Morison's Pouch Research Articles

Ultrasound Detection of Free Intraperitoneal Fluid Associated With Hepatic and Splenic Injuries*

The objective of this study was to compare the sensitivity and specificity of 5 abdominal views for detecting free intraperitoneal fluid in trauma patients later diagnosed with hepatic or splenic injuries. This retrospective study conducted over a 17-month period enrolled patients with trauma. A Focused Abdominal Sonogram for Trauma (FAST) examination was done using 5 abdominal views. Exploratory laparotomy or computed tomography (CT) confirmed the presence of intraperitoneal fluid and associated injuries. The sensitivity and specificity were determined. Of the 245 study patients, 29 had injuries to the liver or spleen or both. The 5-view FAST examination's sensitivity for detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 77%, 90%, and 100%, respectively. The sensitivity of the single Morison's pouch view in detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 38%, 20%, and 67%, respectively. For identifying free intraperitoneal fluid associated with hepatic or splenic injuries, no single view of the FAST examination could match the sensitivity provided by the 5-view technique.

Right anterior subphrenic space: an important site for the early detection of intraperitoneal fluid on abdominal CT

Small rinds of free fluid are frequently seen in the right anterior subphrenic space. Therefore, we investigated patients undergoing abdominal computed tomography (CT) to see whether early fluid collections are seen preferentially at this or any other site. CT examinations of 59 randomly selected patients with minor or moderate quantities of free intraperitoneal fluid were analyzed. The location of the fluid was determined [subphrenic spaces, the right hepatorenal fossa (Morison's pouch), paracolic gutters, pelvis (pouch of Douglas)]. The amount of fluid in each location was subjectively quantified (none, trace, small, or moderate). Free fluid was seen most frequently in the right anterior subphrenic space (44/59 patients, 75%) and pelvis (43/59 patients, 73%). Eight patients had intraperitoneal fluid at an isolated location (three in the pelvis alone, two in the left subphrenic space, one in the right subphrenic space, and one in each of the right and left paracolic spaces). Contrary to popular belief, intraperitoneal fluid is not always seen first in the pelvis when the patient is in the supine position. Although fluid is not consistently seen first in any specific location, the subphrenic space (especially the right anterior) is a common site where small quantities of fluid may be identified.

Sensitivity of transabdominal ultrasonography in detection of intraperitoneal fluid in humans.

The sensitivity and specificity of ultrasonography in detection of free intraperitoneal fluid is over 90 %. The lowest detectable volume of free fluid in humans is unknown. The distribution of intraperitoneal fluid was studied in 86 patients by transabdominal US in group A (n = 21, 10 ml of fluid), in group B (n = 15, 50 ml of fluid) and group C (n = 50, splenic trauma). Ultrasound detected fluid in 15 of 21 patients in group A, and in all patients in groups B and C. In group A 10 ml of fluid was found in 71 % of cases behind the bladder, and in only 5-14 % of cases in the upper abdomen. In group B 50 ml of fluid was found in all patients in the lower pelvis, but in only 20 % in Morison's pouch and in 7 % around the spleen. In group C 200-4500 ml of fluid was detected by US in 72 % of patients in the perisplenic space, in 60 % in Morison's pouch and in 42 % in the retrovesical space. Small volumes of free intraperitoneal fluid (10-50 ml) can be detected with current US scanners, but only near the site of injury. These results support the role of US as a primary imaging modality in abdominal trauma.

Ultrasonography in the Evaluation of Hemoperitoneum in War Casualties

The aim of this study was to evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the detection of hemoperitoneum among war casualties, and to compare the results of this method in a specific war situation and civil conditions. Ninety-four wounded individuals with suspected blunt or penetrating abdominal trauma were treated at a level I war hospital (group W), and 242 civilians with multiple injuries with suspected blunt abdominal trauma were evaluated at the emergency center of a university hospital (group C). All examinations were performed in less than 5 minutes with a portable ultrasonographic scanner, and typical points were scanned (Morison's pouch, Douglas and perisplenic spaces, paracolic gutter). In group W, hemoperitoneum was identified correctly in 19 patients, with three false-negative and no false-positive findings, whereas group C presented 98 true-positive results, 13 false-negative results, and again no false-positive results. We observed that ultrasonography in specific war conditions showed sensitivity of 86%, specificity of 100%, accuracy as high as 97%, positive predictive value of 100%, and negative predictive value of 96%, whereas in civil conditions the corresponding values were 88%, 100%, 95%, 100%, and 91%, respectively. The sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the diagnosis of hemoperitoneum are approximately equal in war and civil conditions.

Ultrasound for the detection of intraperitoneal fluid: The role of Trendelenburg positioning

A prospective, observational study was performed to evaluate the role of Trendelenburg positioning in improving the sensitivity of the single-view ultrasound examination. Hemodynamically stable patients undergoing diagnostic peritoneal lavage (DPL) were assigned to one of two groups: supine or 5° of Trendelenburg positioning. Baseline right intercostal oblique images of Morison's pouch were obtained followed by additional images for each 100 cc of lavage fluid instilled into the peritoneal cavity. The initial volume of fluid required to identify an anechoic stripe was recorded for each patient. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/μL), (2) positive baseline ultrasound study, (3) hemodynamic instability, or (4) lack of documentation (ie, baseline/subsequent hard copy images were not obtained or inadequately demonstrated anechoic stripe). The mean quantity of fluid for visualization of the anechoic stripe was 443.8 cc in the Trendelenburg group (n = 8) and 668.2 cc in the supine group (n = 11). These means were statistically different ( P < .05, t test). The median amount of fluid needed for visualization of the anechoic stripe was 400 cc and 700 cc for the Trendelenburg and supine groups, respectively.

The use of ultrasound in trauma patients: A review

Kate Curtis CNS Trauma and Retrieval Services St George Hospital Ultrasound has been used to evaluate patients with blunt trauma in Germany since 1971, and since then has become the preferred diagnostic tool for initial evaluation of patients with blunt trauma in many European, Japanese and North American trauma centres. 1 Ultrasound can be used as a rapid, portable, non invasive, accurate evaluation of the chest and abdomen following blunt trauma. It offers immediate results, is cost effective, repeatable and sensitive) Ultrasound may also be performed m conjunction with physical assessment and resuscitation withm minutes of the patients arrival in the Emergency Department. Scanning takes 30 to 60 seconds per view and usually no more than 5 minutes for multiple views. ~ Research conducted by Branney and coworkers 3 found that the minimum volume of fluid detectable from a single view of Morrison's pouch in a supine patient averaged 619mls. This amount decreases by tilting the head of the patients bed down by 5 degrees, more tilt means more sensitivity. 4 Obviously the patients' injuries must be considered when increasing the degree of tilt, for example, head and cervical spine injuries. Extensive research has concluded that ultrasound is a sensitive and specific test with which to evaluate adult and paediatric trauma patients for abdominal and chest injuries requiring surgery. 5'6 Routine Ultrasounds can be performed at the bedside in the ED as a timely non invasive diagnostic test, as well as in subsequent monitoring and reassessment. A review of 2,013 trauma presentations to a tertiary trauma centre in the United States found that those patients requirmg investiganon for suspected intra abdominal injures were diagnosed within 22.9 minutes of arrival by ultrasound2 Due to the increasing costs of health care and a decrease in hospital funding, less expensive diagnostic methods should be considered. The Michigan Health System identified several cost centres, for example nursing, pathology, pharmacy and radiology. In an attempt to decrease radiology costs, the use of ultrasound in the ED was increased. After 6 months radiology costs decreased by 7%. ~ Ultrasound's use as a diagnostic tool is useful when the physical examination may be altered. For example injuries to the head or spinal cord, distracting pain and drug intoxication will decrease the accuracy of > © :>

PERFORATION OF THE COMMON BILE DUCT -AN ADULT CASE REPORT-

Perforation of the common bile duct can be associated with congenital biliary dilatation in childhood, but it rarely appears in adults. We experienced a case of perforation of the common bile duct with choledocholith in a 68-year-old man. The patient complaining of fever and upper abdominal pain was emergently admitted because upper abdominal CT and ultrasonography revealed calculus of the common bile duct and fluid collection of Morison's pouch. A remission of abdominal symptom was attained by conservative therapy, but an increase in white blood cell count and fever were sustained. The patient was underwent an emergency operation with a diagnosis of choledocholithis and intraabdominal abscess. Upon laparotomy, dense adhesion due to previous gastrectomy and cholecystectomy was present. The abscess cavity was filled with infectious bile and a perforation 3 mm in diameter in the anterior wall of the common bile duct under the confluence was found. Intraoperative cholangioscopy revealed a stone 15 mm in diameter under the site of perforation. The stone was taken out and a T-tube was placed in the hole. He had an uneventful postoperative course and was discharged from the hospital. We think that stone impaction might cause the perforation in this patient.

A CASE OF INTRAPERITONEAL LOOSE BODY WHICH SHOWED THE APPEARANCE OF LIVER TUMOR

A 66-year-old man was admitted to the hospital because of epigastralgia. Plain abdominal roentgenogram revealed a calcification (8×6mm) in Morrison's pouch. Abdominal ultrasound and CT examinations demonstrated a mass lesion (2.2×2.0cm) in the hepatic segment 6. Endoscopic retrograde cholangiogram showed no abnormality in the biliary system except for a cholesterol polyp (6×4mm) at the neck of the gall bladder. Hepatic angiogram demonstrated no vascularity in the tumor. The enucleation of the hepatic tumor and cholecystectomy were performed. Intraoperative exploration clarified the calcification in Morrison's pouch as a calcified intraperitoneal loose body. Histological examination of the hepatic tumor demonstrated coagulation necrosis of fat cells in the middle surrounded by glassy degenerative fibrous tissue. Since the intraperitoneal loose body found in Morrison's pouch showed same histological findings, the hepatic tumor was diagnosed as intraperitoneal loose body which had migrated into hepatic parenchyma and demonstrated the appearance of hepatic tumor. Althoguh intraperitoneal loose body rarely draws clinician's attention, operative indication should be considered in cases that it causes some clinical symptoms or another neoplastic lesions can not be ruled out.

Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage.

Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension. Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined. The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12. EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.

Low attenuation of acute traumatic hemoperitoneum on CT scans.

This study was undertaken to determine the incidence of low attenuation values in intraperitoneal hemorrhage, which could be confused with ascites. We retrospectively analyzed the CT scans of 42 consecutive patients with hepatic and splenic lacerations and intraperitoneal fluid after blunt abdominal trauma. Patients were excluded if they had prior peritoneal lavage, bladder or bowel injury, or low hematocrit values. Intraperitoneal fluid was categorized by the site of accumulation (perihepatic, perisplenic, Morison's pouch, paracolic gutters, or pelvis). The amount of fluid in each intraperitoneal location was categorized as small, moderate, or large. Attenuation values were obtained from each intraperitoneal site, and overall mean attenuation values were determined for each patient. We correlated the size of each fluid collection with the attenuation value. We also compared attenuation values at locations adjacent to the site of each injury with those at other intraperitoneal sites. We then evaluated technical factors that could have lowered attenuation values, including CT miscalibration, volume averaging, and beam-hardening artifacts. For the 42 patients, we measured 131 separate attenuation values. Attenuation values ranged from 0 to 80 H, with attenuation of 24% of sites (32/131) measuring less than 20 H. Only 16% of sites (21/131) had attenuation values greater than 45 H. Attenuation at the remaining 78 sites (60%) measured from 20 to 45 H. All intraperitoneal locations except the pelvis had mean attenuation values significantly lower then 40 H. Mean attenuation values (determined by averaging measurements from different intraperitoneal sites) were also calculated for each patient. Only 6 (14%) of 42 patients had mean attenuation values greater than 40 H, whereas 4 (10%) of 42 patients had mean attenuation values less than 20 H. The remaining 32 patients (76%) had mean attenuation values between 21 and 40 H. Patients with hepatic lacerations showed no significant difference (p = .3509) in attenuation between perihepatic fluid and the remainder of intraperitoneal fluid. However, in patients with splenic lacerations, perisplenic fluid had a significantly higher (p = .0013) attenuation value (43 H) than did fluid at other intraperitoneal locations. Low attenuation measurements for acute hemoperitoneum represented a common finding that was not attributable to technical factors or underlying anemia. Fluid with attenuation values less than 20 H in acute trauma should not be dismissed as ascitic fluid.

Quantitative Sensitivity of Ultrasound in Detecting Free Intraperitoneal Fluid

The minimum volume of intraperitoneal fluid that is detectable in Morison's pouch with ultrasound in the trauma setting is not well defined. To evaluate this question, we used diagnostic peritoneal lavage (DPL) as a model for intraperitoneal hemorrhage and undertook a blinded prospective study of the sensitivity of ultrasound in detecting intraperitoneal fluid. Participants included attending physicians and residents in emergency medicine, radiology, and surgery. During the infusion of the DPL fluid, participants continuously scanned Morison's pouch until they detected fluid. All participants were blinded to the rate of infusion and the volume infused. One hundred patients were entered into the study. The mean volume of fluid detected was 619 mL. Only 10% of participants detected fluid volumes less than 400 mL and the overall sensitivity at one liter was 97%. We conclude that reliable detection of intraperitoneal fluid in Morison's pouch requires a greater volume than has been previously described.

Morison pouch.

HomeRadiologyVol. 195, No. 2 PreviousNext LettersMorison pouch.M A MeyersM A MeyersM A MeyersPublished Online:May 1 1995https://doi.org/10.1148/radiology.195.2.7724790MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Article HistoryPublished in print: 1995 FiguresReferencesRelatedDetailsCited ByAbdominal Imaging, Vol. 34, No. 3Chemical Engineering & Technology, Vol. 23, No. 4Journal of the American Chemical Society, Vol. 122, No. 46Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 195, No. 2 Metrics Altmetric Score PDF download

Patterns of fluid accumulation in splenic trauma: demonstration by CT.

Detection of hemoperitoneum in splenic trauma is as important as detection of the visceral injury itself. Observation of a consistent spectrum of fluid accumulation in patients with splenic trauma prompted us to investigate the patterns in more detail. Twenty-three computed tomographic (CT) scans in 20 patients were evaluated with respect to presence of fluid collections in various peritoneal and retroperitoneal compartments. These were correlated with severity of injury and operative and pathologic findings. Hemoperitoneum was detected in the pelvis (65%), paracolic gutters (52%), left subphrenic space (48%), perihepatic space (48%), Morison's pouch (17%) and in the lesser sac (9%). In addition to free fluid, pleural fluid (39%) and retroperitoneal hematoma in the left anterior pararenal space (13%) were also encountered. These ancillary findings may help to substantiate the diagnosis of splenic trauma in equivocal cases, particularly when the spleen itself is obscured by artifacts. Early detection may reduce mortality and morbidity associated with splenic trauma.

MRI demonstration of peritoneal implants.

The magnetic resonance imaging (MRI) findings of 12 proven cases of peritoneal implants, mainly carcinomatosis, were reviewed for evidence of peritoneal seedings. The seeded sites include the pouch of Douglas, the ileocecal and retrocecal regions, the right and left paracolic gutters, Morison's pouch, the right subdiaphragmatic parietal peritoneum, the greater and lesser omentum, the gastrocolic, gastrosplenic, and phrenicocolic ligaments, the small bowel mesentery, the sigmoid and transverse mesocolons, and the small and large bowel walls. Sizes varied from less than 1 cm to omental cake and bulky tumors. The findings include linear or tiny nodular infiltrations of the omentum and subperitoneal fat (ligamentous, mesenteric, and mesocolic), focal or segmental wall thickenings, loss of unilateral colonic haustration with sacculation on the contralateral side, and nodular soft tissue masses along different locations of the peritoneal surfaces. Air was introduced via an antegrade or retrograde method to act as a gastrointestinal contrast agent and was found to be useful for delineating the seedings. As is true with computed tomography scan, miliary implants are also not detectable with MRI. The sensitivity and specificity of MRI in detecting peritoneal implants remain to be determined.

Emergency department ultrasound in the evaluation of blunt abdominal trauma

The main objective of this study was to compare bedside sonographic detection of hemoperitoneum with diagnostic peritoneal lavage/laparotomy in the patient with blunt abdominal trauma. A retrospective review was conducted of all blunt trauma patients that underwent emergency department (bedside) sonography to rule out intraperitoneal hemorrhage at a level I trauma center in 1991 to 1992. Patients were included in the study population only if: (1) the results of the ultrasound examination were interpreted before any other diagnostic studies, and (2) a diagnostic peritoneal lavage (DPL) or laparotomy was performed. The ultrasound examination consisted of a single right inter/subcostal longitudinal view with the patient in the trendelenburg position performed by the emergency physician or surgeon. A real-time sector scanner with a 3.5 MHz probe was used. The presence of an anechoic (black) stripe between the liver and the right kidney (Morrison's pouch) was interpreted as a positive study, and the absence of this finding was interpreted as a negative study. A positive DPL was defined as > or = 10 mL of gross blood or a blood cell count > or = 100,000/mm3 in the returned lavage fluid, and a positive laparotomy as > or = 100 mL of intraperitoneal blood. Forty-four patients met the inclusion criteria for the study. Eleven patients (24%) in this population had either a positive DPL or laparotomy. The sensitivity, specificity, and accuracy of bedside sonography in identifying intraperitoneal hemorrhage was 81.8%, 93.9%, and 90.9%, respectively. The ultrasound study provided an answer in less than 1 minute in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal necrotizing enterocolitis: air in Morison pouch.

Six newborn infants with necrotizing enterocolitis (NEC) were noted to have air confined to Morison pouch as an early sign of pneumoperitoneum. Air in Morison pouch appears as a triangular lucency in the right upper quadrant. Extraluminal air in this location is easily mistaken for air within a loop of bowel if its characteristic appearance is not specifically sought. Review of the literature revealed no reported cases of NEC in which air in Morison pouch was mentioned. The authors' observation of six patients suggests that air in Morison pouch may be more common than previously recognized. Air in Morison pouch has the same significance as more obvious signs of pneumoperitoneum, and its detection is an indication for surgery.

Detectability of intraperitoneal fluid by ultrasonography. An experimental investigation.

The detectability of intraperitoneal fluid was investigated by ultrasonography following injection of physiologic saline in conjunction with hysterosalpingography in 40 patients. It was invariably possible to identify 10 to 15 ml fluid in the pouch of Douglas with the patient in supine position and in Morison's pouch after Trendelenburg and right decubitus position. Ultrasonography is superior to conventional radiography for detection of minor intraperitoneal fluid.

A CT evaluation of the intraperitoneal fluid distribution.

The intraperitoneal distribution of fluid and its detectability with a CT scanning were investigated in 13 patients during infusion of dialysate for peritoneal dialysis. An ascending pattern of spread i.e. from the lesser pelvis through the inframesocolic compartment to the supramesocolic compartment prevailed. Accumulation of fluid in the perihepatic space and in Morison's pouch as a function of fluid volume is at best approximated by a parabolic curve. Fifty to two hundred fifty ml. of fluid were detectable with a CT scanning in supine position in the majority of cases within the perihepatic space and Morison's pouch. The lowest amount of fluid detectable in the peritoneal cavity--25 ml. was found between the anterior abdominal wall and bowel loops in right decubitus.

The Morison pouch.

The Morison pouch has assumed eponymic importance in biliary surgery.1This is a review of the article in which he first described the hepatorenal space that has come to bear his name, with the intent of comparing current practice with that originally described. James Rutherford Morison was born at Hutton Henry, Durham, on October 10, 1853. He graduated from the university in Edinburgh in 1874, after which he became a house surgeon to Patrick Heron Watson at the Royal Victoria Infirmary at Newcastle-upon-Tyne. It was here that Morison met and came under the influence of the great Lister. Watson, Morison's chief, opposed Lister's antiseptic concepts, but this did not deter young Morison from spending his free time as a dresser on Lister's wards. After completing his tenure as house surgeon for Watson, Morison set up general practice in Hartlepool. He started his surgical activity at the Royal Victoria Infirmary

The spread and localization of acute intraperitoneal effusions.

Abstract Major routes of spread of intraperitoneal exudates and subsequent localizations of abscesses at sites remote from their source were determined primarily by peritoneography and selected clinical cases. Fluid ascends the right external paracolic gutter from the pelvic cavity to enter Morrison's pouch before progressing to the right subphrenic space. The phrenicocolic ligament restricts flow in either direction between the left paracolic gutter and perisplenic space. The mesenteric attachments themselves may serve as pathways for the spread of exudates. Extravasated pancreatic enzymes may pass down the length of the small-bowel mesentery to the ileocecal region.