However because of the position of the splenocolic

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However, because of the position of the splenocolic ligament and the shear- ing effect on the splenic hilum in blunt trauma, blood usually collects in the subdiaphragmatic space in the LUQ, and looking at the space between the spleen and the diaphragm is much more likely to yield results than the splenorenal recess. This is an important difference between the essential views of the RUQ and LUQ. Figure 2.1 Computed tomography view of Morison’s pouch ( red ). Courtesy of Dr. Lauren Post, Mount Sinai School of Medicine, New York, NY. Figure 2.2 Ultrasound view of Morison’s pouch. Diagnostic ultrasound 29 Focused assessment with sonography in trauma (FAST)
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The rectovesical pouch ( Figure 2.6A ) is the pocket formed by the reflection of the peritoneum from the rectum to the male bladder. It is the most dependent area of the supine male. The rectouterine pouch (pouch of Douglas) ( Figures 2.6B and 2.7 ) is the pocket formed by the reflection of the peritoneum from the rectum and the back wall of the uterus. It is the most dependent area of the supine female. Figure 2.8 shows movement patterns of free intraperitoneal fluid. In the supine patient, fluid in the RUQ will collect first in Morison’s pouch. Over- flow will travel down the right paracolic gutter into the pelvis. Free fluid in the LUQ will collect first between the spleen and the left hemidiaphragm. Fluid will then move into the splenorenal recess, toward the left paracolic Figure 2.3 Labeled view of Morison’s pouch. Figure 2.4 Computed tomography view of splenorenal recess ( red ). Courtesy of Dr. Lauren Post, Mount Sinai School of Medicine, New York, NY. 30 Diagnostic ultrasound Focused assessment with sonography in trauma (FAST)
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gutter into the pelvis. As mentioned, the phrenocolic ligament often shunts fluid to Morison’s pouch before filling the left paracolic gutter. Free fluid in the pelvis will first collect either in the rectovesical pouch or in the pouch of Douglas and then start to flow cephalad toward the paracolic gutters. Of course this depends largely on where the bleeding is coming from. If there is pelvic bleeding only, a large amount of accumulation is necessary Figure 2.5 Labeled view of a normal splenorenal recess. BULBO- CAVERNOSUS MUSCLE COWPER’S GLAND CORPUS CAVERNOSUM SYMPHYSIS BLADDER LEVATOR ANI AMPULLA OR RECTUM SEM VES PR PROCTATE CLITORIS SYMPHYSIS BLADDER RECTUM SM INT ANTERIOR FORNIX POSTERIOR FORNIX SIGMOID COLON L A B I U M M A J U S L A B I U M M I N U S EXT FOPHIN V A O I N A (A) (B) UTERUS URETHRA V A S D E F E R E N S Figure 2.6 ( A ) Male and ( B ) female pelvic anatomy. Images reproduced from Gray’s Anatomy, 1918 (image out of copyright). Diagnostic ultrasound 31 Focused assessment with sonography in trauma (FAST)
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before there is blood in Morison’s pouch, and the pelvic view will be positive much earlier. The converse would be true for bleeding originating from the RUQ.
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