All right well in this video we're gonna discuss hemoperitoneum in the right
upper quadrant since this is the first window where we're discussing
hemoperitoneum before i show you what that looks like I want to discuss in
general what free fluid looks like an ultrasound as hemoperitoneum is a form
of free fluid and this will apply generally to ultrasound it is important
because there's lots of fluid within the body and just because you see fluid on
ultrasound doesn't mean it's pathologic in the concepts pretty simple if I have
a cup and I pour water into that cup then that water fills up the cup in the
fluid takes the shape of the container which it's in similarly in the body if I
have the bladder for example and I have a fluid filled bladder then that fluid
is going to take the shape of the bladder and notice how it's generally a
geometric shape with smooth borders in it's within the walls of that container
well free fluid is different if I have two cups for example sitting on a table
and I pour fluid in between the cups it's free it's not within the cups it's
going to go down to the most dependent areas that it can and it's not taking
the shape of the cup because it's in between the cups in fact its shape is
outlined by the cups well let's say I have the bladder and bow in the body and
I have fluid in between bladder and bowel so that fluid is free it's going
to outline the bow on one side and the bladder on the other and so you notice
that these shapes are more sharp they're not geometric they have sharp borders
and the fluid will go to the most dependent area in that theoretical space
so with that in mind then we can ask ourselves several questions when we're
trying to determine if this is free fluid the first is we just have to have
proper orientation meaning our transducer has to be oriented correctly
we have to know our anatomy and then know is this
Luud in a pathological place or as this fluid in a normal anatomic place the
second and third questions kind of go together
the second one is is there an echogenic wall that's surrounding the fluid that
would let us know that this is fluid within a cavity not free fluid and then
what shape does the fluid take is it smooth and geometric suggesting it's
within a cavity or is it have sharp borders and it's going to the dependent
areas of a theoretical space and then the last one is is is there movement of
the fluid and specifically looking for is there peristalsis
because if there's peristalsis and movement of the fluid that suggests that
this is within bowel and not free fluid all right well now on to looking for
hemoperitoneum in the right upper quadrant and just as a reminder we're
going to be scanning in the right flank approximately mid axillary line with the
indicator pointing superiorly or towards the right exile and we're going to see
diaphragm here are going to see liver here and we're going to see right kidney
here and we're going to be focusing on the interfaces between liver and
diaphragm in the subphrenic space in between the liver and right kidney and
Morrison's pouch and then at the inferior tip here where the right
pericolic gutter meets Morrison's pouch and this is a video clip of what normal
is just to remind us here's liver here's kidney we see diaphragm here and
this would be the subphrenic area that we're going to focus on and then we're
gonna focus on Morrison's pouch and where the right pericolic gutter meets
Morrison's pouch so that's normal now this is our first abnormal what's
different here well if we focus on the subphrenic area underneath the diaphragm
we see this hypoechoic fluid collection under the diaphragm
above the liver in the echo texture of the liver looks different
in this case the patient at a liver laceration with hemoperitoneum and the
right subphrenic space so this is a positive fast exam moving down to
Morrison's pouch in this patient we see liver right kidney and in Morrison's
pouch between those twos we see an anechoic fluid collection free fluid
collection between those organs so this is hemoperitoneum in Morrison's pouch
this is a positive fast in this example we're down to the pericolic gutter where
it meets Morrison's pouch at the inferior tip of the liver and we see
this anechoic fluid collection and as the patient is breathing in and out the
diaphragm is moving up and down in the liver is moving in and out of view here
so this is hemoperitoneum the inferior tip of the liver this is a positive fast
exam so now that we've seen video clips of this let's just review our anatomy
again diaphragm liver right kidney and Morrison's pouch right here has positive
free fluid hemoperitoneum this here is liver this here is the inferior pole of
the right kidney this here is bow you see it outlined
here and here we see fluid in the right pericolic gutter coming up to where it
meets Morrison's pouch now keep in mind there may not be that much fluid as seen
on the previous examples but we still should be able to detect this here's an
example where here is liver here's kidney in in between them we have
a small amount of free fluid but this is still a positive fast exam here we have
inferior portion of the liver the right kidney and where Morrison's pouch meets
the pericolic gutter we see a small amount of free fluid again this is still
a positive fast exam now those were all true positives
there are false positives in some pitfalls that you could fall into in the
right upper quadrant so I want to go over those on the top left here we see
the gallbladder you see an echogenic wall surrounding the gallbladder kind of
a pair like shape and there's fluid within it but as we talked about in the
beginning of the free fluid discussion this is within the container so it takes
the shape of the container and has echogenic walls surrounding it if you
aim to anteriorly in the right upper quadrant you'll begin to see the
gallbladder and this is not free fluid but fluid within the gallbladder the
middle example down here is a case of perinephric fat we have the right kidney
here we have the liver here and in between the two we see this small black
strip this is perinephric fat though it's usually not completely anechoic
although it can be it's usually more dark gray but you'll also notice that
there's a white line on both sides of it and this differs in appearance to what
we saw here here we have the lining of the kidney we see free fluid in
Morison's pouch but there's not another hypoechoic lining on the other side of
it and that's how you can tell the difference and perinephric fat tends to
be a small strip and then this last one is the case of fluid within bowel in the
right upper quadrant this could be the colon at the hepatic flexure and again
notice our principles of free fluid this is not free as it's within the bow and
you see the invaginations of the lining of the bowel and you'll see fluid within
it so here is the wall of the bow this is fluid within not free fluid
so that is hemoperitoneum and the right upper quadrant in the next video we will
discuss hemoperitoneum in the left upper quadrant