The Peritoneal CavityPart I Abdominal SonographyAbd.docx

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

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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
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.jpg
Other causes
include:
• malignancies of
the GI tract
• malnutrition
• heart failure
• mechanical
injuries which
result in internal
bleeding.

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.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
walls
• 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
walls
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.jpg
http://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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