24-04: Right Upper Quadrant (Morison’s Pouch)

Jeremy S. Boyd; Myles Melton; Jordan D. Rupp; Robinson M. Ferre

Technique

With the indicator directed toward the patient’s head, the transducer is oriented in a coronal section through the body in the midaxillary line, extending from the 9th through 12th ribs. Start between the 11th and 12th ribs initially, then move cephalad or caudal, anterior or posterior, to complete the evaluation (Fig. 24.11).
Identify and evaluate the interface of the liver and right kidney. This region is the potential space known as Morison’s pouch. Normally, the liver and kidney are in direct contact with one another or separated by adipose tissue of heterogeneous echoes (Fig. 24.12).
Evaluate the right paracolic gutter by identifying and evaluating the caudal-most portion of the hepatic parenchyma (inferior tip of the liver).

FIGURE 24.11

Right Upper Quadrant View. The transducer is oriented in a coronal section through the body in the midaxillary line extending from the 9th through 12th ribs. (Photo contributor: Lawrence B. Stack, MD.)

A patient lies in the supine position. A practitioner holds the flat side of the transducer against the lower ribs on the right side of the chest below the armpit, to get a Right Upper Quadrant View.

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FIGURE 24.12

Normal Right Upper Quadrant View (Morison Pouch). Identify and evaluate the interface of the liver and right kidney. This region is the potential space known as the pouch of Morison. Normally, the liver and kidney are in direct contact with one another or separated by adipose tissue of heterogeneous echoes. The reflection of the anterior border of the lumbar spine is visualized deep to the kidney and terminates at the costophrenic angle in the absence of fluid within the thoracic cavity. (Ultrasound contributor: Jeremy S. Boyd, MD; illustration contributor: Robinson M. Ferre, MD.)

An ultrasound image of a Normal Right Upper Quadrant View of the Morison Pouch. The top and left are dark and the outline of the Morison Pouch is visualized at the center. A green dot is on the top left outside the image. An illustration depicts a Normal Right Upper Quadrant ultrasound of the Morison Pouch.

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Abnormal Findings

Hemoperitoneum: Anechoic (black) region between the liver and right kidney or in the paracolic gutter. Rarely is blood solely seen collecting between the diaphragm and the liver in the subdiaphragmatic space (Fig. 24.13).
Solid organ injury: Ultrasound is an insensitive exam for solid organ injury. Injuries such as hepatic and renal lacerations as well as organ rupture have been described but are not the goal of this examination.

FIGURE 24.13

Hemoperitoneum (Right Upper Quadrant view). An anechoic (black) region between the liver and right kidney is fluid (blood in this case) accumulating within the potential space. The diagram illustrates the typical locations of these peritoneal potential spaces, marked by asterisks. (Ultrasound contributor: Jeremy S. Boyd, MD; illustration contributor: Robinson M. Ferre, MD.)