Retroperitoneum Flashcards
This is the serous membrane that forms the lining of the abd cavity and covers most of the abd organs.
peritoneum
Name the two layers of the peritoneum.
parietal and visceral
This is the space between the parietal and visceral peritoneum containing serous fluid.
the peritoneal cavity
T/F? In males, the peritoneal cavity is completely closed.
true
The peritoneal cavity is ___ and essentially ___ to the outside environment.
sterile, closed
T/F? In females, the peritoneal cavity is completely closed.
FALSE, there is a communication between the cavity and the outside via the fallopian tubes.
Name the two compartments of the peritoneal cavity.
lesser sac and greater sac
This is the space that is situated between the liver, pancreas, and stomach. The entrance is the epiloic foramen.
lesser sac
The is the space that is situated around the bowel and lower organs.
greater sac
This is a posterior compartment that lies between the transversalis fascia and the parietal peritoneum.
retroperitoneum
This is the connective tissue that circles the inner abd.
transversalis fascia
The superior border of the retroperitoneum is the…
diaphragm.
The inferior border of the retroperitoneum is the…
pelvic rim.
The anterior border of the retroperitoneum is the…
parietal peritoneum.
The posterior border of the retroperitoneum is the…
posterior abd wall muscles.
The lateral border of the retroperitoneum is the…
transversalis fascia and peritoneal portions of the mesentery.
Name the three spaces within the retroperitoneum.
perirenal space, anterior pararenal space, and posterior pararenal space
What connective tissue divides the retroperitoneum into its three spaces?
Gerota’s (renal) fascia
Kidneys and adrenals lie within the ___ space of the retroperitoneum.
perirenal
The perirenal space is separated from the pararenal spaces by the…
anterior and posterior renal (Gerota’s) fascia.
This is the fat area between the peritoneum and Gerota’s fascia.
anterior pararenal space
This is the space between Gerota’s fascia and the posterior abd wall muscles.
posterior pararenal space
SAD PUCKERS is the acronym for what now?
The organs in the retroperitoneum
What does SAD PUCKERS stand for?
Suprarenal Ao/IVC Duodenum Pancreas Ureters Colon Kidneys Esophagus Rectum SMV
These muscles lie in the pararenal space, separated by the transversalis fascia.
psoas and quadratus lumborum muscles
This retroperitoneal condition presents as a dense fibrous tissue proliferation confined to the paravertebral region.
retroperitoneal fibrosis, Ormond’s disease, or inflammatory aneurysm
Where along the aorta does Ormond’s disease tend to appear?
at the bifurcation
Sonographically, this retroperitoneal condition appears as a hyperechoic midline mass.
retroperitoneal fibrosis
This retroperitoneal condition is associated with bilateral ureteral obstruction as it envelopes structures rather than displace them.
retroperitoneal fibrosis
This is the most likely complication of retroperitoneal fibrosis.
hydronephrosis
What causes most cases of retroperitoneal fibrosis?
idiopathic
The adrenal glands are ___ to the kidneys.
anterior, medial, and superior
These are the smallest paired organs found in the abdomen.
adrenal glands
How can we differentiate between adrenal masses and renal masses during an u/s exam?
They will separate during deep inspiration and in the upright position.
Which adrenal gland is shaped like a triangle or pyramid?
right
Which adrenal gland is shaped like a cresent?
left
This part of the adrenal gland is hypoechoic and typically less echogenic than the surrounding retroperitoneal fat.
cortex
This is the echogenic linear structure within the adrenal gland.
medulla
What percentage of the adrenal gland is cortex?
90%. Which makes the medulla 10%.
What three arteries supply each adrenal gland?
suprarenal branch of the inferior phrenic artery, suprarenal branch of the aorta, and suprarenal branch of the renal artery
Which veins drain the adrenal glands?
the right suprarenal vein (drains into the IVC) and the left suprarenal vein (drains into the left renal vein)
What kind of hormones does the cortex produce?
steroids
What kind of steroids does the adrenal cortex produce?
mineralocorticoids (aldosterone)
glucocorticoids (cortisol)
androgens (gonadal hormones)
What do mineralocorticoids do?
Help maintain the body’s fluid & electrolyte balance
What do glucocorticoids do?
Modify the body’s response to inflammation
The adrenal cortical hormones (ACH) are regulated by the ___ hormones of the ___ gland.
adrenocorticotropic, anterior pituitary
The adrenal gland and the anterior pituitary gland function together to…
regulate hormone production.
Which hormones does the adrenal medulla produce?
epinephrine and norepinephrine
Indications for an adrenal u/s:
- tachycardia
- severe anxiety
- HTN
- Abd distention
- sweating
- weight loss
- diabetes mellitus
- eval of a previously seen mass
This adrenal condition is rare, usually unilateral, and asymptomatic.
adrenal cysts
Sonographically, this adrenal condition appears in the typical cystic pattern and may calcify or hemorrhage.
adrenal cysts
This is a benign adrenal cortical mass, usually asymptomatic or elevated adrenal hormones.
adrenal adenoma
Adrenal hyperplasia, adenomas, or adenocarcinomas are tied to…
adrenal cortical hyperfunctioning.
This is caused by excessive cortisol secretions associated with adrenal adenomas.
Cushing’s syndrome
This is caused by excessive cortisol secretions due to a pituitary tumor and causes purplish striae on the skin.
Cushing’s disease
This is caused by excessive aldosterone secretion.
Conn’s disease
This is caused by excessive androgen secretion.
adrenal virilism
The symptoms of this adrenal disease include hirsutism, baldness, acne, and amenorrhea.
adrenal virilism
This is a life-threatening condition caused by partial or complete failure of the adreno-cortical function.
Addison’s disease
Addison’s disease destroys the adrenal ___ and loses the ___ and ___ secretions.
cortex, cortisol, aldosterone
T/F? Females have an increased incidence of Addison’s disease.
true
This condition presents as anorexia, bronzed skin, salt cravings, emotional changes and GI disorders.
Addison’s disease
T/F? The treatment for Addison’s disease is to surgically remove an adrenal gland.
FALSE, to remove both adrenal glands
When endocrine studies are negative (indicating a non-hyperfunctioning adrenal mass), the deicision to resect is usually based on its…
size.
What size would an adrenal mass be before they decide to remove it?
greater than 3 cm
This is a rare adrenal tumor with a poor prognosis.
adrenal cortical carcinoma
T/F? The majority of patients with adrenal cortical carcinoma present with Addison’s disease.
FALSE, Cushing’s syndrome
T/F? Many patients with adrenal cortical carcinoma present with metastatic involvement.
true
T/F? Adrenal cortical carcinomas have a tendency to invade the renal veins and IVC.
true
This is a rare vascular tumor of the medulla that may occur in ectopic locations such as along the para-aortic sympathetic nerve chain.
pheochromocytoma
T/F? Pheochromocytomas are usually malignant.
FALSE, benign
What catecholamines do pheochromocytomas secrete?
epinephrine and noreinephrine
T/F? Pheochromocytomas are associated with Multiple Endocrine Neoplasia (MEN) and Conn’s disease.
FALSE, MEN and von Hippel-Lindau disease
This is the most common childhood adrenal mass.
adrenal neuroblastoma
This adrenal condition presents as a palpable abdominal mass in children.
adrenal neuroblastoma
T/F? Adrenal neuroblastomas are benign.
FALSE, malignant
___ typically displaces the kidneys inferiorly into the pelvis, while ___ originates from and destroys the kidney.
Adrenal neuroblastoma, Wilm’s tumor
This is a benign non-functioning adrenal mass that contains fat and bone elements.
myelolipoma
Sonographically, these appear as hyperechoic masses in the adrenal beds.
myelolipoma
This is the most common cell type of Non-Hodgkin disease.
adrenal lymphoma
T/F? Adrenal involvement with lymphomas is common and frequently unilateral.
FALSE, *bilateral
The adrenal glands are the ___ most common metastatic site.
fourth
The most common primary sites are…
lung, breast, melanoma, kidney, thyroid, and colon cancers.
This is the most common adrenal mass seen in a newborn.
adrenal hemorrhage
Sonographically, the normal evolution of this adrenal condition ends with a pseudocyst formation.
adrenal hemorrhage
What is the most likely diagnosis in a newborn with an abdominal mass and decreasing hematocrit?
adrenal hemorrhage
The crus of the diaphragm is ___ to the aorta.
anterior
The crus of the diaphragm is ___ to the celiac axis.
superior
The crus of the diaphragm is ___ to the IVC.
posterior
The most common manifestation of retroperitoneal pathology is…
the presence of a mass.
Sonographic signs of retroperitoneal disease include…
- displacement of normal structures to an abnormal location
- direct invasion of adjacent organs
- asymmetry of normal structures
- silhouetting of normal structures by disease & loss of retroperitoneal?
If you find a mass you should…
- Assess it in 2 dimensions.
- Trace the circumference and measure it.
- Assess for air or calcium
- Assess if it is fixed or free
- Determine echogenicity and blood flow.
- Determine cystic, solid, or vascular.
- Determine the relationship to other structures.
- Determine its origin.
- Check for the ‘beak’ sign, ‘embedded organ’ sign, and ‘phantom organ’ sign.
This is when a mass deforms the edge of an adjacent organ into a wedge shape, indicating that that is the organ of origin.
‘beak’ sign
This is when a mass compresses an adjacent organ, indicating that it is not the organ of origin.
‘embedded organ’ sign
This is when a large mass obscures a small organ, indicating that it is the organ of origin.
‘phantom organ’ sign
Solid masses of the retroperitoneum are usually classified into these categories:
- lymphadenopathy
- primary malignancies
- secondary malignancies
- infections
- lesions that masquerade as solid masses
T/F? It if frequently possible to determine the categories of solid retroperitoneal masses by u/s alone.
FALSE, *not possible
The function of ___ is to form lymphocytes and antibodies to fight infections.
lymphnodes
The two classifications of lymphnodes are:
- parietal nodes (aka deep)
2. visceral nodes (aka superficial)
These are located in the retroperitoneum along the coarse of the prevertebral vasculature, connected to each other by lymph vessels.
parietal nodes
T/F? Parietal nodes are positioned 360 degrees around the aorta and IVC.
true
These nodes lie in the peritoneal cavity and follow the visceral vasculature.
visceral nodes
Sonographically, these look like a hypoechoic solid mass with a hyperechoic fatty center, smooth margins, oval shape with interal vascular blood flow, usually measuring less than 1 cm.
normal lymphnodes
Sonographically, these appear as an enlarged hypoechoic mass greater than 1 cm with a loss of the hyperechoic fatty center with irregular margins and more round than oval. May displace adjacent structures.
abnormal lymphnodes
Enlarged retroperitoneal lymphnodes are referred to as…
lymphadenopathy.
T/F? U/s is the preferred modality for assessing lymphadenopathy.
FALSE, *CT
Sonographically, these appear as a symmetric, hypoechoic areas around the aorta, possibly with a ‘floating aorta’, ‘silhouette’, or ‘mantle/sandwich’ sign.
para-aortic nodes (lymphadenopathy)
If the angle of the SMA exceeds 15 degrees, what should be considered?
lymphadenopathy
This are a rare form of retroperitoneum tumor. Heterogeneous, secondary lesions.
germ cell tumors
T/F? Germ cell tumors are always benign.
FALSE, they may be either benign or malignant.
Where should you check next if you see a germ cell tumor in the retroperitoneum?
the scrotum
Name five kinds of benign retroperitoneal neoplasms.
- fibroma
- lipoma
- mesothelioma
- myxoma
- teratoma
This retroperitoneal neoplasm is a hyperechoic mass consisting largely of fibrous connective tissue.
fibroma
This retroperitoneal neoplasm is a hyperechoic mass consisting of fatty tissue.
lipoma
This retroperitoneal neoplasm is a localized echogenic mass with irregular walls consisting of an abnormal growth of epithelial cells.
mesothelioma
This retroperitoneal neoplasm is a complex or echogenic mass consisting of connective tissue – usually extremely large.
myxoma
This retroperitoneal neoplasm is a complex mass composed of different types of tissues which do not occur together or at the site of the tumor.
teratoma
This is the most common primary malignant retroperitoneal tumor.
liposarcoma
These rare neoplasms arise and develop in the retroperitoneal space but are not attached to the adjacent retroperitoneal organs.
primary malignant retroperitoneal tumor
This is the most common type of soft tissue tumor.
liposarcoma
T/F? Liposarcomas only happen in the retroperitoneum and the extremeties.
FALSE, They can happen anywhere but those are the most common places.
Sonographically, these appear as a hyperechoic mass due to the large amount of fat content.
liposarcoma
T/F? Liposarcomas are usually large, as much as 20 lbs is not uncommon.
true
This is a malignant smooth muscle tumor.
leiomyosarcoma
This malignant tumor may be found in the uterus or GI tract as well as the retroperitoneum, tends to grow rapidly and invade nearby structures.
leiomyosarcoma
Sonographically, these appear as well-circumscribed mixed echogenicity that can have anechoic fluid filled areas due to hemorrhage and necrosis.
leiomyosarcoma
T/F? Leiomyosarcoma affects more men than women.
true
This is a highly malignant tumor of the striated muscle.
rhabdomyosarcoma
Sonographically, this appears as either a hyperechoic or complex mass in the retroperitoneum.
rhabdomyosarcoma
What are the four divisions of the pelvic retroperitoneum?
- prevesical
- rectovesical
- presacral
- bilateral pararectal & paravesical space
This space spans from the pubis to the anterior margin of the bladder, bordered laterally by the obturator fasica.
prevesical space aka space of retzius
This space spans from the bladder to the rectum.
rectovesical space
This space is located between the rectum and fasia covering the sacrum and posterior pelvic floor musculature.
presacral space
This space is bound laterally by the piriformis and levator ani fascia and medially by the rectum.
bilateral pararectal space
