Abdominal Sonography CTL: Pathology 42% Pt 3

Acute cholecystitis us associated with GB wall thickening greater than _____ mm. Cholangitis is associated with ductal wall thickening greater than _____ mm.

>3mm >2mm

What is a granuloma?

A calcification within splenic or liver tissue that forms after na infection (such as toxoplasmosis)

What is a chondroma?

A cartilaginous tumor

A biloma is:

A collection of bile in the peritoneal cavity It is associated with trauma and invasive procedures to the biliary tree

What is a cystic lymphangioma?

A congenital benign splenic tumor that is composed of lymphatic tissues/vessels

A choledochal cyst is:

A focal dilation of the biliary tree

Which of the following will cause a significant increase in AFP in an adult?

HCC The actual question says "moderate increase" but that is not accurate.

How does a porcelain GB appear on US?

The GB will display varying levels of calcification WES

A new liver mass in a pt with sclerosing cholangitis should cause suspicion of:

The development of cholangiocarcinoma Primary sclerosing cholangitis is the #1 risk factor for the development of cholangiocarcinoma.

What is infarction?

The obstruction of blood supply to an organ or region of tissue, often resulting in death of the tissue.

Does fatty infiltration cause jaundice?

No

Does a Courvoisier GB cause wall thickening?

No Courvoiser GB refers to an overdistended, non-tender GB without wall thickening (hydrops) commonly caused by Ampulla of Vater obstruction.

Do GB polyps shadow?*

No*

Does hepatoblastoma cause an increase in AFP levels?

No, even though it is malignant.

What is the most common type of lymphoma seen in the spleen?

Non-Hodgkin's (?) (contradiction between answer and explanation. Answer said Hodgkin's, explanation said non-Hodgkin's.)

A patient presents for a follow up US due to Budd Chiari syndrome. What is an expected finding on the exam?

Obstruction of the hepatic veins (which could lead to thrombus due to thickening of the HV walls, as well as hepatic congestion)

What are some potential malignant features of a pancreatic cyst?

>3cm Increases in size Internal nodule Thickened septations

Ascites is treated by _____, while pleural effusion is treated by _____.

Ascites = paracentesis PE = thoracentesis

Choedochal cysts are more common in which ethnic population?

Asians

1. What is Sjogren syndrome? 2. What is Sjogren syndrome associated with? 3. What are the symptoms of Sjogren syndrome? 4. Which glands does Sjogren syndrome usually affect?

1. An immune disorder that causes a reduction in saliva and tear production. 2. Rheumatoid arthritis 3. Dry eyes/mouth and swelling of the salivary glands 4. Parotid and submandibular

Patients with cirrhosis have a significantly increased risk of developing: (5 things)

1. Cavernous transformation 2. Dilated coronary/umbilical veins due to portal HTN 3. HCC 4. Ascites 5. Portal thrombosis

1. What is acalculous cholecystitis? 2. Is it more common in men or women? 3. What patients is it usually seen in? 4. What causes it? URR QUESTION: Acalculous cholecystitis is commonly associated with all of the following, except: Mirizii syndrome HIV infection Trauma patients Total parenteral nutrition

1. GB wall thickening (cholecystitis) without the presence of stones (acalculus) 2. Acalculus cholecystitis is more common in men 3. Chronically ill patients AIDS Post-surgery or trauma Sepsis Chronic total parenteral nutrition 4. Bile stasis (i.e. viscous bile) Decreased gb contraction Abnormal fluid levels in the body (i.e. CHF) Infection (i.e. hepatitis, HIV) URR ANSWER: Mirizii syndrom - this is a type of calculous cystitis and occurs due to a stone in the cystic duct, causing compression of the CHD.

What are the three characteristics of Courvoisier's sign?

1. Painless jaundice 2. Distended GB 3. Obstruction at the Ampulla of Vater

What is the maximum portal vein diameter?

13mm

Massive splenomegaly is defined as a spleen that exceeds _____ in length.

18cm

What percentage of HCC cases demonstrate elevated AFP?

70%

What percentage of patients with HCC have preexisting cirrhosis?

80%

In cases of moderate to severe medical renal disease, the renal parenchyma will be:

Atrophied to <10mm thickness

What is prothrombin time (PT)?

A lab test that is measured to detect levels of clotting factors in the blood. There are 12 different clotting factors needed to clot blood, and the liver produces one factor. The liver converts prothrombin to thrombin using vitamin K. Increasing vitamin K will decrease PT, which means it will take a shorter time to produce a clot (i.e. lower/shorter prothrombin time)

What is a urinoma?

A pocket of urine outside the urinary system. It is usually related to renal or bladder surgery.

Describe the sonographic appearance of a pseudocyst.

A pseudocyst can present with cared appearances on US. They usually have fairly well-defined borders. They can be anechoic or demonstrate internal echoes and septations.

What is a splenic hamartoma?

A rare, benign vascular proliferation that is often found incidentally

What is polycthemia vera?

A slow-growing blood cancer in which your bone marrow makes too many red blood cells. These excess cells thicken your blood, slowing its flow. They also cause complications, such as blood clots, which can lead to a heart attack or stroke. https://www.mayoclinic.org/diseases-conditions/polycythemia-vera/symptoms-causes/syc-20355850

What is hyper plastic cholecystosis?

A spectrum of degenerative and proliferative changed in the GB that includes adenomyomatosis and cholesterolosis.

What is the most causee of acute cholecystitis?

A stone lodged in the cystic duct or GB neck

Where is AFP produced and what causes elevated AFP in adults?

AFP is produced by the fetal liver and yolk sac, and the amount decreases after 1yo Trace amounts of AFP in adults is normal AFP in adults increases with primary liver cancers, liver metastasis, hepatitis, and non-seminomatous testicular cancers. It also increases with pregnancy. The most significant increase in AFP occurs with hepatocellular carcinoma.

All of the following lab values will be increased with cirrhosis, except: ALT Bilirubin AST Alkaline phosphatase AFP

AFP. This would rise if the patient developed HCC with the cirrhosis.

ARPKD vs ADPKD 1. Unilateral or Bilateral? 2. Cyst size/location? 3. How does it affect the patient/the kidneys?

ARPKD (recessive): 1. Bilateral 2. Multiple tiny cysts replace the functional tissue of the kidneys 3. Occurs in utero/shortly after birth and is always fatal due to lack of functioning renal tissue (i.e. no adult will have ARPKD. Only fetuses/newborn babies because they it is always fatal early on in life.) ADPKD (dominant): 1. Bilateral 2. Multiple cortical cysts that grow in size and number with age 3. Can lead to a decrease in renal function over time that could cause renal failure later in life.

A pt presents with increasing RUQ pain and vomiting after a recent liver biopsy. An irregular mass with internal debris and an overall heterogeneous appearance is noted in the right lobe. The mass also demonstrated several echogenic foci with bringdown artifact. What is the most likely diagnosis of this finding?

Abscess The echogenic foci are related to air produced by microorganisms causing the infection.

The most common cause of acute renal failure is: The most common cause of chronic renal failure is:

Acute = acute tubular necrosis Chronic = diabetes mellitus

Increased amylase and lipase is associated with which pancreatic condition?

Acute pancreatitis

A 56yo male presents with a sudden onset of epigastric pain that has persisted for ~2days. Lab tests show elevated bilirubin, amylase, and lipase. Multiple mobile echogenic foci are present in the GB wall with a thickness of 2.4mm. The CBD measures 6mm and appears patent. The pancreas is mildly enlarged with posterior enhancement. What are the findings?

Acute pancreatitis and cholelithiasis Increased amylase and lipase are associated with acute pancreatitis. Acute pancreatitis demonstrates inflammation and fluid within the pancreatic tissues, which causes posterior enhancement. The increase in bilirubin is likely due to the cholelithiasis.

What usually affects the pancreatic head? (Select 2) Adenocarcinoma Cystadenoma Psuedocyst Focal pancreatitis Islet cell tumors

Adenocarcinoma and focal pancreatitis These two things usually occur in the pancreatic head and cause biliary ductal dilation and Courvoisier GB.

Which of the following will not cause an increase in LFT values? Adenoma Hepatocellular carcinoma Pyogenic abscess Fatty liver Hepatoblastoma

Adenoma Liver adenomas usually have no effect on LFTs

Oral contraceptive pills have been associated with the formation of: Oral contraception is also a risk factor for what liver syndrome?

Adenoma within liver tissue Budd Chiari syndrome (i.e. obstructed hepatic veins)

An asymptomatic pt presents with elevated LFTs. The gB demonstrates thickened walls with irregular internal contour. Several small echogenic foci are noted within the wall and each exhibits comet tail artifact. What is this?

Adenomyomatosis

Which biliary condition is associated with Rokitansky-Aschoff sinuses?

Adenomyomatosis Rokitansky-Aschoff sinuses are caused by herniation of the GB wall layers, which forms a pocket or sinus. The sinuses may fill with bile or cholesterol deposits (i.e. adenomyomatosis).

What is an intratesticular mass associated with Cushing syndrome and adrenal hyperplasia?

Adrenal Rests Hypoechoic, multifocal masses with wheel spoke vascularity

Which of the following will cause elevated LFTs? Hepatocellular Carcinoma Pyogenic abscess Fatty liver Hepatitis

All of the above

Which of the following will lead to an increase in direct bilirubin in the blood? CBD obstruction Hepatitis Mass in the duodenum All of the above

All of the above (due to biliary obstruction)

Which of the following biliary abnormalities will cause an increase in prothrombin time (PT)? Acute cholecystitis Primary GB carcinoma 3cm pancreatic head mass Sarcoma of GB All of the above What will cause an increase in PT? What will cause a decrease in PT?

All of the above due to biliary obstruction Increase in PT: Metastasis Liver disease Coagulant therapy (i.e. Coumadin or Warfarin) Prolonged biliary obstruction Biliary carcinoma Decrease in PT: Dehydration

Which lab values will increase with mutinous cystuadenocarcinoma of the pancreas?

Amylase Lipase Alkaline phos. Carcinoembryonic antigen (CEA) AFP will NOT increase.

What is Budd Chiari syndrome?

An obstruction of the Hepatic Veins

How does a renal oncocytoma present sonographically?

An oncocytoma has varied echogenicity with a central scar related to necrosis.

An asymptomatic patient presents for a renal US doe size evaluation due to chronic systemic HTN. The RK demonstrates a 1cm rounded hyper echoic mass within the renal cortex. What are the findings?

Angiomyolipoma or lipoma Both of these tumors would appear hyperechoic to the cortex. An oncocytoma has varied echogenicity with a central scar related to necrosis.

Which renal condition is always fatal? Unilateral Renal Agenesis ARPKD Horseshoe Kidney ADPKD

Autosomal Recessive Polycystic Kidney Disease (ARPKD) Unilateral agenesis is only fatal if the remaining kidney is defective Horeshoe kidney usually functions normally ADPKD can be fatal later in life, depending on the cyst formation and how it effects renal function. ARPKD is always fatal, as the kidney tissue is completely replaced by microscopic cysts that render the kidneys non-functional in utero and at birth.

What is an autosplenectomy and what is it a common complication of?

Autosplenectomy: a process that occurs when a disease damages the spleen to such an extend that it becomes shrunken and non-functional This is often the result of sickle cell anemia With sickle cell anemia, multiple infarcts usually result in a small, fibrotic spleen with complete loss of function. This process is called an autosplenectomy.

Are hemangioma benign or malignant?

Benign

Describe the vascularity of benign vs malignant masses.

Benign: peripheral vascularity because the mass is displacing normal tissue Malignant: internal vascularity due to increased flow in the area due to the high growth rate of the tumor

A ot presents for a 6 month follow up for a liver transplant. Lab tests indicate normal LFTs, increased bilirubin, and jaundice. The US shows a new focal dilation of the bile duct at the portal hepatics with mildly dilated intrahepatic ducts just inside the liver. The pancreas is normal. What most likely describes the findings?

Biliary stricture. This is a common complication of liver transplant.

What are complications of liver transplants?

Biloma - collection of bile outside biliary system, usually related to liver trauma or surgery Seroma - pocket of serous fluid that can form anywhere in the body and is usually related to surgery or trauma Abscess - possible complication of any kind of trauma or surgery Hematoma - possible complication of any kind of trauma or surgery

Where do insulinomas usually occur? How do insulinomas affect the amount on insulin in the blood stream? Are patients with insulinomas are usually hyper or hypoglycemic? What age patients do insulinomas usually appear?

Body and tail of pancreas They cause an increase of insulin in the blood stream (i.e. hyperinsulinemia). This results in decreased glucose levels in the blood (i.e. hypoglycemia or low blood sugar) Hypoglycemic (due to decreased increased insulin in blood stream) 40-60yo

What is the US finding for cross-fused renal ectopia?

Both kidneys are located on the same side of the body and are fused together at varied locations

What is the most significant complication of a hernia?

Bowel strangulation If the bowel becomes strangulated, infarction can occur.

Causes of dilation of the intrahepatic biliary tree without dilation of the extra hepatic biliary tree includes all of the following, except: Liver mass in porta hepatis Klatskin's tumor Cholangiocarcinoma Brenner's Tumor

Brenner's tumor (this is a tumor of the ovaries, not the liver/biliary tree) Any mass within the liver/at the portal hepatics can lead to intrahepatic dilation with a normal CBD.

What is within the anterior perarenal space?

CBD Portions of the duodenum Pancreas Ascending colon Descending colon

The double duct sign refers to the dilation of _____ and _____, and it is associated with:

CBD and Pancreatic duct (i.e. Wirsung) The double duct sign is associated with pancreatic adenocarcinoma, as a mass in the pancreatic head can obstruct both the CBD and pancreatic duct simultaneously.

Enlarged gallbladder with intra-hepatic ductal dilation indicate:

Extra-hepatic obstruction (e.g. mass at ampulla of Vater)

In a cirrhotic patient, the _____ lobe of the liver can enlarge to nearly half to size of the rt lobe.

Caudate enlarges as the right and left lobes shut down due to cirrhosis. A caudate to right lobe ration > 0.65 is said to be cirrhotic atrophy. The caudate lobe is drained by the emissary veins, which drain into the IVC.

Inflammation of the biliary tree common in HIV patients is called:

Cholangitis is a common complication of the HIV infection

A 6mo asian female presents with jaundice and fever. While scanning the liver, you notice a 1cm anechoic, round structure attached to the CBD at the portal hepatics. Color Doppler does not demonstrate flow within the structure. What is the likely dx?

Choledochal cyst Choledochal cysts are congenital defects of the biliary tree than are more common in the Asian population. US usually demonstrates a focal dilation of the biliary tree near the port hepatics. The dilation can be cystic or fusiform. If the cyst causes ductal obstruction, then pain, jaundice, and fever can develop.

Which of the following is the least likely cause of shadowing from the area of the GB fossa? Valves of Heister Gas in diodenum Pneumobilia Choledochal cyst

Choledochal cyst Cystic structures exhibit enhancement not shadowing. Gas containing structures cause scatter of the sound leading to dirty shadowing. The valves of Heister are spiral shaped muscular ridges that control the bile in and out of the gallbladder. Due to their dense structure, they can cause shadowing at the gallbladder fossa.

While scanning the GB, you notice several echogenic foci within the mildly thickened walk that do not demonstrate bringdown artifact. What is this?

Cholesterolosis = a polyp without ringdown Adenomyomatosis = a polyp with ringdown

You are scanning through the liver and note the caudate lobe is nearly the same size as the right lobe. The surface of the liver appears lobulated/nodular. What is the likely dx? Cirrhosis Focal Nodular Hyperplasia Hepaticellular Carcinoma Hepatitis

Cirrhosis The caudate lobe enlarges as the rt and lt lobes shut down due to cirrhosis bc the caudate is drained by the emissary veins

What commonly causes recantilization of the vessel located within the left intersegmental fissure?

Cirrhosis (due to portal HTN and the resultant flow reversal of the portal vein and the congestion in the portal tributaries)

Compensatory enlargement of the caudate lobe occurs with which conditions?

Cirrhosis and Budd Chiarri syndrome

A 43yo female with a hx of hepatitis C presents with jaundice, increased abdominal girth, and pain. The most probable US finding in the liver will be:

Cirrhosis and ascites The jaundice indicates chronic liver malfunction HepC is associated with liver dysfunction and cirrhosis Chronically decreased liver function usually leads to ascites formation in the abdomen

Cholesterol polyps in the GB will cause what artifact?

Comet tail/ring down Cholesterol polyp = adenomyomatosis

An abdominal US is ordered for a pt with bilateral pedal edema. The abdomen demonstrates mild ascites but otherwise normal organs. The IVC appears prominent with a consistent dis of 2.8ch. A continuous venous waveform is demonstrated on Doppler. Which of the following is the most likely cause for the US findings? Malignant HTN Portal HTN Congestive Heart Failure All of the above

Congestive Heart Failure CHF indicates poor cardiac function. Blood flow returns to the heart from the lower extremities via the IVC. If the heard is not ejected enough blood during systole, the venous return will backlog into the IVC. The IVC should normal collapse with respiration and demonstrate a triphasic, pulsatile waveform on Doppler.

A 64yo pt presents with painless jaundice. The GB is over-distended with an obstruction at the ampulla of Vater. What is this condition called?

Courvoisier's sign

A pateint presents for a US to evaluate a potential cystuadenocarcinoma of the pancreatic head that was identifies on a recent CT. The US demonstrates a complex mass in the pancreatic head. Also demonstrated is a 12cm gallbladder with no stones or wall thickening. The CBD is measuring 10mm. The pt has a negative Murphy sign. What term can be used to describe the findings?

Courvoisier's sign A Courvoisier GB refers to an enlarged, non-tender GB caused by a distal obstruction.

A pt presents with epigastric pain and nausea. Lab values demonstrate increased amylase, bilirubin, alkaline phosphatase, and LFTs. A cystic mass with thickened walls is identified in the head of the pancreas. No color flow is identified in the mass. Two small hypoechoic masses are identified in the area of the pancreatic head near the portal hepatics. What is the likely finding?

Cystadenocarcinoma The cystic mass with irregular walls indcates an "abnormal" cyst, which is seen with cyst adenoma and cystuadenocarcinoma. The two small hypoechoic masses near the portal hepatics indicate lymphadenopathy, which is associated with carcinoma.

Acute cholecystitis can lead to wall thickening and hypervascularity. The _____ artery and its branches will be prominent with color Doppler evaluation of the thickened GB wall.

Cystic artery

Acute hepatitis will cause a _____ in echogenicity, the presence of _____, and an _____ WBC count. What about chronic hepatitis/cirrhosis?

Decreased echogenicity (due to fluid accumulation within the tissues as a response to the infection Ascites Increased WBC due to infection Chronic hepatitis and cirrhosis will demonstrate increased echogenicity due to the associated fibrosis and scarring of the tissues.

Fatty infiltration of the liver appears sonographically as which of the following? (may be multiple) Cystic degeneration Decreased visualization of vessels Increased attenuation Hepatomegaly Brighter parenchymal echoes

Decreased visualization of vessels Increased attenuation Hepatomegaly Brighter parenchymal echoes Fatty infiltration causes an increase in liver size and in the amount of scatter of the US beam as it passes through the liver tissue. The increased attenuation leads to poor visualization of the liver vasculature. The fatty tissue produces a brighter reflection and echogenicity of the tissues displayed. Cystic degeneration is not normally a characteristic of fatty liver infiltration.

What will cause a decrease in PT?

Dehydration

Primary GB carcinoma most commonly presents as:

Diffusely thickened GB wall with stones

While scanning the liver, you notice a small dilated tubular structure with stellate branches coursing anterior to the right portal vein. Which of the following best describes the findings?

Dilated right hepatic duct

Obstruction of the CBD by a pancreatic head mass would lead to:

Dilation/distention of the biliary tree and the GB (because this obstruction would be at the level of the CBD).

Bacterial cholangitis is nearly always seen with:

Ductal obstruction (i.e. stone or tumor) Bile is infected by gram-negative bacteria. Parasitic cholancitis involves liver flukes or ascariasis. May see worms within ducts as tortuous strands in the lumen. HIV cholangitis occurs in patients with advanced HIV infection. Most patients with primary sclerosing cholangitis have IBS or ulcerative colitis. This causes chronic inflammation and fibrosis of the biliary ducts.

The renal anomaly where the kidneys demonstrate congenital duplication of the renal pelvis/calyses is called:

Duplicated collecting system

A pt presents for an abdomen ultrasound with RUQ pain, nausea, fever, and leukocytosis. An abnormal enlarged gb demonstrates thickened walls at 1.2cm. An anterior segment of the wall is echogenic and ring down and dirty shadowing is present posterior to this area. What is identified on the exam?

Emphasematous cholecystitis - bacterial air is present in the walls and lumen of the gb, causing ring down, dirty shadowing, and an abnormally enlarged gb.Symptoms include pain, nausea, vomitting, leukocytosis, and fever.

Which biliary abnormality would be an acute complication caused by bacterial infection of the GB?

Emphysematous cholecystitis This is an acute complication caused by bacterial infection of the GB. It is a critical finding that should be reported to the radiologist immediately.

A 45yo femal presents with nausea and vomitting, RUQ pain, fever, and increased WBC. The GB is enlarged and filled withe chogenic material that does not shadow or demonstrate fluid levels. This likely represents:

Empyema of the GB Empyema - the accumulation of pus Pus does not shadow or demonstrate fluid/debris levels like sludge/stones would demonstrate.

You identidy free fluid above the right diaphragm that contains internal debris and separations. The fluid collection has a honeycomb appearance. What is it?

Exudative pleural effusion These are usually complex collections with internal debris and separations. They may be multiloculated with a honeycomb appearance. Transudative PEs are anechoic or hypoechoic fluid collections without septations. There are usually seen immediately deep to the chest wall.

Which of the following can lead to a false positive diagnosis of stones in the biliary system? What about a false negative? Improperly decreased TGCs Shadowing from a surgical clip in the portal hepatis Decreased color Doppler gain Rejection setting too high

FLASE POSITIVE: Shadowing from a surgical clip in the portal hepatis Surgical clips are highly echogenic and cause posterior shadowing, which can mimic a ductal stone. FALSE NEGATIVE: Decreased TGCs or Rejection setting too high Rejection removes low-level echoes from the image. If this setting is too high, the image will be overly grainy and black and white. This could remove reflections from small gallstones, leading to a false negative. Decreased gain could also remove important info from reflectors in the GB, leading to a false negative for stones.

What is within the posterior perarenal space?

Fat (i.e. no organs)

Which of the following is most likely to be confused with breast cancer? Sebaceous cyst Fat necrosis after breast surgery Single 5cm fibroadenoma in the breast Multiple fibroadenomas in both breasts

Fat necrosis after surgery

What causes pseudopancreatitis?

Fatty Liver Disease can cause the pancreas to appear hypoechoic due to sound attenuation in the liver. In these cases, it is very important to correlate US findings with lab results and to evaluate the GB and biliary system for other signs of pancreatitis.

Is fatty infiltration of the liver reversible or irreversible?

Fatty infiltration is reversible. Changes to diet and lifestule modifications can reduce the level of infiltration.

A pt is scanned for symptoms of mild epigastric pain. A nearly isoechoic liver mass is identified in the caudate lobe. A liver biopsy demonstrates normal liver cell structure but abnormal cellular arrangement. What type of mass was it?

Focal Nodular Hyperplasia FNH tumors form due to hyperplasia of normal liver cells that are arranged abnormally. These tumors are usually isoechoic to mildly hypoechoic to the liver tissue and commonly demonstrate a central scar with spoke-wheel vascularity.

All of the following will demonstrate normal LFTs, except: Fungal abscess Glycogen storage disease Focal nodular hyperplasia Polycystic disease of the liver Hemangioma Hemorrhagic liver cyst Adenoma

Fungal abscess

Which of the following statements about GB sludge is not true? Changing pt position and rescanning the GB can differentiate sludge from artifact GB sludge is always associated with wall thickening Tumefactive sludge can have a sonographic appearance similar to GB carcinoma Sludge can appear as varied layers of echogenic material in the GB lumen

GB sludge is always associated with wall thickening Biliary sludge can be associated with biliary stasis in a normal GB, so wall thickening does not always occur with sludge.

The WES sign indicates a diagnosis of:

Gallstones The WES sign refers to identifying the: 1. Wall of the gb 2. Echoes from the dense stone(s) 3. Shadowing identified posterior to the stone

What covers the kidneys?

Gerotas fascia

Which splenic tumor is associated with tuberous sclerosis or Wiskott-Aldrich syndrome?

Hamartoma - a benign mass of the spleen that usually compresses and displaces normal splenic tissue. They are associated with tuberous sclerosis or Wiskott-Aldrich syndrome

Malignant pancreatic masses are usually in the _____. Benign pancreatic masses are usually in the _____.

Head = malignant Tail = benign

The patient with a history of a 2 cm simple cyst in the right lobe of the liver presents for an ultrasound. He complains of the recent onset of pain and bloating. Lab values are normal except for a mild decrease in hematocrit. Ultrasound showed a single 4 cm round well-defined structure filled with varied low level internal echoes in the mid right lobe. what are the findings?

Hemorrhagic cyst Decreased hematocrit accompanied by the new onset of pain can indicate acute hemorrhage. The increased size of the cyst and presence of internal echoes most likely indicates internal hemorrhage within this cyst.

A 56yo male presents with epigastric pain, nausea, and a chronic hx of alchoholism. Lab values demonstrate increased amylase and lipase. Hematocrit levels are below normal values. The US shows a hypoechoic, enlarged pancreas with periglandular fluid. What is the dx?

Hemorrhagic pancreatitis The key to this question is the decreased hematocrit and periglandular fluid. The enzymes have damaged the pancreatic tissue and vessels, causing bleeding around the organ. Hematocrit levels will drop when a bleed is present.

Which of the following will cause an increase in LFTs? Adenoma Hepatitis FNH GSD All of the above

Hepatitis Normal LFTs are seen with: Simple cysts Hemorrhagic cysts Polycystic Liver Disease Adenomas Hemangiomas Focal Nodular Hyperplasia Glycogen Storage Disease

What is the most common malignant liver mass found in children?

Hepatoblastoma

Which of the following will cause an increase in AFP? Liver adenoma Glycogen storage disease Focal nodular hyperplasia Hepatoblastoma

Hepatoblastoma AFP essentially increases with malignancy and pregnancy. "AFP in adults increases with primary liver cancers, liver metastasis, hepatitis, and non-seminomatous testicular cancers. It also increases with pregnancy."

A 3yo presents with a palpable right upper quadrant mass. The ultrasound demonstrates a four centimeters solid hypoechoic mass within the liver parenchyma and lymphadenopathy. What is the likely diagnosis?

Hepatoblastoma This is the most common liver malignancy in children

A 65yo male presents with a hx of cirrhosis, RUQ pain, and recent weight loss over the last 6 months and abnormal lab values, including increased AFP.

Hepatocellular Carcinoma Increased AFP is a sign of primary liver malignancy, and so is unintended weight loss.

A 75yo pt presents with RUQ pain. She was diagnoses with cirrhosis 4 years ago. Lab values demonstrate increased AFP, ALP, AST, and ALT. The US shows a heterogeneous liver texture that is decreased in size. The left lobe contains a new round hypoechoic mass with increased vascularity. What is the most likely dx?

Hepatocellular carcinoma 70% HCC cases demonstrate elevated AFP. 80% of patients that develop HCC have preexisting cirrhosis.

If PT is increased and administration of vitamin K is given, but little-to-no improvement of PT occurs (i.e. it does not decrease), what does the patient likely have?

Hepatocellular disease

_____ is one of the most common surgical procedures in the US and most patients are males, less than 1yo.

Herniorrhaphy (hernia repair)

Which of the following is least likely to be associated with splenomegaly in an adult male? Infection Neoplasm Circulation problems Heterozygous sickle cell anemia Homozygous sickle cell anemia

Heterozygous sickle cell anemia - this leads to splenic atrophy in adults. Homozygous sickle cell anemia will cause splenomegaly and infarction Infections cause the spleen to become edematous and enlarged Neoplasm formation will cause an overall increase in splenic size Portal HTN will lead to splenomegaly due to decreased outflow of the spleen.

Which one causes splenomegaly/infarction and which causes splenic atrophy? Heterozygous sickle cell anemia Homozygous sickle cell anemia

Heterozygous sickle cell anemia = atrophy Homozygous sickle cell anemia = splenomegaly/infarction

The renal anomaly where the kidneys don't separate completely during embryonic development is called:

Horseshoe kidney

A pt presents with abdominal pain for 3 months after returning from India. Lab values demonstrate normal LFTs. The US exam demonstrates a 3cm cyst with septations in the right lobe of the liver. What are the findings?

Hydatid cyst This is common in countries with lots of cows and sheep The parasite infests the liver parenchyma and a cyst with numerous separations form.

A contrast enhanced US is performed on a pt with suspected HCC. Where are the expected findings if the exam is positive for HCC?

Hyerechoic lesions during the arterial phase and hypoechoic lesions during the portal venous phase Malignant tumors demonstrate hypervascular enhancement (rapid uptake of contrast). Most malignant masses demonstrate contrast enhancement during the arterial phase but rapid contrast washout during the venous phase. This will result in hyerechoic lesions during the arterial phase and hypoechoic lesions during the portal venous phase.

Patients with cirrhosis should have their liver vasculature evaluated regularly due to:

Increased risk of portal thrombosis or tumor invasion from HCC

What is cholesterolosis?

Multiple polyps in the GB that do not demonstrate comet tail artifact. It is also known as a strawberry GB.

How will an acute infection of the pancreas present sonographically and how will it affect amylase and lipase levels?

Infection will cause fluid accumulation, resulting in decreased echogenicity and an increase in size. Amylase and lipase levels in the blood will increase due to the infection.

A mass in the Ampulla of Vater would cause dilation of the:

Intra and extra hepatic ducts (to include the pancreatic duct)

How does breast cancer appear sonographically?

Irregular shape/borders Indistinct margins Hypoechoic Heterogeneous Shadowing Scar tissue and fat necrosis can present with similar findings

A hernia with a narrow neck:

Is at increased risk for incarceration and strangulation

What is Kasabach-Merritt syndrome?

KMS is a rare but potentially fatal complication of rapidly growing vascular lesions in infants. KMS is defined as the combination of giant hemangiomas, thrombocytopenia, and consumption coagulopathy. Symptoms include: - Visible giant hemangiomas or multiple smaller hemangiomas, usually on the extremities - Enlarged abdomen -Hepatomegaly or jaundice -Petechiae, bruising, and frank bleeding -Painful lesions -Anemia https://emedicine.medscape.com/article/956136-overview

What is within the perirenal space?

Kidneys Adrenals Portions of the IVC Aorta

A 45-year-old male presents for an abdominal ultrasound due to suspected hepatomegaly. The exam demonstrates numerous cysts of all sizes throughout the liver parenchyma. Which other organ or structure should be evaluated for the same abnormality?

Kidneys Pancreas Spleen Polycystic liver disease is commonly seen with renal cyst formation. The pancreas and spleen can also show cystic changes.

What is Klippel-Trenaunay-Weber syndrome?

Klippel-Trenaunay syndrome is a condition that affects the development of blood vessels, soft tissues (such as skin and muscles), and bones. The disorder has three characteristic features: 1. A red birthmark called a port-wine stain (caused by swelling of small blood vessels near the surface of the skin and it usually covers part of an extremity) 2. Abnormal overgrowth of soft tissues and bones (starts in infancy and usually only affects one limb - usually a leg, sometimes an arm, and rarely the torso) 3. Vein malformations (i.e. varicose veins, but deep veins can also be affected)

The most common location for the formation of a pancreatic pseudocyst is within the _____ sac of the omental layers.

Lesser The lesser sac is formed between the greater and lesser omentum (AKA mental bursa).

A long standing, partial obstruction of the cystic duct will most likely lead to:

Mucocele of the GB A chronic cystic duct obstruction would lead to an over distended and enlarged GB that is filled with sterile, non-pigmented mucin from the mucosal lining because bile is being resorbed.

A mass that demonstrates propagation speed artifact is:

Lipoma because the speed of sound in fat is much slower than in soft tissue

Which organs can polycystic disease affect?

Liver Pancreas Kidneys Spleen Ovaries

All of the following are benign splenic neoplasms, except: Lymphoma Hemangioma Granuloma Hamartoma

Lymphoma - this is a primary malignancy of the spleen related to lymphatic tissues

What is MEN syndrome associated with?

MEN = Multiple Endocrine Neoplasm MEN is associated with tumor formation in the endocrine organs. Gangioneuromatosis Pituitary Adenoma Medullary Cancer of the Thyroid Parathyroid Adenoma Islet Cell Tumor Pheochromocytoma

While scanning the abdomen, you note the GB is moderately over distended. Which of the following is the most likely cause for the finding? Portal HTN Gastric mass Rt hepatic duct stone Mass of the ampulla of Vater

Mass of the ampulla of Vater A mass in this location will lead to a dilated biliary tree and pancreatic ducts.

Acute cholecystitis is associated with all of the following except: Fever RUQ pain McBurney's point Positive Murphy's sign

McBurney's point - the most common location of the appendix and the point of origin for the greatest tenderness in the RLQ in pots with appendicitis

The most common primary malignancy to metastasize to the spleen is:

Melanoma (i.e. skin cancer)

A mass that presents with a bull's eye appearance in the liver tissue is most likely:

Metastasis

What will cause an increase in PT?

Metastasis Liver disease Coagulant therapy (i.e. Coumadin or Warfarin) Prolonged biliary obstruction Biliary carcinoma

What is Epstein-Barr syndrome?

Most commonly known as "mono" According to the CDC: "Epstein-Barr virus (EBV), also known as human herpesvirus 4, is a member of the herpes virus family. It is one of the most common human viruses. EBV is found all over the world. Most people get infected with EBV at some point in their lives. EBV spreads most commonly through bodily fluids, primarily saliva. EBV can cause infectious mononucleosis, also called mono, and other illnesses."

What is the most common congenital pancreatic anomaly?

Pancreas divisum The two embryonic buds do not fuse properly and separate portions of the gland form with separate ductal systems. This can lead to pancreatitis due to abnormal ductal drainage of enzymes.

What congenital anomaly of the pancreas results in two separate ductal systems that drain the pancreas?

Pancreas divisum This is the most common congenital pancreatic anomaly. The two embryonic buds do not fuse properly and separate portions of the gland form with separate ductal systems. This can lead to pancreatitis due to abnormal ductal drainage of enzymes.

What is an insulin pump for?

Patients who do not produce enough insulin (i.e. diabetics)

When an AAA ruptures, which retroperitoneal space will fill with blood first?

Perirenal - this is the space that encloses the kidneys, adrenals, portions of the IVC, and aorta

A 66yo female presents with bloating and pain following a recent cholecystectomy. The bile ducts appear echogenic with dirty shadowing and ring down artifact posterior to several portions of the ductal system. What are the findings?

Pneumobilia

What is a pneumothorax and is US able to evaluate it?

Pneumothorax - air accumulation in the chest between the visceral and parietal pleural lung layers (this can be caused by a thoracentesis and will result in the loss of the lung-gliding sign) US can be used for evaluation of a pneumothorax if a pt cannot sit upright for a chest x-ray

An US demonstrates a non-shadowing, non-mobile echogenic foci on the GB wall. What is it?

Polyp

Chronic cholecystitis is commonly associated with:

Porcelain GB and GB carcinoma

Which biliary abnormality is associated with chronic cholecystitis?

Porcelain gb Chronic cholecystitis can lead to calcium formation within the gb wall.

The most common cause of splenomegaly is:

Portal HTN

A pt presents for an abdominal US due to nausea and vomiting. While scanning the GB, the patient expresses pain over the GB due to the transducer pressure. How should you report this to the radiologist?

Positive Murphy's sign

Do liver hemangioma present with shadowing or posterior enhancement? What are hemangioma comprised of? What is blood flow like in a hemangioma and is color Doppler effective in evaluating it?

Posterior enhancement Comprised of abnormal amounts of vascular liver tissue (?) Slow flow but highly vascular (contradiction between answer and explanation..? Hemangiomas have slow flow.) Doppler is not an effective tool

A porcelain GB causes an increased risk of:

Primary GB carcinoma

Are metastasis or primary malignancies more common in children?

Primary malignancies Mets are not nearly as common in the pediatric population as primary malignancies

What is the #1 risk factor for the development of cholangiocarcinoma?

Primary sclerosing cholangitis

What is sclerosing cholangitis?

Primary sclerosing cholangitis (PSC) is a chronic liver disease characterized by a progressive course of cholestasis with inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. https://emedicine.medscape.com/article/187724-overview

While evaluating the liver and biliary tree, a stone is identifies in the CBD adjacent to the pancreatic head. Which of the following is least likely to be identified as a related finding on the exam? Pseudoaneurysm Pancreatitis Cholelithiasis Dilated biliary tree

Pseudoaneurysm Choledocholithiasis is related to pancreatitis, dilated biliary ducts, and cholelithiasis.

What are the associated findings with pancreatitis?

Pseudocyst Abscess Phlegmon Hemorrhage Psuedoaneurysm Ascites Dilated biliary system due to extrinsic compression at pancreas

Which of the following is not describing Marfan syndrome? Genetic disorder that affects connective tissues of the heart, vessels, and bones Cardiovascular defects are common Pts are usually less than 48 inches tall with foreshortened limbs and digits Abraham Lincoln is believed to have had Marfan syndrome

Pts are usually less than 48 inches tall with foreshortened limbs and digits

The development of scar tissue and fibrous plaque formation involving the tunica albuginea of the penis describes:

Pyrenees' Disease This causes restriction and curvature of the affected side of the penis during erection and can be very painful. 2D imaging demonstrates hyperechoic areas along the outer margins of the corpus cavernous.

What is required when reporting a suspected hernia?

Reducibility Hernia contents Tenderness at area of interest Hernia size Dynamic maneuvers used during exam (i.e. valsalva?) The presence or absence of hernia

The most common primary malignant renal tumor in adults is:

Renal Cell Carcinoma

A 55yo with a hx of alcoholism and jaundice presents for a US. Cirrhosis of the liver is identified on the exam. All of the following are associated findings, except: Portal thrombosis Ascites Dilated coronary vein Renal oncocytoma

Renal oncocytoma This is a benign tumor of the kidney that is unrelated to cirrhosis

What is the most common location for a pancreatic allograft?

Right iliac fossa

A pyogenic abscess in the liver has been associated with:

Sickle Cell Anemia

Splenic atrophy in adults is often associated with:

Sickle cell anemia Sickle cell anemia is determined by abnormally shaped RBCs that carry abnormal forms of hemoglobin. These abnormal cells can cause pooling of blood in the spleen. The spleen will become enlarged and painful from the increase in blood volume early in life. After repeated episodes of splenic sequestration, the spleen becomes scarred and permanently damaged, causing atrophy.

What is an immune system disorder that commonly affects the salivary glands?

Sjogren syndrome is an immune disorder that causes a reduction in saliva and tear production. It is associated with rheumatoid arthritis and lupus. Primary symptoms are dry eyes and dry mouth. It may cause swelling of the salivary glands. It usually affects the parotid and submandibular glands.

US demonstrates an enlarged GB with a rounded, fluffy, non-shadowing, mobile mass in the lumen. What is the dx?

Sludge ball = mobile and non-shadowing Stones = mobile and shadowing Carcinoma/polyp = not mobile

What are the valves of Heister?

Spiral shaped muscular ridges that control the bile in and out of the gallbladder. Due to their dense structure, they can cause shadowing at the gallbladder fossa.

What is the most common benign tumor of the spleen?

Splenic hemangioma. It is comprised of vascular tissue.

All of the following are congenital anomalies of the spleen, except: Splenomegaly Agenesis Ectopic spleen Splenunculi

Splenomegaly = an acquired condition (usually from infection or portal HTN) Agenesis = congenital absence of spleen Ectopic spleen forms in an abnormal location Splenunculi = accessory spleen

Types of splenic rupture include:

Subcapsular hematoma - hematoma formation between the splenic tissues and capsule Extracapsular hematoma - hematoma formation between the splenic tissues and intraperitoneal tissues Intraparenchymal hematoma - hematoma formation within the splenic tissues

Which is commonly found in third-world countries that have high amounts of cattle/sheep, and it comes from contact with animal feces/ingestion of raw pork, and which is a water fluke parasite that is commonly found in polluted waters of Mediterranean countries? Echinococcal cyst/Hydatid cyst vs Schistosomiasis

Third-world countries, cattle/sheep, and feces/raw pork = Echinococcal cyst/Hydatid cyst Water fluke/Mediterranean countries = Schistosomiasis

Jaundice is usually associated with which conditions?

Those that result in increased bilirubin in the blood (usually due to a ductal obstruction) RBC destruction Ductal obstruction Hepatocellular disease NOT fatty infiltration

True or false: Patients with one hernia usually have multiple.

True Patients with one hernia, usually have multiple and they should be evaluated for other types of ipsilateral and contralateral groin or anterior abdominal hernias.

What are the two most common infections that cause granuloma formation in the spleen?

Tuberculosis and histoplasmosis

What condition most likely lead to a patient needing both a kidney and a pancreatic transplant?

Type I diabetes Type I diabetes can lead to renal failure. Pancreas transplants are performed to reduce insulin dependeny caused by diabetes

While scanning the urinary bladder using color Doppler, the left urinary jet is detected but is partially obstructed by a thin membrane that balloons into the bladder lumen. What is the finding?

Ureterocele This is a thin membrane that covers the jxjn of the errata and bladder

How can you differentiate between tumefactive sludge and gb carcinoma?

Use color Doppler Sludge will have no vascularity but carcinoma will

Appendicitis usually occurs in patients aged ___ - ___ yrs, and rarely in patients before the age of ___yrs.

Usually in pts 10-30yo Rarely in pts before 2yo

Causes of hydronephrosis include all of the following, except: Vascular calcification Mass effect Pregnancy Stone formation

Vascular calcification

How do fibroadenomas of the brest appear?

Well-defined Oval in shape Hypoechoic Homogenous Posterior enhancement

What is Mirizzi's syndrome?

When a stone in the cystic duct causes extrinsic compression of the CBD. It is very painful.

What is renal agenesis?

When one or both kidneys fail to develop. If both kidneys are affected, it is fatal, but if only one is affected, the it is not fatal (unless the developed kidney fails)

Peliosis hepatis refers to the formation of:

blood-filled cavities of various sizes within the liver tissue It is associated with chronic wasting disorders, renal and liver transplants, many kinds of drugs (especially anabolic steroids), and HIV.