peritoneum and mesentery Flashcards by Alex Grushky

Most common bug in SBP?

E coli

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With regards to bowel displacement, what processes moves them medial? posterior?

Medial - ascites

Posterior - intraperitoneal abscess

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What is pseudomyxoma peritonei? What are the causes?

Gelatinous ascites from ruptured appendiceal mucinous tumor or other mucinous tumors

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What are the differentiating features of pseudomyxoma compared to simple ascites

Pseudomyxoma will have a scalloped liver margin due to mass effect from mucinous implants. There will also be high attenuating septa and punctate “ring and arc” calcifications

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Where are the most common sites of peritoneal carcinomatosis? why?

Due to the flow of ascites

Pelvic cul de sac
Right paracolic gutter
Mesenteric root at ileocecal junction
Sigmoid mesocolon

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DDx for enhancing nodules along peritoneal surface with marked nodular thickening of the omentum

Peritoneal carcinomatosis
Mesothelioma
Tuberculous peritonitis

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DDx for peripherally enhancing centrally necrotic masses intraperitoneally?

Colon cancer
Invasive peritoneal mets
Primary peritoneal tumor
Peritoneal abscess

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How does primary peritoneal mesothelioma present?

Multiple enhancing soft tissue masses present along peritoneum IN CONTACT with peritoneum with large volume ascites

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How does cystic peritoneal mesothelioma differ from primary? Who gets it?

Young women

Benign

Low attenuation/anechoic multiloculated cystic mass filling peritoneal cavity

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Most common primary tumor of small bowel?

Caricinoid

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What cells does carcinoid arise from?

Enterochromaffin cells of kulchitsky in crypts of lieberkuhn

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DDx for calcified mesenteric mass with radiating strands and adjacent bowel wall thickening

Carcinoid

Retractile mesenteritis

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Where do most small bowel carcinoid tumors arise?

Terminal ileum

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How does one differentiate carcinoid from mesenteric mets?

Mets wont have desmoplastic reaction, will be multiple

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What causes the desmoplastic reaction in carcinoid?

Thickening along neurovascular bundles

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What is the cardiac complication with carcinoid? Why

Tricuspid valve insufficiency due to direct release of serotonin into the hepatic veins by metastatic carcinoid

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What is retractile mesenteritis?

Idiopathic mesenteric mass with dense calcifications and bowel tethering and obstruction.

Similar to carcinoid, but wont have spokewheel thickening and small bowel wall thickening

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DDx for a solitary, ill defined mass at root of small bowel mesentery with marked associated calcification and bowel tethering

Retractile mesenteritis

Carcinoid

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Most common primary mesenteric tumor

Desmoid

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Which lymphoma more commonly affects the mesentery?

NHL

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Lobulated confluent soft tissue mass encasing superior mesenteric vessels
What is the sign? Dx?

Hamburger/sandwich sign

Mesenteric lymphoma

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DDx for low attenuation mesenteric LN with perihperal enhancement?

Treated lymphoma
Infection (fungal, MAI)
Whipples
testicular mets

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Which nodes does abdominal TB affect most often?

Mesenteric and peripancreatic

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HIV patient with centrally low attenuating LN

What clues help differentiate MAI vs TB when considering them for centrally necrotic LN

TB more often has focal hepatic or splenic abnormalities and peritoneal involvement

What make up the nodes in CMLNS?

Chylous fluid surrounded by a thin rim of fibrous tissue

Cystic mesenteric adenopathy in a patient with celiac disease?

Cavitary mesenteric lymph node syndrome

What are the two responses with a retained surgical sponge?

Fibrinous - foreign body granuloma Exudative - abscess formation

What is a gossypiboma?

Masslike inflammatory response surrounding a surgical sponge

Where do spilled gallstones accumulate?

Subdiaphragmatic or hepatorenal recess

When do complications most often occur with spilled gallstones?

4 months, but can be 1month-20years

What are the three types of abdominal hernia?

External, internal, diaphragmatic

Which hernia is most common?

Indirect

Which inguinal hernia goes medial/lateral to the inferior epigastric vessels? How can you quickly tell the difference?

MD - medial, direct Lateral, indirect Direct will NOT extend to the scrotum

What are the defects in the inguinal hernia types?

Direct - directly protrudes through abdominal wall defect | Indirect - protrudes through inguinal canal and emerges at the external ring

What is an incarcerated hernia?

One that cannot be manually reduced

Femoral hernias are more common in which sex?

Female

Where does a femoral hernia extend?

ALWAYS below the inguinal ligament and lateral to the pubic tubercle Immediately medial to the femoral vein

Which hernia is more common to strangulate?

Femoral (10x) more than inguinal

Obstruction with pain radiating down medial thigh suggest what kind of hernia?

Obturator (impingement on obturator nerve)

Which hernia has the highest rate of mortality if strangulated?

Obturator

What is a richter hernia?

Hernia with only a portion of the circumference of a bowel loop

What is a spigelian hernia?

Abdominal wall defect involving the linea semilunaris

What is the most frequent internal hernia?

Paraduodenal

Where do most paraduodenal hernias occur and why?

Left side, as a result of bowel herniating through a peritoneal reflection created by the inferior mesenteric artery. Bowel resides lateral to the ascending limb of the duodenum

How do paraduodenal hernias appear?

Mass of small bowel loops in LUQ appearing to be encapsulated

What is a foramen of winslow hernia? Which part of bowel is more commonly herniated through it?

Herniation into the lesser sac ``` Small bowel (70%) Ascending colon/cecum (30%) ```

What is the cause of infantile bochdalek hernia?

Failure of closure of the pleuroperitoneal canal

Which side do bochdalek usually occur?

Left, always posterior

What is a morgagni hernia?

Midline defect where right and left pleuoroperitoneal folds do not join. Substernal herniation often involving omentum

Which organ most commonly herniates through a traumatic diaphragmatic hernia?

Stomach!

Which side do most traumatic hernias usually occur?

Left due to protective effect of liver

Which side do morgagni hernias usually occur?

Right, and anterior

What is the progression of infantile umbilical hernia?

Spontaneous closure

What is the differential for misty mesentery?

Fluid - CHF, portal hypertension, hypoalbuminemia, mesenteric arterial or venous thrombosis Inflammation - pancreatitis, IBD, diverticulitis Neoplasm - NHL Retractile mesenteritis

Soft tissue stranding with the epicenter distinct from the colon wall or appendix along the antimesenteric border?

Epiploic appendigitis

Which side are omental infarcts more common?

Right side, due to longer length of right omentum

What is the key feature in differentiating diverticulitis/appendicitis and omental infarct?

Omental infarct will have a normal adjacent colon