abdominal anatomy week 2

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Workbook Chapter 3 The Peritoneal Cavity pages 17 through 25

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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.

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2711166307051

The peritoneum that
lines the abdominal
cavity is known as
the parietal
peritoneum

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.

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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.

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.

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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.

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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.

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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

Rectouterine
pouch

Known as Posterior cul-de-sac or
Pouch of Douglas.

Located posterior to uterine body and
cervix, between uterus and rectum.

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

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

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

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

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

• An abscess may form

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

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

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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