Download Exploring peritoneal cavity: Practical approach to peritoneum

Exploring peritoneal cavity: Practical approach to
peritoneum visualized in multi slice computed tomography
Award:
Certificate of Merit
Poster No.:
C-427
Congress:
ECR 2009
Type:
Educational Exhibit
Topic:
Abdominal and Gastrointestinal
Authors:
E. Czekajska-Chehab, G. Staskiewicz, S. Uhlig, E. Siek, A. Drop;
Lublin/PL
Keywords:
anatomy, computed tomography, Peritoneum, Mesentery
DOI:
10.1594/ecr2009/C-427
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Page 1 of 62
Learning objectives
1.
2.
To review normal anatomy of peritoneum, particularly for identification of
ligaments, recesses and vessels.
To remind main pathologies and their potential routes of spread in relation to
communication of parts of peritoneal cavity.
Background
The peritoneum serves not only as a support for abdominal organs, but also forms a
complex communication system of blood and lymph vessels, ligaments and recesses
which determinesspecific pathologies of peritoneum and potential routes of spread of
diseases such as inflammations or neoplasms. The familiarity with normal anatomy of
peritoneum is essential for correctcomprehension of pathophysiology of these processes.
The authors realized, that this knowledge is limited among young residents , who
consider it exceptionally difficult. Therefore, an attempt of clear and short explanation
anatomy and the review ofmost common pathologies of peritoneum was made.
Imaging findings OR Procedure details
Anatomy of peritoneum
Peritoneum is a serous membrane lining the abdominopelvic wall (parietal peritoneum)
and viscera (visceral peritoneum).
Space between the peritoneal layers is peritoneal cavity [Fig 1] on page 42. In normal
conditions, it isfilled only by fluid which reduces friction between the viscera. Main part of
peritoneal cavity is referred to as greater sac. Its largest recess is referred to as lesser
sac. The lowest recesses ofthe peritoneal cavity are rectouterine pouch in females and
rectovesical pouch in men [Fig2] on page 43.
Page 2 of 62
Fig.: Figure 1. Schematic presentation of peritoneal cavity and peritoneal formations. L
- liver, P - pancreas, S - stomach, TC - transverse colon, SI - small intestine.
Page 3 of 62
Fig.: Figure 2. Sagittal MIP, male peritoneal dialysis patient. Arrows - dialysis catheter,
Red - rectovesical pouch, R - rectum, V - urinary bladder.
Perihepatic space is subdivided by ligaments forming borders of the bare area of the
liver:
•
coronary ligaments
•
triangular ligaments
Page 4 of 62
•
falciform ligament (containing round ligament - obliterated umbilical vein
[Fig. 3] on page 44)
Fig.: Figure 3. Axial view. Arrowhead: round ligament (ligamentum teres), Arrow:
falciform ligament.
Page 5 of 62
Right subhepatic space is referred to as Morrison pouch [Fig. 4] on page 45, which
is located betweenliver, right adrenal gland and right kidney. Space between parietal
peritoneum of the diaphragm and visceral peritoneum is referred to as right and left
subphrenic space [Fig. 5] on page 46.
Fig.: Figure 4. Axial view. Green - right subhepatic space (Morrison's pouch).
Page 6 of 62
Fig.: Figure 5. Coronal Minimum IP. Green - right subphrenic space, Red - left
subphrenic space, Purple - splenorenal ligament.
Lesser sac, the largest recess of peritoneal cavity is located posterior to the stomach,
and extends superiorly to the diaphragm, posterior to the coronary ligament, and
inferiorly between the layersof greater omentum [Fig. 6] on page 47.
Page 7 of 62
Lesser and greater sacs communicate by omental foramen (of Winslow) [Fig. 7] on
page 48, bound byhepatoduodenal ligament, IVC and right crus of diaghragm,
visceral surface of liver and 1st part of duodenum.
Fig.: Figure 6. Oblique view. Red - leser sac, L - liver, S - stomach, SP - spleen, P pancreas.
Page 8 of 62
Fig.: Figure 7. Oblique parasagittal Minimum IP. Structure within hepatoduodenal
ligament: black arrowhead - hepatic artery, black arrow - portal vein, white arrow - bile
duct. White arrowhead - omental foramen, IVC - inferior vena cava.
Peritoneum forms several structures, which connect viscera each with another, or
viscera with abdominal wall. Double folds of peritoneum are mesenteries, lesser and
greater omentum, as well asperitoneal ligaments.
Page 9 of 62
Lesser omentum is a peritoneal fold which runs between liver and stomach and
proximal duodenum. Therefore, two parts are distinguished: hepatogastric ligament,
and hepatodudenal ligament.Hepatodudenal ligament contains structures of portal
triad: portal vein, hepatic artery and common bile duct [Fig. 7] on page 48.
Greater omentum extends from the greater curvature of the stomach, three parts are
distinguished:
•
gastrophrenic ligament
•
gastrosplenic ligament - contains short gastric vessels
•
gastrocolic ligament, commonly referred to as greater omentum, as its
largest part [Fig. 8] on page 49. Layers of gastrosplenic ligament, part of
lesser omentum, cover the spleen and rejoin, forming splenorenal ligament
[Fig. 5] on page 46.
Page 10 of 62
Fig.: Figure 8. Sagittal Minimum IP, female patient with excessive ascites, after Csection. Yellow - lesser omentum, Green - gastrocolic ligament, Red - transverse
mesocolon, Blue - greater omentum. L - liver, S - stomach, TC - transverse colon.
Transverse mesocolon divides the greater sac into supracolic and infracolic
compartments [Fig.1] on page 42, which communicate by paracolic gutters [Fig. 9]
on page 50.
Page 11 of 62
Fig.: Figure 9. Paraaxial Minimum IP. RPcG - right paracolic gutter, LPcG - left
paracolic gutter. Purple - mesentery of small intestine.
Transverse mesocolon is attached to posterior abdominal wall in front of: descending
part of duodenum, head and body of pancreas and ascending part of duodenum [Fig.
8] on page 49. Lateral extensions of the mesocolon form duodenocolic phrenicocolic
Page 12 of 62
ligament. Main distinguishable structuretransmitted by the transverse mesocolon is
middle colic artery from superior mesenteric artery.
Mesentery of small intestine runs obliquely from the duodenojejunal junction to the
ileocecal valve, transversing ascending and horizontal duodenum, aorta, IVC, right
ureter and right psoas major andright gonadal vessels [Fig. 9] on page 50. It
contains blood vessels, lymphatics and nerves for theintestine.
Root of sigmoid mesocolon [Fig. 10] on page 51 forms am inverted V-shaped
attachment, with its apexpointing to the bifurcation of the left common iliac artery.
Below the attachment, intersigmoid space is formed.
Page 13 of 62
Fig.: Figure 10. Coronal Minimum Intensity Projection. Yellow - sigmoid mesocolon, S
- sigmoid rectum.
Pathologies of peritoneum
The most common manifestation of pathologies involving peritoneum is ascites, that is
accumulation of abnormal fluid in peritoneal cavity. Causes of ascites are various and
can be classifieddepending on its character:
Page 14 of 62
1.Transudate [Fig. 11] on page 52 appears usually in general disorders with
decreased osmoticpressure:
•
cirrhosis (leading to hypoalbuminaemia)
•
kwashiorkor
•
Budd - Chiari syndrome (veno - occlusive disease)
It can be also related to increased hydrostatic pressure in vessels in:
•
left ventricular heart failure
•
constrictive pericarditis
•
embolism
•
nephrotic syndrome
Fig.: 35-y-o male suffering from cirrhosis. Heterogenous liver with irregular margins
and enlarged spleen due to portal hypertension are typical for the disease. Fluid in
subphrenic spaces and in Morrison's pouch (arrow).
2.Exudate most commonly appears in neoplasms [Fig. 12] on page 53, both
primary tumors and metastases. Itcan be also related to local or general inflammatory
processes, such as:
•
pancreatitis [Fig. 13] on page 53, cholecystitis
•
serositis (inflammation of serous membranes)
•
tuberculosis
Page 15 of 62
Fig.: 60-y-o female with ovarian cancer. Massive metastatic lesions in peritoneum
(arrows) and exudate in right subphrenic space (arrowheads).
Fig.: Acute pancreatitis in 42-y-o male. Inflammatory infiltration of surrounding tissues
with extensive exudate.
3.Less frequent causes of fluid's accumulation in peritoneal spaces include: bleeding
[Fig.14] on page 54, lymphangitis, hypothyroidism, etc.
Page 16 of 62
Fig.: 37-y-o male after cholecystectomy procedure. Complications in the form of
heterogeneous fluid collection in right subphrenic space. Mixture of blood and bile
presents as area of increased density (arrow).
Other, commonly met manifestations of peritoneal pathologies are:
1.Enlargement of mesenteric and retroperitoneal lymph nodes. Size of retroperitoneal
and mestenteric lymph nodes in healthy people should not exceed 5mm in short axis.
Causes of their enlargementare:
•
inflammations: pancreatitis, cholecistitis, ventriculitis, tuberculosis
•
spread of neoplasms through the lymphatic root: lymphoma [Fig. 15] on
page 54, carcinoid, gastrointestinal stromal tumors (GIST), tumors of
pancreas, lung and breast cancer, melanoma
•
systemic diseases: lupus erythromatosus, sarcoidosis, rheumatoid arthritis
Page 17 of 62
Fig.: 33-y-o male with enlargement of mesenteric and retroperitoneal lymph nodes
(arrows) in the course of lymphoma
2.Neoplasms:
•
•
primary neoplasms: mesothelioma, sarcoma, desmoids tumor, lipoma,
schwannoma
metastases spreading to the peritoneum through mesenteric vessels,
lymphatic, peritoneal fluid root or through infiltration [Fig. 16] on page 55:
lymphoma, GIST, carcinoid, ovarian tumors, breast cancer, melanoma
Page 18 of 62
Fig.: Figure 11. Routes of metastatic spread. Schematic presentation on a small
intetine mesentery. A: Direct infiltration of mesenteric vessels and adipose tissue
(carcinoid, pancreatic cancer, colorectal cancer). B: Mesenteric perilymphatic spread
(lymphoma, metastatic lymphnodes - breast cancer, melanoma, ovarian and colorectal
cancer). C: hematogenous route - melanoma, breast and lung cancer). D: peritoneal
fluid route (ovarian cancer, pancreatic cancer, stomach and breast cancer).
3.Increased density of mesenteric adipose tissue called "misty mesentery" [Fig. 17] on
page 56in the course of various diseases: inflammatory process, edema, fibrosis,
neoplastic infiltration
Page 19 of 62
Fig.: 70-y-o female with nonspecific increase density of mesenteric adipose tissue.
Typical signs of "fat rings" surrounding lymph nodes and vessels (arrow) and false
capsule (arrowhead) around the lesion.Because neoplasms, especially non-Hodkin's
lymphomas can manifest with similar picture, the diagnostics were extended. No signs
of neoplastic process were found. Diagnosis of idiopathic inflammation of mesentery panniculitis was established.
4.Pneumoperitoneum [Fig. 18] on page 56 usually caused by injuries or
inflammations
Page 20 of 62
Fig.: 54-y-o female with pneumoperitoneum. Arrows indicate air in perihepatic spaces.
5.Other:
•
Pathologies of vessels: vasculitis, portal hypertension, embolism of superior
mesenteric artery, thrombosis of mesenteric vein, vascular fistulas [Fig. 19]
on page 57
•
Intestinal torsion [fig. 20] on page 58, intussusception
Page 21 of 62
•
Calcifications [Fig. 21] on page 59
Fig.: 51-y-o male with A-V fistula between superior mesenteric artery and mesenteric
vein.
Page 22 of 62
Fig.: 61-y-o male with intestinal torsion. Typical "whirlpool sign" created by superior
mesenteric vein and mesentery twisting around the superior mesentery artery.
Page 23 of 62
Fig.: Calcifications in peritoneum in 30-y-o female in the course of dialysis
Page 24 of 62
Images linked within the text of this section:
Fig.: 37-y-o male after cholecystectomy procedure. Complications in the form of
heterogeneous fluid collection in right subphrenic space. Mixture of blood and bile
presents as area of increased density (arrow).
Fig.: 60-y-o female with ovarian cancer. Massive metastatic lesions in peritoneum
(arrows) and exudate in right subphrenic space (arrowheads).
Page 25 of 62
Fig.: Calcifications in peritoneum in 30-y-o female in the course of dialysis
Page 26 of 62
Fig.: 35-y-o male suffering from cirrhosis. Heterogenous liver with irregular margins and
enlarged spleen due to portal hypertension are typical for the disease. Fluid in subphrenic
spaces and in Morrison's pouch (arrow).
Page 27 of 62
Fig.: 51-y-o male with A-V fistula between superior mesenteric artery and mesenteric
vein.
Page 28 of 62
Fig.: 33-y-o male with enlargement of mesenteric and retroperitoneal lymph nodes
(arrows) in the course of lymphoma
Fig.: 70-y-o female with nonspecific increase density of mesenteric adipose tissue.
Typical signs of "fat rings" surrounding lymph nodes and vessels (arrow) and false
capsule (arrowhead) around the lesion.Because neoplasms, especially non-Hodkin's
lymphomas can manifest with similar picture, the diagnostics were extended. No signs
of neoplastic process were found. Diagnosis of idiopathic inflammation of mesentery panniculitis was established.
Page 29 of 62
Fig.: Acute pancreatitis in 42-y-o male. Inflammatory infiltration of surrounding tissues
with extensive exudate.
Page 30 of 62
Fig.: Figure 1. Schematic presentation of peritoneal cavity and peritoneal formations. L
- liver, P - pancreas, S - stomach, TC - transverse colon, SI - small intestine.
Fig.: Figure 2. Sagittal MIP, male peritoneal dialysis patient. Arrows - dialysis catheter,
Red - rectovesical pouch, R - rectum, V - urinary bladder.
Page 31 of 62
Fig.: Figure 3. Axial view. Arrowhead: round ligament (ligamentum teres), Arrow:
falciform ligament.
Page 32 of 62
Fig.: Figure 4. Axial view. Green - right subhepatic space (Morrison's pouch).
Page 33 of 62
Fig.: Figure 5. Coronal Minimum IP. Green - right subphrenic space, Red - left subphrenic
space, Purple - splenorenal ligament.
Page 34 of 62
Fig.: Figure 6. Oblique view. Red - leser sac, L - liver, S - stomach, SP - spleen, P pancreas.
Page 35 of 62
Fig.: Figure 7. Oblique parasagittal Minimum IP. Structure within hepatoduodenal
ligament: black arrowhead - hepatic artery, black arrow - portal vein, white arrow - bile
duct. White arrowhead - omental foramen, IVC - inferior vena cava.
Page 36 of 62
Fig.: Figure 8. Sagittal Minimum IP, female patient with excessive ascites, after Csection. Yellow - lesser omentum, Green - gastrocolic ligament, Red - transverse
mesocolon, Blue - greater omentum. L - liver, S - stomach, TC - transverse colon.
Page 37 of 62
Fig.: Figure 9. Paraaxial Minimum IP. RPcG - right paracolic gutter, LPcG - left paracolic
gutter. Purple - mesentery of small intestine.
Page 38 of 62
Fig.: Figure 10. Coronal Minimum Intensity Projection. Yellow - sigmoid mesocolon, S
- sigmoid rectum.
Page 39 of 62
Fig.: Figure 11. Routes of metastatic spread. Schematic presentation on a small intetine
mesentery. A: Direct infiltration of mesenteric vessels and adipose tissue (carcinoid,
pancreatic cancer, colorectal cancer). B: Mesenteric perilymphatic spread (lymphoma,
metastatic lymphnodes - breast cancer, melanoma, ovarian and colorectal cancer). C:
hematogenous route - melanoma, breast and lung cancer). D: peritoneal fluid route
(ovarian cancer, pancreatic cancer, stomach and breast cancer).
Page 40 of 62
Fig.: 61-y-o male with intestinal torsion. Typical "whirlpool sign" created by superior
mesenteric vein and mesentery twisting around the superior mesentery artery.
Page 41 of 62
Fig.: 54-y-o female with pneumoperitoneum. Arrows indicate air in perihepatic spaces.
Additional images for this section:
Page 42 of 62
Fig. 1: Figure 1. Schematic presentation of peritoneal cavity and peritoneal formations.
L - liver, P - pancreas, S - stomach, TC - transverse colon, SI - small intestine.
Page 43 of 62
Fig. 2: Figure 2. Sagittal MIP, male peritoneal dialysis patient. Arrows - dialysis catheter,
Red - rectovesical pouch, R - rectum, V - urinary bladder.
Page 44 of 62
Fig. 3: Figure 3. Axial view. Arrowhead: round ligament (ligamentum teres), Arrow:
falciform ligament.
Page 45 of 62
Fig. 4: Figure 4. Axial view. Green - right subhepatic space (Morrison's pouch).
Page 46 of 62
Fig. 5: Figure 5. Coronal Minimum IP. Green - right subphrenic space, Red - left
subphrenic space, Purple - splenorenal ligament.
Page 47 of 62
Fig. 6: Figure 6. Oblique view. Red - leser sac, L - liver, S - stomach, SP - spleen, P
- pancreas.
Page 48 of 62
Fig. 7: Figure 7. Oblique parasagittal Minimum IP. Structure within hepatoduodenal
ligament: black arrowhead - hepatic artery, black arrow - portal vein, white arrow - bile
duct. White arrowhead - omental foramen, IVC - inferior vena cava.
Page 49 of 62
Fig. 8: Figure 8. Sagittal Minimum IP, female patient with excessive ascites, after
C-section. Yellow - lesser omentum, Green - gastrocolic ligament, Red - transverse
mesocolon, Blue - greater omentum. L - liver, S - stomach, TC - transverse colon.
Page 50 of 62
Fig. 9: Figure 9. Paraaxial Minimum IP. RPcG - right paracolic gutter, LPcG - left paracolic
gutter. Purple - mesentery of small intestine.
Page 51 of 62
Fig. 10: Figure 10. Coronal Minimum Intensity Projection. Yellow - sigmoid mesocolon,
S - sigmoid rectum.
Page 52 of 62
Fig. 11: 35-y-o male suffering from cirrhosis. Heterogenous liver with irregular margins
and enlarged spleen due to portal hypertension are typical for the disease. Fluid in
subphrenic spaces and in Morrison's pouch (arrow).
Fig. 12: 60-y-o female with ovarian cancer. Massive metastatic lesions in peritoneum
(arrows) and exudate in right subphrenic space (arrowheads).
Page 53 of 62
Fig. 13: Acute pancreatitis in 42-y-o male. Inflammatory infiltration of surrounding tissues
with extensive exudate.
Fig. 14: 37-y-o male after cholecystectomy procedure. Complications in the form of
heterogeneous fluid collection in right subphrenic space. Mixture of blood and bile
presents as area of increased density (arrow).
Page 54 of 62
Fig. 15: 33-y-o male with enlargement of mesenteric and retroperitoneal lymph nodes
(arrows) in the course of lymphoma
Page 55 of 62
Fig. 16: Figure 11. Routes of metastatic spread. Schematic presentation on a small
intetine mesentery. A: Direct infiltration of mesenteric vessels and adipose tissue
(carcinoid, pancreatic cancer, colorectal cancer). B: Mesenteric perilymphatic spread
(lymphoma, metastatic lymphnodes - breast cancer, melanoma, ovarian and colorectal
cancer). C: hematogenous route - melanoma, breast and lung cancer). D: peritoneal fluid
route (ovarian cancer, pancreatic cancer, stomach and breast cancer).
Fig. 17: 70-y-o female with nonspecific increase density of mesenteric adipose tissue.
Typical signs of "fat rings" surrounding lymph nodes and vessels (arrow) and false
capsule (arrowhead) around the lesion.Because neoplasms, especially non-Hodkin's
lymphomas can manifest with similar picture, the diagnostics were extended. No signs
of neoplastic process were found. Diagnosis of idiopathic inflammation of mesentery panniculitis was established.
Page 56 of 62
Fig. 18: 54-y-o female with pneumoperitoneum. Arrows indicate air in perihepatic spaces.
Page 57 of 62
Fig. 19: 51-y-o male with A-V fistula between superior mesenteric artery and mesenteric
vein.
Page 58 of 62
Fig. 20: 61-y-o male with intestinal torsion. Typical "whirlpool sign" created by superior
mesenteric vein and mesentery twisting around the superior mesentery artery.
Page 59 of 62
Fig. 21: Calcifications in peritoneum in 30-y-o female in the course of dialysis
Page 60 of 62
Conclusion
Multi slice computed tomography allows detailed visualization of peritoneum and
its substructures and appropriate knowledge of anatomy is useful in evaluation of
pathologies of abdominal cavity, especially diffused ones. Postprocessing techniques
are extremely useful in explaining the complex anatomy of blood vessels, spaces and
ligaments especially for inexperienced readers.
Fig.
Personal Information
Elzbieta Czekajska - Chehab
1st Department of radiology, Medical Univesity of Lublin, Poland
Page 61 of 62
[email protected]
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