CASE 196:PSEUDOMYXOMA PERITONEI due to Appendiceal Mucinous Adenocarcinoma, Dr. Phan Thanh Hai, Dr. Le Tu Phuc, Dr. Le Thong Nhat, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 75 year-old man, without history of interested diseases or surgery, came to Medic Diagnosis Center because of progressive abdominal distention for years.

Abdominal ultrasound detected an amount of large volume, echogenic ascites looked like jelly in peritoneal space. But there were some differences in morphology of ascites between right and left side of abdomen. 

In the right lower quadrant, there were two rim-calcified cysts which were adjacent to cecum. One cyst was ruptured and from this ruptured hole, many echogenic bands radiated to jelly ascites like "sunrise" in appearance. The ascites was immobile.

                      
                     

While in the left abdomen, the fluid was mobile with many floating echogenic nodules. Ultrasound was also detected a membrane covering small bowel loops in the left side.

                      

MDCT showed massive ascites into peritoneum of  fat density. The ascites compressed the visceral liver surface, and the small bowel loop was pushed into the center of fluid cavity. There were two rim calcified cysts in the right lower quadrant, and one cyst had discontinuous wall. 

          

Blood test raised up of Beta 2 Microglobuline of 2,238 ( < 2000 Micro g/L ) and CEA of 7.83 (<5 ng/ml )

An open abdominal surgery was done at Binh Dan Hospital, removed about 5 liters of jelly-like substance. The surgeon detected a tumor of appendix adjacent to the cecum. He also reported about the membrane cover the bowel loops.
   
            

PATHOLOGY: Appendiceal Mucinous Adenocarcinoma

QUESTION: 
Why was the fluid in left abdominal side mobile but in the right one immobile?
How do we explain the membrane covering the small bower loops in the left abdominal side?