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From the RSNA Refresher Courses

Imaging Evaluation for Acute Pain in the Right Upper Quadrant¹

¹ From the Department of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Ontario, Canada. Presented as a refresher course at the 2002 RSNA scientific assembly. Received June 13, 2003; revision requested July 14 and received September 22; accepted September 23. All authors have no financial relationships to disclose. Address correspondence to A.E.H., Department of Medical Imaging, Toronto General Hospital, NCSB 1C-571, 585 University Ave, Toronto, ON, Canada M5G 2N2 (e-mail: anthony.hanbidge@uhn.on.ca).

View larger version (147K): [in a new window]   Figure 1a.  Acute cholecystitis in a 38-year-old woman. (a) Sagittal sonogram shows stones (arrow) in a tense, distended gallbladder. The patient experienced maximal tenderness when the transducer was pressed over the fundus of the gallbladder (arrowhead) (sonographic Murphy sign). (b) Transverse oblique intercostal sonogram of the neck of the gallbladder (arrowheads) shows an obstructing stone (arrow).

View larger version (101K): [in a new window]   Figure 1b.  Acute cholecystitis in a 38-year-old woman. (a) Sagittal sonogram shows stones (arrow) in a tense, distended gallbladder. The patient experienced maximal tenderness when the transducer was pressed over the fundus of the gallbladder (arrowhead) (sonographic Murphy sign). (b) Transverse oblique intercostal sonogram of the neck of the gallbladder (arrowheads) shows an obstructing stone (arrow).

View larger version (147K): [in a new window]   Figure 2.  Acute cholecystitis in a 42-year-old man. Sagittal sonogram shows stones in the fundus (arrowheads) and an obstructing stone in the neck (arrow) of a tense, distended gallbladder, which was also tender.

View larger version (163K): [in a new window]   Figure 3.  Recurrent gallbladder cancer in a 57-year-old man. Axial CT scan shows recurrent tumor at the site of the right upper quadrant port (arrow). There was also evidence of tumor recurrence at the site of the umbilical port (not shown).

View larger version (141K): [in a new window]   Figure 4a.  Acute cholecystitis in a 64-year-old woman with pain and fever. (a) Sagittal sonogram shows stones (arrowheads) embedded in heterogeneous material. Abdominal CT was performed to rule out gallbladder cancer. (b) Axial CT scan shows a distended gallbladder with stones, wall thickening, and edema (arrowheads). A breach in the enhancing mucosa (arrow) suggests early, focal gangrene. No enhancing mass was seen at comparison with the unenhanced images (not shown). Acute cholecystitis was confirmed at surgery.

View larger version (134K): [in a new window]   Figure 4b.  Acute cholecystitis in a 64-year-old woman with pain and fever. (a) Sagittal sonogram shows stones (arrowheads) embedded in heterogeneous material. Abdominal CT was performed to rule out gallbladder cancer. (b) Axial CT scan shows a distended gallbladder with stones, wall thickening, and edema (arrowheads). A breach in the enhancing mucosa (arrow) suggests early, focal gangrene. No enhancing mass was seen at comparison with the unenhanced images (not shown). Acute cholecystitis was confirmed at surgery.

View larger version (140K): [in a new window]   Figure 5.  Gangrenous cholecystitis in a 38-year-old man with polyarteritis nodosa and vague abdominal pain. Sagittal sonogram shows sloughed membranes (arrows) and sludge or pus layered in the gallbladder. The diagnosis was confirmed at urgent cholecystectomy.

View larger version (110K): [in a new window]   Figure 6a.  Emphysematous cholecystitis in a 58-year-old diabetic man with end-stage renal disease. (a) Sagittal sonogram shows a curvilinear echogenic interface in the gallbladder fossa (arrowheads) with reverberation artifact (arrows). These findings are suggestive of gas in the wall of the gallbladder. (b) Axial CT scan shows gas in the gallbladder lumen (GB) and wall (arrow).

View larger version (157K): [in a new window]   Figure 6b.  Emphysematous cholecystitis in a 58-year-old diabetic man with end-stage renal disease. (a) Sagittal sonogram shows a curvilinear echogenic interface in the gallbladder fossa (arrowheads) with reverberation artifact (arrows). These findings are suggestive of gas in the wall of the gallbladder. (b) Axial CT scan shows gas in the gallbladder lumen (GB) and wall (arrow).

View larger version (94K): [in a new window]   Figure 7.  Cholelithiasis in a 34-year-old woman. Sagittal sonogram of the gallbladder shows the wall (W)-echo (E)-shadow (S) complex, which indicates that the gallbladder is filled with stones.

View larger version (143K): [in a new window]   Figure 8a.  Subacute gallbladder perforation in a 72-year-old man. (a) Sagittal sonogram shows a large stone (arrowhead) in the neck of a decompressed gallbladder (GB). There is evidence of a heterogeneous mass in the liver (?). (b) Sagittal sonogram of the liver shows the mass (A), which is complex, located in segment V, and suggestive of an abscess. (c) Sagittal sonogram obtained in a different plane than in a shows a breach in the gallbladder wall (arrow), which leads into the abscess. (d) Axial CT scan of the abdomen shows the large defect (arrowhead) in the gallbladder (GB) wall. The pericholecystic extent of the abscess is also seen.

View larger version (145K): [in a new window]   Figure 8b.  Subacute gallbladder perforation in a 72-year-old man. (a) Sagittal sonogram shows a large stone (arrowhead) in the neck of a decompressed gallbladder (GB). There is evidence of a heterogeneous mass in the liver (?). (b) Sagittal sonogram of the liver shows the mass (A), which is complex, located in segment V, and suggestive of an abscess. (c) Sagittal sonogram obtained in a different plane than in a shows a breach in the gallbladder wall (arrow), which leads into the abscess. (d) Axial CT scan of the abdomen shows the large defect (arrowhead) in the gallbladder (GB) wall. The pericholecystic extent of the abscess is also seen.

View larger version (143K): [in a new window]   Figure 8c.  Subacute gallbladder perforation in a 72-year-old man. (a) Sagittal sonogram shows a large stone (arrowhead) in the neck of a decompressed gallbladder (GB). There is evidence of a heterogeneous mass in the liver (?). (b) Sagittal sonogram of the liver shows the mass (A), which is complex, located in segment V, and suggestive of an abscess. (c) Sagittal sonogram obtained in a different plane than in a shows a breach in the gallbladder wall (arrow), which leads into the abscess. (d) Axial CT scan of the abdomen shows the large defect (arrowhead) in the gallbladder (GB) wall. The pericholecystic extent of the abscess is also seen.

View larger version (164K): [in a new window]   Figure 8d.  Subacute gallbladder perforation in a 72-year-old man. (a) Sagittal sonogram shows a large stone (arrowhead) in the neck of a decompressed gallbladder (GB). There is evidence of a heterogeneous mass in the liver (?). (b) Sagittal sonogram of the liver shows the mass (A), which is complex, located in segment V, and suggestive of an abscess. (c) Sagittal sonogram obtained in a different plane than in a shows a breach in the gallbladder wall (arrow), which leads into the abscess. (d) Axial CT scan of the abdomen shows the large defect (arrowhead) in the gallbladder (GB) wall. The pericholecystic extent of the abscess is also seen.

View larger version (171K): [in a new window]   Figure 9a.  Gallstone ileus in a 46-year-old woman. (a) Axial CT scan shows a fistulous communication (arrowhead) between the gallbladder and the duodenum, both of which are filled with air. Note the dilated loops of the proximal small intestine (BL). (b) Axial CT scan obtained inferiorly to a shows gallstones in a distal ileal loop (arrow). The stones are the cause of the obstruction.

View larger version (161K): [in a new window]   Figure 9b.  Gallstone ileus in a 46-year-old woman. (a) Axial CT scan shows a fistulous communication (arrowhead) between the gallbladder and the duodenum, both of which are filled with air. Note the dilated loops of the proximal small intestine (BL). (b) Axial CT scan obtained inferiorly to a shows gallstones in a distal ileal loop (arrow). The stones are the cause of the obstruction.

View larger version (123K): [in a new window]   Figure 10a.  Duodenal obstruction by a gallstone (Bouveret syndrome) in an 85-year-old woman. (a) Transverse oblique sonogram of the gallbladder fossa shows gas (arrowhead) with reverberation artifact (arrows). (b) Sagittal sonogram obtained adjacent to the gallbladder fossa shows a large, fluid-filled structure (D). This structure demonstrated active peristalsis, which suggested that it was the duodenum. A gallstone (arrow) is seen within the structure. (c) Axial CT scan shows a fistulous communication (arrow) between the air-filled gallbladder and the distended, fluid-filled duodenum. (d) Axial CT scan obtained inferiorly to c shows a gallstone (arrow) in the third part of the duodenum. This large stone is the one seen on the sonogram (b). (e) Axial CT scan obtained inferiorly to d shows an additional large, laminated stone (arrow) that obstructs the jejunum. This stone was not seen at US.

View larger version (119K): [in a new window]   Figure 10b.  Duodenal obstruction by a gallstone (Bouveret syndrome) in an 85-year-old woman. (a) Transverse oblique sonogram of the gallbladder fossa shows gas (arrowhead) with reverberation artifact (arrows). (b) Sagittal sonogram obtained adjacent to the gallbladder fossa shows a large, fluid-filled structure (D). This structure demonstrated active peristalsis, which suggested that it was the duodenum. A gallstone (arrow) is seen within the structure. (c) Axial CT scan shows a fistulous communication (arrow) between the air-filled gallbladder and the distended, fluid-filled duodenum. (d) Axial CT scan obtained inferiorly to c shows a gallstone (arrow) in the third part of the duodenum. This large stone is the one seen on the sonogram (b). (e) Axial CT scan obtained inferiorly to d shows an additional large, laminated stone (arrow) that obstructs the jejunum. This stone was not seen at US.

View larger version (167K): [in a new window]   Figure 10c.  Duodenal obstruction by a gallstone (Bouveret syndrome) in an 85-year-old woman. (a) Transverse oblique sonogram of the gallbladder fossa shows gas (arrowhead) with reverberation artifact (arrows). (b) Sagittal sonogram obtained adjacent to the gallbladder fossa shows a large, fluid-filled structure (D). This structure demonstrated active peristalsis, which suggested that it was the duodenum. A gallstone (arrow) is seen within the structure. (c) Axial CT scan shows a fistulous communication (arrow) between the air-filled gallbladder and the distended, fluid-filled duodenum. (d) Axial CT scan obtained inferiorly to c shows a gallstone (arrow) in the third part of the duodenum. This large stone is the one seen on the sonogram (b). (e) Axial CT scan obtained inferiorly to d shows an additional large, laminated stone (arrow) that obstructs the jejunum. This stone was not seen at US.

View larger version (149K): [in a new window]   Figure 10d.  Duodenal obstruction by a gallstone (Bouveret syndrome) in an 85-year-old woman. (a) Transverse oblique sonogram of the gallbladder fossa shows gas (arrowhead) with reverberation artifact (arrows). (b) Sagittal sonogram obtained adjacent to the gallbladder fossa shows a large, fluid-filled structure (D). This structure demonstrated active peristalsis, which suggested that it was the duodenum. A gallstone (arrow) is seen within the structure. (c) Axial CT scan shows a fistulous communication (arrow) between the air-filled gallbladder and the distended, fluid-filled duodenum. (d) Axial CT scan obtained inferiorly to c shows a gallstone (arrow) in the third part of the duodenum. This large stone is the one seen on the sonogram (b). (e) Axial CT scan obtained inferiorly to d shows an additional large, laminated stone (arrow) that obstructs the jejunum. This stone was not seen at US.

View larger version (164K): [in a new window]   Figure 10e.  Duodenal obstruction by a gallstone (Bouveret syndrome) in an 85-year-old woman. (a) Transverse oblique sonogram of the gallbladder fossa shows gas (arrowhead) with reverberation artifact (arrows). (b) Sagittal sonogram obtained adjacent to the gallbladder fossa shows a large, fluid-filled structure (D). This structure demonstrated active peristalsis, which suggested that it was the duodenum. A gallstone (arrow) is seen within the structure. (c) Axial CT scan shows a fistulous communication (arrow) between the air-filled gallbladder and the distended, fluid-filled duodenum. (d) Axial CT scan obtained inferiorly to c shows a gallstone (arrow) in the third part of the duodenum. This large stone is the one seen on the sonogram (b). (e) Axial CT scan obtained inferiorly to d shows an additional large, laminated stone (arrow) that obstructs the jejunum. This stone was not seen at US.

View larger version (127K): [in a new window]   Figure 11a.  Incomplete gallbladder torsion in a 94-year-old woman. (a) Sagittal sonogram of the midabdomen shows a cystic mass (C) with edematous walls anterior to the abdominal aorta (A). (b) Coronal oblique maximum intensity projection CT scan shows that the mass has a beaked neck (arrow), which extends into the gallbladder fossa.

View larger version (161K): [in a new window]   Figure 11b.  Incomplete gallbladder torsion in a 94-year-old woman. (a) Sagittal sonogram of the midabdomen shows a cystic mass (C) with edematous walls anterior to the abdominal aorta (A). (b) Coronal oblique maximum intensity projection CT scan shows that the mass has a beaked neck (arrow), which extends into the gallbladder fossa.

View larger version (154K): [in a new window]   Figure 12.  Acute viral hepatitis in a 38-year-old woman. Sagittal sonogram of the gallbladder shows a tiny, slitlike lumen (*) with massive "onion peel" edema of the wall (arrowheads).

View larger version (130K): [in a new window]   Figure 13.  Congestive heart failure in a 56-year-old man. Sagittal sonogram of the gallbladder shows edema of the wall (arrowheads), pericholecystic free fluid (FF), and distention of the inferior vena cava (IVC).

View larger version (125K): [in a new window]   Figure 14.  Cirrhosis in a 37-year-old man. Sagittal sonogram of the gallbladder shows a thickened wall (arrowheads) and free fluid (FF).

View larger version (98K): [in a new window]   Figure 15a.  Perforated diverticulitis of the hepatic flexure in a febrile 67-year-old woman. (a) Sagittal sonogram shows a distended gallbladder (GB) with a small amount of pericholecystic fluid (arrow) but no stones. (b) Sagittal sonogram obtained at the site of maximal tenderness shows a thickened hepatic flexure (HF) with an inflamed diverticulum (*), from which extends a linear tract of extraluminal gas (arrow) surrounded by inflamed fat (arrowheads).

View larger version (142K): [in a new window]   Figure 15b.  Perforated diverticulitis of the hepatic flexure in a febrile 67-year-old woman. (a) Sagittal sonogram shows a distended gallbladder (GB) with a small amount of pericholecystic fluid (arrow) but no stones. (b) Sagittal sonogram obtained at the site of maximal tenderness shows a thickened hepatic flexure (HF) with an inflamed diverticulum (*), from which extends a linear tract of extraluminal gas (arrow) surrounded by inflamed fat (arrowheads).

View larger version (133K): [in a new window]   Figure 16a.  Perforated duodenal ulcer in a 76-year-old man. (a) Sagittal sonogram shows a stone in the gallbladder neck (arrow). The patient had epigastric tenderness. Note that the gallbladder is not tensely distended. (b) Sonogram of the right upper quadrant, obtained with the patient in the left posterior oblique position, shows enhancement of the parietal peritoneal line (arrowhead) with reverberation artifact (arrow), findings suggestive of free air. (c) Axial CT scan of the abdomen shows pericholecystic inflammation (arrow) and pneumoperitoneum (arrowhead). GB = gallbladder.

View larger version (144K): [in a new window]   Figure 16b.  Perforated duodenal ulcer in a 76-year-old man. (a) Sagittal sonogram shows a stone in the gallbladder neck (arrow). The patient had epigastric tenderness. Note that the gallbladder is not tensely distended. (b) Sonogram of the right upper quadrant, obtained with the patient in the left posterior oblique position, shows enhancement of the parietal peritoneal line (arrowhead) with reverberation artifact (arrow), findings suggestive of free air. (c) Axial CT scan of the abdomen shows pericholecystic inflammation (arrow) and pneumoperitoneum (arrowhead). GB = gallbladder.

View larger version (172K): [in a new window]   Figure 16c.  Perforated duodenal ulcer in a 76-year-old man. (a) Sagittal sonogram shows a stone in the gallbladder neck (arrow). The patient had epigastric tenderness. Note that the gallbladder is not tensely distended. (b) Sonogram of the right upper quadrant, obtained with the patient in the left posterior oblique position, shows enhancement of the parietal peritoneal line (arrowhead) with reverberation artifact (arrow), findings suggestive of free air. (c) Axial CT scan of the abdomen shows pericholecystic inflammation (arrow) and pneumoperitoneum (arrowhead). GB = gallbladder.

View larger version (97K): [in a new window]   Figure 17.  Choledocholithiasis in a 78-year-old man. Sagittal sonogram shows a large stone (arrows) with a faint shadow (lines), which is a result of scanning with compound imaging (arrowhead). With compound imaging, the sound waves are steered off axis, providing up to nine transmit angles (lines of sight) in the course of a single scan. Thus, the sound waves strike the stone from many different angles and disperse the shadow. SCT = sono-CT.

View larger version (136K): [in a new window]   Figure 18.  Choledocholithiasis in a 93-year-old man. Axial MR cholangiopancreatogram shows a stone (arrow) in the distal common bile duct.

View larger version (173K): [in a new window]   Figure 19a.  Choledocholithiasis in a 69-year-old man. (a) Axial CT scan obtained after intravenous administration of contrast material shows an area of high attenuation in the distal common bile duct (arrow), a finding that raises the possibility of an enhancing mass. The bile ducts were dilated to this level (not shown). (b) Axial CT scan obtained without contrast material at the same level as a shows that the area of high attenuation is a stone (arrow).

View larger version (163K): [in a new window]   Figure 19b.  Choledocholithiasis in a 69-year-old man. (a) Axial CT scan obtained after intravenous administration of contrast material shows an area of high attenuation in the distal common bile duct (arrow), a finding that raises the possibility of an enhancing mass. The bile ducts were dilated to this level (not shown). (b) Axial CT scan obtained without contrast material at the same level as a shows that the area of high attenuation is a stone (arrow).

View larger version (130K): [in a new window]   Figure 20.  Hemobilia in a 47-year-old woman after transjugular liver biopsy. Sagittal sonogram of the bile duct shows a linear, heterogeneous clot (arrow) within the lumen. L = liver.

View larger version (109K): [in a new window]   Figure 21a.  Hepatic artery aneurysm in a 70-year-old man with a 3-week history of jaundice and a 1-day history of severe pain in the right upper quadrant. (a) Sagittal sonogram shows a cystic mass (C) obstructing the common bile duct, which is dilated proximally (arrow). (b) Color Doppler image of the mass shows flow typical of a large aneurysm. Surgery was performed on the same day after CT angiography because of concern about imminent rupture.

View larger version (148K): [in a new window]   Figure 21b.  Hepatic artery aneurysm in a 70-year-old man with a 3-week history of jaundice and a 1-day history of severe pain in the right upper quadrant. (a) Sagittal sonogram shows a cystic mass (C) obstructing the common bile duct, which is dilated proximally (arrow). (b) Color Doppler image of the mass shows flow typical of a large aneurysm. Surgery was performed on the same day after CT angiography because of concern about imminent rupture.

View larger version (143K): [in a new window]   Figure 22.  Ascending cholangitis in a 48-year-old woman. Transverse sonogram of the common bile duct shows dramatic wall thickening (arrow). L = liver.

View larger version (133K): [in a new window]   Figure 23a.  Ascending cholangitis in an 81-year-old woman in septic shock. (a) Sagittal sonogram shows a markedly dilated common bile duct (arrowheads) filled with sludge and stones. (b) Endoscopic retrograde cholangiopancreatogram shows a dilated intra- and extrahepatic biliary system with multiple filling defects (arrow). The patient recovered after urgent papillotomy and administration of antibiotics and intravenous fluids.

View larger version (126K): [in a new window]   Figure 23b.  Ascending cholangitis in an 81-year-old woman in septic shock. (a) Sagittal sonogram shows a markedly dilated common bile duct (arrowheads) filled with sludge and stones. (b) Endoscopic retrograde cholangiopancreatogram shows a dilated intra- and extrahepatic biliary system with multiple filling defects (arrow). The patient recovered after urgent papillotomy and administration of antibiotics and intravenous fluids.

View larger version (122K): [in a new window]   Figure 24.  Liver abscess in a 38-year-old man with pain, fever, and chills. Transverse sonogram of the right lobe of the liver shows a large, complex mass (A), which is suggestive of an abscess. Pus was obtained at percutaneous drainage.

View larger version (117K): [in a new window]   Figure 25a.  Large liver abscess in a 30-year-old man with fever and pain in the right upper quadrant that radiated to the right shoulder. (a) Transverse sonogram shows a large mass (A) in the right lobe of the liver. The mass appears solid. (b) Axial CT scan shows the mass (A). Low-attenuation areas are seen, which reflect early liquefaction.

View larger version (148K): [in a new window]   Figure 25b.  Large liver abscess in a 30-year-old man with fever and pain in the right upper quadrant that radiated to the right shoulder. (a) Transverse sonogram shows a large mass (A) in the right lobe of the liver. The mass appears solid. (b) Axial CT scan shows the mass (A). Low-attenuation areas are seen, which reflect early liquefaction.

View larger version (137K): [in a new window]   Figure 26.  Recurrent pyogenic cholangiohepatitis in a 32-year-old Asian woman. Sagittal sonogram of the right lobe of the liver shows a linear band of shadowing stones (arrows) in the bile ducts of segment VI. The bile ducts are close to the edge of the liver, an appearance that reflects marked atrophy of the involved segment.

View larger version (119K): [in a new window]   Figure 27a.  Ruptured hepatic adenoma in a 29-year-old woman using the oral contraceptive pill. She had abdominal pain and a falling hemoglobin level. (a) Axial contrast material-enhanced CT scan of the abdomen shows free fluid (arrows) around the liver and a large, heterogeneous mass (arrowheads), which is exophytic from the tip of the left lobe. (b) Photograph obtained during surgery shows the ruptured adenoma.

View larger version (123K): [in a new window]   Figure 27b.  Ruptured hepatic adenoma in a 29-year-old woman using the oral contraceptive pill. She had abdominal pain and a falling hemoglobin level. (a) Axial contrast material-enhanced CT scan of the abdomen shows free fluid (arrows) around the liver and a large, heterogeneous mass (arrowheads), which is exophytic from the tip of the left lobe. (b) Photograph obtained during surgery shows the ruptured adenoma.

View larger version (129K): [in a new window]   Figure 28a.  Ruptured hepatocellular carcinoma in a 70-year-old man with hepatitis B. (a) Sagittal sonogram of the liver shows a large mass (M), which is exophytic from segment V. (b) Sagittal sonogram of the right lobe of the liver shows an echogenic rind (arrows) anterior to the liver, a finding suggestive of acute hemoperitoneum.

View larger version (111K): [in a new window]   Figure 28b.  Ruptured hepatocellular carcinoma in a 70-year-old man with hepatitis B. (a) Sagittal sonogram of the liver shows a large mass (M), which is exophytic from segment V. (b) Sagittal sonogram of the right lobe of the liver shows an echogenic rind (arrows) anterior to the liver, a finding suggestive of acute hemoperitoneum.

View larger version (162K): [in a new window]   Figure 29a.  Ruptured cavernous hemangioma in a 48-year-old woman. (a) Sagittal sonogram of the liver shows a large, heterogeneous mass (M) in the right lobe. (b) Arterial phase CT scan of the abdomen shows that the mass (M) has peripheral nodular enhancement (arrow), which is typical of a cavernous hemangioma. There was fluid of high attenuation in the pelvis (not shown), a finding suggestive of hemoperitoneum. (c) Photograph obtained during surgery shows the lesion, which was confirmed to be a cavernous hemangioma.

View larger version (172K): [in a new window]   Figure 29b.  Ruptured cavernous hemangioma in a 48-year-old woman. (a) Sagittal sonogram of the liver shows a large, heterogeneous mass (M) in the right lobe. (b) Arterial phase CT scan of the abdomen shows that the mass (M) has peripheral nodular enhancement (arrow), which is typical of a cavernous hemangioma. There was fluid of high attenuation in the pelvis (not shown), a finding suggestive of hemoperitoneum. (c) Photograph obtained during surgery shows the lesion, which was confirmed to be a cavernous hemangioma.

View larger version (105K): [in a new window]   Figure 29c.  Ruptured cavernous hemangioma in a 48-year-old woman. (a) Sagittal sonogram of the liver shows a large, heterogeneous mass (M) in the right lobe. (b) Arterial phase CT scan of the abdomen shows that the mass (M) has peripheral nodular enhancement (arrow), which is typical of a cavernous hemangioma. There was fluid of high attenuation in the pelvis (not shown), a finding suggestive of hemoperitoneum. (c) Photograph obtained during surgery shows the lesion, which was confirmed to be a cavernous hemangioma.