Intraperitoneal Mass Research Articles

Plasma cell granuloma (inflammatory pseudotumor) a hitherto unreported complication of appendicitis during childhood

An 11-month-old boy was admitted with a mobile, solid intraperitoneal mass. The mass was shown to be a plasma cell granuloma that developed following a ruptured appendicitis.

Computed tomography in the differential diagnosis of pelvic and extrapelvic disease

Displacement of various landmarks within the pelvis by enlarging mass lesions can be used advantageously to determine the nature and origin of a particular mass. The noncompliant pelvic osseous ring accentuates the effect of displacement by forcing the vector inwards. This usually results in cephalad extension of a pelvic process into the abdomen. Lesions originating in the sidewall force the neurovascular bundle medially while central lesions will displace these structures against the noncompliant osseous pelvis. The differentiation of supralevator from infralevator lesions by CT aids in planning the appropriate approach to a lesion preoperatively. The various peritoneal spaces can become enlarged by intraperitoneal abscesses, fluid collections or tumor. These processes will also displace sidewall structures laterally against the osseous rim. It is extremely rare for an intraperitoneal process to extend below the level of the mid-femoral head. Extraperitoneal disease arising out of the pelvis may involve areas caudad to the femoral heads as there is no peritoneum to limit the distal spread. The differentiation of intraperitoneal and large extraperitoneal masses arising out of the pelvis can be difficult. A mass which incorporates bowel loops suggests intraperitoneal disease, whereas one which abuts them smoothly suggests an extraperitoneal lesion.

Sonography of Abdominal Posttransplant Lymphoma

Five patients developed abdominal lymphoma an average of 89 months after successful renal transplantation. Sonographically, the lymphomas presented as bulky intraperitoneal masses or focal deposits in the liver. These lesions exhibited good sound transmission and intrinsic patterns ranging from sparse, soft echoes to coarse trabeculations. Prompt diagnosis of this serious late complication of renal transplantation is crucial.

Prevention of carcinomatosis and bloody malignant ascites in the rat by an inhibitor of angiogenesis

It has previously been shown that protamine sulfate is an angiogenesis inhibitor. Regional infusion of protamine into the peritoneal cavity is now reported to prevent the growth of intraperitoneal vascularized tumor masses in rats. Walker 256 carcinoma was implanted directly into the liver or into the peritoneal cavity of rats. Hepatic implants grew in the liver with metastases to the wound and mesentery. Injected tumor cells grew as solid tumor masses in the mesentery. Bloody ascites developed after 7 days. Animals received an intraperitoneal infusion of protamine or saline. Protamine significantly inhibited growth of solid tumors in the mesentery ( P < 0.001). Histology showed tumor cells growing only in monolayer but without vascularization. Ascites was not bloody. In saline-treated animals large vascularized tumors grew in the peritoneal cavity and ascites became bloody.

Intraperitoneal cisplatin with systemic thiosulfate protection.

Seventeen patients with intraperitoneal tumors were treated by 4-hour intraperitoneal dialysis with cisplatin alone, or in combination with an intravenous neutralizing agent, sodium thiosulfate. Cisplatin alone, 90 mg/m2 body surface area intraperitoneally, produced nephrotoxicity. When intraperitoneal cisplatin therapy was combined with intravenous thiosulfate treatment, the dose of cisplatin could be escalated to 270 mg/m2 body surface area without causing an increase in serum creatinine levels or undue myelosuppression. Even at doses up to 270 mg/m2, no local toxicity occurred. The peak peritoneal concentration of free reactive cisplatin averaged 21-fold higher than the plasma level, and the area under the peritoneal cisplatin elimination curve averaged 12-fold more than the area under the plasma curve. Neither of these ratios varied significantly with cisplatin dose. Regression of intraperitoneal tumor masses was observed in patients with far-advanced ovarian carcinoma, mesothelioma, and malignant carcinoid.

Echinococcus multilocularis: Distribution and persistence of specific host immunoglobulins on cyst membranes

Cyst vesicles were obtained from larval cyst masses of Echinococcus multilocularis grown in Medium 858 in vitro or isolated from the intraperitoneal or subcutaneous larval cyst mass of C57BL/6J mice infected 12 weeks previously. Antigenic determinants were present on the outermost section of the laminated layer and throughout the germinal layer of the cysts. Specific host antibodies of the IgG1, IgG2a, IgG2b, and IgM classes and complement component C3 but not host IgA or C-reactive protein were detected on the intact cysts by the indirect immunofluorescent technique. Specific antibodies were bound to the epitopes on the laminated layer but were not detected on the germinal layer. Host albumin, however, was found on the laminated layer, germinal layer, and within the intact cyst. IgG2a and IgG2b were high-affinity antibodies but IgG1 and IgM were low-affinity antibodies as they were eluted easily from the laminated layer with two washes of sodium phosphate buffer (0.01 M, pH 7.2) containing 0.15 M NaCl. The significance of bound antibody in complement activation and antibody-dependent cell-mediated cytotoxicity of the proliferative phase (cyst) of alveolar hydatid cyst is discussed.

Increased extravasation and lymphatic return rate of albumin during diuretic treatment of ascites in patients with liver cirrhosis.

During steady state the overall lymphatic return rate of albumin equals the transvascular escape rate of albumin [TERalb, i.e. the fraction of intravascular mass of albumin (IVMalb) passing to the extravascular space per unit time] provided local back-transport is negligible, as previously substantiated in patients with cirrhosis. In nine untreated patients with cirrhotic ascites, TERalb (as determined from the disappearance of intravenously injected radiodinated serum albumin) was on the average 8.5% IVMalb X h-1 (range 4.6-12.7). This value is higher than that of normals (mean 5.9% IVMalb X h-1, range 4.3-7.4, P less than 0.05, one-sided tests). During diuretic treatment TERalb increased to a mean of 13.0% IVMalb.h-1 (range 9.2-22.2), which is significantly higher compared to the untreated state (P less than 0.05) and compared to normals (P less than 0.01). In the untreated condition IVMalb was mean 1.24 mmol (range 0.96-1.64), and this value increased by 20% (P less than 0.01) to an average of 1.49 mmol (range 1.36-1.79) during diuretic treatment. The average increase in IVMalb (0.25 mmol) corresponded to 45% of the intraperitoneal mass of albumin in the untreated state (mean 0.59 mmol), indicating a net transport of albumin from the peritoneal cavity to the plasma during diuretic treatment. The results suggest an increased lymphatic drainage of albumin during diuretic treatment, which may play a role in amelioration of cirrhotic ascites.

Filtration as the main transport mechanism of protein exchange between plasma and the peritoneal cavity in hepatic cirrhosis.

Fractional peritoneal reabsorption rates (FPRR) were determined from the plasma activity after simultaneous intraperitoneal injection of 131I-labelled serum albumin (a) and 125I-labelled immunoglobulin G-IgG (g) in eight patients with cirrhosis (+ ascites 6, -ascites 2) and in one patient with carcinomatous ascites. Trans-vascular escape rates of albumin (TERa) and IgG (TERg) were determined in the cirrhotic patients from the disappearance of simultaneously intravenously injected 131I-labelled serum albumin and 124I-labelled IgG. Peritoneal space to plasma appearance times ranged 0.1-3.3 h, and the appearance times of albumin and IgG were almost identical. In patients with cirrhosis FPRRa and FPRRg were on average 1.27 and 1.21% of intraperitoneal protein masses returning to plasma per hour, respectively. Mean FPRRg/FPRRa ratio was 0.95 and this value was not significantly different from unity, but significantly higher (P < 0.001) than the ratio between the free diffusion coefficients of IgG and albumin (0.06). The calculated ascitic fluid flow rate was on average 61 ml/h. TERa and TERg were on average 9.6 and 8.6% of intravascular protein masses per hour, mean TERg/TERa ratio was 0.95. Peritoneal space to plasma protein flux averaged 0.4% of the intravascular protein mass per hour. The results point to filtration (convective flux) as the main transport mechanism responsible for protein passage into the peritoneal cavity as well as for the protein passage (lymphatic drainage) back into the plasma. Pressure measurements during catheterization confirmed pressure differences essential for convective flux.

Sonographic evaluation of mesenteric and omental masses in children

Masses in the mesenteries and omentum are often difficult to diagnose by conventional radiographic techniques. Gray scale sonography was a valuable adjunct to radiographic vector analysis in four children with such masses. Masses that are clearly separable from the liver and spleen and do not distort identifiable extraperitoneal structures are probably intraperitoneal. In children most cystic intraperitoneal masses are related to the mesenteries, omentum, ovary, or bile ducts. An anterior fluid collection with internal septa (which might be mistaken for loculated ascites) is the typical sonographic appearance of an omental cyst. Echogenic masses are more difficult to evaluate: careful study of the acoustical features yielded important information in cases of omental lipoma and rhabdomyosarcoma metastatic to the mesenteries and omentum.

Transperitoneal Percutaneous Retroperitoneal Lymph Node Aspiration Biopsy

Percutaneous aspiration biopsies of opacified retroperitoneal lymph nodes, and retroperitoneal, intraperitoneal and paraspinal masses were successfully accomplished in 14 of 17 patients. A 23-guage needle was utilized for the procedure which is performed under fluoroscopic guidance. Metastatic carcinoma, sarcoma and melanoma were readily identified by aspiration biopsy while the diagnosis of lymphoma, especially as to type, was more difficult. No significant complications have resulted from the passage of the needle through the peritoneal cavity.

Detection and localization of intra-abdominal abscesses by diagnostic ultrasound.

In four patients, intra-abdominal abscesses were identified by ultrasonic technique: a right lower quadrant abscess in Crohn disease, a pyogenic liver abscess, a pelvic abscess following rejection and removal of a transplanted kidney, and a perinephric abscess. In all four the establishment by ultrasound that the mass was filled with fluid was critical in guiding drainage. Diagnostic ultrasound is a safe and effective means for the detection, localization, and characterization of retroperitoneal, intraperitoneal, or intraparenchymal inflammatory masses.

Positive-Contrast Peritoneography and Herniography

Positive-contrast peritoneography is a reasonably safe and quite accurate method of identifying patent vaginal processes, hernias, communicating hydroceles, and undescended testes. It is especially valuable in the evaluation of an infant or child who appears to have a unilateral hernia or hydrocele or who has cryptorchidism. The examination is simple to perform and interpret and can also be used to evaluate diaphragmatic abnormalities such as hernias and eventrations, the size and shape of the liver and spleen, and some intraperitoneal masses.

Displacement of duodenum by an enlarged liver.

Displacement of the retroperitoneal organ by intraperitoneal mass is not an infrequent finding.Seven cases of displacement of the descending portion of the duodenum by an enlarged liver are reported and discussed.

The extraperitoneal perivisceral fat pad. II. Roentgen interpretation of pathological alterations.

THE PURPOSE of this paper is to describe the roentgen manifestations of alterations of the normal anatomy of the extraperitoneal perivisceral fat pad and to emphasize that both intra- and extraperitoneal pathologic processes can affect the e. p. f. p. Intraperitoneal Disease A. Fluid: Intraperitoneal fluid in the upper abdomen frequently manifests itself radiologically by collecting adjacent to the properitoneal fat line as a linear density, displacing the colon medially and thinning the properitoneal fat. This shadow has been called the “flank stripe” (5). In addition, the medial margin of the “hepatic angle” may be lost (Fig. 1). What is the explanation for the loss of the hepatic angle by intraperitoneal fluid if the shadow of the hepatic angle is cast by the liver's contrasting with extraperitoneal Iat?3 The great pliability of the e. p. f. p. explains this finding. The intraperitoneal fluid fills the peritoneal recess about the posterior inferior portions of the liver, widening and blunting it. The fluid also displaces the liver medially and anteriorly. The pliable e. p. f. p. which encases this medial portion of the hepatic angle is thinned and flattened (similarly to the properitoneal fat line) by the combined fluid and liver in the peritoneal recess. The resultant anterior-posterior soft-tissue-fat interface disappears, rendering the hepatic angle invisible to the roentgen ray (Figure 2). A similar explanation applies to the loss of the splenic angle with intraperitoneal fluid. B. Mass: Intraperitoneal masses which significantly indent the e. p. f. p. may be visualized on plain supine films. These masses are located posteriorly in the peritoneum (Fig. 3). Anteriorly situated intraperitoneal masses are notoriously difficult to visualize except as they displace gas-containing portions of the gastrointestinal tract. The difficulty in demonstrating hydrops of the gallbladder on plain films is an example of this. Extraperitoneal Disease A. Fluid: Extraperitoneal fluid infiltrates the e. p. f. p. and by increasing the fat's density negates its contrast, causing loss of the normal shadows. The obliteration of the psoas and renal shadows by extraperitoneal fluid are well known radiological signs. Less well known manifestations of extraperitoneal fluid should, however, be emphasized. Extraperitoneal fluid in the posterior right upper quadrant may dissect superiorly and laterally. It can obliterate the hepatic angle by infiltrating the properitoneal fat laterally and, medially, the e. p. f. p. which juxtaposes the medial inferior border of the liver angle (Fig. 4). In addition, when the fluid is loculated in the perirenal space medial to the lateroconal fascia and without extension into the pararenal space, the hepatic angle can be lost, even though the properitoneal fat line is intact.

Urographic studies in abdominal masses. The diagnostic value of kidney rotation.

It has been well documented in the literature that intra-abdominal space-occupying processes and enlarged intra-abdominal organs can displace the kidney in the same manner as do masses in retroperitoneal location (2, 6, 7, 17). Observations related to enlargement of the spleen (8, 10, 21), liver, and gallbladder (2, 15) have been reported in increasing numbers. Though the relative incidence of such displacement is less frequent than with retroperitoneal masses, it occurs more commonly than was believed previously. Also, it has been stated that tumor of the pancreas, which is a retroperitoneal structure, displaces the kidney only rarely (19). On the basis of these and related observations, there seems to be a general agreement that renal displacement cannot be used as a diagnostic sign for the differentiation between intra- and retroperitoneal masses (5, 22). Rotation commonly accompanies displacement of the kidneys and it may be the earliest manifestation of an abdominal space-occupying process. Except for rotation around the sagittal axis, which is easily recognized on the sagittal view, lateral pyelograms make the recognition of rotation easy; an excretory urogram in lateral projection may also be useful in this respect. Kidney Rotation as a Diagnostic Sign on Sagittal Urograms It is the purpose of this presentation to suggest that rotation of the kidneys with or without obvious displacement can be utilized in localization of abdominal masses. Emphasis will be placed on excretory urographic studies and on the value of sagittal (anteroposterior and postero-anterior) views. In excretory urography a lateral view is not ordinarily taken. If its indication is recognized during the procedure, it is commonly too late for adequate visualization; also, both the technic and interpretation may present some difficulties. The physical factors operating in rotation and displacement of the kidneys were found to be similar in the presence of both intraperitoneal and retroperitoneal masses, and there was no essential difference in this respect whether or not the mass was attached to the kidneys. Our diagnostic approach seeks to identify the direction of the space-occupying “force” and its effect on the position of the kidneys. The mechanism of rotation and its roentgenographic demonstration have been discussed in two previous papers and will not be presented here in detail (11, 12). For the purposes of the current study, masses are classified according to their topographic-anatomical relationship to the kidneys, as follows: (a) posterior or medial (or postero-medial); (b) anterior; (c) lateral; (d) proximal or distal. Masses Posterior or Medial (or Postero-Medial) to the Kidneys: Because of the oblique plane (with the hilus looking an-teromedially) in which the kidney is most commonly found, it seems more practical if masses posterior and medial to it are discussed together.

Roentgen Diagnosis of Abdominal Tumors in Childhood.

This volume thoroughly covers the roentgenologic aspects of abdominal tumors in childhood. The book emphasizes the importance of the so-called plain roentgenogram of the abdomen with the variations in position of the patient that are often helpful in diagnosis. I believe that this emphasis is correctly placed. There is a brief description of anatomy and embryology, with particular reference to the development of secondary attachments of the mesentery and peritoneal reflections, illustrated by diagrams. The various roentgenologic procedures available to aid in diagnosis are then reviewed, with some estimation of the value of each in the demonstration of certain lesions. The classification and incidence of abdominal masses is brief but sufficient, since the book deals primarily with roentgenologic diagnosis. Intra-abdominal masses are divided into (1) those in the region of the liver, (2) other intraperitoneal masses, (3) renal and adrenal masses, and (4) other extraperitoneal masses. Each section is illustrated