Morison's Pouch

Case: FAST RUQ Exam - Hemorrhage

Read more about Case: FAST RUQ Exam - Hemorrhage

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This video (part 2 of 2) focuses on positive findings found during right upper quadrant (RUQ) ultrasound examinations; it also includes instructions for performing the trauma FAST RUQ-hepatorenal ultrasound exams

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- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
In this module entitled,
Part Two of the Right Upper Quadrant View
of the Trauma Fast Exam,
we're going to focus entirely on positive findings
from this view.
Hopefully you've had a chance to join me prior
for Part One of the Right Upper Quadrant View
of the Trauma Fast Exam where we focused entirely
on normal findings from the right upper quadrant.
And hopefully have a chance to join me back
as we go through the left upper quadrant
and suprapubic views of the Trauma Fast Exam.
So let's begin this module by going through a
review of how to perform
the right upper quadrant view of the Trauma Fast Exam.
Remember that the probe is positioned in the
long axis configuration with the marker dot superiorally
and that we're going to place the probe in between the ribs
at about the anterior axillary line.
Here we'll want to focus on the three areas
as I emphasized in Part One of this module.
Number one, the infra-diaphragmatic space
looking at that region just below the diaphragm
and above the liver,
and actually looking into the chest cavity for a hemothorax.
Position two, which is the traditional Morison's Pouch
or hepatorenal interface.
And position three, to round out the exam
looking at the caudal liver tip representing the
beginning of the right paracolic gutter.
Here's a nice illustration showing a positive examination
from the right upper quadrant view of the Trauma Fast Exam.
We see the liver smack in the middle of the image
and the kidney slightly posterior and inferior to the liver.
Let's look at the preferential deposition of fluid
as shown here in the orange color,
and we see that it layers out predominantly around
the caudal tip of the liver as shown towards the
inferior edge of the image here.
Notice that it flows from the caudal tip of the liver
into that potential space which is Morison's Pouch
in between the liver and the kidney.
Now this is very important to emphasize as many times,
fresh fluid can only be seen around that
caudal tip of the liver,
and then it would move into that hepatorenal interface
or Morison's Pouch.
Here's a positive ultrasound examination from a patient
who was hit by a car while crossing the street
and we see here the liver
smack in the middle of the image here.
Notice the kidney located inferior and posterior
to the liver.
And in between the liver and the kidney in that
potential space known as Morison's Pouch,
we see a dark or anechoic fluid collection.
Not insignificant,
actually a pretty large stripe in this patient.
This represents the positive examination,
or the presence of fresh fluid,
in this case blood within Morison's Pouch.
And notice that it layers out in between
that liver and kidney.
To emphasize the point that a complete right upper quadrant
view includes looking at the caudal tip of the liver,
let's examine this video clip from another trauma patient.
If we look at the hepatorenal interface there,
we fail to see the presence of any fluid,
but as we move the probe inferiorially,
we see that the caudal tip of the liver as shown right there
is well outlined by fluid.
And here we see the inferior pole of the kidney,
the caudal tip of the liver extending above the kidney,
and notice all the fresh fluid
both anterior and posterior to the caudal tip of the liver.
Making the point that this is a very important area
to look for in the right upper quadrant exam.
Here's a video clip from a patient who was stabbed
with a really big knife to the epigastric region.
And as we look at the right upper quadrant,
we can actually see a linear liver laceration
extending through the medial aspect of the liver.
We also appreciate the presence of a large
amount of fresh fluid.
That dark or anechoic fluid collection
layering out posteriorally there to the liver
and extending into Morison's Pouch,
the hepatorenal interface.
So as this patent had unstable hemodynamics,
the next move was to package for the operating room.
And here we can actually see the caudal tip of the liver
waving around in all the fresh fluid,
in this case blood.
And I obtained this view by moving the probe
one intercostal space inferior from the last view
to well delineate the caudal tip of liver
which we can see here moving around in all the fresh fluid.
In the last few video clips the appearance of fresh fluid
on bedside sonography was darker, anechoic.
However as blood clots it can take on a more echogenic
or lighter appearance.
In this video clip a patient was stabbed
and had a significant down time before being
brought to the Emergency Department.
As we look at the hepatorenal interface,
we see a large amount of clotted blood there
made up by that echogenic
or lighter appearance of the blood there.
Notice that the large amount of blood extends into
the right paracolic gutter as we scan inferiorially.
And here we can see the liver,
the kidney,
and the clotted blood,
that more echogenic or lighter blood in Morison's Pouch.
So in conclusion,
I'm glad I could share with you this Part Two Module
on the Right Upper Quadrant View of the Trauma Fast Exam.
I hope now you have a better understanding
on how to perform a complete exam
looking into the three areas as we discussed.
Infradiaphragmatic,
Morison's Pouch,
and inferior tip of the liver.
And hopefully now you'll be able to discern
the presence of fresh blood versus clotted blood
on bedside sonography.
So I hope to see you back as Sono access continues
and as we move further through the other views of the
Trauma Fast Exam.

Brightcove ID

5508109915001

https://youtube.com/watch?v=Gj5IioG7SyM

Case: FAST RUQ Exam - Normal Exam

Read more about Case: FAST RUQ Exam - Normal Exam

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This video (part 1 of 2) details how performing the right upper quadrant (RUQ) ultrasound examination on trauma patients enables clinicians to potentially identify internal injuries.

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- Hello, my name is Phil Perera and I'm the emergency
ultrasound coordinator at the New York Presbyterian Hospital
in New York City, and welcome to SoundBytes Cases.
In this module we're going to focus entirely on
the trauma fast exam.
Specifically, we're going to look further into the
right upper quadrant view, also known as
the hepatorenal view.
Now, we're going to cover the two other views of
the trauma fast exam in upcoming modules of SoundBytes.
The left upper quadrant view, also known as
the splenorenal or perisplenic view,
and the suprarpubic view, also known as the bladder view.
There's a tremendous amount of information we can gain by
looking closely into the right upper quadrant area
in our trauma patient.
Traditionally it's been emphasized that the hepatorenal area
or Morison's pouch view, is the primary target for the
right upper quadrant, but it can take up to 600 ccs of fluid
to make a positive exam if only looking into that area.
So I'll show some alternative views in this module that can
help us to possibly improve on that number.
Now let's take a look at a slide showing us how to perform
the right upper quadrant view of the trauma fast exam.
We'll want to place the probe at about the anterior axillary
line and using the liver as an acoustic window aiming
the probe down towards the bedside retroperitoneally to get
a good view of these anatomical structures.
It's best to have a small footprint probe that can easily
sit between the ribs giving a good view on to this area.
Notice that this is a long axis view with a probe marker
position superiorly.
Now our first view from this right upper quadrant area
will be position one as shown here in the
infra-diaphragmatic space just below the diaphragm
and above the liver.
Second, we'll move the probe slightly inferiorly to look in
to the traditional Morison's pouch or hepatorenal interface,
and the last view is the caudal tip of the liver shown here
in position three.
It's very important to look at the caudal tip of the liver,
as this represents the beginning of the right paracolic
gutter and small amounts of fluid will pool here before
moving into Morison's pouch.
Now that we know how to perform the right upper quadrant
view of the trauma fast exam, let's take a look at a normal
image that you might obtain.
Remembering that this is a long axis view,
I have the probe marker here positioned towards
the patient's head.
So towards the left of the clip here is
superior chest cavity and towards the right is
inferior or abdominal cavity.
Notice the first large structure that comes into view
in the middle of the image is the liver and to the right,
or inferior to the liver we see the football shaped kidney.
Now it's that interface between the liver and kidney that
represents a potential space known as Morison's pouch
where we're be looking for dark, anechoic fluid collections.
Note here, we see a thin, white line making up a normal exam
and representing the fat within the capsule
around the kidney.
Notice to the left of the liver we see the white diaphragm
that represents the interface between chest
and abdominal cavities.
Let's take a look at another normal
right upper quadrant examination.
Again the probe marker is towards the patient's head.
This is the superior chest cavity towards the left.
Inferior abdominal cavity towards the right.
We see the liver in the middle of the image,
and notice the diaphragm above the liver moving up and down
as the patient breathes.
We see the kidney inferior to the liver, and notice
the potential space in between the liver and the kidney
that makes up the hepatorenal fossa or pouch of Morison.
Notice in this video clip all we see is a white line
representing the fat within the capsule around the kidney
or Gerota's capsule.
If there was fluid, we would see a dark or anechoic fluid
collection in this potential space.
Let's now look at the diaphragm which we see above the liver
and if we look above the diaphragm this is where we would
look for fluid within the chest cavity or hemothorax
in the trauma patient.
We may have to move the probe several intercostal spaces
on the patient's side to fully investigate
the right upper quadrant for fluid.
Here's a swing view where I'm starting relatively superior
right there looking in the area between the diaphragm
and the liver, going through Morison's pouch, as I'll show
coming up right here the area between the liver
and the kidney and terminating at the inferior
tip of the liver.
Notice here we notice the caudal tip of the liver extending
almost all the way inferiorly down past the inferior pole
of the kidney, and it's important to look at that caudal
tip of the liver, as it represents the beginning
of the right paracolic gutter.
So in conclusion, I'm glad I could share with you part one
of the right upper quadrant view of the trauma fast exam.
Now we know how to recognize a normal examination
looking all the way from the area below the diaphragm
through Morison's pouch and terminating at a view of
the caudal tip of the liver.
So I hope to see you back as SoundBytes continues,
and we look at part two of the right upper quadrant view
focusing on positive examinations.

Brightcove ID

5767048880001

https://youtube.com/watch?v=lzgxZsFZhTU

How to: FAST Exam: RUQ

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Learn to examine Morison's pouch in the right upper quadrant for fluid collections.

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- So the patient's gonna arrive in a supine position,
they'll often be on a backboard as full spinal precaution,
so motion of the patient will be impossible.
We're gonna choose our transducer.
We have chosen the phased array transducer,
we're gonna put a little gel on top of it.
And I like to put the probe marker
toward the patient's head, toward the axilla,
at about the midaxillaral line, 10 to 11th ribs.
Another easy tip to find out the location
is get to the costal margin,
go about three finger-breadths above it,
and you should be able to find the kidney
and see the adjacent liver.
I'm just adjusting my gain here.
And already I can see the interface
between the kidney and the liver, which is Morison's pouch.
So what we see here, on the bottom,
this crescent shaped organ, is the kidney.
Above it we see the liver,
and just to the left side of the screen
we see the diaphragm.
So when I'm examining this area,
I'm gonna carefully scan through
the entire area of Morison's pouch,
including at the liver tip.
So we see this whole area here
looking for an anechoic stripe.
An anechoic stripe would be indicative of free fluid.
I'm also identifying the diaphragm,
so when I look at the diaphragm,
this is the hypoechoic or white line
to the left side of the screen,
and I should be able to see that pretty easily
and you can see what appears to be
liver on both sides of the diaphragm,
on the bottom far left of the screen.
That is mirror artifact and is a normal finding.
If the patient had a pleural fluid collection after trauma
that would be a hemothorax,
we would see an anechoic or black area in this location.

Brightcove ID

5508114130001

https://youtube.com/watch?v=0VTRm_DNW8s

RUQ Liver/R Kidney1

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RUQ Liver/R Kidney

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Liver/Hepatic Veins Trv

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3D How To: eFAST RUQ

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3D animation demonstrating a Right Upper Quadrant (RUQ) view while performing the eFAST exam.

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- [Voiceover] A phased array transducer
with an abdomen exam type is used to perform
the right upper quadrant view of the FAST exam.
The orientation marker is directed
towards the patients head.
The transducer is placed in a long axis orientation
along the right mid-auxiliary line between
the 7th to 9th inter-costal space.
Rotation and oblique positioning of the transducer
will help eliminate rib shadows.
To evaluate the entire area of the hepatorenal recess
for free fluid sweep the transducer
from an anterior to posterior position.
If present, fluid will appear as a dark
or aniconic strip between the kidney and the liver.
If it is difficult to visualize the hepatorenal recess.
A deep inspiration will move the diaphragm
and other structures in this area
down and below the ribs for easier access.
Sliding the transducer upward will visualize
the diaphragm and plural interface.
Sliding the transducer downward will visualize
the inferior pole of the right kidney.

Brightcove ID

5508136019001

https://youtube.com/watch?v=wgCSZkCkkeI

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Case: FAST RUQ Exam - Hemorrhage

Case: FAST RUQ Exam - Hemorrhage

Case: FAST RUQ Exam - Normal Exam

Case: FAST RUQ Exam - Normal Exam

How to: FAST Exam: RUQ

How to: FAST Exam: RUQ

RUQ Liver/R Kidney1

RUQ Liver/R Kidney1

RUQ Liver/R Kidney

RUQ Liver/R Kidney

Liver/Hepatic Veins Trv

Liver/Hepatic Veins Trv

3D How To: eFAST RUQ

3D How To: eFAST RUQ

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