Perirenal Metastases
The perirenal space because of its perforating capsular vessels and lymphatics may be a site for the metastatic deposits of many malignant conditions. Common sources of perirenal metastatic disease include melanoma, lung, breast, renal cell, or transitional cell carci Fig. 8-187 . In cases in which the primary is not of renal origin, the metastases are generally present without the involvement of either kidney. Fig. 8-186. Perirenal extramedullary hematopoiesis in a patient with agnogenic...
Staging of Renal Cell Carcinoma
Survival rates in patients with renal cell carcinoma have been correlated with the extent of tumor at the time of presentation.226-229 The Robson system of staging226 is still used by most urologists, but the TNM system230 is also used, especially in Europe Table 8-2 . Fig. 8 175. Contrast extravasation during percutaneous nephrostomy outlines bridging perirenal septa. a and b Fortuitous in vivo CT observations at two levels show multiple septa through the perirenal fat and contrast loculation...
Pelvic and Mesenteric Continuities
Clinical instances of the anatomic continuity of the extraperitoneal conjoined anterior and posterior pararenal spaces below the cone of renal fascia with the extraper- itoneal spaces within the pelvis provide striking evidence of the continuum of the subperitoneal space and the potential for bidirectional spread between the abdomen and the pelvis.9,12,18,135,136 Figures 8-103 and 8104 demonstrate direct cephalad extension into the anterior pararenal space and small bowel mesentery from pelvic...
Bleeding from Bare Area of Spleen Splenic Artery or Hepatic Artery
The hilum of the spleen receives the reflections of its supporting mesenteries, the gastrosplenic and spleno-renal ligaments Fig. 8-97 . The bare area of the spleen is the nonperitonealized area representing the fusion of the splenorenal ligament to the surface of the perirenal fat. It bears a constant relationship to the upper anterior part of the left kidney. Its length is usually about 2-3 cm, and its width is about 2 cm.130 The splenorenal ligament provides an anatomic bridge for bleeding...
b Kkg
Fig. 4-150. Simultaneous metastatic seeding in Morison's pouch and the right subphrenic space. Three different examples illustrate the range of magnitude from minimal deposits to masses M of varying sizes and shapes. The primary tumors were b Carcinoma of the ovary. Reproduced from De Meo, et al.111 c Pineal germinoma, with peritoneal dissemination via a ventriculo-peritoneal shunt. Courtesy of Hiromu Mori, M.D., Oita Medical Center, Oita, Japan. Fig. 4-150. Simultaneous metastatic seeding in...
Lymphatic Extravasation
Extraperitoneal extravasation of lymph often selectively involves the posterior pararenal compartment Fig. 8207 . Drainage laterally may coalesce into a flank lym-phocyst Fig. 8-208 . At times, circumscribed solid masses of extraperito-neal lymph node origin can be identified clearly as localized to the posterior pararenal space. Figure 8-209 illustrates this in an instance of reticulum cell sarcoma. Fig. 8-191. Posterior pararenal hemorrhage in a hemophiliac. a Intravenous urogram. The axis of...
Ductus Venosus
The ductus venosus in utero carries blood from the umbilical vein Fig. 2-42 via the left portal vein into the IVC. It has been reported that the ductus is patent in 100 of neonates 1-2 days after birth and is still patent in 68 of neonates 6-7 days after birth.75 Beyond this age of life, patent ductus venosus causes pulmonary hypertension, hypoxemia, cardiac failure, hepatic dysfunction, and hyperammonemia.76 Ultrasound, CT, and or angiography are used for diagnosis77 Fig. 2-43 .
Carcinoma of the Stomach
In the TNM classification of gastric cancer1-3 Table 52 , depth of invasion is the main criterion, as in esophageal carcinoma. The current T staging system is illustrated in Figure 5-1. The classification presents some limitations. The T1 designation does not distinguish mucosal and submu-cosal invasion. In the definition of a T2 cancer, no distinction is made as to whether the muscularis propria is merely invaded or there is extension to involve the sub-serosa. Invasion of the serosa is the...
Carcinoma of the Esophagus
Patients with esophageal carcinoma should be stratified to determine whether palliative treatment or attemptive curative therapy is appropriate. The importance of the staging of esophageal cancer Table 5-1 lies in judging the resectability of the tumor and evaluating the prognosis of the patient. The stage of the disease has a direct effect on survival.8-11 Lymph node metastases are seldom present with a T1 mucosal T1m tumor, whereas the incidence with a T1 submucosal T1sm tumor is...
Perirenal Abscess
Initially, fluid introduced into the perirenal space is evenly dispersed throughout the perirenal fat. Preferential flow then seeks the abundant fat dorsolateral to the lower pole of the kidney8,12 Figs. 8-130 through 8133 . The exudate is guided by gravity along the path of least resistance. This natural drainage is also illustrated in Figure 8-134, in which a portion of a large staghorn Fig. 8 130. Coalescence of perirenal effusions. This typically develops behind and somewhat lateral to the...
Nodal Metastases in the Gastrohepatic Ligament
Tumors arising from the area of the stomach along the lesser curvature and the esophagogastric junction, supplied by the left gastric artery, generally metastasize to the lymph nodes in the gastrohepatic ligament. The primary nodal group N1 station consists of nodes along Table 6-4. Pathways of Lymphatic Drainage of the Stomach Table 6-4. Pathways of Lymphatic Drainage of the Stomach the left and right gastric artery anastomosis along the lesser curvature. The N2 station includes the nodes...
IllDefined Periduodenal Lucency
Another anterior collection of free air but situated more inferiorly, ill-defined periduodenal lucency appears as an agglomeration of bubbles or slitlike lucency in the per-iduodenal region. It is more difficult to detect than the anterior superior bubble due to nearby duodenal and colonic gas. It also may resemble localized retroperito-neal gas collections.6 Fig. 7 33. Anterior superior bubble. Free air is aggregated as a small lucency ventral to the liver curved arrow on a supine digital...
Retromesenteric Plane Fluid Collections
Retromesenteric plane fluid collections are well-defined planes anterior to the perirenal spaces and posterior to the pancreas, duodenum, and right and left colonic compartments. Because of the presence of primitive roots of the dorsal mesenteries in the midline, communication across the midline is only possible where fusion planes cross the midline, as especially occurs behind the horizontal portion of the duodenum, just inferior to the superior mesenteric artery Figs. 8-114 and 8-116 ....
Pouch of Douglas Rectosigmoid Junction Radiologic Features
Intraperitoneal fluid consistently seeks the pouch of Douglas, the most caudal and posterior part of the peritoneal cavity, and then the lateral paravesical recesses Fig. 4-106 . The lower extension of the peritoneal reflections, comprising the pouch of Douglas, projects generally at the level of the lower second to upper fourth sacral segment Fig. 4-107 . This variability is determined by the developmental fixation of the peritoneum to Denonvillier's fascia rectovaginal or rectovesical septum...
The Extraperitoneal Spaces Normal and Pathologic Anatomy
The extraperitoneal portion of the abdomen has always been considered a difficult region in terms of anatomic definitions, clinical evaluation, and radiologic diagnosis. Anatomically, it has been vaguely considered as occupying the posterior half of the abdomen, without well-defined fascial boundaries. Clinically, it is commonly recognized that extraperitoneal effusions are difficult to diagnose. The area is not accessible to the bedside modalities of auscultation, palpation, or percussion....
Portohepatic Venous Shunt
Although intrahepatic portal-systemic hepatic venous shunt had been thought to be a rare disease, recent advances in ultrasound, CT, and MRI have made it possible to depict this condition in an increasing number of patients67-69 Figs. 2-39 and 2-40 . A high degree of shunt may produce hepatic encephalopathy due to hy-perammonemia. Single or multiple shunts may be present, and there may be other anomalies such as membranous obstruction of the IVC.70 It has recently been reported that hepatic...
Anatomic Considerations 1
Since the first descriptions by Toldt Fig. 8 106 in 1879,140 the fusion of contiguous peritonealized surfaces and blending of the connective layers of the apposed peritoneal sheets forming a fibrous layer strong enough to call a fascia has been widely accepted.139,141 The sheet of tissue behind the head of the pancreas and the duodenal loop has been called the retroduodenopancreatic fascia of Treitz, following his description in 1853.142 Its em-bryologic basis, however, of mesoduodenum fused to...
Intraperitoneal Spread of Infections
A remarkable change in the epidemiology of subphrenic and subhepatic abscesses has occurred over the past several decades. In the past, the most common causes included perforations of anterior gastric or duodenal ulcers and rupture of a gangrenous appendix. Today, 6071 of such abscesses are postoperative and are particularly frequent following gastric and biliary tract operations and colonic surgery. 1-3 Many of the cases of postoperative abscesses are secondary to anastomotic leaks.4 More...
Distinction Between Perirenal and Subcapsular Collections
Abscesses or hematomas in the perirenal space and in the subcapsular region of the kidney can simulate each other and a host of other conditions closely. Identification of their specific localization may be very important in the clinical diagnosis and in determining the most appropriate therapy. Advances in establishing the characteristic features of abscesses or hematomas are based on the anatomic structures that define their collection.11 Anatomic Considerations. The renal capsule Fig. 8158...
Uriniferous Perirenal Pseudocyst Urinoma
A unique type of perirenal collection is acutely extrav-asated urine secondary to ureteral obstruction or laceration165 Figs. 8-142 and 8-143 . It has been long established that chronic partial obstruction with repeated pyelosinus backflow may lead to uriniferous pseudocyst formation.166 The chronic extravasation of urine into the extra-peritoneal tissues around the kidney and upper part of the ureter, leading to an encapsulated collection, is a distinct clinical and radiologic entity. The...
Renal Carcinoma
Hematogenous metastasis to bowel from a renal carcinoma is rare. In some cases, Batson's vertebral venous plexus is a possible route.261 It typically presents as a solitary bulky intramural lesion92 Fig. 4-233 . Fig. 4-215. Different cases of breast metastases to stomach. Opposite page These are characterized by rigidity and narrowing with markedly decreased peristalsis and fixation, spiculation, and angulation of folds. Although any portion of the stomach may be involved, the changes are more...
The Sectional and Isotopic Imaging Modalities
The sectional imaging modalities have not only confirmed the pathways of extension but have provided a striking advance in the diagnosis and localization of in- Ultrasonography has a sensitivity of almost 95 and a specificity approaching 100 if the study is not limited by bowel gas, obesity, and surgical wounds and band-ages.80-82 The absence of ionizing radiation makes it particularly safe in evaluating children and young women. Abscesses present generally as irregular fluid collections with...
Info Glp
A 44-year-old man presented with abdominal pain. a Upper GI series shows a localized stenosis of the descending duodenum arrows . b and c Enhanced CT scans and MR images d and e show pancreatic tissue arrows encircles the descending duodenum D . Coned-down view from a supine radiograph of the abdomen shows an air-filled duodenal sweep. A short constriction is noted in the proximal descending portion arrows secondary to the presence of an annular pancreas. From Jadvar H, Mindelzun RE.90...
Invasion by Lymphatic Permeation
Lymphatic permeation plays an apparently minor role in the dissemination of secondary neoplasms of the bowel. The process refers to lymphatic-borne tumor emboli from a primary neoplasm of the bowel, which may not be arrested in the nearest lymph nodes along the chain of drainage. Rather, complete blockage of a more remote node can occur from cellular impaction, with retrograde passage along other afferent channels to involve a segment of bowel adjacent to, or at some distance from, the primary...
Peritoneal Ligaments of the Liver
Because the liver is developed in the ventral mesentery attaching the foregut to the anterior abdominal wall and the transverse septum, it is covered almost completely by the peritoneum derived from the ventral mesentery. The peritoneal reflections between the liver and the diaphragm, the anterior abdominal wall, and the stomach form peritoneal ligaments around the liver.2,3 Along the diaphragmatic surface, the liver is attached to the hemi-diaphragm by the coronary ligaments and triangular...
T4 Stage
In esophageal carcinoma, direct invasion of mediastinal structures can be predicted using criteria of mass effect or localized loss of fat planes39,42-47 Figs. 5-24 through 5-30 . Actual unresectability, however, remains difficult to predict with CT or MRI.47-52 In the assessment of unresectability by EUS, criteria include tumor invasion into the left atrium, the wall of the descending aorta, EUS demonstrates a hypoechoic tumor deeply invading the muscularis propria layer arrow . the pulmonary...
Riglers Sign
Also known as the bas relief or double wall sign, Rigler's sign is the most frequently cited plain film manifestation of free air. It refers to the demarcation of both the inner and outer surface of the bowel wall by the simultaneous presence of air in the lumen and outside the serosa Fig. 7-13 . Sometimes, only the serosal surface of the bowel is delineated because its lumen is completely filled with fluid. Large accumulations of air are needed to demonstrate the bas relief sign. Furthermore,...
Pathway of Nodal Metastases from Carcinoma of the Transverse Colon
After the paracolic nodes, lymphatic spread from carcinoma of the transverse colon may follow along the branches of the middle colic vessels in the transverse mesocolon toward the root of the mesocolon Figs. 617 through 6-20 . From the hepatic flexure, the spread would follow the right colic vessels or right middle colic vessels to the nodal group at the gastrocolic trunk where it drains into the SMV anterior to the head of the pancreas. From the splenic flexure, the lymphatic drainage would...
The Three Extraperitoneal Compartments and Perirenal Fasciae
Detailed evaluation shows that the extraperitoneal region, rather than being composed of amorphous straggling mesenchyme, is distinctly demarcated by well-defined fascial planes. Figure 8-1a is an enlarged horizontal cross-section through the flank at the lower pole of the kidney. Central to the division of the extra-peritoneal region are the conspicuous anterior and posterior layers of renal fascia. The posterior renal fascia was first described by Zuckerkandl21 Fig. 8-2 and the anterior renal...
Anterior Superior Bubble
This sign refers to a small isolated aggregation of gas situated anterior to the upper hepatic surface. It is the most frequent, therefore the most important, among the various right upper quadrant gas signs.5,6,15,17 The anterior superior bubble may be single or multiple, with the gas describing an oval or circular shadow, ranging from a few millimeters to several centimeters in diameter There is diffuse lucency over the liver with a straight lateral border arrowheads from a large...
Extraperitoneal Perforations of the Colon and Appendix
Figure 8-45 illustrates that extraperitoneal perforations of the colon can be identified as clearly localized to the anterior pararenal space, even on plain films. The extra-peritoneal collection of mottled gaseous lucencies is oriented with a general vertical axis, medially overlaps the psoas muscle and approaches the spine, and does not obscure the flank stripe laterally. In this patient, who Fig. 8-40. a Postmortem injection into the anterior pararenal space. The collection has a generally...
Ectopic and Accessory Gallbladders
A communication between the bile ducts of the right lobe and the gallbladder exists during fetal development. When it persists into adulthood, this cystohepatic duct of Luschka Fig. 2-27 may be severed during a cholecystectomy, resulting in a bile leak.44,45 Other anomalies that may involve the gallbladder include a wandering gallbladder in which an elongated suspending mesentery allows marked mobility of the gallbladder46-48 Fig. 2-28 . When the more caudal of the biliary buds from the foregut...
Urinary Tract
The embryologic development of the kidneys encompasses three phases. These are the pronephros, meso-nephros, and metanephros. They go through overlapping cycles of growth and regression, resulting in the formation of the definitive kidneys and urogenital system from the latter two stages. At the end of the third week, paired collections of primitive tubules form and empty into paired excretory ducts that lead to the cloaca.123 This pronephros never functions in humans and involutes by the early...
The Psoas Muscle
I have clarified the radiographic anatomy of the psoas muscle by anatomic sections through the extraperitoneal tissues at different levels.8 The upper and lower segments of the psoas muscle are visualized by virtue of the contrast provided by different aspects of the extraperitoneal fat. At the level of the kidney, it is the perirenal fat that predominantly marginates the lateral border of the psoas muscle. However, below the kidney, secondary to the lines of fusion of the cone of renal fascia,...
Small Bowel Mesentery
The small bowel mesentery is a voluminous fat-laden peritoneal reflection. Whereas its root Fig. 4-41 is only 15 cm long as it extends obliquely from the region of the pancreas to the right lower quadrant, the mesentery itself suspends 20-25 feet ofjejunal and ileal loops.72 This is achieved by its characteristic ruffled nature, which markedly lengthens its intestinal border. The mesenteric ruffles thereby provide routes of spread Fig. 4 50. Spread of pancreatic carcinoma into the transverse...
References 1
1. Moore KL The Developing Human, 4th ed. WB Saunders, Philadelphia, 1988, pp 50-59. 2. Moore KL The Developing Human, 4th ed. WB Saunders, Philadelphia, 1988, pp 159-169. 3. Javors BR Pertinent embryology of the gastrointestinal tract A brief review. Radiologist 1995, 2 51-63. 4. Javors BR, Sloves JH Applied embryology of the gastrointestinal tract. In Textbook of Gastrointestinal Radiology. Edited by RM Gore, MS Levine, I Laufer. WB Saunders, Philadelphia, 1994, pp 1362-1378. 5. Balfe DM,...
Volvulus
Gastric volvulus is a rare condition encountered in the adult as well as the pediatric age group. The majority of cases are of the mesenteroaxial type rather than the or-ganoaxial type.23 Anomalies associated with acute gastric volvulus include diaphragmatic defects, intestinal malrotation, and wandering spleen.24 Most cases of gastric volvulus seem to be secondary to deficient fixation. Absence of the gastrophrenic ligament and the gastrosplenic ligament as well as an absence of the spleen may...
Developments and Advances in Imaging
Multiple approaches have been applied in pursuit of refining the diagnostic accuracy of peritoneal carcino- Fig. 4-185. Omental caking demonstrated secondary to ovarian carcinoma. Tl-weighted gadolinium-enhanced fat-saturated MR image demonstrates enhancement of tumor implants on the greater omentum arrows . Reproduced from Ricke and Hosten.141 The greater omentum, in contrast to the small bowel mesentery, has scanty vascular structures. In this patient with portal hypertension and ascites,...
Nodal Metastases in the Gastrocolic Ligament
Primary tumors involving the greater curvature of the antrum of the stomach in the distribution of the right gastroepiploic artery spread to the perigastric nodes N1 station accompanying the right gastroepiploic vessels that course along the greater curvature of the stomach. They drain into the nodes at the gastrocolic trunk N2 station Fig. 6-10 or the nodes at the origin of the right gastroepiploic artery and the nodes along the gas-troduodenal artery the subpyloric or retropyloric node . From...
Transverse Mesocolon and Duodenocolic Ligament
The root of the transverse mesocolon extends across the infraampullary segment of the descending duodenum, the head of the pancreas, and continues along the lower edge of the body and tail of the pancreas anteriorly to bear continuity with the splenorenal and phrenicocolic ligaments6,56 Fig. 4-41 . Near the uncinate process of the pancreas it becomes confluent as well with the root of the small bowel mesentery. These bare areas thus establish anatomic planes of continuity between a the pancreas...
Ligamentum Teres Fissure Sign
Another distinctive sign of pneumoperitoneum is free air confined in the intrahepatic fissure for the ligamen-tum teres. It appears on supine films as a small but sharply defined vertically oriented slitlike or ovoid lu-cency projecting upon the medial half of the right upper quadrant4 Figs. 7-25 and 7-26 . The fissure for the ligamentum teres is a crevice in the liver that contains fat, the ligament itself, and a variable protrusion of peritoneum. It is situated anterior and superior to the...
Cupola Sign
An anterior free air collection in the midsubphrenic space underneath the middle leaf of the central tendon of the diaphragm can be detected on supine films by its characteristic location and configuration.5'16'28 The cupola sign, also known as visualization of the inferior border of the heart, appears as a radiolucency of varying size, sharply defined above but poorly delimited below, overlying and extending lateral to the spinejust caudad to the heart Figs. 7-19 through 7-21 . Its upper...
Lymphatic Drainage of the Liver and Pathways of Lymph Node Metastasis
The lymphatic drainage of the liver consists of two major pathways the deep pathways and the superficial pathways.1 The lymphatic vessels in the liver are believed to originate in the perilobular connective tissue. The perilobular lymphatic vessels from the lobules deep inside the parenchyma drain into the deep networks along the periportal space in the Glisson's sheath toward the porta hepatis and along the hepatic veins. The perilobular lymphatic vessels from the lobules near the surface of...
Preduodenal Portal Vein
Preduodenal portal vein consists of the persistence of a preduodenal vitelline communicating vein a caudal in- ERCP shows that the common bile duct terminates in a localized saccule pouting into the descending duodenum. Note fusiform dilatation of the left hepatic duct. ERCP shows that the common bile duct terminates in a localized saccule pouting into the descending duodenum. Note fusiform dilatation of the left hepatic duct. Intraoperative cholangiogram demonstrates a large saccular...
Inverted V Sign
The inverted V sign refers to visualization of the medial umbilical folds they are also known as umbilical ligaments, but folds are the preferred term , which together form an inverted V-shaped increased density in the pelvis outlined by free air24,25 Fig. 7-11 . Anatomically, there are actually two pairs of folds in the lower abdominal wall that can create an inverted V the medial umbilical folds representing the obliterated umbilical arteries, and the lateral umbilical folds containing the...
Morisons Pouch Air doges Cap Sign
Triangular or linear collection of air in the posterior intraperitoneal recess bounded anteriorly by the liver and posteriorly by the right kidney may simulate the conformation of the tip of a doge's cap, the ceremonial headgear worn only by the doges of Venice34 Fig. 78 . Potential simulators include gas in the duodenal bulb, a gas-filled gallbladder, and intraperitoneal abscess, or a malrotated bowel. Fig. 7 26. Ligamentum teres fissure sign. a Free air in the fissure in a patient with a...
Triangle Sign
Air trapped between two bowel loops and also abutting the nearby lateral edge of the peritoneal cavity or a third bowel loop appears as a sharply outlined, triangular lu-cency Fig. 7-15 . Sometimes only two sides of the triangle are well delineated, with the border of the third one less distinct Fig. 7-16 . Although it is not a very sensitive indicator of free air, the triangle sign is highly specific and is best depicted at the periphery of the lower abdomen. The triangle sign is also valuable...
Delineation of Normal Mural Components by Sectional Imaging
Five discrete layers of the wall are shown by conventional endoscopic ultrasonography. The first hyper-echoic and second hypoechoic layers represent the mucosa, the third hyperechoic layer represents the submucosa, the fourth hypoechoic layer is the muscu-laris propria, and the fifth hyperechoic layer reflects the subserosa and serosa Figs. 5-3 and 5-4 . In the esophagus, lacking a serosa, the latter represents adventitia. With the development of small 15-20 MHz ultrasonic probes, nine distinct...
Gastrosplenic Ligament Splenorenal Ligament Phrenicocolic Ligament
The peritoneal reflections in the left upper quadrant of the abdomen are shorter but are certainly no less important in providing avenues of spread of disease. Anatomic continuity between multiple sites is readily established. The gastrosplenic ligament is continuous with the gastrocolic ligament and extends from the greater curvature of the stomach to the spleen Fig. 4-63 . It con tains the left gastroepiploic and short gastric vessels as well as associated lymphatics. The splenorenal ligament...
Direct Invasion from Noncontiguous Primary Tumors
Invasion Along Mesenteric Reflections The mesenteric reflections provide an important natural pathway for extension of primary neoplasms to other sites that may not be in actual contiguity.1'9 In the upper abdomen, peritoneal reflections constitute nine major ligaments and mesenteries that provide continuity of anatomic planes for the spread of malignancies Figs. 4-1 and 4-2 Table 4-2 . These not only connect intraperitoneal sites, but also extend between intraperitoneal and extraperitoneal...