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US of the Peritoneum¹

¹ From the Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4. Received July 17, 2002; revision requested September 17 and received November 5; accepted November 6. Address correspondence to S.R.W. (e-mail: stephanie.wilson@uhn.on.ca).

View larger version (127K): [in a new window]   Figure 1a.  Optimization of the technique in a 73-year-old woman with stage 3 papillary serous adenocarcinoma of the ovary. (a) Sagittal suprapubic US image of the right adnexa, obtained with a 5-2-MHz curvilinear transducer during the initial survey, shows ascites and a solid, lobulated, hypoechoic mass (M). The field of view includes the full depth of the peritoneal cavity but no more, and the focal zone was set to optimize visualization of the mass. (b) Sagittal transabdominal US image of the left flank obtained with a 7-4-MHz curvilinear transducer shows ascites and seeding on the serosal surface of the descending colon (arrows). A low gain setting was used, and the focal zone was positioned to optimize visualization of the seeding. The seeding is seen as a thin continuous line on the serosal surface of the intestine, which contains shadowing air. (c) Transverse transvaginal US image of the right adnexa obtained with an 8-4-MHz transvaginal probe shows the mass (M) and particulate ascites. A high gain setting was used to better characterize the ascites.

View larger version (120K): [in a new window]   Figure 1b.  Optimization of the technique in a 73-year-old woman with stage 3 papillary serous adenocarcinoma of the ovary. (a) Sagittal suprapubic US image of the right adnexa, obtained with a 5-2-MHz curvilinear transducer during the initial survey, shows ascites and a solid, lobulated, hypoechoic mass (M). The field of view includes the full depth of the peritoneal cavity but no more, and the focal zone was set to optimize visualization of the mass. (b) Sagittal transabdominal US image of the left flank obtained with a 7-4-MHz curvilinear transducer shows ascites and seeding on the serosal surface of the descending colon (arrows). A low gain setting was used, and the focal zone was positioned to optimize visualization of the seeding. The seeding is seen as a thin continuous line on the serosal surface of the intestine, which contains shadowing air. (c) Transverse transvaginal US image of the right adnexa obtained with an 8-4-MHz transvaginal probe shows the mass (M) and particulate ascites. A high gain setting was used to better characterize the ascites.

View larger version (137K): [in a new window]   Figure 1c.  Optimization of the technique in a 73-year-old woman with stage 3 papillary serous adenocarcinoma of the ovary. (a) Sagittal suprapubic US image of the right adnexa, obtained with a 5-2-MHz curvilinear transducer during the initial survey, shows ascites and a solid, lobulated, hypoechoic mass (M). The field of view includes the full depth of the peritoneal cavity but no more, and the focal zone was set to optimize visualization of the mass. (b) Sagittal transabdominal US image of the left flank obtained with a 7-4-MHz curvilinear transducer shows ascites and seeding on the serosal surface of the descending colon (arrows). A low gain setting was used, and the focal zone was positioned to optimize visualization of the seeding. The seeding is seen as a thin continuous line on the serosal surface of the intestine, which contains shadowing air. (c) Transverse transvaginal US image of the right adnexa obtained with an 8-4-MHz transvaginal probe shows the mass (M) and particulate ascites. A high gain setting was used to better characterize the ascites.

View larger version (140K): [in a new window]   Figure 2.  Localization of an abnormality in a 72-year-old man with squamous cell carcinoma of the lung and a peritoneal metastasis. Sagittal US image of the right upper quadrant shows a hypoechoic nodule (arrows) anterior to the liver (L). With respiration, the liver moved freely independent of the nodule, which stayed stationary. This finding correctly suggested that the nodule was located on the parietal peritoneum. K = kidney.

View larger version (117K): [in a new window]   Figure 3.  Normal mesentery with gross ascites in a 58-year-old woman with cirrhosis of the liver and portal hypertension. Sagittal oblique US image of the midabdomen shows the leaves of the normal small bowel mesentery (arrows) outlined by fluid.

View larger version (120K): [in a new window]   Figure 4.  Quantification of ascites in a 39-year-old man with cirrhosis of the liver and portal hypertension. Sagittal US image of the right upper quadrant clearly shows a large amount of ascites surrounding an enlarged, bulbous, fatty liver.

View larger version (181K): [in a new window]   Figure 5.  Quantification of ascites in a 40-year-old woman with grade 2-3 ovarian mucinous cystadenocarcinoma. Transverse transvaginal US image of the right adnexa shows a small amount of particulate free fluid (F) and serosal seeding (arrowheads) on bowel loops in the pelvis. This appearance was visible only on transvaginal scans.

View larger version (148K): [in a new window]   Figure 6a.  Characterization of peritoneal fluid in a 60-year-old woman 13 days after liver transplantation. (a) Unenhanced CT image of the upper abdomen shows ascites (arrowheads) and two hypoattenuating, homogeneous, subhepatic fluid collections (arrows). Intravenous contrast material was not administered because of renal failure. (b) Transverse US image obtained through the fluid collections shows a complex appearance with thick septa and low-level echoes (arrows), which was correctly suggestive of abscesses.

View larger version (126K): [in a new window]   Figure 6b.  Characterization of peritoneal fluid in a 60-year-old woman 13 days after liver transplantation. (a) Unenhanced CT image of the upper abdomen shows ascites (arrowheads) and two hypoattenuating, homogeneous, subhepatic fluid collections (arrows). Intravenous contrast material was not administered because of renal failure. (b) Transverse US image obtained through the fluid collections shows a complex appearance with thick septa and low-level echoes (arrows), which was correctly suggestive of abscesses.

View larger version (145K): [in a new window]   Figure 7a.  Hemoperitoneum in a 61-year-old man with hepatoma on a background of cirrhosis and portal hypertension who became hemodynamically unstable 1 day after therapeutic paracentesis. (a) Sagittal US image of the right upper quadrant obtained at the time of therapeutic paracentesis shows anechoic ascites (A) and an ill-defined echogenic mass (M) in the cirrhotic liver (L). (b) Transverse US image obtained 1 day later shows gross particulate ascites (A). Hemoperitoneum was proved at surgery. An artifact (arrowheads) is noted in the near field.

View larger version (122K): [in a new window]   Figure 7b.  Hemoperitoneum in a 61-year-old man with hepatoma on a background of cirrhosis and portal hypertension who became hemodynamically unstable 1 day after therapeutic paracentesis. (a) Sagittal US image of the right upper quadrant obtained at the time of therapeutic paracentesis shows anechoic ascites (A) and an ill-defined echogenic mass (M) in the cirrhotic liver (L). (b) Transverse US image obtained 1 day later shows gross particulate ascites (A). Hemoperitoneum was proved at surgery. An artifact (arrowheads) is noted in the near field.

View larger version (118K): [in a new window]   Figure 8.  Hemoperitoneum in a 38-year-old man who underwent recent revision of a liver transplantation because of hepatic artery thrombosis. He became hemodynamically unstable in the intensive care unit. Transverse US image of the left lower quadrant shows a heterogeneous mass (arrowheads) with a highly echogenic component (arrows). At surgery, the entire mass was confirmed to be an acute blood clot, which was secondary to rupture of a pseudoaneurysm at the hepatic artery anastomosis.

View larger version (125K): [in a new window]   Figure 9.  Peritoneal inclusion cyst in a 37-year-old woman with a long history of pelvic infection. Transverse transvaginal US image of the right adnexa shows a normal right ovary with follicles (arrow) surrounded by complicated strandy fluid.

View larger version (114K): [in a new window]   Figure 10a.  Sagittal (a) and coronal (b) drawings of the midabdomen and pelvis show common locations for the spread of peritoneal carcinomatosis. Commonly involved sites include the right subphrenic region (arrowhead in b), omentum (straight arrows), and pouch of Douglas (curved arrow in a). (Courtesy of J. Tomash, Toronto, Canada.)

View larger version (122K): [in a new window]   Figure 10b.  Sagittal (a) and coronal (b) drawings of the midabdomen and pelvis show common locations for the spread of peritoneal carcinomatosis. Commonly involved sites include the right subphrenic region (arrowhead in b), omentum (straight arrows), and pouch of Douglas (curved arrow in a). (Courtesy of J. Tomash, Toronto, Canada.)

View larger version (129K): [in a new window]   Figure 11.  Peritoneal carcinomatosis in a 57-year-old man with increasing abdominal girth 1 year after surgery for colon cancer. US showed evidence of peritoneal carcinomatosis. Transverse US image of the right side of the midabdomen shows a large amount of ascites (A) with a small parietal peritoneal implant in the right paracolic gutter (arrow).

View larger version (95K): [in a new window]   Figure 12a.  Calcified implants in a 21-year-old woman with a serous ovarian neoplasm. (a) Unenhanced CT image obtained through the inferior liver (L) shows a small calcified implant on the surface of segment VI (arrow). (b) Transverse US image obtained at the same level shows the implant (arrow). (c) Sagittal US image obtained through the Morison pouch shows multiple other calcified implants (arrows), which were not evident at CT even in retrospect. K = kidney.

View larger version (130K): [in a new window]   Figure 12b.  Calcified implants in a 21-year-old woman with a serous ovarian neoplasm. (a) Unenhanced CT image obtained through the inferior liver (L) shows a small calcified implant on the surface of segment VI (arrow). (b) Transverse US image obtained at the same level shows the implant (arrow). (c) Sagittal US image obtained through the Morison pouch shows multiple other calcified implants (arrows), which were not evident at CT even in retrospect. K = kidney.

View larger version (112K): [in a new window]   Figure 12c.  Calcified implants in a 21-year-old woman with a serous ovarian neoplasm. (a) Unenhanced CT image obtained through the inferior liver (L) shows a small calcified implant on the surface of segment VI (arrow). (b) Transverse US image obtained at the same level shows the implant (arrow). (c) Sagittal US image obtained through the Morison pouch shows multiple other calcified implants (arrows), which were not evident at CT even in retrospect. K = kidney.

View larger version (158K): [in a new window]   Figure 13.  Peritoneal carcinomatosis without ascites in a 77-year-old woman with papillary serous ovarian cancer. Transverse US image of the upper midabdomen shows hypoechoic seeding (arrows) that encases the gastric antrum.

View larger version (148K): [in a new window]   Figure 14.  Tiny peritoneal implants in a 53-year-old woman with papillary serous ovarian cancer. Transverse transvaginal US image of the right adnexa shows particulate ascites (A), a "rind" of hypoechoic seeding on the serosal surfaces of small bowel loops (arrowheads), and tiny parietal peritoneal implants in the near field (arrows), which measure 2 mm in maximum diameter.

View larger version (152K): [in a new window]   Figure 15.  Omental cake in a 79-year-old man who underwent right nephrectomy 2 years earlier for renal cell carcinoma. Sagittal US image shows a floating omental cake (arrows) with its free inferior margin (arrowhead) surrounded by ascites, an appearance indicative of peritoneal carcinomatosis.

View larger version (113K): [in a new window]   Figure 16.  Omental cake in a 71-year-old woman with proved metastatic adenocarcinoma. Transverse US image of the midabdomen shows a thick omental cake (arrowheads) that adheres to the visceral peritoneum and encases gas-filled bowel loops (BL).

View larger version (125K): [in a new window]   Figure 17.  Mesenteric tumor deposit in a 39-year-old man with known metastatic hepatocellular carcinoma. Transverse oblique US image of the midabdomen shows a tumor deposit (T) on a mesenteric fold, which is outlined by ascites. Note the normal adjacent mesenteric fold (arrow).

View larger version (123K): [in a new window]   Figure 18a.  Peritoneal mesothelioma in a 73-year-old woman with biopsy-proved malignant mesothelioma. (a) Sagittal US image of the left upper quadrant shows a lobulated, heterogeneous mass (M) that involves the greater omentum. (b) Sagittal US image of the lower abdomen shows two small, hypoechoic implants in the near field (arrows). (c) Sagittal US image of the right lower quadrant shows an omental cake (arrows). Note the absence of ascites.

View larger version (119K): [in a new window]   Figure 18b.  Peritoneal mesothelioma in a 73-year-old woman with biopsy-proved malignant mesothelioma. (a) Sagittal US image of the left upper quadrant shows a lobulated, heterogeneous mass (M) that involves the greater omentum. (b) Sagittal US image of the lower abdomen shows two small, hypoechoic implants in the near field (arrows). (c) Sagittal US image of the right lower quadrant shows an omental cake (arrows). Note the absence of ascites.

View larger version (133K): [in a new window]   Figure 18c.  Peritoneal mesothelioma in a 73-year-old woman with biopsy-proved malignant mesothelioma. (a) Sagittal US image of the left upper quadrant shows a lobulated, heterogeneous mass (M) that involves the greater omentum. (b) Sagittal US image of the lower abdomen shows two small, hypoechoic implants in the near field (arrows). (c) Sagittal US image of the right lower quadrant shows an omental cake (arrows). Note the absence of ascites.

View larger version (124K): [in a new window]   Figure 19a.  Non-Hodgkin lymphoma of the peritoneum in a 37-year-old man with biopsy-proved non-Hodgkin lymphoma in the right lower quadrant. (a) Transverse US image shows a hypoechoic mass (M) that encompasses a gas-containing bowel loop. An echogenic mass effect (arrows) represents infiltrated fat and omentum. (b) CT image of the lower abdomen shows a large, homogeneous peritoneal mass (M) that displaces bowel loops (arrowheads). Note infiltration of the fat anterolateral to the mass (arrows).

View larger version (92K): [in a new window]   Figure 19b.  Non-Hodgkin lymphoma of the peritoneum in a 37-year-old man with biopsy-proved non-Hodgkin lymphoma in the right lower quadrant. (a) Transverse US image shows a hypoechoic mass (M) that encompasses a gas-containing bowel loop. An echogenic mass effect (arrows) represents infiltrated fat and omentum. (b) CT image of the lower abdomen shows a large, homogeneous peritoneal mass (M) that displaces bowel loops (arrowheads). Note infiltration of the fat anterolateral to the mass (arrows).

View larger version (135K): [in a new window]   Figure 20a.  Pseudomyxoma peritonei in a 70-year-old woman with increasing abdominal girth. Surgery showed pseudomyxoma peritonei, which was likely of appendiceal origin. (a) Transverse US image of the midabdomen shows bowel loops (BL) displaced centrally by echogenic ascites with a starburst appearance. At real-time imaging, the echogenic foci in the ascites were nonmobile. (b) Sagittal US image of the pelvis shows the uterus (U) surrounded by echogenic ascites.

View larger version (134K): [in a new window]   Figure 20b.  Pseudomyxoma peritonei in a 70-year-old woman with increasing abdominal girth. Surgery showed pseudomyxoma peritonei, which was likely of appendiceal origin. (a) Transverse US image of the midabdomen shows bowel loops (BL) displaced centrally by echogenic ascites with a starburst appearance. At real-time imaging, the echogenic foci in the ascites were nonmobile. (b) Sagittal US image of the pelvis shows the uterus (U) surrounded by echogenic ascites.

View larger version (119K): [in a new window]   Figure 21.  Pseudomyxoma peritonei secondary to a ruptured appendiceal mucocele in a 51-year-old man. Sagittal oblique US image of the right upper quadrant shows echogenic ascites (A) with scalloping of the liver.

View larger version (142K): [in a new window]   Figure 22.  Purulent peritonitis 1 week after laparotomy in a 23-year-old man. Sagittal US image of the midabdomen from the initial survey shows diffuse peritoneal thickening between bowel loops (arrowheads). There is strandy ascites in the near field (arrows).

View larger version (113K): [in a new window]   Figure 23.  Abscess in a 46-year-old man with fever and fatigue after liver transplantation. Transverse US image of the midabdomen shows a large abscess (A).

View larger version (134K): [in a new window]   Figure 24.  Abscess in a 55-year-old woman with constipation and perforation of the sigmoid colon with fecal peritonitis. Sagittal oblique US image of the left lower quadrant shows a large fluid collection (arrows) with stranding and bright echogenic foci (arrowheads), which represent gas bubbles.

View larger version (101K): [in a new window]   Figure 25a.  Tuberculous peritonitis in a 30-year-old Vietnamese woman with drug-resistant tuberculosis. (a) Transverse midline US image shows ascites (A) with matted bowel loops (BL). (b) Sagittal US image of the left adnexa shows ascites and the left ovary (O) embedded in thickened visceral peritoneum (arrowheads).

View larger version (100K): [in a new window]   Figure 25b.  Tuberculous peritonitis in a 30-year-old Vietnamese woman with drug-resistant tuberculosis. (a) Transverse midline US image shows ascites (A) with matted bowel loops (BL). (b) Sagittal US image of the left adnexa shows ascites and the left ovary (O) embedded in thickened visceral peritoneum (arrowheads).

View larger version (131K): [in a new window]   Figure 26a.  Tuberculous peritonitis in a 27-year-old Vietnamese man. (a) Transverse US image of the right upper quadrant shows echogenic fluid (F) scalloping the liver (L). (b) Contrast material-enhanced CT image obtained at the same level shows fluid (arrows) scalloping the liver. Note the enhancing rind (arrowheads).

View larger version (128K): [in a new window]   Figure 26b.  Tuberculous peritonitis in a 27-year-old Vietnamese man. (a) Transverse US image of the right upper quadrant shows echogenic fluid (F) scalloping the liver (L). (b) Contrast material-enhanced CT image obtained at the same level shows fluid (arrows) scalloping the liver. Note the enhancing rind (arrowheads).

View larger version (122K): [in a new window]   Figure 27.  Sclerosing peritonitis in a 62-year-old man who discontinued peritoneal dialysis 2 months earlier because of loss of ultrafiltration. Transverse US image of the midabdomen shows extensive, complex, septated ascites (A).

View larger version (121K): [in a new window]   Figure 28.  Localized inflamed fat in a 26-year-old woman with Crohn disease. Sagittal US image of the right lower quadrant shows the thickened terminal ileum in transverse section (arrows). Note the surrounding echogenic inflamed fat (arrowheads).

View larger version (109K): [in a new window]   Figure 29.  Localized inflamed fat and phlegmon in a 19-year-old woman with Crohn disease. Sagittal oblique US image of the right lower quadrant shows the thickened terminal ileum (TI) with echogenic inflamed fat (arrowheads) and a hypoechoic perienteric phlegmon (arrows).

View larger version (123K): [in a new window]   Figure 30a.  Endometriotic plaques in a 33-year-old woman with endometriosis. Sagittal (a) and corresponding transverse transvaginal (b) US images of a pelvic bowel loop show hypoechoic endometriotic plaque along one serosal surface (arrowheads).

View larger version (116K): [in a new window]   Figure 30b.  Endometriotic plaques in a 33-year-old woman with endometriosis. Sagittal (a) and corresponding transverse transvaginal (b) US images of a pelvic bowel loop show hypoechoic endometriotic plaque along one serosal surface (arrowheads).

View larger version (118K): [in a new window]   Figure 31.  Right-sided segmental infarction of the omentum in a 38-year-old woman with pain in the right side of the middle to lower abdomen. Transverse US image of the right side of the midabdomen shows an ovoid echogenic mass (arrows), which was noted to be adherent to the parietal peritoneum during respiration. This region was the site of maximal tenderness.

View larger version (146K): [in a new window]   Figure 32a.  Pneumoperitoneum in a 28-year-old woman with a perforated duodenal ulcer. (a) Sagittal upper midline US image obtained with the patient supine shows a small area of enhancement of the peritoneal stripe (arrow) with ring-down artifact (arrowheads). (b) Sagittal US image of the right upper quadrant, obtained with the patient in the left decubitus oblique position, shows that the area of enhancement of the peritoneal stripe (arrow) has moved anterior to the liver.

View larger version (134K): [in a new window]   Figure 32b.  Pneumoperitoneum in a 28-year-old woman with a perforated duodenal ulcer. (a) Sagittal upper midline US image obtained with the patient supine shows a small area of enhancement of the peritoneal stripe (arrow) with ring-down artifact (arrowheads). (b) Sagittal US image of the right upper quadrant, obtained with the patient in the left decubitus oblique position, shows that the area of enhancement of the peritoneal stripe (arrow) has moved anterior to the liver.

View larger version (120K): [in a new window]   Figure 33a.  Lymphangioma in a 58-year-old asymptomatic man. (a) Transverse US image obtained along the midline of the abdomen shows the inferior vena cava (I) and aorta (A). Anterior to these vessels, in the expected location of the mesentery, there is a multicystic mass with thin septa and a lobulated border. (b) Portal venous phase CT image shows that the mass is lobulated, of low attenuation, and nonenhancing.

View larger version (170K): [in a new window]   Figure 33b.  Lymphangioma in a 58-year-old asymptomatic man. (a) Transverse US image obtained along the midline of the abdomen shows the inferior vena cava (I) and aorta (A). Anterior to these vessels, in the expected location of the mesentery, there is a multicystic mass with thin septa and a lobulated border. (b) Portal venous phase CT image shows that the mass is lobulated, of low attenuation, and nonenhancing.