mucinous tumor of appendix or ovarian mass

Urinoma

-Collection of urine outside of kidney or bladder -Etiology: urinary system trauma, post-op injury, obstruction with renal TX -Can have sub-capsular hematomaDDX

Incarcerated Hernia

-Complication of hernia, non reducible -Tenderness at abdominal site, abd pain, bloating, n/v, absence of bowel movements

Landmarks of the Thoracic Cavity

-Costal margin, midaxillary line, midclavicular line, midsternal line, suprasternal notch, sternal angle, xiphoid

Sono of Hematoma

-Depends on age -Acute; hypo -Middle: Hyper; echogenic (clot) -Chronic: After hemolysis: Calcified or anechoic or isoechoic, hypo or mildly echoic with subtle fluid/debris level

Parts of Chest

-Diaphragm,; crura; anchors diaphragm; Rt anterior to aorta, Lt posterior to IVC

Paracentesis

-Drain fluid in peritoneal cavity -Eval largest pocket and measure depth, needle with US guidance to drain

Hemorrhage causes what lab value

-Drop in hematocrit

Hemorrhage/Hematoma Labs

-Drop in hematocrit

S/S of Abscess

-Elevated WBC, pain, malaise, N/V, abd tenderness, distension

Sono of Urinoma

-Elliptical cystic mass with sharp well defined borders, anechoic, perinephric

Ascites

-Excessive accumulation of serous fluid in peritoneal cavity, MAL or BEN, drain with paracentesis

Bilomas

-Extra-hepatic collections of extravasated bile, abd trauma, GB disease, biliary surgery. Anechoic mass, internal debris, RUQ or epigastric, continuous with liver, BDs or GB

perinephric abscess

-Fever, chills, flank pain, localized tenderness, perforation into surrounding areas , variable

Splenic Abscess

-Fever, leukocytosis, LUQ tenderness, Lt flank pain, splenomegaly -Complex, gas, debris

Bowel-Containing Hernia

-Fluid or air filled loops of bowel with peristalsis in IC or scrotum, gas/shadowing, strangulated bowel appears as fluid or air filled loops of bowel without peristalsis -Omentum-Containing: Highly echo mass representing omental fat

Rectus Sheath

-Forms a covering for the paired rectus abdominal muscles, Both sides of midline of anterior abdomen -Divided by band of connective tissue; Linea alba located in midline of abdomen

Femoral hernia

-Groin herniation, superior pubic ramus

Trauma causes

-Hematoma in Spleen-Blunt trauma to LUQ, severe LUQ pain, Decreased hematocrit level indicating active bleeding

Abdominal Wall Hernias

-High frequency linear transducer -Valsalva Technique: Show movement and change in size of hernia -Should be careful examined for bowel content and peristaltic motion of potentially trapped bowel

Hernia's on US use what technique

-High frequency linear transducer -Valsalva Technique: Show movement and change in size of hernia -Should be careful examined for bowel content and peristaltic motion of potentially trapped bowel

Sono of Rectus Sheath Hematoma

-Hypo, hyper, comlex or anechoic depending on stage of development

Strangulated Hernia

-Incarcerated + compromised vascularity; ischemia and gangrene -Surgical Emergency -Complication of hernia

Complications of Abdominal Wall Hernia

-Incarceration, strangulation and ischemia of infected bowel

Scrotal Hernia

-Indirect inguinal hernia that descend into scrotum, contains bowel or mesenteric/omental fat

Locations of Abscess

-Intra-parenchymal, Rt/Lt subphrenic, Morrison's pouch (subhepatic), perinephric, lesser sac (btwn panc and stomach), Rt/LT paracolic gutters (flanks), pelvis (CDS), Intra-organ (change in texture), intra-muscular, around incisions, post-op, Appendix, GI tract; thickened bowel or paralytic ileus

Abscess

-Localized collection of pus in potential spaces or abdominal wall, Causes displacement and immobilization of surrounding structures Result of pre-existing fluid collection or focal tissue infection -Pt with DM, HIV, hematoma, CA, CT disorders

Lymphocele

-Lymph filled cystic mass without epithelial lining -Postop or renal TX, gyn vasc, urological surgery, leakage of lymph from lymphatic channels from injury to lymph vessels

Subdiaphragmatic or Subphrenic

-Mimics PE, btwn bare area of liver and diaphragm -Potential space btwn diaphragm and spleen or diaphragm and liver

US of Pseudomyxoma Peritonei

-Mimics ascites, may have internal echoes, linear stranding, cyst or solid, multiple, matter post located bowel loops, CT to diagnose

Indirect Inguinal Hernia

-Patent processus vaginalis, abd contents exit thru internal inguinal ring, extending into inguinal canal and possibly into scrotum -Most common in children, LAT to INF epigastric A

Pitfalls of Hernia Evaluation

-Pitfalls: Atrophy of anterior abdominal wall muscles, focal spasm, xiphoid process after w/l, enlarged lymph nodes, hematoma, focal fluid collection, subcutaneous endometrioma

Pleural Cavity

-Potential space btwn chest wall (parietal pleura) and lungs (visceral pleura)

Direct Inguinal Hernia

-Protrusion thru weakness in abdominal wall at Hesselback triangle (bordered by inguinal ligament INF, Inferior epigastric A LAT, LAT border of rectus sheath MED) -Medial to INF epigastric A

Anterior Abdominal Muscles

-Rectus abdomonius, External and internal oblique, transversus abdominus, pyramidalis -Fluid accumulation, abscesses, hematomas, lipoma, herniated bowel, rectus sheath hematoma

Rectus Sheath Hematoma Causes

-Rupture in muscle or associated vasculature, abdominal trauma or spontaneous -Abdominal contractions that result from childbirth, sneezing, coughing, defecation, urination and intercourse

Peritoneal Cavity

-Serous membrane lining the abdominal and pelvis walls/viscera -Parietal: Lines walls of cavities that open to exterior, Visceral: covers organs -Ascites; accumulation here -Peritoneal Gutters: Rt paracolic (Rt of ascending colon) & Lt paracolic (lt of descending colon), Rt and Lt pelvic

Valsalva Technique

-Show movement and change in size of hernia

Mediastinum

-Superior Mediastinum: Thymus, great veins, great arteries, trachea, esophagus and thoracic duct, sympathetic trunks -Inferior Mediastinum: Thymus, heart, esophagus and thoracic duct, descending aorta, sympathertic trunks

Benign vs. MAL ascites

-Transudative vs. Exudative

Types of Ascites

-Transudative: Benign, freely mobile, heart, liver or kidney failure, minimal is normal in post CDS -Chylous: Due to lymphoma, acute; trauma, GGI obstruction, rupture of chylous cyst -Urine: Trauma, obstruction, renal tx or chronic hemodialysis -Exudative:Due to inflammation (cobwebs) or MAL (tethering adhesions); septations, echogenic debris, loculations, thickened interfaces, matted bowel loops

Etiology of Hematoma

-Trauma, surgery, anticoagulant therapy, leukemia or hemophiliacs

Subcapsular

-Unilateral, conform to shape of organ

Sono of Abscess

-Variable: Internal echoes, fluid filled level with debris, septations, gas with comet tail or dirty shadow, irregular, shaggy and thick borders -Shape of surrounding tissues or space if within a cavity, rounded within an organ -Not respect tissue space

Direct vs. Indirect Inguinal Hernia

-directly thru inguinal wall vs. thru deep ring and enter inguinal canal

Testicular Abscess

-painful swollen scrotum, fever, WBC, complex intratesticular mass; no flow central but increased around margins, could have pyocele; complex hydrocele that contains pus

US of Lymphocele

-rounded well defined cystic mass, PAE, anechoic usually no echoes, may have septations

Fluid Collections`

Etiology: Post-op, trauma, chemo, CA, AIDS, rupture/infection -Clinical correlation with labs