Diagnostic ultrasound ( PDFDrive )

CHAPTER 14 The Peritoneum 507
FIG. 14.4 Tumor Implant in the Pouch of Douglas. Oblique transverse TVS shows a small solid hypoechoic nodule (arrow) in the pouch of
Douglas. See also Videos 14.2 and 14.3.
L
P
K
FIG. 14.5 Cirrhosis of the Liver With Portal Hypertension. Sagittal
ultrasound image of the right upper quadrant readily demonstrates a
large amount of ascites surrounding an enlarged, bulbous, fatty liver (L).
K, Right kidney.
FIG. 14.6 Grade 2/3 Ovarian Mucinous Cystadenocarcinoma.
Transverse TVS of the right adnexa shows a small amount of particulate
free luid (P) and serosal seeding (arrows) on loops of bowel in the
pelvis. This was visible only on the TVS.
for 90% of all cases of ascites. Accumulations of blood, urine,
chyle, bile, or pancreatic juice are more unusual causes.
Ascites can be detected with physical examination when the
volume reaches 500 mL. Transabdominal ultrasound can readily
detect large volumes of ascites (Fig. 14.5). TVS is more sensitive
in this regard, and volumes of free luid as small as 0.8 mL can
be demonstrated with the transvaginal probe 14 (Fig. 14.6). With
the patient lying supine, free luid tends to accumulate in the
paracolic gutters and pelvis, 15 particularly the superior end of
the right paracolic gutter and Morison pouch. hese areas should
therefore be carefully assessed when ascites is suspected. Ultrasound
is also accurate at quantifying 16 and localizing ascites
and may be used to guide both diagnostic and therapeutic
paracentesis.
In addition to its excellent capability to quantify ascites,
ultrasound can also characterize ascites as anechoic or particulate.
his may be helpful in determining the source because particulate
ascites suggests the presence of blood, pus, or neoplastic cells
in the luid. he observation of particulate ascites should prompt
a more detailed assessment of the peritoneum with ultrasound, 17,18
further imaging with CT/MRI, and diagnostic paracentesis.
Hemoperitoneum has many causes, including trauma,
ruptured aneurysm, ruptured ectopic pregnancy, ruptured liver
mass (e.g., adenoma, hepatoma), and postsurgical bleeding.
Spontaneous hemorrhage may occur in patients receiving
anticoagulants. he appearance of acute blood is varied, including
anechoic or particulate free luid (Fig. 14.7). A luid-debris level
may develop if the patient has maintained a stable position for