DOI: 10.1148/rg.271065050
The Perihepatic Space: Comprehensive Anatomy and CT Features of Pathologic Conditions1
Suk Kim, MD,
Tae Un Kim, MD,
Jun Woo Lee, MD,
Tae Hong Lee, MD,
Suck Hong Lee, MD,
Tae Yong Jeon, MD and
Ki Hyung Kim, MD
1 From the Departments of Diagnostic Radiology (S.K., T.U.K., J.W.L., T.H.L., S.H.L.), Surgery (T.Y.J.), and Obstetrics and Gynecology (K.H.K.), Pusan National University Hospital, 1-10 Ami-Dong, Seo-gu, Busan 602-739, Korea. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 30, 2006; revision requested May 24; final revision received August 9; accepted August 14. All authors have no financial relationships to disclose.
View larger version (111K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Coronal reformatted computed tomographic (CT) scans (a obtained anterior to b) show the peritoneal spaces and ligaments. The images were obtained with intraperitoneal contrast material in a patient undergoing continuous ambulatory peritoneal dialysis. Lt = left, Rt = right.
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Coronal reformatted computed tomographic (CT) scans (a obtained anterior to b) show the peritoneal spaces and ligaments. The images were obtained with intraperitoneal contrast material in a patient undergoing continuous ambulatory peritoneal dialysis. Lt = left, Rt = right.
|
|
View larger version (139K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Free perihepatic air in a 67-year-old man with perforating sigmoid diverticulitis. (a) Axial contrast-enhanced CT scan (lung window) shows free air (arrowheads) in the perihepatic space. Free air is more easily identified by using lung window settings. (b) CT scan of the pelvis shows a thickened wall of the sigmoid colon (arrow) and mild pericolonic inflammatory fat stranding, findings that represent diverticulitis.
|
|
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Free perihepatic air in a 67-year-old man with perforating sigmoid diverticulitis. (a) Axial contrast-enhanced CT scan (lung window) shows free air (arrowheads) in the perihepatic space. Free air is more easily identified by using lung window settings. (b) CT scan of the pelvis shows a thickened wall of the sigmoid colon (arrow) and mild pericolonic inflammatory fat stranding, findings that represent diverticulitis.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4a. Ruptured teratoma in a 51-year-old woman with a palpable periumbilical mass. (a) Axial contrast-enhanced CT scan shows a floating fat droplet (arrowhead) with a fat-fluid level in the perihepatic space and ascites in the peritoneal space. The hazy omental infiltration is suggestive of chronic granulomatous peritonitis. (b) Axial contrast-enhanced CT scan of the pelvis shows an ovarian teratoma (*) with fat attenuation and foci of calcification. (Case courtesy of Y. W. Kim, MD, Pusan Baik Hospital, Busan, Korea.) a pneumoperitoneum is suspected because of the cost and radiation burden of the procedure.
|
|
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4b. Ruptured teratoma in a 51-year-old woman with a palpable periumbilical mass. (a) Axial contrast-enhanced CT scan shows a floating fat droplet (arrowhead) with a fat-fluid level in the perihepatic space and ascites in the peritoneal space. The hazy omental infiltration is suggestive of chronic granulomatous peritonitis. (b) Axial contrast-enhanced CT scan of the pelvis shows an ovarian teratoma (*) with fat attenuation and foci of calcification. (Case courtesy of Y. W. Kim, MD, Pusan Baik Hospital, Busan, Korea.)
|
|
View larger version (177K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7. Omental infarct in a 27-year-old man. Axial contrast-enhanced CT scan shows a small, ovoid, fatty mass (arrowhead) surrounded by fat stranding around the falciform ligament.
|
|
View larger version (142K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8. Omental packing in a 65-year-old woman who underwent surgery for hepatocellular carcinoma. Axial contrast-enhanced CT scan shows a metallic surgical clip (arrowhead) and a fat-containing masslike lesion (*), which is consistent with omentopexy due to hepatocellular carcinoma surgery.
|
|
View larger version (139K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9a. Hemoperitoneum in a 45-year-old man with hepatocellular carcinoma. (a) Nonenhanced CT scan shows an exophytic mass in the caudate lobe (arrowhead). Note the high-attenuation fluid (*) around the liver and spleen. (b) Coronal contrast-enhanced reformatted image shows leakage of contrast material (arrowhead) from the caudate lobe mass into the lesser sac. This appearance is suggestive of hemoperitoneum from rupture of a hepatocellular carcinoma. * = high-attenuation fluid.
|
|
View larger version (190K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9b. Hemoperitoneum in a 45-year-old man with hepatocellular carcinoma. (a) Nonenhanced CT scan shows an exophytic mass in the caudate lobe (arrowhead). Note the high-attenuation fluid (*) around the liver and spleen. (b) Coronal contrast-enhanced reformatted image shows leakage of contrast material (arrowhead) from the caudate lobe mass into the lesser sac. This appearance is suggestive of hemoperitoneum from rupture of a hepatocellular carcinoma. * = high-attenuation fluid.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Abscess due to "dropped" appendicoliths in a 46-year-old woman who underwent laparoscopic appendectomy 2 months earlier. (a) Axial contrast-enhanced CT scan shows calcification (arrowhead) in the Morison pouch, a finding that represents dropped appendicoliths. (b) Axial contrast-enhanced CT scan obtained cephalad to a shows a cystic mass with wall enhancement (*). This appearance is consistent with an abscess in the posterior right subhepatic space.
|
|
View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Abscess due to "dropped" appendicoliths in a 46-year-old woman who underwent laparoscopic appendectomy 2 months earlier. (a) Axial contrast-enhanced CT scan shows calcification (arrowhead) in the Morison pouch, a finding that represents dropped appendicoliths. (b) Axial contrast-enhanced CT scan obtained cephalad to a shows a cystic mass with wall enhancement (*). This appearance is consistent with an abscess in the posterior right subhepatic space.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11. Actinomycosis in a 37-year-old woman. The diagnosis was confirmed with sonographically guided percutaneous biopsy. Axial contrast-enhanced CT scan shows an inhomogeneously and avidly enhancing mass (arrowheads) with focal areas of low attenuation in the anterior right subhepatic space, findings suggestive of a small abscess.
|
|
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Acute Fitz-Hugh–Curtis syndrome in a 31-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the capsule of the left hepatic lobe (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows disappearance of the hepatic capsular enhancement. The findings in a and b are suggestive of acute Fitz-Hugh–Curtis syndrome. (c) Axial contrast-enhanced CT scan of the pelvis shows a tubo-ovarian abscess (*) in the left adnexal region.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Acute Fitz-Hugh–Curtis syndrome in a 31-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the capsule of the left hepatic lobe (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows disappearance of the hepatic capsular enhancement. The findings in a and b are suggestive of acute Fitz-Hugh–Curtis syndrome. (c) Axial contrast-enhanced CT scan of the pelvis shows a tubo-ovarian abscess (*) in the left adnexal region.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12c. Acute Fitz-Hugh–Curtis syndrome in a 31-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the capsule of the left hepatic lobe (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows disappearance of the hepatic capsular enhancement. The findings in a and b are suggestive of acute Fitz-Hugh–Curtis syndrome. (c) Axial contrast-enhanced CT scan of the pelvis shows a tubo-ovarian abscess (*) in the left adnexal region.
|
|
View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13a. Chronic Fitz-Hugh–Curtis syndrome in a 30-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the hepatic capsule (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows persistence of the hepatic capsular enhancement (arrowhead). The findings in a and b are suggestive of chronic Fitz-Hugh–Curtis syndrome. (c) Laparoscopic image shows the classic "violin string" adhesions between the anterior liver capsule and the anterior abdominal wall or diaphragm.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13b. Chronic Fitz-Hugh–Curtis syndrome in a 30-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the hepatic capsule (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows persistence of the hepatic capsular enhancement (arrowhead). The findings in a and b are suggestive of chronic Fitz-Hugh–Curtis syndrome. (c) Laparoscopic image shows the classic "violin string" adhesions between the anterior liver capsule and the anterior abdominal wall or diaphragm.
|
|
View larger version (99K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13c. Chronic Fitz-Hugh–Curtis syndrome in a 30-year-old woman with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan shows enhancement of the hepatic capsule (arrowhead). (b) Equilibrium phase contrast-enhanced CT scan shows persistence of the hepatic capsular enhancement (arrowhead). The findings in a and b are suggestive of chronic Fitz-Hugh–Curtis syndrome. (c) Laparoscopic image shows the classic "violin string" adhesions between the anterior liver capsule and the anterior abdominal wall or diaphragm.
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Perforation of a hepatic abscess in a 51-year-old woman. Axial contrast-enhanced CT scans show enhancement of the hepatic capsule (arrowhead in a) caused by perihepatitis, which was secondary to perforation of a hepatic abscess (* in b).
|
|
View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Perforation of a hepatic abscess in a 51-year-old woman. Axial contrast-enhanced CT scans show enhancement of the hepatic capsule (arrowhead in a) caused by perihepatitis, which was secondary to perforation of a hepatic abscess (* in b).
|
|
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15a. Peritoneal tuberculosis in a 34-year-old man. (a) Axial contrast-enhanced CT scan of the midabdomen shows enhancement of the hepatic capsule (arrow). (b) Axial contrast-enhanced CT scan of the lower abdomen shows thickening of the parietal peritoneum (arrowheads), nodularity of the mesenteric fat, and ascites.
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15b. Peritoneal tuberculosis in a 34-year-old man. (a) Axial contrast-enhanced CT scan of the midabdomen shows enhancement of the hepatic capsule (arrow). (b) Axial contrast-enhanced CT scan of the lower abdomen shows thickening of the parietal peritoneum (arrowheads), nodularity of the mesenteric fat, and ascites.
|
|
View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16a. Peritoneal carcinomatosis in a 53-year-old man with stomach cancer. (a) Axial contrast-enhanced CT scan shows subtly thickened parietal peritoneum with mild enhancement (arrow), thickening of the falciform ligament (arrowhead), and ascites. (b) Axial contrast-enhanced CT scan obtained at a lower level shows stomach cancer and an omental cake (*).
|
|
View larger version (148K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16b. Peritoneal carcinomatosis in a 53-year-old man with stomach cancer. (a) Axial contrast-enhanced CT scan shows subtly thickened parietal peritoneum with mild enhancement (arrow), thickening of the falciform ligament (arrowhead), and ascites. (b) Axial contrast-enhanced CT scan obtained at a lower level shows stomach cancer and an omental cake (*).
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17. Fatty liver in a 44-year-old man. Axial contrast-enhanced CT scan shows linear high attenuation along the hepatic surface (arrow), a finding that represents pseudoenhancement. The diaphragm has high attenuation relative to the decreased attenuation of the fatty liver and thus mimics an enhanced hepatic capsule.
|
|
View larger version (146K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18. Peritoneal carcinomatosis in a 61-year-old woman with a history of ovarian cancer. Coronal reformatted image from abdominal CT performed with intravenous contrast material shows thickening of the right hemidiaphragm by tumor plaque (arrowheads), omental implants (*), and ascites.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19a. Peritoneal carcinomatosis secondary to serous cystadenocarcinoma of both ovaries in a 73-year-old woman. (a) Axial contrast-enhanced CT scan shows sheetlike calcified tumor plaque (arrowheads) along the right lobe of the liver. (b) Axial contrast-enhanced CT scan shows multiple calcified masses (*) in the pelvic cavity.
|
|
View larger version (154K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19b. Peritoneal carcinomatosis secondary to serous cystadenocarcinoma of both ovaries in a 73-year-old woman. (a) Axial contrast-enhanced CT scan shows sheetlike calcified tumor plaque (arrowheads) along the right lobe of the liver. (b) Axial contrast-enhanced CT scan shows multiple calcified masses (*) in the pelvic cavity.
|
|
View larger version (169K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20. Pseudomyxoma peritonei due to rupture of an appendiceal mucocele in a 73-year-old man. Coronal contrast-enhanced reformatted CT scan shows multiple septated, low-attenuation masses (*) throughout the peritoneal space. Small cystlike masses create impressions on the hepatic surface (arrowheads).
|
|
View larger version (73K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21. Glisson capsule and Glisson sheath. The Glisson capsule covers the hepatic surface as an extension of the peritoneum, except for the bare area, which is attached to the diaphragm. The Glisson sheath is defined as the part of the Glisson capsule that surrounds the intrahepatic portion of the hepatic portal system. The Glisson capsule or sheath continues into the subperitoneal space of the gastrohepatic and hepatoduodenal ligaments in one direction. It also continues into the subperitoneal space of the ligamentum teres and falciform ligament in the other direction (long curved arrows).
|
|
View larger version (180K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22a. Emphysematous cholecystitis in a 61-year-old man. (a) Axial contrast-enhanced CT scan shows gas originating from perforation of the gallbladder (arrows). (b) Axial contrast-enhanced CT scan shows that the gas has diffused along the hepatoduodenal ligament to the Glisson sheath (arrow).
|
|
View larger version (176K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22b. Emphysematous cholecystitis in a 61-year-old man. (a) Axial contrast-enhanced CT scan shows gas originating from perforation of the gallbladder (arrows). (b) Axial contrast-enhanced CT scan shows that the gas has diffused along the hepatoduodenal ligament to the Glisson sheath (arrow).
|
|
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23a. Spread of pancreatitis along the Glisson sheath in a 41-year-old man. Axial contrast-enhanced CT scans show the inflammatory changes of pancreatitis extending upward along the portal vein (arrow) to the ligamentum teres (arrowhead in a). A peripancreatic fluid collection (* in b) is also seen.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23b. Spread of pancreatitis along the Glisson sheath in a 41-year-old man. Axial contrast-enhanced CT scans show the inflammatory changes of pancreatitis extending upward along the portal vein (arrow) to the ligamentum teres (arrowhead in a). A peripancreatic fluid collection (* in b) is also seen.
|
|
View larger version (140K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 24a. Extramedullary hematopoiesis in a patient with known chronic myelogenous leukemia. Axial contrast-enhanced CT scans (a obtained at a higher level than b) show a hypoattenuating mass around the portal vein (arrows), ascites, and splenomegaly. The mass demonstrates subperitoneal spread through the Glisson sheath.
|
|
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 24b. Extramedullary hematopoiesis in a patient with known chronic myelogenous leukemia. Axial contrast-enhanced CT scans (a obtained at a higher level than b) show a hypoattenuating mass around the portal vein (arrows), ascites, and splenomegaly. The mass demonstrates subperitoneal spread through the Glisson sheath.
|
|
Copyright © 2007 by the Radiological Society of North America.
