1. Retroperitoneum
Adrenal glands

2. Adrenal Gland sonography
Ability to visualize depends on:
Patient body habitus
Operator experience
High resolution equipment
Right adrenal gland:
Best evaluated intercostally,midaxillary line
Remember suprarenal location/IVC relationship
Left adrenal gland:
Best evaluated intercostally through spleen/kidney
Epigastrium and suprarenal location
More difficult to visualize than right adrenal

3. Infectious diseases Tuberculosis: Histoplasmosis:
Acutely-bilateral diffuse enlargement
Inhomogenous- due to caseous necrosis
Chronically-more atrophic and calcified
Histoplasmosis:
Adrenal calcifications
The 2 most common causes of adrenal calcifications in the adult

4. Benign adrenal neoplasms
Adenomas
Most common adrenal tumor-incidentalomas
Found in 9% of autopsies
Incidence:
Increases with age
Hypertensive individuals
Diabetics
Hyperthyroidism
RCC
Hereditary colorectal adenomatosis

5. Adenomas No specific ultrasound features (> 1 cm)
Nonhyperfunctioning
More common
Asymptomatic-incidentally found
Hyperfunctioning
Present clinically with symptoms related to excess hormone production
Cushing’s Syndrome
Conn’s disease
Refer to page 435 figure 11-9

6. Hyperfunctioning adenomas
Cushing’s syndrome:
Excessive cortisol excretion
Hyperplastic glands
Characterised by:
Truncal obesity
Hirsutism
Amenorrhea
Hypertension
Weakness
Conn’s disease:
Excessive aldosterone excretion
Characterised by:
Hypertension
Muscular weakness
Tetany
ECG abnormalities

7. Outcome of adrenal masses
Adrenal masses > 6cm
Suspicious for malignancy
Typically resected
Adrenal masses 4-6cm
Close imaging followup
Or surgical excision
Adrenal masses < 4cm
Management is based on additional imaging findings
CT,MRI,PET-CT may be helpful

8. Pheochromocytoma Neuroendocrine tumor of the medulla Hyperfunctioning
Secrete norepinephrine and epinephrine into blood
Clinical manifestations:
Hypertension
Severe headache
Palpitations
Tachycardia
Excessive perspiration

9. Pheochromocytomas con’t
Seen most frequently in adults 40-60years
Rare but curable cause of hypertension
Sonographically:
5-6cm in diameter-easily seen
More often in right gland
Well marginated
May be calcified
Heterogenous or homogenously solid
May have areas of necrosis or hemorrhage

10. Rare benign adrenal tumors
Ganglioneuromas
Hemangiomas
Teratomas
Fibromas
Leiomyomas
Osteomas
Neurofibromas
Diagnosis must be made histologically

11. Malignant adrenal neoplasms
Primary Adrenocortical cancer
Rare
Arises from any layers of adrenal cortex
Hyperfunctioning or nonhyperfunctioning
Clinical manifestations of excess hormone production in hyperfunctioning tumors
Highly malignant
Invades adrenal vein,IVC and lymphatics
Recurs after surgical excision

12. Sonographic appearance
Variable,depending on size of mass
Hyperfunctioning:
Smaller when discovered
Homogenous echo pattern
Nonhyperfunctioning:
Heterogenous
Central areas of necrosis and hemorrhage
Calcifications
Well defined lobulated border

13. Large solid adrenal mass

14. Solid adrenal mass

15. Benign VS Malignant
Cannot sonographically differentiate between adenomas,carcinoma,pheochromocytoma and metastases
Smaller lesions more likely to be benign
Larger lesions more likely to be malignant if:
Hemorrhage
Necrosis
Calcifications
Duplex and color doppler useful to R/O venous tumor extension

16. Metastases Adrenal gland -4th most frequent site of metastatic disease
After lung ,liver and bone
Most common primary tumors to spread to adrenal gland:
Lung
Breast
Melanoma
Kidney
Thyroid
Colon

17. Sonographically Solid,typically heterogenous Inhomogeneity due to
Necrosis
Hemorrhage
May be bilateral
Ct and MRI help distinguish between adenoma and metastases

18. Adrenal cysts Rare benign lesions More frequently-3rd to 5th decades
May be bilateral
More frequently in females
Asymptomatic
May cause symptoms with growth
If large can displace or compress adjacent structures
Typical cystic appearance
May be pseudocysts

19. Metabolic disorders Hemochromatosis: Wolman’s disease:
Increased iron absorption
Leads to mild adrenocortical insufficiency
Glands are typically small
Wolman’s disease:
Rare autosomal recessive
Lipid storage disease
Infants die within 6 months of life

20. Adrenal pseudomasses Thickened diaphragmatic crus Accessory spleen
Gastric fundus/diverticulum
Renal vein
Adenopathy
Retrocrural or retroperitoneal
Hypertrophied caudate lobe of liver
Upper pole renal cysts
Pancreatic tumors
Fluid filled colon between stomach and kidney

21. Pitfalls Use doppler to exclude vascular structure
Change patient position
Try another window
Give patient water to outline stomach
Rescan at end of exam to see if bowel gas has moved

22. Nonvascular diseases of retroperitoneum
Lymphadenopathy:
Most common solid retroperitoneal mass
Enlarged lymph nodes
Benign or malignant causes
Infection or lymphoma
Most commonly hypoechoic
If rounded with loss of echogenic central fat-suspicious
Located:
Para-aortic
Paracaval
Mesentery

23. Lymph nodes
Normal lymph node
Abnormal lymph node

24. Nonvascular diseases con’t
Metastatic disease
Frequently spreads to lymph nodes
Appear as solid retroperitoneal masses
Primary malignancies
Most common malignant retroperitoneal tumor:
Lymphoma
Other primaries include:
Sarcomas
High rate of recurrence after surgical excision

25. Benign retroperitoneal masses
Fibromas
Schwannomas
Neurofibromas
Lipomas
Fluid collections
Hematoma
Urinoma ,lymphocele
Abscess,pseudocyst
CT or MRI needed to define benignity

26. Retroperitoneal fibrosis
Associated with inflammatory AAA-5%
Patients more prone to back ache
Chronic periaortis
Mass(rind of tissue) encases the aorta and common iliac arteries
May involve ureters
Most common complication
Ureteral obstruction and hydronephrosis
Regresses after repair of AAA

27. peritoneum

28. Sonographic technique
Evaluation of peritoneum includes
Parietal and visceral peritoneum
Mesentery
Omentum
Peritoneal cavity
Graded compression is used to displace bowel
Palpation of mass determines compliance and mobility
Masses from parietal peritoneum-fixed
Masses from visceral peritoneum-mobile

29. Peritoneum

30. Ascites Normally 50-75ml of free fluid is in peritoneal cavity
Acts as a lubricant
Ascites occurs with excess accumulation
Transudate
Exudate
Depends on protein content
90%of cases result of-
Cirrhosis
Peritoneal carcinomatosis
Congestive heart failure TB

31. Ascites con’t In supine position,free fluid accumulates in
Paracolic gutters
Pelvis
Morison’s pouch
These areas should be thoroughly examined if ascites is suspected
Ultrasound can characterize ascites as anechoic or particulate
Particulate suggests blood ,pus,neoplastic cells

32. Ascites

33. Hemoperitoneum Many causes:
Trauma
Ruptured aneurysm
Ruptured ectopic pregnancy
Ruptured liver mass
Adenoma,hepatoma
Post surgical bleeding
Spontaneous hemorrhage in patients receiving anticoagulants
May appear as anechoic or particulate

34. Trauma Focused abdominal sonography Detect free intraperitoneal fluid
Fluid strongly suggests significant intra-abdominal injury
Requires urgent laparotomy

35. Chyla ascites Lymph accumulates in peritoneal cavity Causes: Trauma
Surgery
Lymphangioma
Lymphoma
Intestinal lymphangiectasia
Cystic hygroma
Appears as particulate ascites
Fluid-fluid level-layering of lymphatic fluid

36. Free fluid vs loculated fluid
Conforms to surrounding organs
Exhibits acute angles when in contact with bowel loops
Loculated fluid:
Rounded margins
Mass effect
Displaces surrounding structures
Occur anywhere in abdominopelvic cavity

37. Mesenteric cysts Intra-abdominal masses discovered incidentally
May present clinically with pain if large
Or acutely if complications
Hemorrhage
Rupture
Torsion
Lymphangiomas
Enteric duplication cyst

38. Peritoneal tumors Generally malignant Metastatic most common
Ovary is the primary site usually
Other sites
Stomach ,colon
Breast
Pancreas
Kidney,bladder
Uterus
Melanoma of skin

39. Peritoneal Carcinomatosis
Diffuse involvement of the peritoneum with metastatic disease
Seeding involves parietal and visceral peritoneum
Discrete hypoechoic nodules
Irregular masses
Hypoechoic rind like thickening of peritoneum
Ascites is common
Pouch of Douglas,greater omentum,Morison’s pouch right subphrenic space most affected

40. Non-cardiac chest
Effusion and mass

41. Pleural effusion
Excess fluid that accumulates between two parietal layers
Visceral and parietal
Excessive fluid impairs the ability to breath
Easily detected on abdominal ultrasound
Liver and spleen imaging reveals pleural effusion
My appear anechoic or have echoes within
Consolidation causes echoes-solid appearance

42. Left pulmonary consolidation

43. Pleural effusion
Large effusion

44. Small pleural effusion

45. Thoracentesis Intervention used to drain pleural effusions
Ultrasound guided

46. Lung mass

47. Lung mass

48. Images from text Chapter 14-peritoneum page 524-544
Chapter 12-retroperitneum page 482 fig 12-46