Diogo Torres Marques, MD Luiz Tenório de Brito Siqueira, MD

IMAGING EVALUATION OF PERITONEAL DISEASE: OVERVIEW OF ANATOMY AND DIFFERENTIAL DIAGNOSIS
Diogo Torres Marques, MD Luiz Tenório de Brito Siqueira, MD Regis Otaviano Franca Bezerra, MD Marcos Roberto Menezes, MD Manoel de Souza Rocha, MD, PhD Giovanni Guido Cerri, MD, PhD Address correspondence to D.T.M., Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, Bela Vista, São Paulo-SP, Brazil (

Purpose To provide an overview of the anatomy, including its embryologic development, with emphasis on the anatomic structures and spaces that are most important for surgical decision making, and to review cases of primary and secondary peritoneal diseases and their differential diagnosis.

Table of Contents Introduction Anatomic terms
Development from embryonic to adult anatomy Adult anatomy Extra- and intraperitoneal structures Extra- and intraperitoneal spaces Peritoneal spaces, folds, and ligaments Ligaments and recesses of clinical and surgical importance Intraperitoneal flow of free fluid 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 “Hideouts” of malignant disease Locations in which complete surgical resection may be difficult Summary Acknowledgments and suggested readings

Introduction Diseases of the peritoneum are commonly seen in medical practice, especially at oncologic centers. They represent a challenge for general radiologists, with overlap in radiologic imaging appearances often leading to diagnostic mistakes. 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.

Anatomic Terms Douglas pouch = rectouterine pouch, cul-de-sac
Greater omentum = great omentum, gastrocolic omentum, epiploon Greater sac = peritoneal cavity proper Lesser sac or omental bursa = greater omentum + lesser omentum Lesser omentum = small omentum, gastrohepatic omentum Morison pouch = hepatorenal recess of the subhepatic space Retzius space = retropubic space

Development from Embryonic to Adult Anatomy

Adult Anatomy Abdominal structures can be divided into those that are surrounded by the peritoneal membrane (intraperitoneal) and those that are outside the peritoneal cavity (extraperitoneal). Parietal peritoneum is reflected over the peritoneal organs to form supporting ligaments, mesenteries, and omenta. The peritoneal reflections carry blood vessels, nerves, and lymphatics from the extraperitoneal space to the peritoneal organs. These reflections may act as natural connections between the extraperitoneal space and the peritoneal cavity, providing pathways for dissemination of intraabdominal disease.

Extraperitoneal Structures
Thoracic part of the esophagus Second and third portions of the duodenum (some authors also include the fourth portion) Head, neck, and body of the pancreas Aorta and inferior vena cava (IVC) Suprarenal (adrenal) glands, kidneys, ureters, and bladder Ascending and descending colon Lower third of the rectum Intraperitoneal Structures Abdominal part of the esophagus First portion of the duodenum Pancreatic tail (located within the splenorenal ligament) Transverse and sigmoid colon (surrounded by mesocolon)

Extra- and Intraperitoneal Spaces
∗ Kidneys Pancreas Aorta IVC Descending colon Psoas muscle Common iliac arteries ∗ Ascending Bladder ∗ Rectum Uterus 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.

Peritoneal Spaces, Folds, and Ligaments
Subdiaphragmatic space L Lesser omentum Subhepatic space S Transverse mesocolon Greater omentum / gastrocolic ligament T I I Small bowel mesentery I I I Rectouterine pouch Sagittal schematic (right) and corresponding contrast-enhanced CT image (left) of the abdominopelvic cavity show the surgically most important peritoneal spaces and ligaments. I = small bowel, L = liver, S = stomach, T = transverse colon. (Adapted and reprinted, with permission, from Kyriazi S, Kaye SB, deSouza NM, “Imaging ovarian cancer and peritoneal metastases: current and emerging techniques,” Nat Rev Clin Oncol 2010;7(7):381–393. doi: /nrclinonc )

Gastrohepatic ligament Gastrosplenic ligament Hepatoduodenal ligament Transverse mesocolon Small bowel mesentery Sigmoid mesocolon Coronal contrast-enhanced CT images show the major peritoneal ligaments in a patient with diffuse peritoneal carcinomatosis and a large amount of ascites.

Le O Axial T2-weighted magnetic resonance (MR) image obtained at the level of the upper abdomen shows the right triangular ligament (arrow), which separates the right subphrenic space from the Morison pouch (M). Axial T2-weighted MR image, obtained at a level inferior to that of the image at the left, depicts the right (Ri) and left (Le) subphrenic spaces, which are separated by the falciform ligament (white arrow). The lesser omentum (O) and right pararenal fascia (red arrow) also are seen.

Coronal (left) and axial (right) T2-weighted MR images show the splenorenal ligament (white arrow).

Le S L Sp Coronal T2-weighted MR image shows the right (Ri) and left (Le) subphrenic spaces and the paracolic gutters (black arrows). White arrow = lesser omentum. L = liver, S = stomach, Sp = spleen.

B ∗ a B ∗ b Coronal T2-weighted MR (left) and contrast-enhanced CT (right) images show the supravesical (arrow) and right and left paravesical (∗) spaces. B = bladder.

B V U ∗ Re B P Re ∗ Sagittal T2-weighted fast spin-echo MR image in a female patient shows the location of the rectouterine pouch (arrow) in relation to the supravesical space (∗), bladder (B), rectum (Re), uterus (U), and vagina (V). Sagittal contrast-enhanced CT image in a male patient depicts the location of the rectovesical pouch (arrow) relative to the supravesical space (∗), bladder (B), prostate (P), and rectum (Re).

Ligaments and Recesses of Clinical and Surgical Importance
Axial (left) and coronal (right) T2-weighted MR images show a thickened uterosacral ligament (arrow) delimiting the rectouterine pouch. The rectouterine pouch and uterosacral ligament are the sites most commonly involved in pelvic endometriosis and the main routes of spread of ovarian tumors. A = anterior, P = posterior, R = right.

Ligaments and Recesses of Clinical and Surgical Importance
B Re SV * Sagittal T2-weighted MR images show the deflection peritoneal line (dotted red line) in female (left) and male (right) patients. ∗ ∗ = Rectouterine pouch, ∗ = rectovesical pouch, B = bladder, R = rec-tum, SV = seminal vesicle, U = uterus, V = vagina. B V U Re ** The status of the deflection peritoneal line has fundamental importance for rectal cancer staging and treatment. When it is affected by tumors, the prognosis becomes significantly worse (stage T4 disease).

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). Next, the fluid ascends through the paracolic gutters (4). Its progress through the left paracolic gutter is slow because of the presence of the sigmoid colon and splenocolic ligament. Most of the flow is channeled through the right paracolic gutter and distributed in the right subphrenic (5), right subhepatic (6), and right subsplenic (7) spaces. Direct passage of fluid from the right to the left subphrenic space is prevented by the falciform ligament. 5 7 6 4 4 1 4 2 3 3

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. Because infected fluid does not enter the right subphrenic space until it has filled the Morison pouch, abscesses in the right subphrenic space often occur in association with abscesses in the Morison pouch. Fitz-Hugh and Curtis syndrome, which involves perihepatitis secondary to inflammatory pelvic disease, is one example of the many disease conditions that may result from the ascent of infected fluid through the abdomen. 5 7 6 4 4 1 4 2 3 3

Intraperitoneal Flow of Free Fluid (continued)
In cases of pancreatitis, fluid originating from the body and tail of the pancreas can enter the left retroperitoneal colonic compartment and left retromesenteric colonic plane, retrorenal and perirenal spaces, and lateroconal interfascial space posterior to the ascending and descending colon. It can also spread to the root of the transverse meso-colon and the splenorenal and phrenicocolic ligaments. From the transverse mesocolon and right retromesenteric colonic plane, fluid from the pancreatic head may spread into the right colonic com-partment at the hepatic flexure and dissect along the mesenteric vessels into the small bowel mesentery. *- Axial contrast-enhanced CT image obtained in a patient with acute pancreatitis shows stranding of peripancreatic fat (∗) and free fluid in both anterior pararenal spaces (white arrows) and between lamellae of the posterior pararenal fascia (red arrows).

Peritoneal Diseases The following primary and secondary peritoneal diseases are reviewed, with emphasis on surgical anatomy and differential diagnosis: 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

Peritoneal Carcinomatosis
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. In patients with ovarian tumors it is the most common form of dissemination, and its correct identification by the radiologist is crucial for disease staging, treatment, and follow-up. Neoplastic cells shed by ovarian tumors follow the pathways of normal hydrodynamic flow of intraabdominal ascites and tend to deposit in loci of fluid stasis, such as the rectouterine or rectovesical recess (50% of cases), lower small bowel mesentery (40% of cases), sigmoid mesocolon (20% of cases), and right paracolic gutter (20% of cases).

Peritoneal Carcinomatosis (continued)
Three possible pathways for the pathogenesis of peritoneal carcinomatosis are generally recognized: dissemination from a primary tumor (eg, colon cancer, pseudomyxoma peritonei) by means of the detachment of individual or clustered tumor cells from the primary mass and their infiltration into the peritoneal cavity primary tumor of the peritoneum (eg, peritoneal mesothelioma, serous papillary peritoneal adenocarcinoma, diffuse malignant mesothelioma related to inhalation of asbestos fibers) polyclonal multifocal origin states (ie, independent origin of a primary tumor and peritoneal implants), a condition observed in the presence of an ovarian tumor with low malignant potential or an extraovarian papillary serous carcinoma of the peritoneum

Peritoneal Carcinomatosis: Case 1
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).

Coronal contrast-enhanced CT images (left and center) show diffuse colon wall thickening due to serosal infiltration (red-shaded region) in a patient with an ovarian tumor. Axial contrast-en-hanced CT image (below) from the same study shows a large implant on the gastro-hepatic ligament (arrow).

Axial contrast-enhanced CT image (left) obtained after the administration of oral contrast material shows a gastro-intestinal stromal tumor in the small bowel (white arrow). Axial (center) and coronal (right) images from the same study show malignant peritoneal implants (red arrows) in the paracolic gutters.

Peritoneal Carcinomatosis:
Case 4 Contrast-enhanced CT images from a patient with a pancreatic tumor, peritoneal carcinomatosis, and history of Crohn disease. In A, peritoneal implants in the left paracolic gutter (white arrow) and mild wall thickening in the small bowel (red arrow) are seen. In B (images obtained at follow-up CT 1 month later), substantial worsening of small bowel wall thickening and associated inflammation of mesenteric fat (red arrow) are seen. However, the nodules in the left paracolic gutter are smaller (white arrow). The latter finding, along with the patient’s elevated sedimentation rate, led the radiology team to wonder whether the bowel wall thickening was due to a Crohn disease exacerbation instead of malignant infiltration. The reduced size of the nodules in the left paracolic gutter was indeed found to represent response to chemotherapy, and the bowel wall thickening, to be due to Crohn disease. A B

Complications of Peritoneal Carcinomatosis: Bowel Obstruction
D Axial (left) and coronal (right) contrast-enhanced CT images show peritoneal implants (arrows) in a patient who presented with a duodenal obstruction (D) after undergoing gastrectomy with a Roux-en-Y anastomosis for treatment of gastric cancer.

Complications of Peritoneal Carcinomatosis: Bile Duct Obstruction
Axial contrast-enhanced CT image obtained in a patient with gastric carcinoma and jaundice shows solid tissue infiltrating the hepatic hilum (arrow), with upstream dilatation of the biliary tree.

Complications of Peritoneal Carcinomatosis: Ureteral Obstruction
Coronal (left), sagittal (right), and axial (bottom) contrast-enhanced CT images obtained in a patient with peritoneal carcinomatosis due to metastases from breast cancer show a solid infiltrative lesion (red arrows) involving the right distal ureter, in which a double-J catheter (white arrows) is seen.

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.

Mesothelioma (continued)
Follow-up coronal (top) and axial (bottom) contrast-enhanced CT images obtained in the same patient after attempted surgical resection show persistent lesions in the hepatoduodenal (black arrow) and falciform (white arrow) liga-ments, although there is no evidence of remaining lesions in the right subdiaphragmatic space.

Sclerosing Encapsulated Peritonitis
A rare condition caused by chronic inflammation of the peritoneal membrane; also known as abdominal cocoon or chronic fibrous peritonitis Most frequent in patients undergoing continuous peritoneal dialysis; may also be idiopathic or associated with liver transplantation, ventriculoperitoneal shunt, tuberculosis, a foreign body, or, rarely, use of beta-blockers Peritoneal membrane becomes dense, opaque, thickened, and may be calcified; abdominal ascites is typical, and the small bowel may be encased by multiple loculated fluid collections

Sclerosing Encapsulated Peritonitis (cont’d)
Encapsulating peritonitis and peritoneal tuberculosis in a pa-tient who underwent peritoneal dialysis for 8 years for chronic renal disease and who reported evolving symptoms with wor-sening constipation over the preceding month. Abdominal radiograph (top left) and axial, coronal, sagittal, and three-dimensional contrast-enhanced CT images obtained with the use of oral contrast material show an opaque, thickened, and extensively calcified peritoneal membrane (white arrow).

Peritoneal Tuberculosis
May be seen in up to 38% of patients with pulmonary tuberculosis More common in patients with compromised immune status, Laënnec cirrhosis, or drug addiction CT features may be indistinguishable from those of peritoneal carcinomatosis, with multiple nodules involving the peritoneal membrane, omentum, and mesentery; nodules may converge to form masses Findings suggestive of the diagnosis: lymph nodes with hypoattenuating centers and hyperattenuating enhancing rims characteristic of caseous necrosis, thickening of the terminal ileum, hepatic and splenic microabscesses, and adrenal and lung involvement Adenosine deaminase (ADA) levels in serum and ascitic fluid, along with other laboratory test results, are useful for differential diagnosis; biopsy may be needed to verify the absence of malignancy and to confirm the diagnosis. Axial contrast-enhanced CT image (left) obtained after the administration of oral contrast material shows nodular thickening of the greater omentum (arrows) in a patient with a tubercle bacillus isolated in cerebrospinal fluid. Axial unenhanced CT image of the right lung (middle) in a patient with miliary tuberculosis shows centrilobular micronodules. Axial abdominal CT image (right) obtained in the same patient after the administration of intravenous contrast material shows an area of lymphadenopathy with a hypoattenuating center (red arrow) and splenic microabscesses (black arrow).

Polycystic Echinococcosis
Infectious disease caused by ingesting Echinococcus granulosus eggs Larvae penetrate the intestinal mucosa and enter the liver, where they form intrahepatic hydatid cysts Peritoneal involvement usually occurs because of iatrogenic or spontaneous rupture of the cysts Coronal (left) and axial (right) contrast-enhanced CT images obtained in a patient with polycystic echinococcosis show multiple peritoneal cystic implants (arrows).

Pseudomyxoma Peritonei
Results from intraperitoneal rupture of a mucinous cystadenocarcinoma or cystadenoma 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 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.

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).

Omental Infarction Infrequently causes acute abdominal pain
Its clinical manifestations resemble those of appendicitis, appendagitis, cholecystitis, or diverticulitis Its most common causes: torsion, venous insufficiency, and thrombosis Coronal (top row) and axial (bottom row) contrast- enhanced CT images obtained with oral contrast material show omental infarction in the acute phase (left column) and at follow-up imaging (center column), at which time it has decreased in size and has more defined margins.

Mesenteric Panniculitis
Nonspecific inflammatory condition of the peritoneum with an unknown etiology Most often recognized at CT May represent an acute phase of sclerosing mesenteritis Axial (center) and coronal (right) contrast-enhanced CT images obtained in an asymptomatic patient for monitoring of ureteral calculi show mesenteric fat stranding and an in-creased number of lymph nodes.

Sclerosing Mesenteritis
A rare peritoneal condition of unknown cause; considered to fall within the spectrum of mesenteric panniculitis May be associated with infection, trauma, autoimmune disease, ischemia, or previous surgery Commonly affects the mesentery, especially its root, and may involve the mesocolon In as many as 69% of cases, coexists with a malignancy, including lymphoma, melanoma, or cancer of the colon, breast, or lung CT appearances vary from blurring of mesenteric fat to a solid mass with soft-tissue attenuation Axial CT image series acquired sequentially (top left to bottom right) after the administration of oral contrast material demonstrates a retractable and irregular solid mass with soft-tissue attenuation and associated parenchymal calcifications affecting the mesentery root.

Inflammatory Infiltration of the Phrenicocolic Ligament
D E B Axial (A, B), coronal (C), and sagittal (D) unenhanced CT images and abdominal radiograph (E) obtained in a 78-year-old woman show a known cancer in the head of the pancreas (yellow arrow), with metastases to the liver and regional lymph nodes (T4N1M1). CT was performed without intravenous contrast material because of the patient’s poor condition. Her intractable abdominal pain and vomiting were thought to be due to colitis and colonic spasm secondary to splenic infarction (blue arrow). Note the “colon cutoff” sign, an abrupt discontinuity in the dilated and air-filled ascending and transverse colon at the splenic flexure (white arrow). Thickening of the phrenicocolic ligament (red arrow) is suggestive of inflammatory infiltration.

Peritoneal Calcification
Peritoneal calcification is not a common finding at CT and may be associated with a primary or secondary malignancy or have a benign cause. Its most common causes are dialysis, peritonitis, and ovarian cancer. When associated with calcified lymph nodes, it is likely to be indicative of malignancy. When it has a sheetlike appearance, it is most likely to be associated with a benign condition. Other important causes of peritoneal calcification: peritoneal tuberculosis, meconium peritonitis, hyperparathyroidism, Pneumocystis carinii infection, and postoperative heterotopic ossification.

“Hideouts” of Malignant Disease
Although the entire abdomen and pelvis are explored in patients who undergo staging laporotomy, certain sites are difficult for the surgeon to evaluate. It is important that the radiologist examine these locations carefully and inform the surgeon if they are compromised: Diaphragm Splenic hilum Stomach Lesser sac Liver Mesenteric root and paraaortic nodes above the renal vessels

Locations in Which Complete Surgical Resection May Be Difficult
Subphrenic space– hepatic dome See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Mesentery root See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Serosal surface of the intestine See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Porta hepatis See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Intersegmental fissure See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Gastrohepatic ligament See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Gastrosplenic ligament See Qayyum et al, “Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer,” Gynecologic Oncology, 2005;96:301–306.

Summary Peritoneal disease is common and may be difficult to diagnose.
CT and MR imaging substantially aid in its identification. The primary goal of radiologic imaging evaluation of peritoneal disease is to distinguish between benign and malignant disease. Radiologists must be familiar with the peritoneal anatomy in order to recognize and correctly characterize imaging findings of peritoneal disease. In the presence of peritoneal carcinomatosis, the radiologist’s precise localization and accurate description of all affected sites help the surgeon determine whether curative resection is possible and are likely to improve the prognosis.

Acknowledgments.—The authors thank Leandro Hideki Otani, MD, Frederico Ferreira de Souza, MD, and Cinthia Denise Ortega, MD, for contributing some of the images used in this presentation. Suggested Readings Agarwal A, Yeh BM, Breiman RS, Qayyum A, Coakley FV. Peritoneal Calcification: Causes and Distinguishing Features on CT. AJR Am J Roentgenol 2004;182:441–445. DeMeo JH, Fulcher AS, Austin RF. Anatomic CT demonstration of the peritoneal spaces, ligaments and mesenteries: normal and pathologic processes. RadioGraphics 1995;15:755–770. Frate CD, Girometti R, Pittino M, Frate GD, Bazzocchi M, Zuiani C. Deep Retroperitoneal Pelvic Endometriosis: MR Imaging Appearance with Laparoscopic Correlation. RadioGraphics 2006;26:1705–1718. Hamrick-Turner JE, Chiechi MV, Abbitt PL, Ros PR. Neoplastic and inflammatory processes of the peritoneum, omentum, and mesentery: diagnosis with CT. RadioGraphics 1992;12:1051–1068. Horton KM, Lawler LP, Fishman EK. CT Findings in Sclerosing Mesenteritis (Panniculitis): Spectrum of Disease. RadioGraphics 2003;23:1561–1567. Kusamura S, Baratti D, Zaffaron N, Villa R, Laterza B, Balestra MR, Deraco M. Pathophysiology and biology of peritoneal carcinomatosis. World J Gastrointest Oncol 2010;2(1):12–18. Kyriazi S, Kaye SB, deSouza NM. Imaging ovarian cancer and peritoneal metastases—current and emerging techniques. Nat Rev Clin Oncol 2010;7:381–393. Levy AD, Arnáiz J, Shaw JC, Sobin LH. Primary Peritoneal Tumors: Imaging Features with Pathologic Correlation. RadioGraphics 2008;28:583–607. Levy AD, Shaw JC, Sobin LH. Secondary Tumors and Tumorlike Lesions of the Peritoneal Cavity: Imaging Features with Pathologic Correlation. RadioGraphics 2009;29:347–373. Meyers MA. Dynamic radiology of the abdomen: normal and pathologic anatomy. Germany; Springer-Verlag, 2005. Pickhardt PJ, Bhalla S. Unusual Nonneoplastic Peritoneal and Subperitoneal Conditions: CT Findings. RadioGraphics 2005;25:719–730. Pickhardt PJ. The Colon Cutoff Sign. Radiology 2000;215:387–389. Qayyum A, Coakley FV, Westphalen AC, Hricak H, Okunoa WT, Powell B. Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer. Gynecol Oncol 2005;96:301–306. Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute Epiploic Appendagitis and Its Mimics. RadioGraphics 2005;25:1521–1534.

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