Lymphatic Extravasation

Extraperitoneal extravasation of lymph often selectively involves the posterior pararenal compartment (Fig. 8207). Drainage laterally may coalesce into a flank lym-phocyst (Fig. 8-208).

At times, circumscribed solid masses of extraperito-neal lymph node origin can be identified clearly as localized to the posterior pararenal space. Figure 8-209 illustrates this in an instance of reticulum cell sarcoma.

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Cells Hemophiliac

Fig. 8-191. Posterior pararenal hemorrhage in a hemophiliac.

(a) Intravenous urogram. The axis of the extraperitoneal density on the right is oriented inferolaterally. The psoas shadow is obliterated and the flank stripe obscured. The collection displaces the kidney laterally and superiorly. The obstructive nephrogram is outlined further by intact perirenal fat (arrowheads).

(b) Right lateral projection. The posterior collection displaces the kidney anteriorly. (Reproduced from Meyers et al. )

Fig. 8-191. Posterior pararenal hemorrhage in a hemophiliac.

(a) Intravenous urogram. The axis of the extraperitoneal density on the right is oriented inferolaterally. The psoas shadow is obliterated and the flank stripe obscured. The collection displaces the kidney laterally and superiorly. The obstructive nephrogram is outlined further by intact perirenal fat (arrowheads).

(b) Right lateral projection. The posterior collection displaces the kidney anteriorly. (Reproduced from Meyers et al. )

Fig. 8-192. Posterior parar-enal hemorrhage secondary to overanticoagulation.

The partially obstructed kidney on the right is displaced superiorly and laterally by the collection of blood that extends in an inferolateral axis. The hemorrhage obscures the psoas muscle margin but has not yet extended into the flank fat. The perirenal fat is not involved.

Perirenal Pararenal FatIntravenous Urogram Renal Cell Carcinoma

Fig. 8-193. Chronic bilateral hematomas in the posterior pararenal spaces in an adult hemophiliac.

(a and b) Intravenous urography demonstrates a calcified mass on the right and a soft-tissue density on the left. The lower segments of the psoas muscles are obliterated. The larger blood collection on the left displaces the lower pole of the kidney superiorly and laterally and the ureter medially and anteriorly.

Fig. 8-193. Chronic bilateral hematomas in the posterior pararenal spaces in an adult hemophiliac.

(a and b) Intravenous urography demonstrates a calcified mass on the right and a soft-tissue density on the left. The lower segments of the psoas muscles are obliterated. The larger blood collection on the left displaces the lower pole of the kidney superiorly and laterally and the ureter medially and anteriorly.

Pararenal Aneurysm

Fig. 8-194. Posterior pararenal hemorrhage from ruptured aneurysm of the abdominal aorta.

Plain film demonstrates streaky radiolucent lines on the left in an area of an ill-defined mass that also causes loss of visualization of the psoas muscle border. These changes are secondary to blood dissecting, often in sheets, through the posterior pararenal fat.

Visualized Aorta Demonstrates MildDissecting Abdominal Aortic Aneurysm

Fig. 8-195. Posterior pararenal hemorrhage from ruptured abdominal aortic aneurysm.

Intravenous urogram demonstrates streaky radiolucent lines in an ill-defined extraperitoneal soft-tissue mass that obscures the psoas muscle margin and displaces the kidney laterally.

Psoas Margins

Fig. 8—196. Posterior pararenal hemorrhage from leaking aneurysm of the abdominal aorta.

(a) CT scan after intravenous contrast medium demonstrates a large aneurysm of the abdominal aorta containing thrombus (T) surrounding its residual opacified lumen (Lu). Hemorrhage (H) has extended from a site of rupture into the adjacent tissues on the left.

(b) At a higher level, the hemorrhage has risen into the posterior pararenal space (PPS), displacing the kidney anteriorly and laterally.

Fig. 8—196. Posterior pararenal hemorrhage from leaking aneurysm of the abdominal aorta.

(a) CT scan after intravenous contrast medium demonstrates a large aneurysm of the abdominal aorta containing thrombus (T) surrounding its residual opacified lumen (Lu). Hemorrhage (H) has extended from a site of rupture into the adjacent tissues on the left.

(b) At a higher level, the hemorrhage has risen into the posterior pararenal space (PPS), displacing the kidney anteriorly and laterally.

Fig. 8—197. Posterior pararenal hemorrhage from ruptured abdominal aortic aneurysm.

From the site of extravasation from the infrarenal aorta, the hemorrhage has risen toward the left diaphragm within the posterior pararenal space (PPS).

Posterior Pararenal Space

Fig. 8—198. Posterior pararenal hemorrhage from bleeding complication of femoral catheterization.

Postcatheterization bleeding on the right has risen from the pelvis to the diaphragm within the posterior pararenal space (PPS). Some perirenal blood tracks along upper bridging septa.

Fig. 8-199. Posterior pararenal abscess secondary to spinal osteomyelitis.

Staphylococcal osteomyelitis involves the left transverse process of L5 (arrow). Infection in the posterior pararenal space is revealed by the characteristic displacement of the lower pole of the left kidney upward and outward. Loss of visualization of the psoas margin may be due to the abscess as well, or it may be a consequence only of the scoliosis present.

Regional Enteritis Definition

Fig. 8-200. Posterior pararenal abscess following bowel resection for regional enteritis.

(a) The density on the right is directed inferiorly and laterally, obscures the psoas margin, and displaces the lower pole of the kidney upward and outward.

(b) Right lateral view confirms the extreme posterior position of the abscess, which displaces the kidney and ureter forward.

Fig. 8-200. Posterior pararenal abscess following bowel resection for regional enteritis.

(a) The density on the right is directed inferiorly and laterally, obscures the psoas margin, and displaces the lower pole of the kidney upward and outward.

(b) Right lateral view confirms the extreme posterior position of the abscess, which displaces the kidney and ureter forward.

Fig. 8-201. Posterior pararenal infection postnephrectomy.

Following left nephrectomy for renal cell carcinoma, hematoma infected with gas-producing organisms occupies the renal bed and progresses across the posterior pararenal space to involve the flank and abdominal wall. (Courtesy of Gary Ghahremani, M.D., Evanston Hospital, Evanston, IL.)

Posterior Abdominal WallGary Ghahremani

Fig. 8-202. Posterior pararenal abscess secondary to sigmoid colon perforation.

This patient received pelvic irradiation for carcinoma of the cervix. Sigmoid perforation results in an extensive gas and fluid collection throughout the posterior pararenal space on the left, displacing the obstructed kidney and descending colon medially.

(Courtesy ofJay P. Heiken, M.D., Mallinckrodt Institute of Radiology, St. Louis, MO.)

Diverticulitis The Sigmoid Colon

Fig. 8—203. Posterior pararenal abscess secondary to diverticulitis of the sigmoid colon.

In this 72-year-old man, contrast- and gas-containing infection can be traced in continuity throughout the posterior pararenal space.

(a) Diverticular abscess (arrows) of the descending colon-sigmoid colon junction has penetrated into the posterior pararenal space.

(b) Scan at the level of the kidneys shows superior continuation of the abscess (A) within the posterior pararenal space. The abscess is displacing the left perirenal space anteriorly.

(c) The posterior pararenal abscess (A) continues superiorly to reach the diaphragm.

(Reprinted with permission from Gore RM, Meyers MA: Pathways of abdominal and pelvic disease spread. In Textbook of Gastrointestinal Radiology. Edited by RM Gore, MS Levine, I Laufer. WB Saunders, Philadelphia, 1993.)

Gore Textbook Radiology

Fig. 8-204. Perforated retrocecal extraperitoneal appendicitis.

(a and b) Gas has risen into the posterior pararenal space on the right.

(Courtesy of Emil Balthazar, M.D., Bellevue Hospital, New York University School of Medicine, New York, NY.)

Fig. 8-204. Perforated retrocecal extraperitoneal appendicitis.

(a and b) Gas has risen into the posterior pararenal space on the right.

(Courtesy of Emil Balthazar, M.D., Bellevue Hospital, New York University School of Medicine, New York, NY.)

Treatment Perforated Appendix Pathway

Fig. 8—205. Posterior pararenal abscess secondary to extraperitoneal appendicitis.

(a and b) Erect AP urogram and lateral plain film in a child demonstrate an air-fluid level in an abscess (arrows) behind and a little lateral to the right kidney.

(c and d) Frontal and lateral views of barium enema study demonstrate an undescended subhepatic cecum from which arises an ascending appendix (curved arrows). In this situation, the appendix is extraperitoneal in location, and its perforation can then lead to infection in unusual sites.

Fig. 8—205. Posterior pararenal abscess secondary to extraperitoneal appendicitis.

(a and b) Erect AP urogram and lateral plain film in a child demonstrate an air-fluid level in an abscess (arrows) behind and a little lateral to the right kidney.

(c and d) Frontal and lateral views of barium enema study demonstrate an undescended subhepatic cecum from which arises an ascending appendix (curved arrows). In this situation, the appendix is extraperitoneal in location, and its perforation can then lead to infection in unusual sites.

Fig. 8-206. Posterior pararenal abscess secondary to an infected abdominal aortic graft.

The gas-producing infection extends from the paraaortic tissues on the right predominantly to the posterior pararenal space adjacent to the psoas muscle.

Pararenal CystsLymphatic Drainage Liver

Fig. 8-207. Posterior pararenal lymphocyst after sympathectomy.

A mass density on the right displaces the lower pole of the kidney superiorly and laterally and obscures the psoas margin.

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Responses

  • kieran
    What is a contrast extravasation in the leftward subheptaic space?
    6 months ago

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