(Advanced Ultrasound)

Lecture: Pleura, Peritoneum and

Retroperitoneum

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 READINGS
• Moore, KL & Dalley, AF 2006, Clinically Oriented Anatomy,
5th Ed. Lippincott, Williams & Wilkins Company, Canada.

• Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic

Ultrasound Vol.1, 4th Ed. Mosby, St. Louis

• Bates, JA 2011, Abdominal Ultrasound: How, Why and When,

3rd Ed. Churchill Livingstone, Edinburgh

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 Learning outcomes

• describe the anatomy and sonographic appearances of the

diaphragm,
pleural space, peritoneum and retroperitoneum
• describe the sonographic appearances of a pleural effusion,
ascites and be able to differentiate between them
• describe the possible pathways for ascites distribution
• discuss common pathologies affecting these areas

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 Diaphragm

• Active muscle of respiration

• Musculo-skeletal sheet separating thoracic and

abdominal cavities
- (eg. lung and liver/spleen)

• Dome-shaped, convexity toward thorax

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 Diaphragm

• Diaphragm in US appears as a thin hypoechoic band

• Interface between diaphragm and liver/spleen thin

echogenic line

• Interface between diaphragm and lung stronger and

thicker echogenic line

• Mirror Image Artefact

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Diaphragm

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Mirror Image artefact

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 Diaphragm-Pathology

• Paralysis
• Rupture
• Hernia
• Diaphragmatic slip(congenital variant)

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 Pleural Space

• Parietal pleura
- Outer layer attached to chest wall
• Visceral pleura
- Inner layer which surrounds lungs

• On U/S - thin hypoechoic line of pleural fluid

which separates parietal and visceral pleura-
allows lung sliding

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Pleural Space

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 Pleural Pathology

• Pleural effusion

• Pleural thickening

• Pneumothorax

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 Pleural Effusion
• Accumulation of fluid in pleural space

Causes:
- CCF (congestive cardiac failure) ,
- renal failure,
- TB,
- pneumonia,
- malignancy,
- cirrhosis

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 PLEURAL EFFUSION
• U/S to evaluate and quantify effusion, U/S guided pleural
drainage

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Pleural Effusion-uncomplicated

Pleural Effusion

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Pleural Effusion

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Pleural Effusion- complex

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• What is the significance of a complex pleural effusion seen
on ultrasound?

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 Pleural Effusion Types: Transudate vs Exudate

Transudate:

• The fluid is similar in character to fluid normally in pleural

space

• rarely require drainage, unless very large

• CCF is a typical cause

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Exudate:

• The fluid has excess protein, blood, inflammation or infection

• Evidence of septations and debris

• May require drainage, depending on its size and the severity of

inflammation.

• Causes include pneumonia and lung cancer.

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 Pleural Thickening

• Thickening of pleura

• Many causes, eg. Malignancy, TB, fibrosis, pneumonia

• U/S – smooth or lobulated pleural tissue displacing air

filled lung away from chest wall

• More apparent with effusion

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Pleural Thickening

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 Peritoneum
 Largest serous membrane which forms the lining of the
abdominal cavity

- Parietal peritoneum
• Outer layer that lines abdominal wall
- Visceral peritoneum
• Inner layer that covers abdominal organs
- Peritoneal cavity
• Potential space between parietal and visceral layers
containing serous fluid

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 Peritoneum

- Mesentery
• Double layer of peritoneum which suspends most of
the intestine to posterior peritoneum
• Blood vessels, lymphatics and nerves run in
mesenteries

- All other double layers and folds of peritoneum are

ligaments or omenta

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 Mesentery

• The small bowel mesentery

• The transverse mesocolon

• The sigmoid mesentery

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 Omenta

• greater omentum: connects

the stomach to the colon

• lesser omentum: connects

the stomach to the liver

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 Peritoneal Cavity

Greater Sac
• Larger abdominal cavity
• Extends from diaphragm to pelvis
• All peritoneal organs protrude into this sac

Lesser Sac
• Omental Bursa, formed by greater and lesser omentum

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Greater & Lesser Sacs

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 Peritoneum Pathology :
Ascites

• Accumulation of fluid in the peritoneal cavity

• Causes may include CCF, liver disease, malignancy, trauma,

nephrotic syndrome, infections

• Usually transudate or exudate. May also contain blood,

pancreatic juice, pus, urine

• Approx 500ml needed for clinical detection

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 Ascites

• Simple ascites will appear anechoic (transudate)

• Complicated ascites may contain echoes, debris

and/or septations (exudate)

• Fluid will collect in dependent portion of abdomen

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Ascites transudate

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Ascites transudate

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 Is this a transudate or an exudate?

Ascites

Exudate
(Septations)

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 Retroperitoneum

 Situated behind the peritoneum

 3 spaces:

• Anterior para-renal space

• Peri-renal space
• Posterior para-renal space

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Retroperitoneum

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 Retroperitoneum
Anterior Para-renal Space contains
• Ascending and descending colon
• 2nd, 3rd & 4th parts of duodenum
• Pancreas
• IVC
• Aorta
• Proximal SMA (superior mesenteric artery ) and SMV (superior
mesenteric vein)
• Hepatic and Splenic vessels

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 Retroperitoneum
Posterior Para-renal Space
• No solid organs

Peri-renal
• Kidneys
• Adrenal Glands
• Proximal Ureter

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 Retroperitoneal Pathology
• Collections
i. haematoma
ii. abscess
They are:
- Difficult to differentiate on ultrasound alone
- Complex heterogeneous appearances

• Retroperitoneal fibrosis
• Lymphadenopathy

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 Retroperitoneal Fibrosis
Excess fibrous tissue develops in the Retroperitoneal space causes a mass

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 Lymphadenopathy

• Disease affecting the lymph nodes & it is common

retroperitoneal pathology on ultrasound

• US provides detection and measurement of nodes

• Size of nodes important

• Commonly seen with lymphoma

• Malignant nodes are usually round/ovoid with narrowed

or absent hilum

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 Lymphadenopathy

• Variable appearances

• Ovoid or round, hypoechoic masses

• Seen anterior and posterior to great vessels

• May displace vessels or cause compression

• No posterior enhancement

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Lymphadenopathy

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Lymphadenopathy

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Lymphadenopathy

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Lymphadenopathy

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QUESTIONS

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 QUIZ

1. List 5 structures that are retro-peritoneal

2. What is the difference between a transudate and an

exudate?

3. Briefly define 2 pathologies affecting the pleura.

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