Abdominal Sonography CTL: Pathology 42% Part 1,2

Pyloric stenosis is diagnosed when the muscle wall thickness exceeds:

4mm

Which type of liver abscess is caused by a parasite?

Amebic

What is caput medusa?

refers to dilated tortuous vessels around the umbilicus caused by portal HTN

A patient present for an ultrasound of the RUQ due to a recent diagnosis of lung cancer. If liver metastasis is present, what are the expected sonographic findings?

"Bulls-eye" appearance usually relates to lung primary - multiple target lesions Cystic lesions usually associated with sarcoma Hypoechoic lesions usually related to lymphoma Hyperechoic lesions with hypervascularity related to renal cell carcinoma Hyperechoic lesions usually related to GI tract primary

WHich of the following lab values is usually unaffected by an isolated biliary duct obstruction?

ALP, GGTP and bilirubin levels will increase with ductal obstructions Total bilirubin refers to the amount of conjugated bilirubin plus the amount of unconjugated bilirubin in the blood serum levels of conjugated bilirubin will increase with ductal obstruction, therefore the total bilirubin level will increase also AST (aspartate aminotransferase) levels are not affected by a ductal obstruction

Which liver disorder leads to the sonographic appearance of hepatomegaly with decreased echogenicity and scattered bright portal reflections within the parenchyma?

Acute hepatitis demonstrates the sonographic appearance of hepatomegaly with decreased echogenicity and scattered bright portal reflections within the parenchyma (starry night)

Which of the following is the most common cancer of the GI tract?

Adenocarcinoma

____ is the most common malignant neoplasm found in the prostate

Adenocarcinoma

Where is the most common location for the occurrence of retroperitoneal fibrosis?

At the aortic bifurcation Retroperitoneal fibrosis (Ormond Disease) usually occurs at the level of the aortic bifurcation It refers to idiopathic (usually) overgrowth of fibrous tissue It can be related to drugs, infection, malignancy or cancer therapy. The overgrowth of tissue may lead to ureteral obstruction causing hydronephrosis

Which of the following is a cause of parasitic cholangitis?

Biliary Ascariasis

The most common location of ectopic thyroid tissue formation outside the neck is in the ____

CHEST The thyroid forms within the pharyngeal pouches in the neck and migrates inferiorly to it position at the base of the neck when ectopic tissue is present, it most commonly migrates beyond the base of the neck and is located more inferiorly in the mediastinum area

Which of the following are common associated findings with horseshoe kidneys?

Calculi and Hydronephrosis Horseshoe kidneys refer to the attachment of the kidneys across the midline of the body, usually the lower poles. Hydronephrosis is common due to abnormal structure of collecting system and course and location of ureter. Caliculi and Pyelocaliectasis are also common findings

____ lobe of the liver does not normally atrophy with chronic Budd Chiari Syndrome

Caudate Lobe In the later stages of Budd Chiari Syndrome, the right and left lobes will atrophy but the caudate lobe does not reduce in size because the emissary veins drain the blood from this lobe, not the hepatic veins

Which of the following is a common cause of transudate pleural effusion?

Congestive Heart failure Transudate fluid has a low protein and lactate dehydrogenase concentrations free fluid id pushed outside the capillary bed due to high pressure in the capillary beds. It is usually related to CHF, liver and kidney disease Exudate fluid has high protein and lactate dehydrogenase concentration It is usually related to malignancy, lupus, pneumonia and tuberculosis Free fluid leaks outside the capillary cells due to inflammation

Which of the following is NOT a medication that can be used to treat patients with hypothyroidism?

Coumadin Medication that IS used to treat patients with hypothyroidism: Iodine supplements Levothyroxine/Synthroid Iron supplements

A mass is identified in the left testicle. It is rounded with well-defined borders. There are internal rings of hyperechoic and hypoechoic tissues giving the appearance of an onion. No color flow is demonstrated within the mass. These findings are most consistent with:

Epidermoid cyst

Which type of liver abscess presents as a mass with internal septations similar to the spokes of a wheel

FUNGAL

patient presents with right groin pain. You identify a hernia sac medial to the common femoral vein. What type of hernia is present?

Femoral Hernia - hernia sac usually lies medial to the common femoral vein (below the inguinal ligament) Umbilical and spigelian hernias are abdominal hernias a direct inguinal hernia occurs superior to the inguinal ligament and inferior and medial to the inferior epigastric artery origin.

A 10 yr old presents for an ABD US with a palpable RUQ mass. He has no history of liver disease and alphafetoprotein levels are normal You identify a 9cm mass in the right lobe that demonstrates punctate calcifications and a central scar. These findings are most suggestive of?

Fibrolamellar Carcinoma - subtype of HCC found in adolescents and young adults with no coexisting liver disease AFP levels are normal Punctate calcifications and a central echogenic scar help to differentiate it from a hepatoma All other choices would have elevated AFP in most cases

A patient presents with a history of a 5mm Leydig Cell tumor identified on an exam 6 months ago. What is a common complication of this type of neoplasm

GYNECOMASTIA Leydig cell tumors can cause an endocrine imbalance which can lead to the development of gynecomastia Any testicular tumor that is associated with elevated beta hCG can lead to gynecomastia

A patient presents for a thyroid US due to increased T3 and T4 levels in the blood. Additional symptoms include weight loss, night sweats and exophthalmos. The thyroid demonstrates an increase in size and a diffuse decrease in echogenicity with a course, heterogenous texture. Which of the following best describes these findings?

Graves' Disease - most common cause of hyperthyroidism sonographically the gland will enlarge with a heterogenous echotexture and increased vascularity

The hormone changes with pregnancy have been associated with the enlargement of what type of liver mass?

Hemangioma - estrogen replacement therapy and pregnancy can cause a hemangioma to increase in size

Elevated AFP

Hepatoblastoma Hepatoma Metastasis

A patient presents with a history of hepatitis C and you identify a solid liver mass with a hypoechoic halo, this finding is most consistent with:

Hepatocellular carcinoma = hypoechoic halo + hx of chronic liver disease

Which of the following Doppler findings is most consistent with uncomplicated epididymo-orchitis?

Hypervascularity will be present in the area of infection The affected side will show decreased vascular resistance (low resistant flow and hypervascularity) The RI value is typically between 0-1 Acute infection is associated with RI values less than 0.5 in affected teste

A referring doctor requests a scrotal US to rule out orchitis. Which of the following is an expected sonographic finding for the abnormality?

Increased intratesticular vascularity Testicular infection can lead to increased blood flow to the testicle which causes hypervascularity identified on color doppler

if a liver transplant patient has an interposition anastomosis, how does this affect your evaluation?

Interposition- donor IVC segment replaces a segment of the native IVC; TWO anastomosis sites Piggy back- hepatic confluence of transplant liver attached to native IVC; single anastomosis site

a 65 yr old male patient presents with bilateral scrotal swelling and mild pain. The US exam demonstrates bilateral hypoechoic, solid masses within the testicular parenchyma. Which of the following is the most likely diagnosis for the findings?

Lymphoma most primary testicular cancers are unilateral in formation Testicular lymphoma, leukemia and metastasis usually occur bilaterally

Pateint presents with a 2cm palpable reddened lump on the bottom of her foot. The patient states she accidentally stepped on a piece of broken glass. The doctor suspects there may be some glass remaining in her foot. WHich of the following statements is true regarding the evaluation of this patients foot?

MRI is contraindicated for some types of foreign bodies(metallic) most foreign bodies present as an echogenic structure with some degree of posterior shadowing Inflammation usually leads to a hypoechoic ring surrounding the foreign body Improved visualization of the foreign body occurs as the US beam becomes more perpendicular to the structure

The GB wall is asymmetrically thickened with hypervascularity and perfusion defects noted on color doppler evaluation. Intra-luminal membranes and sludge are also present. What is the Most likely cause for these findings?

Membranous gangrenous cholecystitis is a potential complication of untreated cholecystitis it would present as a diffusely thickened GB wall with hyper vascularity and intralumial membranses There will be areas where perfusion defects are detected int he thickened wall by color doppler, which indicate areas of necrosis (gangrene) Abscess formation may also be demonstrated

The ____ zone is the prostate zone most commonly affected by malignancy

Peripheral

which zone of the prostate has the highest risk for carcinoma development?

Peripheral 70% transitional 20% central 10%

Bilateral ureteral obstruction can be caused by?

Retroperitoneal fibrosis typically occurs at the level of the aortic bifurcation in the pelvis area The ureters pass through this space to reach the bladder If both ureters are impinged, bilateral hydronephrosis will occur, the other choices listed would only cause unilateral hydronephrosis retroperitoneal Fibrosis= bilateral hydronephrosis Splenic varices, RCC of the left kidney and a liver mass in the posterior right lobe = Unilateral hydronephrosis

Tuberculosis and ____ will demonstrate similar ultrasound findings in the spleen

Sarcoidosis and TB will demonstrate multiple hypoechoic nodules in the spleen with active disease. After the nodules heal, they become echogenic foci that can demonstrate posterior shadowing

Spontaneous splenic rupture is associated with all of the following except:

Splenic rupture occurs due to trauma or it can occur spontaneously Spontaneous rupture seen in patients with hepatitis A, malaria, cytomegalovirus, monomucleosis, and HIV Splenosis refers tot he autotransplantation of splenic tissue in the peritoneal cavity when the spleen ruptures. Traumatic and spontaneous splenic rupture are associated with splenosis

an 85 yr old patient presents with a history of epigastric pain. Lab values are normal, The exam demonstrates normal intrahepatic ducts and a 10mm CBD that appears patent. The pancreas appears normal. What is the most likely reason for the 10mm CBD

The CBD normally dilates with age 1mm diameter = 10yrs in age

Which of the following statements best describes the appearance of color doppler evaluation of a testicular abscess?

The central portion of the abscess is fluid and debris with no vascularity. The surrounding tissues are inflamed which leads to increased flow an an increase in the color flow displayed

Which of the following are vascular complications seen with pancreatitis?

Thrombosis of the splenic vein or Pseudoaneurysm of the splenic artery

A patient presents for a renal US due to a history of tuberous sclerosis. What is the doctor looking for?

Tuberous Sclerosis is commonly associated with the formation of angiomyolipomas in the kidney

A 1 yr old presents for a testicular sonogram due to a palpable lump The lab work in the chart indicates high levels of alpha fetoprotein A mostly solid intratesticular mass is identified in the right testicle. There is a small area of possible necrosis centrally These findings are most consistent with:

Yolk Sac Tumor - most common testicular tumor in patients less than 2 years old They produce AFP sonographically, they usually have areas of hemorrhage and necrosis in the mass causing a complex appearance

The most common benign, solid lesion of the thyroid is

adenoma the cyst and hematoma are not considered a solid mass Goiter is a diffuse condition

The most common extra-testicular neoplasm is:

adenomatoid tumor

The twinkle artifact is an expected finding in cases of

adenomyomatosis and renal calculi adenomyomatosis - proliferation of mucosal tissue into the muscularis layer and the thickened muscularis increases overall wall thickness GB diverticula or Rokitansky-Aschoff sinuses are caused when herniation of the wall layers forms a pocket or sinus The sinuses may fill with bile or cholesterol deposits and can collect sludge or stones. Comet tail and twinkle artifacts are seen with deposits in the diverticula Renal calculi demonstrate posterior shadowing and the twinkle artifact

Which type of thyroid cancer is most Lethal?

anaplastic CA make up 10% of thyroid malignancies; it is very aggressive and the most lethal type of thyroid malignancy It most commonly presents as a hard, fixed mass with rapid growth and usually invades surrounding neck structures

A right adrenal mass will displace the IVC

anteriorly the rt adrenal gland is posterior to the IVC tumor formation can displace the IVC more anteriorly

What biliary anomaly is suspected if jaundice persists more than 14 days after birth?

biliary atresia

Which of the following is a potential collateral pathway formed in patients with cirrhosis?

blood moves from the coronary and short gastric veins into the esophageal veins

Which of the following prostate abnormalities most significantly elevates the amount of serum prostate specific antigen in lab testing?

carcinoma BPH causes increases levels of PSA in the blood Carcinoma also causes increased PSA but usually much more significantly than BPH

what is the most common cause of cholangitis?

choledocholithiasis- occurs when a gallstone blocks the CBD and bile cannot flow past it and instead backs up into the liver Cholangitis- inflammation of the bile duct system

which testicular tumor will cause b-hCG levels to rise but AFP levels will be normal?

choriocarcinoma embryonal cell carcinoma usually leads to increased levels of b-hCG and AFP Yolk sac tumors usually cause an increase in AFP choriocarcinoma usually leads to an increase in b-hCG

Which of the following abnormalities is associated with the production of milk of calcium bile?

chronic cholecystitis Milk of Calcium Bile ( aka limey bile) refers to sludge like material with a high concentration of calcium

Which of the following is an expected sonographic finding with complete duplication of the collecting system of the kidney?

circumferential cortex at the mid pole

A significant increase in blood supply/drainage to thyroid will be seen with thyroditis. This can be demonstrated with ____ doppler and is called the ____ sign

color, inferno sign

How is the renal cortex measured correctly?

cortical thickness should be measured in the longitudinal view of the kidney. Calipers are placed on the base of the pyramid to the outer edge of the parenchyma; > 1.0cm thickness is normal

Most patient with adrenal cortical cancer have associated:

cushing syndrome - when body makes too much cortisol (stress hormone)

A patient presents with an enlarged left scrotum and palpable mass. The US demonstrates an intratesticular mass that is hypoechoic and heterogenous with multiple course calcifications There is also an irregular central cystic area. These findings are most suggestive of:

cystic areas and coarse calcifications are common in embryonal cell tumors and testicular teratomas seminomas normally present as hypoechoic, heterogenous solid tumors

What changes occur on the US image when scanning breast tissue affected by acute mastitis?

decreased tissue penetration due to tissue edema fluid int he breast tissues will cause an increase in the sound attenuation This attenuation will reduce penetration and resolution

Schistosomiasis and Chronic cystitis are commonly associated with what sonographic findings in the urinary bladder?

diffuse bladder wall calcification

Distal cholangiocarcinoma is most commonly found ____ and a Klatskin Tumor is most commonly found ____

distal cholangiocarcinoma is most commonly identified in the extrahepatic CBD near the porta hepatis. Klatskin tumors are a type of cholangiocarcinoma that are most commonly identified at the junction of the right and left hepatic ducts

Which of the following is most likely to demonstrate a simple cyst with gravity dependent debris in the right lobe of the liver?

early echinococcal infection -presentation of echinoccal infection varies with the length of time untreated Early appearance of a simple cyst with debris that was produced with development (hydatid sand) Later, larger cysts with "daughter cysts" within them will form Honeycomb appearance, Water Lily sign) walls may be thick or calcified in cases of chronic infection Chronic infestation can result in a calcified mass Echinococcal infection most commonly affects the right lobe

Which of the following correctly describes how to differentiate a liver hemangioma from focal fatty infiltration?

hemangiomas can compress or displace surrounding structures, fatty infiltration has NO mass effect

Which of the following describes the doppler appearance of liver transplant rejection?

high resistant hepatic artery is abnormal - normal flow in the hepatic artery is lo resistance with forward flow in diastole Transplant rejection will cause increased resistances int he liver tissue which causes increased resistance in the HA waveform flow in the portal vein should be low resistance

All of the following statements correctly describe infantile hemangioendothelioma ,EXCEPT:

highly aggressive liver malignancy seen early in life Infantile Hemangioendothelioma: Most common benign vascular liver tumor in infancy: Normally occurs within first six months of life; usually presents with cardiac failure early in life due to the AV malformation within the tumor; spontaneously regresses in most patients before age 2 yrs

in an otherwise normal kidney, an angiomyolipoma is ____ to the renal cortex and ____ to the renal sinus

hyperechoic, isoechoic the lipoma is going to be echogenic due to fat and the sinus has fat

Which of the following correctly describes how to determine if a peripheral mass is intrahepatic or extrahepatic

identify the origin of the artery and vein that supply and drain the blood to the tumor

What type of hernia is a delayed complication of upper abdominal surgery?

incisional hernia- delayed condition of ABD surgery It usually occurs in first few months after surgery and is more common with vertical incisions than with transverse incisions Elderly, obese and malnourished patients have increased risk of an incisional hernia

a right sided pheochromocytoma will displace the ipsilateral (same side) kidney____

inferiorly

The most common location for an aortic aneurysm:

infrarenal - below the level of the renal artery if the aneurysm is at or above the level of the renal arteries, the possible complications are much greater and treatment is more difficult

Which of the following is not usually treated by surgical intervention?

intussusception is treated by nonsurgical reduction Air or contrast is administered through the rectum (enema) to push the involuted bowel back out of the colon. The other choices all require surgical treatment

The term used to describe the involution of the small bowel upon itself is:

intussusception- refers to the segment of the bowel that involutes into itself. You will see a focal area of concentric rings of bowel that do not persitalse or change shape

ectopic spleen

is in an abnormal position in the abdomen if the spleen is absent from the LUQ, scan the rest of the abdomen for a mass of tissue that has the expected size and echotexture as the spleen This condition increases the risk for splenic torsion

patient history of a primary cancer int he body + liver mass with halo =

liver metastasis

Which of the following is least likely to cause anterior displacement of the aorta?

mass in the left diaphragm crura the left and right crura cross just anterior to the aorta and extend to the spine on both sides of the aorta A mass in this structure would displace the aorta posteriorly the IVC is anterior to the right crura

Which of the following is true regarding a renal oncocytoma?

may have a central scar similar to RCC oncocytomas are most commonly benign tumors that occur later in life. They cannot be distinguished from renal cell carcinoma without a biopsy Both RCC and Oncocytomas can demonstrate a central scar

A renal mass will displace the IVC

medially

Alcohol abuse is the most common cause for:

micronodular cirrhosis and chronic pancreatitis Biliary tract disease is the most common cause of acute pancreatitis, alcohol abuse is #2

A lab report demonstrates that a testicular tumor contains choriocarcinoma cells and embryonal cell carcinoma. Which of the following best describes the tumor?

mixed germ cell tumors contain components of two or more types of germ cell growth

What is the sonographic appearance of pseudomyxoma peritonei?

mucinous secretions and tumor formation within the lower abdomen cause bowel to be matted down against posterior abdominal wall this refers to intraperitoneal accumulation of a gelatinous ascites secondary to rupture of a mucinous tumor The most common cause is a ruptured mucinous tumor of the appendix

A patient presents with a recent diagnosis of lymphoma. which of the following is an expected finding on the ultrasound

multiple solid tumors are present causing marked increase in spleen size Leukemia, Lymphoma and myelofibrosis= severe splenomegaly typically caused by multiple solid tumors are present causing marked increase in spleen size AIDS, portal HTN, infection= mild to moderate splenomegaly due to increased blood pooling or edema with infection

Adrenal hemorrhage is most commonly seen in

newborns usually presents as jaundice and anemia caused by the birthing process in adults it is related to trauma and hemotologic disorders such as thrombocytopenia

Evaluating Liver Neoplasms

note the loction of the mass related to the liver capsule because the liver is adjacent to so many structures, establishing if the mass is intra- or extra hepatic is important Intrahepatic lesions can push outward toward the capsule causing irregular contour or bulging Extrahepatic lesions can compress the capsule causing irregular contour and indentations Note the location of the mass related to surrounding vasculature Lesions can cause extrinsic compression and distort normal flow patterns The vessel feeding the mass can aid in determination of mass origin (inside or outside the liver) Note the location of the mass related to biliary structures Extrinsic compression of ducts may lead to dilation connection to the biliary tree can indicate biliary origin Note the presence/ absence of associated lymphadenopathy

which of the following foreign body types is better visualized on sonography than with radiology?

organic foreign bodies are seen better in ultrasound - ROSE THORN where as they are not seen well in radiography. metal and inorganic foreign bodies such as gravel, glass or a broken needle are radiopaque on n x-ray and are more easily identified.

While scanning the thyroid, you note a 1.5cm hypoechoic, mildly heterogenous nodule that appears to be posterior to the lower pole of the right lobe of the thyroid. There is a distinct fascial plane between the thyroid and the nodule There are no other nodules identified on the exam. WHich of the following most likely describes the findings?

parathyroid adenoma - solid hypoechoic nodule posterior and inferior to the thyroid gland The esophagus is located on the left side of the neck and would not appear as a hypoechoic nodule A goiter refers to an enlarged thyroid gland usually with multiple solid nodules A branchial cleft cyst would appear anechoic and would be located more cephalic in the neck

The diaphragm sign, displaced crus sign and bare area sign are indicative of what abnormality?

pleural effusion Diaphragm sign- when using abdominal approach to view the fluid, fluid below the diaphragm and more centrally located = ascites fluid above diaphragm and more peripherally located = pleural effusion Displaced Crus sign = if the fluid is displacing the crus away from the spine, it is located in the chest cavity Bare Area sign- pleural fluid will extend behind the liver at the level of the bare area , ascites cannot reach this area

Which of the following describes how to differentiate adenomyomatosis of the GB from Cholesterolosis of the GB?

polyps in cholesterolosis do not exhibit the comet tail artifact but polyps with adenomyomatosis do demonstrate the artifact

If a patient complains of a recent onset of uncontrollable systemic HTN with average BP readings exceeding 170/90mmHg, what vascular cause should be suspected?

renal artery stenosis - sudden increases in systemic BP with no response to medication

Multicystic dysplastic kidneys are usually the result of:

result of an insult to the kidney during embryonic development, Usually related to UPJ (uteropelvic junction in utero) obstruction

If gallstone impaction is suspected:

scan the patient in multiple positions to attempt to. move the stone

A patient presents with a small, palpable extratesticular mass on the left side. The US exam demonstrates a mobile, hyperechoic mass with posterior shadowing. Which of the following best describes the findings?

scrotal pearl

Which of the following is the most commonly occurring germ cell tumor of the testicle?

seminomas make up 40-50% of all germ cell tumors identified in the testicle

A hematoma of the rectus abdominis muscle that occurs below the arcuate line can extend into:

space of Retzius acute hematoma will be anechoic or mildly hypoechoic to surrounding tissues the linea alba stops the blood from crossing the midline, above the level of the arcuate line

Liver elastography is used for

staging of fibrosis

Which testicular tumor is composed of bone, cartilage and smooth muscle fibers?

teratoma

Which of the following statements describes the appearance of a testicular prosthetic on the US image?

testicular prosthetics are most commonly silicone or gel filled which provides no reflection of the sound beam (anechoic) round structure with reflective borders and an anechoic lumen

Chronic infection in soft tissue organs typically leads to:

the formation of calcifications calcifications are common with liver, pancreas, adrenal and spleen infection Wall calcification is common with chronic cystitis

why does the spleen have an increased risk of infarction compared to the other abdominal organs?

the intrasplenic arteries do not have communicating branches splenic artery branches into the superior and inferior splenic arteries The superior and inferior splenic arteries give rise to several segmental arteries The intrasplenic arterial branches do not communicate with each other - this is a characteristic that is unique to the intrasplenic arteries collateral circulation can not be made when needed - the lack of anastomoses in the intrasplenic arterial circulation eliminates the possibility of collateral formation when infarction occurs

The ____ zone is the prostate zone most commonly affected by BPH

transitional zone

Primary Testicular Carcinoma is usually ____ and Secondary testicular malignancy is usually____

unilateral, bilateral

Weakened gastrosplenic and splenorenal ligaments can lead to:

wandering spleen