GARQs Questions 1-5

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Question 1: Living Anatomy Diagram

Question 1: Please name three different types of contrast agents (identified by chemical name).

1) Iodinated contrast agent named Gastrografin ("oral" contrast agent) 2) Barium sulfate ("oral" contrast agent) 3) Gadolinium

Question 1: For each, identify (1) the anatomic area/structure for which it is best suited, (2) the imaging modality for which it is best suited, (3) at least one clinical condition in which it should be employed, and (4) at least one clinical condition in which it should NOT be employed. Gadolinium

1) Gastrointestinal tract [highlights vasculature (blood vessels) as high signal intensity; internal organs like liver, spleen] 2) MRI 3) enhancement pattern helps characterize liver lesions 4) renal failure; risk for pancreatitis

Question 1: For each, identify (1) the anatomic area/structure for which it is best suited, (2) the imaging modality for which it is best suited, (3) at least one clinical condition in which it should be employed, and (4) at least one clinical condition in which it should NOT be employed. Barium sulfate ("oral" contrast agent)

1) Used to visualize the gastrointestinal tract 2) X-Ray [Esophagram (X-ray exam of the esophagus)] 3) diverticulum (outpouching); narrowing/strictures (can be from inflammation or scar, can be from tumor); gastroesophageal hernia; reflux disease 4) never administer when concern for bowel perforation; can cause severe inflammation (peritonitis) and foreign body reaction in the mediastinum or peritoneal cavity

Question 1: For each, identify (1) the anatomic area/structure for which it is best suited, (2) the imaging modality for which it is best suited, (3) at least one clinical condition in which it should be employed, and (4) at least one clinical condition in which it should NOT be employed. Gastrografin

1) Used to visualize the gastrointestinal tract 2) X-Ray [Esophagram (X-ray exam of the esophagus)] 3) suspected perforations; following surgery to rule out leakage 4) never administer when concern for aspiration into the lungs; can cause lung edema and lung damage as it is hyper-osmolar

Question 5: How does venous blood leave the liver?

Blood flows in from the interlobular hepatic artery and hepatic portal vein into the sinusoids. As the blood travels through the sinusoids, the hepatocytes detoxify the blood. The blood then reaches the central vein. The central veins of each lobule accumulate into the three hepatic veins which drain into the IVC.

Question 1: Please identify four imaging modalities that you can use to visualize and evaluate vessels. 1) For each of them, indicate if you would need to use contrast agents. 2) Give an example of the use of each technique in the abdomen or pelvis.

Computed Tomography Angiography (CTA) 1)Need contrast agent 2) Looking at an aneurysm in the abdominal aorta Magnetic Resonance Angiography (MRA) 1) Need contrast agent 2) Useful in the assessment of vasculitis involving medium to large sized abdominal vessels (not for the small vessels because of resolution limitations) Digital Subtraction Angiography (w/ intravascular catheter) (DSA) 1) Need contrast agent 2) DSA is the gold standard for assessment of the venous system, can be used in the abdomen to visualize potential renal artery stenosis; Showing high grade stenosis of the right common iliac artery Vascular Ultrasound 1)Do not need contrast 2) Screening for aortic dissection

Question 1: What is the common branching pattern of the celiac trunk? Make a diagram of the celiac trunk, and include, in addition to its three main branches, the following vessels: esophageal, short gastrics, left gastro omental (gastro-epiploic), proper hepatic, cystic, right gastric, gastroduodenal, right gastro-omental (gastro-epiploic), and superior pancreaticoduodenal

Explanations in the GARQ document

Question 3: Describe the path taken by a thrombus in the left popliteal vein to reach the left pulmonary artery.

Left popliteal vein becomes the left femoral vein after passing through the opening of the adductor magnus. The left femoral vein continues as the external iliac vein. The external iliac vein combines with the internal iliac vein to form the left common iliac vein. The left common iliac vein continues as the inferior vena cava. Inferior vena cava drains into the right atrium. Blood goes through the tricuspid valve to the right ventricle. Blood passes through the pulmonary valve to the pulmonary trunk and then the left pulmonary artery.

1)The catheter used to introduce the contrast agent 2) This is an invasive procedure using an iodinated contrast agent

Question 1: 1) What structure is highlighted by the yellow arrow? 2) Is contrast agent needed for this examination? If so, what type of contrast agent is used? Please indicate if this is an invasive or non-invasive procedure.

1) The hepatic artery area 2) A = left hepatic artery; B = right hepatic artery ; C = gastroduodenal artery 3) The common hepatic artery (which originates from the celiac trunk which originates from the abdominal aorta) 4) The catheter was placed inside of the common hepatic artery so the dye flows through to the subsequent vessels. The celiac trunk or abdominal aorta come before the common hepatic artery so they would not receive that dye when the photos are taken

Question 1: 1) Which vascular territory is shown in this image? 2) Please name the major branches that are labeled A through C. 3) Which major abdominal vessel do these ultimately originate from? 4) Why is that major abdominal vessel not seen in the image?

Digital Subtraction Angiography (DSA) → 1) non-contrast mask image is taken of the area of interest using a catheter, iodinated contrast is injected into the blood vessels and live fluoroscopic images are taken 2) The mask image is then subtracted from the contrast images (subtracting whatever is stationary). 3) The resulting image shows an accurate depiction of the blood vessels

Question 1: Please identify the type of examination demonstrated in Figure 1. Describe briefly how it is performed.

2) The vast majority of abdominal aortic aneurysms are located infrarenal (below the kidneys).

Question 2: 1) Identify the structures labeled "A" - "E" in Figure 3b below. [SEPARATE QUIZLET] 2)Where are the vast majority of AAA located?

2) A curvilinear probe was used

Question 2: 1) Identify the structures labeled "A" - "F" in Figure 3a below. [SEPARATE QUIZLET] 2) What transducer was used to obtain the image in Figure 3a?

1) CT angiograms 2) Maximum intensity projections = MIP 3) A = celiac trunk; B = superior mesenteric artery; C = abdominal aorta

Question 2: 1) Please indicate which type of examination is shown in Figure 3 (below). 2) Please name the type of post-processing / reconstruction that was performed from the original data set. 3) Indicate the vessels that are labeled with the letters A, B & C.

1) Superior mesenteric artery and branches 2) A = middle colic artery; B = right colic artery 3) jejunum 4) Diagnosis and treatment of arterial stenosis

Question 2: 1) Which vascular territory is shown in Figure 2? 2) Please identify the vessels that are labeled A and B. 3) Which organ territory is supplied by the vessels labeled C? 4) Please name one clinical condition, and indication, in which it would be appropriate to perform this examination so that diagnosis and treatment can be accomplished in the same session.

1) A filter is placed in the inferior vena cava to prevent pulmonary embolism 2) Calcified athersclerotic plaques 3) Filter is deployed in an infrarenal position to minimize the risk of filtered occlusive thrombus occluding the renal vein outflow

Question 3: 1) In which of these two vessels is a filter placed to prevent pulmonary embolism? 2)What is the high-density structure in the other vessel? 3) Are such filters placed above or below the level of the renal vasculature? Why?

1) CT 2) It's performed without intravenous contrast. All tissues except bone have a similar density. If there was contrast, we would see hyperdense material opacifying the organs and vasculature. 3) A = Inferior Vena Cava; B = Abdominal Aorta

Question 3: 1)What type of examination is shown in Figure 4? 2) Is this examination performed with intravenous contrast? How can you determine this? 3) Identify the vascular structures labeled A and B.

1) This is a pathology 2) 1. Do a CT of the liver with intravenous contrast in order to see the enhancement pattern 2. Measure the Hounsfield units within the lesion which measures the attenuation within the lesion and gives more insight into what the lesion could be

Question 3: 1) In this same image you also see a hypodense structure in the liver (blue arrow). Is this a normal anatomic structure or a pathology? 2) What could you do to better characterize this structure? (Please name two possibilities.)

1) Highlights venous structures 2) SEPARATE QUIZLET 3)Superior mesenteric vein, inferior mesenteric vein and the splenic vein 4) Gadolinium contrast is used for MRI

Question 5: 1) The figure below (Figure 5) is a splenoportogram performed with MRI. Does this highlight venous or arterial structures in the abdomen (which structures are brightest)? 2) Please name the anatomic structures which are labeled with the letters A through G in this image. [SEPARATE QUIZLET] 3)Please indicate the vessels in this image which ultimately drain into the main portal vein and identify them. 4) Which type of contrast is used for MR imaging?

Castell Method: The most favorable method; you will follow the anterior axillary line to the lowest intercostal space and then percuss that area (Castell's spot). Cranial-caudal movement: as you take in a deep breath, the spleen is going to come down but under normal circumstances, the stomach will still be in the anterior position so the area should stay tympanic throughout the respiratory cycle. If the percussion is dull or becomes dull on full inspiration then that is considered a positive test. Traube's space: Traube's space is the space bordered by the anterior axillary line laterally, the costal margin and the 6th rib. You pick an intercostal space and percuss. What sits posterior to Traube's space is the stomach so you would expect a tympanic sound. If you get a dull sound, that is considered a positive test and is concerning for splenomegaly.

Question 5: Describe the technique of splenic percussion.

Yes, the spleen measurement is 18.0cm. If the length of the spleen is >13cm in any dimension, that is a sign of splenomegaly Yes. The cranial-caudal length measurement of the spleen is 18.0cm and the upper limit of normal for the spleen should be 13 cm length.

Question 5: Does this patient have splenomegaly?

No

Question 5: Is dullness to percussion over Traube's space during inspiration consistent with a normal spleen size (YES or No)?

1) Portal Hypertension 2) Hematologic diseases like leukemias and lymphomas 3) Infectious diseases (HIV, malaria, mononucleosis) 4) Trauma

Question 5: List three causes of splenomegaly.

Question 4: Diagram the abdominal aorta. Below is an anterior view of the caudal portion of the vertebral column. On the drawing provided, please label the bones, and indicate where the aorta passes from the thoracic into the abdominal cavity. Illustrate and label each branch.

T12 -> where the aorta passes from the thoracic into the abdominal cavity branches (unpaired) celiac artery (T12) superior mesenteric artery (L1) inferior mesenteric artery (L3) median sacral artery branches (paired) middle adrenal arteries renal arteries (L1-L2) gonadal arteries (between L2 and L3) inferior phrenic arteries lumbar arteries termination: bifurcates into right and left common iliac arteries at L4

Question 5: Diagram the hepatic portal venous system. Be sure to include these tributaries -- left gastric vein, splenic vein, inferior and superior mesenteric veins, paraumbilical vein, and retroperitoneal veins associated with the ascending and descending colons. Using the illustration provided, indicate four possible sites where portosystemic anastomoses occur; for each site, illustrate and label the vessels that are involved.

Sites of Anastomoses 1)Between the esophageal veins, draining into either the azygous vein (systemic) or the left gastric vein 2)Between the inferior and middle veins draining into the IVC system (systemic system) and the superior rectal vein (portal system) 3) Para-umbilical veins of the anterior abdominal wall (portal system) and the peri-umbilical superficial epigastric veins (systemic system) 4) Twigs of the colic veins (portal system) with retroperitoneal veins (systemic system)

Question 3: On the drawing below, please label the bones, and diagram the inferior vena cava in its entirety, from its point of formation to its termination in the right atrium. Please note at which vertebral level it traverses the diaphragm. Illustrate and label each tributary at its correct vertebral level. Note the veins that drain to different locations on the right versus left side.

T8: when the IVC traverses the diaphragm T8: paired inferior phrenic veins T8: hepatic veins 3 (left, middle, right) L1: right suprarenal vein Left suprarenal vein is a branch of the left renal vein L1: renal veins L2: right gonadal vein Left gonadal vein is a branch of the left renal vein L1-L5: lumbar veins (1st, 2nd, 3rd, 4th lumbar veins) L5: common iliac veins (origin) Common iliac veins - T12: left and right ascending lumbar veins Median sacral vein enters into the left common iliac vein at L5 The internal and external iliac veins join at the sacroiliac joint https://radiopaedia.org/articles/inferior-vena-cava-1?lang=us

Question 3: A "filter" can be placed in the inferior vena cava (IVC) of patients in whom a DVT develops and who have contraindications for anticoagulation therapy. The filter is usually introduced through the femoral vein. Why?

The femoral vein is typically readily palpable and is a nearly direct conduit to the IVC. It is not near any critical structures that could be inadvertently punctured while obtaining access.

Question 2: Describe the marginal artery (of Drummond).

an anastomotic connection between the ileocolic, right colic and middle colic arteries. It runs parallel with the large intestine and connects to branches of the inferior mesenteric artery

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