Diseases of the peritoneal

cavity

Maria Tsitskari, MD, MSc, PhD, EBIR

Medical School, European University of Cyprus
 Diseases of the peritoneal cavity
Peritoneum

The peritoneum is a serosal membrane, which is composed of a single layer of flat mesothelial cells supported by submesothelial
connective tissue
The visceral peritoneum lines all the organs that are intraperitoneal.
The parietal peritoneum lines the anterior, lateral and posterior walls of the peritoneal cavity. The parietal peritoneum is reflected
over the peritoneal organs to form supporting ligaments, mesenteries, and omenta. These reflections may act as natural connections
between the extraperitoneal space and the peritoneal cavity, providing pathways for dissemination of intra-abdominal disease.
The deepest portion of the peritoneal cavity is the pouch of Douglas in women and the retrovesical space in men, both in the upright
and supine position.
The mesentery is a double fold of the peritoneum.
 Diseases of the peritoneal cavity

Peritoneal disease is common and may be difficult to diagnose.

Disease is disseminated along known pathways in the peritoneal cavity, and radiologists who are familiar with the
anatomy of the peritoneum, including the ligaments, can help guide referring physicians toward the most
appropriate therapy (surgical or nonsurgical).
Knowledge about the various peritoneal disease patterns is of crucial importance for accurate differential diagnosis.
■ Computed tomography and magnetic resonance imaging substantially aid in the identification of peritoneal
disease.
■ The primary goal of radiologic imaging evaluation of peritoneal disease is to distinguish between benign and
malignant disease.
 Diseases of the peritoneal cavity

Peritoneum

orresponding schematic (right) show the locations of the peritoneal spaces and ligaments that are most important for surgical planning. I = small bowel, L = liver, S = s
 Extra- and Intraperitoneal Spaces
Common iliac arteries
Pancreas ∗ IVC Aorta

∗ ∗
∗
Uterus
∗ ∗
Ascending Descending
colon Psoas muscle colon Bladder Rectum

Kidneys

Axial (left, middle) and sagittal (right) images from contrast material–enhanced computed
tomography (CT) depict the extraperitoneal space (area inside dashed red contour lines) and
its most important structures. Notice how the extraperitoneal space is separated from the
intraperitoneal space, which is filled with free fluid (∗). The Retzius space (red arrow), also
known as the retropubic space, is extra-peritoneal and not normally fluid filled; the observation
of markedly enhancing fluid in this space at urography is indicative of an extraperitoneal
bladder rupture.
 Intraperitoneal Flow of Free Fluid

Under the influence of gravity, free fluid in

the inframesocolic compartment (1) flows
first into the pelvic recesses, filling the
rectouterine/rectovesical recess (2) and the
right and left paravesical spaces (3).
7
Next, the fluid ascends through the
paracolic gutters (4). Its progress through the 5 6
left paracolic gutter is slow because of the
presence of the sigmoid colon and 4
splenocolic ligament.
Most of the flow is channeled through the 1
right paracolic gutter and distributed in the
right subphrenic (5), right subhepatic (6), and
4 4
right subsplenic (7) spaces.
2
Direct passage of fluid from the right to the 3 3
left subphrenic space is prevented by the
falciform ligament.
 Intraperitoneal Flow of Free Fluid
(continued)
The spread of infected fluid along this
pathway explains why abscesses occur in
the right subphrenic space with two to three
times the frequency with which they occur in
the left subphrenic space.
7
Because infected fluid does not enter the
right subphrenic space until it has filled the 5
6
Morison pouch, abscesses in the right
subphrenic space often occur in association 4
with abscesses in the Morison pouch.
Fitz-Hugh and Curtis syndrome, which 1
involves perihepatitis secondary to
inflammatory pelvic disease, is one example 4
4
of the many disease conditions that may
2
result from the ascent of infected fluid 3 3
through the abdomen.
 Peritoneal Diseases

Primary and secondary peritoneal diseases

• Peritoneal carcinomatosis and its complications
• Mesothelioma
• Sclerosing encapsulated peritonitis
• Peritoneal tuberculosis
• Polycystic echinococcosis
• Pseudomyxoma peritonei
• Desmoid tumor
• Omental infarction
• Mesenteric panniculitis
• Sclerosing mesenteritis
• Inflammatory infiltration of the phrenicocolic ligament
• Peritoneal calcification
 Diseases of the peritoneal cavity

Peritoneal masses
Cystic vs solid masses

Differential diagnosis of cystic

peritoneal masses
 Diseases of the peritoneal cavity
Peritoneal masses
Cystic vs solid masses

Differential diagnosis of solid

peritoneal masses
 Diseases of the peritoneal cavity
Peritoneal masses
Cystic masses
Mucinous Carcinomatosis
Mucinous carcinomatosis is the most common cystic tumor to affect the peritoneal cavity.
Usually these metastases arise from mucinous carcinomas of the ovary or of the gastrointestinal tract (stomach, colon, pancreas).
The prognosis is poor.
In peritoneal carcinomatosis we see tumor nodules along the peritoneal lining, omental tumor deposits, and bowel obstruction

mucinous carcinomatosis with a tumour nodule

 Diseases of the peritoneal cavity
Peritoneal masses
Cystic masses

Pseudomyxoma peritonei
Pseudomyxoma peritonei is the result of intraperitoneal rupture of a mucinous adenocarcinoma or cyst
adenoma of the appendix, that spreads to the peritoneal cavity.
At CT, usually appears as a hypoattenuating mass that can be distinguished from ascites by the presence
of septations and bulging of the hepatic and splenic capsules; less often, manifests as a hyperattenuating
mass
rarely calcifies

pseudomyxoma peritonei with scalloping of the liver

 Diseases of the peritoneal cavity

Peritoneal masses
Cystic masses

Pseudomyxoma peritonei

Axial contrast-enhanced CT image shows a hypoattenuating solid mass with calcifications (red
arrow). The mass produces bulges on the surface of the liver and spleen (white arrows) and
posterior displacement of the bowel. These features represent pseudomyxoma peritonei
secondary to mucinous adenocarcinoma of the appendix.
 Diseases of the peritoneal cavity
Peritoneal masses
Solid masses

Peritoneal metastases-carcinomatosis

Peritoneal metastases are the most common peritoneal solid masses.

• Peritoneal carcinomatosis may result from the metastatic spread of tumors from the gastrointestinal tract, ovary, lung, breast, or uterus.
• Primary peritoneal carcinomatosis in male patients most often originates from cancers of the gastrointestinal tract; that in female patients,
from cancers of the reproductive system.
Usually there are omental metastases, i.e. omental cake and ascites

CT demonstrating omental cake and ascites in a patient with ovarian cancer

 Peritoneal Carcinomatosis
Axial unenhanced CT image obtained after the
administration of oral contrast material depicts
a large mass (black arrow) in the left adnexal
region and multiple nodules in the greater
omentum (white arrow), findings indicative of
diffuse peritoneal dissemination from ovarian
cancer in a 55-year-old woman.

Coronal contrast-enhanced
CT image obtained after the
administration of oral
contrast material shows the
same abdominopelvic mass
(black arrow), with implants
on the left lateral fascia
(white arrow), a large implant
next to the gallbladder (blue
arrow), and a small
subcapsular hepatic implant
(red arrow).
 Diseases of the peritoneal cavity
Peritoneal masses
Solid masses
Lymphoma

NHL is the most common cause of lymphadenopathy.

Usually there are other sites with lymphoma.
The CT attenuation at diagnosis is very homogeneous in most cases with
minimal to no enhancement

NHL located in the small bowel mesentery

 Diseases of the peritoneal cavity
Primary peritoneal malignancies
 Diseases of the peritoneal cavity
Malignant mesothelioma

• Rare primary tumor of the peritoneum, commonly related to asbestos exposure

• Involves peritoneum in 6%–10% of cases
• Originates from mesothelial cells lining the peritoneal cavity
• May occur in any age group, including children, but is most commonly found in
middle-aged men
• Findings include peritoneal and omental nodules that converge to form masses
and may invade abdominal organs

Coronal (top) and axial (bottom) contrast-enhanced CT images

obtained in a patient with a diagnosis of pulmonary
mesothelioma confirmed at biopsy show multiple confluent
nodules involving the right subdiaphragmatic space (white
arrow), hepatoduodenal ligament (red arrow), and falciform
ligament (black arrow), locations in which surgical resection is
difficult and unlikely to be curative.
 Desmoid Tumor
• Benign but locally aggressive
• High rate of recurrence after surgical resection
• About 40% originate from the mesentery, and one third are infiltrative
• More common in young and multiparous women
• May occur spontaneously or in association with Gardner syndrome or a history
of surgery or local trauma
• At CT, these masses show iso- or hyperattenuation relative to muscle

Sequentially acquired axial contrast-enhanced CT images demonstrate a mesenteric solid mass

(arrows).