Retroperitoneum Flashcards
1
Q
The peritoneum is the ____ membrane that forms the lining of the ____ and covers most of the abdominal organs.
A
serous
abdominal cavity
2
Q
What are the 2 layers of the peritoneum
A
Parietal (outer layer)
Visceral (inner layer)
3
Q
The parietal layer does what?
A
lines the abdominal wall
4
Q
The visceral layer does what?
A
covers the abdominal organs
5
Q
Between the parietal and visceral peritoneum is a space containing ____ fluid. This space is called the ____.
A
serous
peritoneal cavity
6
Q
What organs are in the peritoneal cavity?
A
It is not inhabited by any organs! The organs lie in the abdominal cavity, which is enclosed or surrounded by the peritoneum.
7
Q
During digestion, the organs are able to move and expand, essentially without friction, because of the ____.
A
lubricating peritoneal fluid
8
Q
The peritoneal fluid contains ____ and ____ to ward off infection.
A
leukocytes
antibodies
9
Q
The peritoneal cavity is ____ and essentially closed to the outside environment. In males, this potential space is completely ____ (open/closed).
A
sterile
closed
10
Q
In females there is a communication pathway from the abdominal cavity to the outside world, via the (3). This communication creates potential vulnerability to ____.
A
uterine tubes
uterine cavity
vagina
infection
11
Q
The peritoneal cavity contains 2 separate compartments:
A
lesser sac
greater sac
12
Q
Lesser sac:
The space that is situated between the ____, ____, and stomach. The entrance to the lesser sac is the ____.
A
liver
pancreas
epiploic foramen
13
Q
Greater Sac:
This is the rest of the ____ cavity. When you are imaging ____ with floating bowel, you are looking in the greater sac area.
A
peritoneal cavity
ascites
14
Q
The RETROperitoneum is a ____ compartment that lies between the ____ and the ____.
A
posterior
transversalis fascia
parietal peritoneum
15
Q
This lining circles the inner abdomen.
A
transversalis fascia
16
Q
Borders of the retroperitoneum:
Superior border = \_\_\_\_ Inferior border = \_\_\_\_ Anterior border = \_\_\_\_ Posterior border = \_\_\_\_ Lateral border = \_\_\_\_
A
diaphragm pelvic rim parietal peritoneum posterior abdominal wall muscles trasversali fascia and peritoneal portions of the mesentery
17
Q
2 layers of renal fascia (AKA _____ fascia) divide the retroperitoneum coronally into 3 compartments/spaces:
A
Gerota’s
perirenal space
anterior pararenal space
posterior pararenal space
18
Q
Kidneys and adrenal glands lie within the ____ space and are separated from the pararenal spaces by the ____ and ____ renal fascia (AKA ____ fascia).
A
perirenal
anterior and posterior
Gerota’s
19
Q
Space separated from the pararenal space by Gerota’s fascia.
A
perirenal space
20
Q
The perirenal space includes the (8):
A
kidneys adrenal glands perinephric fat ureters renal vessels AO IVC lymph nodes
21
Q
Fat area between the peritoneum and Gerota’s fascia.
A
anterior pararenal space
22
Q
The anterior pararenal space includes the (5):
A
pancreas descending portion of the duodenum ascending & descending colon superior mesenteric vessels inferior portion of the CBD
23
Q
Space between Gerota’s fascia and the posterior abdominal wall muscles.
A
posterior pararenal space
24
Q
The posterior pararenal space includes the (4):
A
Iliopsoas muscle
quadratus lumborum muscle
posterior abdominal wall
fat
25
These are ____ structures:
```
STOMACH
JEJUNUM
1ST PART OF DUODENUM
APPENDIX
SPLEEN
CECUM
TRANSVERSE COLON
SIGMOID COLON
RECTUM (PART OF IT)
LIVER
UTERUS
FALLOPIAN TUBES
OVARIES
```
itraperitoneal
26
These are ____ structures:
```
KIDNEYS
ADRENAL GLANDS
ASCENDING COLON
DESCENDING COLON
PANCREAS
AORTA & IVC
URETERS
RENAL VESSELS
GONADAL VESSELS
PROSTATE
LYMPHATICS
ESOPHAGUS
2ND, 3RD, 4TH PARTS OF THE DUODENUM RECTUM (part of it)
SUPERIOR MESENTERIC VESSELS
```
retroperitoneal
27
A useful mnemonic to aid recollection of the abdominal retroperitoneal viscera is
SAD PUCKERS
* S = Suprarenal glands (aka the adrenal glands)
* A = Aorta/IVC
* D = Duodenum (except for its first portion)
* P = Pancreas
* U = Ureters
* C = Colon (only ascending/descending branches)
* K = Kidneys & Renal Vessels
* E = Esophagus
* R = Rectum
* S = SMV
28
These lie posterior in the posterior pararenal space, and are separated from this spaces by their own fascia (____ fascia).
quadratus lumborum and psoas muscles
| transversalis fascia
29
This joins with iliacus and is directly involved with most low back problems because it connects the lumbar vertebrae and discs.
psoas major
30
This is a deep core muscle located in the lower back.
quadratus lumborum
31
What is the abdominal sandwich (order)?
ANTERIOR
```
trasversalis fascia
anterior parietal peritoneum
peritoneal space
posterior parietal peritoneum
anterior pararenal space
anterior renal fascia (Gerota's)
perirenal space
posterior renal fascia (Gerota's)
posterior pararenal space
transversalis fascia
```
POSTERIOR
32
This is a dense fibrous tissue proliferation confined to the paravertebral region (AKA ____ or ____).
retroperitoneal fibrosis
AKA
Ormond's disease
or
Inflammatory aneurysm
33
Where is a retroperitoneal fibrosis (AKA Ormond's disease or Inflammatory aneurysm) generally located?
centered at the aortic bifurcation
34
A hypoechoic midline mass, centered at the aortic bifurcation is most likely ____
retroperitoneal fibrosis (AKA Ormond's disease or inflammatory aneurysm)
35
What is associated with bilateral uretral obstruction, as it envelopes structures rather than displaces them?
retroperitoneal fibrosis (AKA Ormond's disease or inflammatory aneurysm)
36
What is the most likely complication of retroperitoneal fibrosis? Why?
hydronephrosis
| because the fibrotic masses may put pressure on the ureter(s), causing an obstruction
37
A large percentage of retroperitoneal fibrosis cases are ____.
idiopathic (arising from an unknown or obscure location)
38
These are other causes of what?
```
malignancies
various drugs and chemicals
Crohn’s disease
sclerosing cholangitis
radiation therapy
chemotherapy
aortic aneurysms
```
retroperitoneal fibrosis
39
The adrenal glands and the kidneys are located within the ____ space.
They are located ____, ____, and ____ to the kidneys.
perirenal
anterior
medial
superior
40
These are the smallest paired organs found in the abdomen. They weigh about ____ each, measure from ____ to ____ wide, ____ to ____ in length, and _____ in height.
```
adrenal glands
4 grams
2-3 cm
3-5 cm
1 cm
```
41
Each adrenal gland is about the size of the end of your ____.
thumb
42
The adrenal glands are composed of 5 parts:
```
anteromedial ridge
medial wing
lateral wing
cortex
medulla
```
43
What causes the adrenal glands to be relatively fixed?
fascial support
44
Adrenal glands have a more constant relationship with the ____ than the ____.
great vessels
| kidneys
45
The adrenal gland and kidney will separate during ____ or in the ____ position. This may allow for differentiation between renal and adrenal masses if doing an ultrasound exam.
deep inspiration
| upright
46
The echogenic linear ____ (part of adrenals) is most prominent in the fetus/newborn, however it can be identified in thin adults.
medulla
47
The right adrenal gland is shaped like a ____ or ____ and is located on the superior, anterior and medial aspect of the upper pole of the right kidney.
triangle
| pyramid
48
The left adrenal gland is ____-shaped and is located ____ to the upper pole of the left kidney.
crescent
| anteromedial
49
Adrenal cortex is ____ and typically ____ (more/less) echogenic than the surrounding retroperiotneal fat.
Adrenal medulla is ____ ____ structure within the adrenal gland.
hypoechoic
less
echogenic
Linear
50
3 arteries supply each adrenal gland:
suprarenal branch of the inferior phrenic artery
suprarenal branch of the AO
suprarenal branch of the RA
51
A single vein drains each adrenal gland:
right suprarenal vein drains into the IVC
| left suprarenal vein drains into the LRV
52
This is the outer portion of the adrenal gland that comprises about 90% of the gland.
adrenal cortex
53
Which part of the adrenal gland produces steroid hormones?
adrenal cortex
54
What are the 3 steroid hormones that the adrenal cortex produces and what do they do?
mineralocorticoids (aldosterone) – helps maintain the body’s fluid & electrolyte balance
glucocorticoids (cortisol) – modifies the body’s response to inflammation
androgens (gonadal hormones)
55
The adrenal cortical hormones (ACH) are regulated by the ____ hormones of the anterior pituitary gland.
The adrenal gland and the anterior pituitary gland function together to regulate ____ production.
adrenocorticotropic (ACTH)
hormone
56
This is the inner portion of the adrenal gland that comprises about 10% of the gland.
adrenal medulla
57
The medulla produces ____.
catecholamines
58
What are the 2 catecholamines that the medulla produces? What do they do?
epinephrine (adrenalin) - increases in times of excitement or emotional stress
norepinephrine - modifies BP
59
These are an indication for a ____:
```
Tachycardia
Severe anxiety
HTN
Abdominal distention
Sweating
Weight loss
Diabetes Mellitus
Evaluation of a mass demonstrated on a previous medical imaging study
```
renal ultrasound
60
Is it possible to differentiate between adenomas, carcinomas, pheochromocytomas, or mets sonographically?
no
61
T or F? Adrenal cysts are common.
False (they are rare)
62
Are adrenal cysts usually bilateral or unilateral?
unilateral
63
What are the symptoms of adrenal cysts?
they are usually asymptomatic
64
Are adrenal cysts unilocular or multilocular?
can be both
65
Adrenal cysts generally have a typical cystic pattern that may ____ or hemorrhage.
calcify
66
This is a benign cortical mass that is asymptomatic or sometimes causes elevated adrenal hormones.
adrenal adenoma
67
Adrenal adenoma can be hyper functioning or non-hyperfunctioning. Adrenal cortical hyperfunctioning can be caused by adrenal ____, ____, or ____.
hyperplasia
adenomas
adenocarcinomas
68
4 conditions that are caused by adrenal hyper functioning are:
Cushing's syndrome
Cushing's disease
Conn's disease
Adrenal virilism
69
Hyperfunctioning adrenals:
| Cushing’s SYNDROME is excessive ____ secretions associated with adrenal ____ (due to an adrenal mass).
cortisol
| adenomas
70
Hyperfunctioning adrenals:
| Cushing’s DISEASE is excessive cortisol secretion that causes ____ (due to a tumor on the ____).
purplish striae on the skin
| pituitary
71
Hyperfunctioning adrenals:
| Conn's disease causes excessive ____ secretion.
aldosterone
72
```
Hyperfunctioning adrenals:
Adrenal virilism (____ syndrome) causes excessive androgen secretion, producing symptoms such as ____ (excessive hairiness in females), baldness, ____, and ____.
```
adrenogenital
hirsutism
acne
amenorrhea
73
This is a life threatening condition caused by partial or complete failure of adreno-cortical function.
Addison's disease
74
Addison's disease destroys the adrenal ____ and loses the ____ and ____ secretions. There is an increased incidence in ____ (males/females).
cortex
cortisol
aldosterone
females
75
What is the usual necessary treatment for Addison's disease?
surgical removal of both glands
76
Often an Addison's patient is anorexic with bronzed skin pigmentation, has salt and/or ice cravings, emotional changes, and ____ disorders.
anorexic
| GI
77
With an adrenal mass, when endocrine studies are negative, indicating a non-hyperfunctioning adrenal mass, the decision to resect is usually based on its ____, which would usually be >____. In patients with known primary malignancy, ____ is often performed to exclude metastatic disease.
size
3cm
biopsy
78
This is a rare tumor with a poor prognosis. The majority of patients present with Cushing’s syndrome and many patients present with metastatic involvement.
adrenal cortical carcinoma
79
T or F? With an adrenal cortical carcinoma, differentiation from a benign adenoma is difficult sonographically.
true
80
Adrenal cortical carcinomas have a tendency to invade the ____ and the ____.
renal veins
| IVC
81
This is a rare vascular tumor of the medulla, that also may occur in ectopic locations such as along the para-aortic sympathetic nerve chain.
pheochromocytoma
82
Are pheochromocytomas usually benign or malignant?
benign
83
Rare + vascular tumor + in medulla =
pheochromocytoma
84
Pheochromocytomas secrete ____.
catecholamines
85
The 2 catecholamines that pheochromocytomas secrete are
epinephrine
| norepinephrine
86
Pheochromocytomas are associated with these 2 conditions:
MEN - Multiple Endocrine Neoplasia
(masses grow on endocrine glands)
Von Hippel-Lindau disease
(an inherited mutation of the VHL gene, which causes tumors to form in areas of the body that contain large numbers of blood vessels)
87
This is the most common childhood adrenal mass.
adrenal neuroblastoma
88
An adrenal neuroblastoma is usually ____ (benign/malignant). How does it typically present in children?
malignant
| palpable abdominal mass
89
What is a major differentiation between an adrenal neuroblastoma and a Wilm's Tumor?
An adrenal neuroblastoma typically displaces the kidneys inferiorly into the pelvis, as opposed to the Wilm’s tumor that originates from and destroys the kidney.
90
The average age for an adrenal neuroblastoma is ____ - ____ years old. 50% of patients present with ____.
1-2
| metastatic involvement
91
These are benign, non-functioning adrenal masses that contain fat and bone elements.
myelolipoma
92
Myelolipoma are usually seen as ____ masses in the adrenal beds. They are associated with propagation speed artifact due to the ____ composition.
hyperchoic
| fat
93
Adrenal lymphoma:
| Adrenal involvement with lymphomas is common and frequently ____ (unilateral/bilateral).
bilateral
94
The most common type of adrenal lymphoma is
Non-Hodgkin disease
95
The ____ are the 4th most common metastatic site after lungs, liver and bone. The most common primary sites are ____, ____, ____, ____, ____, and ____ cancers.
```
adrenal glands
lung
breast
melanoma
kidney
thyroid
colon
```
96
Specifically, there is a common correlation between ____ cancer and adrenal mets.
lung
97
This is most common adrenal mass seen in a newborn.
adrenal hemorrhage
98
This is caused by the large size of the neonatal adrenals and their high degree of vascularity, which make them vulnerable to birth trauma.
adrenal hemorrhage
99
Adrenal hemorrhage:
| Sonographically, the normal evolution of a hematoma ends with a ____ formation.
pseudocyst
100
T or F? Adrenals are at least ½ the size of the newborn kidney, so they’re very large at birth. Going through the birth canal is difficult and tends to cause problems.
True
101
What is the most likely diagnosis in a newborn with an abdominal mass and decreasing hematocrit?
adrenal hemorrhage
102
This is a linear muscular portion of the diaphragm that anchors the back of the diaphragm.
crus of the diaphragm
103
The crus of the diaphragm are located ____ to the AO, ____ to the celiac axis, and ____ to the IVC.
anterior
superior
posterior
104
The crus of the diaphragm is located medial and posterior to all structures EXCEPT the ____. It can be imaged in the ____ and ____ planes.
AO
transverse
sagittal
105
The most common manifestation of retroperitoneal pathology is the presence of a ____.
mass
106
These are sonographic signs of what:
1. Displacement of normal structures to an abnormal location
2. Direct invasion of adjacent organs
3. Asymmetry of normal structures
4. Silhouetting of normal structures by disease & loss of retroperitoneal
retroperitoneal pathology/disease
107
When you find a mass you should:
1) assess it in 2 dimensions and ensure it is real
2) trace its entire circumference and measure it
3) assess for the presence of air or calcium
4) assess whether it is fixed or free
5) determine its internal echogenicity and blood flow
6) discover whether it is cystic, solid, or vascular
7) determine the relationship of a mass to other organs, blood vessels, and structures
8) seek its origin
9) check for the “beak sign”, “embedded organ” sign and “phantom organ” sign
yep
108
Mass in the Retroperitoneum signs:
When a mass deforms the edge of an adjacent organ into a “beak” shape, it is likely that the mass arises from that organ.
beak sign
109
Mass in Retroperitoneum signs:
| When a tumor compresses an adjacent organ.
embedded organ sign
110
Mass in Retroperitoneum signs:
| When a large mass arises from a small organ, the organ sometimes becomes undetectable.
phantom (invisible) organ sign
111
T or F? With solid masses in the retreoperitoneum, it is frequently not possible to clearly assign them to a particular class, based on the ultrasound appearance alone.
True
112
The function of these is to form lymphocytes and antibodies to fight infections. They fight against foreign particles like bacteria and viruses, and serve as filters, removing invading organisms and debris from infected areas in order to protect the body.
lymph nodes
113
What are the 2 classifications of lymph nodes and their alternate names?
```
parietal nodes (AKA deep)
visceral nodes (AKA superficial)
```
114
Parietal (aka deep) nodes are located in the retroperitoneum, along the course of the ____ vasculature. They are connected to each other by ____ and grouped according to the ____ with which they are associated.
pre-vertebral
lymph vessels
arterial vessels
115
The upper parietal nodes are (5):
```
celiac
SMA
SMV
IMA
IMV
```
116
The lower parietal nodes are (2):
common external iliacs
| common internal iliacs
117
These nodes are positioned 360 degrees around the AO and IVC.
parietal nodes
118
The parietal nodes lying posterior to the main vessels are the most reliable indicator of ____ because this condition displace these vessels anteriorly.
lymphadenopathy
119
These nodes lie anywhere in the peritoneal cavity and follow the course of the visceral vasculature.
visceral nodes
120
The common groupings of visceral nodes are (4):
gastric
hepatic
pancreatic
splenic
121
Sonographically, normal lymph nodes look like a ____ (echogenicity), ____ mass with a ____ (echogenicity) fatty center, smooth margins, oval shape, with internal vascular ____. They usually measure
```
hyopechoic
solid
hyperechoic
blood flow
1cm
```
122
Sonographically, abnormal lymph nodes appear as an enlarged ____ (echogenicity) mass, >____, with a loss of the ____ (echogenicity) fatty center, more rounded with ____ margins. They usually displace ____.
```
hypoechoic
1cm
hyperechoic
irregular
adjacent structures
```
123
This is the term for enlarged retroperitoneal lymph nodes.
lymphadenopathy
124
T or F? CT is usually the choice imaging procedure for lymphadenopathy because it provides a standard and repeatable view that is not degraded by gas.
True
125
These nodes have a saddle bag appearance as they hover over the TRV AO.
para-aortic nodes (floating AO sign)
126
Para-aortic nodes are ____ (symmetric/asymmetric) and ____ (echogenicity).
symmetric
| hyopechoic
127
This para-aortic node sign shows a saddle bag appearances as they hover over the TRV AO.
floating AO sign
128
This para-aortic node sign appears as an echogenic anterior AO wall that is obliterated because of lymphadenopathy.
silhouette sign
129
If, in the sagittal view of the AO, the SMA has a posterior hypoechoic structure below it that is causing the SMA to exceed an angle of 15 degrees, ____ should be considered.
lymphadenopathy
130
Sometimes nodes fuse to form a ____ (AKA ____) sign, which is visualized anterior and posterior to vessels of the abdomen, creating this sign.
mantle
| sandwich
131
This is a rare retroperitoneal tumor that can be benign OR malignant. Most are secondary ____ (to some other condition). They are usually ____ (texture).
Germ cell tumor
lesions
heterogeneous
132
Germ cell tumors are most always associated with ____ pathology.
scrotum
133
BENIGN NEOPLASMS:
| This is a hyperechoic mass consisting largely of fibrous connective tissue
fibroma
134
BENIGN NEOPLASMS:
| This is a localized echogenic mass with irregular walls, consisting of an abnormal growth of epithelial cells.
mesothelioma
135
BENIGN NEOPLASMS:
| This is a complex or echogenic mass consisting of connective tissue – usually extremely large.
myxoma
136
BENIGN NEOPLASMS:
| This is a complex mass composed of different types of tissues which do not occur together or at the site of the tumor.
teratoma
137
The most common malignant retroperitoneal neoplasm is
liposarcoma
138
MALIGNANT NEOPLASMS:
| "Fat that went wrong," the most common type of soft tissue tumor. It is a malignant growth of fat cells.
liposarcoma
139
MALIGNANT NEOPLASMS:
| Liposarcomas can occur anywhere in the body, but they are frequently seen in the ____ and ____.
retroperitoneal tissues
| extremities
140
MALIGNANT NEOPLASMS:
| T or F? Liposarcomas do not often metastasize.
False, they have a tendency to metastasize.
141
MALIGNANT NEOPLASMS:
Liposarcomas are ____ (echogenicity) due to the large amount of ____ content. They are usually huge (about ____ or more in size is not rare). Because they are ____, they can grow to be large before even being diagnosed.
hyperechoic
fat
20cm
retroperitoneal
142
MALIGNANT NEOPLASMS:
This is a malignant smooth muscle tumor of the retroperitoneum. Besides the retroperitoneum, they are frequently found in the ____ and ____ tract. They grow ____ (fast/slow) are invade surrounding tissues and ____ structures.
```
leiomyosarcoma
uterus
GI
fast
venous
```
143
MALIGNANT NEOPLASMS:
Leiomysarcomas sonographically appear as ____, mixed ecogenicity, that can have ____ (echogenicity) fluid filled areas due to hemorrhage and ____.
well-circumscribed
anechoic
necrosis
144
MALIGNANT NEOPLASMS:
70-90% of leiomyosarcomas are ____ (benign/malignant). They occur more commonly in ____ (men/women), with a 22-50% 5-year survival rate.
malignant
| men
145
MALIGNANT NEOPLASMS:
| This is a tumor that involves extra fibrin but in a different classification (huh?).
malignant fibrous histiocytoma
146
MALIGNANT NEOPLASMS:
| This is a highly malignant tumor that is derived from striated muscle.
rhabdomyosarcoma
147
MALIGNANT NEOPLASMS:
| A rhabdomyosarcoma appears as either a ____ or ____ mass (echogenicity/textures/etc.).
hyperechoic
| complex
148
The 4 subdivisions of the pelvic retroperitoneum are:
prevesical
rectovesical
presacral
bilateral pararectal and paravesical space
149
This pelvic space spans from the pubis to the anterior margin of the bladder. It is bordered laterally by the obturator fascia.
prevesical space
150
The prevesical space is AKA
space of Retzius
151
The prevesical space spans from the ____ to the ____ margin of the bladder. It is bordered ____ by the obturator fascia.
pubis
anterior
laterally
152
This pelvic space is between the bladder and the rectum.
rectovesical space
153
This pelvic space is located between the rectum and fascia that covers the sacrum and posterior pelvic floor musculature.
presacral space
154
The presacral space is located between the ____ and fascia that covers the ____ and posterior ____.
rectum
sacrum
pelvic floor musculature
155
This pelvic space is bound laterally by the piriformis and levator ani fascia, and medially by the rectum.
bilateral pararectal space
156
The bilateral pararectal space is bound laterally by the ____ and _____, and medially by the rectum.
piriformis
| levator ani fascia
157
The mnemonic to aid recollection of the abdominal retroperitoneal viscera that is GoLymP stands for:
Gonadals
Lymphatics
Prostate
158
Besides adrenal adenoma, what 2 other masses cause cortical hyper-functioning?
adrenal hyperplasia
| adenocarcinomas
