Chapter 4

1. What three structures comprise the portal triad?

1. (B) The three structures that make up the portal triad are the hepatic artery, portal vein, and bile duct. (1:82)

22. A renal sonogram is performed and an echogenic well-defined mass is identified in the renal cortex. This is characteristic of which of the following?

22. (A) Angiomyolipoma is an uncommon benign renal mass, which is composed of blood vessels, fat, and muscle. They appear on ultrasound as an echogenic well-defined mass located in the renal cortex. When the mass is small, the patient is usually asymptomatic. Symptoms usually do not appear until the mass enlarges and bleeds, which causes severe flank pain and hematuria. (10:152)

123. Islet cell tumors of the pancreas are most likely to be located in which portion of the pancreas?

123. (D) Body and tail. Islet cell tumors of the pancreas are well-circumscribed solid masses with low-level echoes and are frequently found in the body and tail of the pancreas and rarely in the head of the pancreas. (2:219, 223)

124. What do the celiac axis branches consist of?

124. (C) The celiac artery has three branches: the common hepatic artery, left gastric artery, and the splenic artery. (6:72)

125. What is the most common benign mass of the spleen?

125. (A) The most common benign mass of the spleen is a cavernous hemangioma. The most common malignant tumor of the spleen is an angiosarcoma. Congenital cysts of the spleen are rare, and lymphomas are not benign masses. (6:234)

126. Which of the following is the membrane that lines the abdominal cavity?

126. (B) The parietal peritoneum lines the abdominal cavity. Organs are intraperitoneal if they are surrounded by peritoneum or retroperitoneal if only their anterior surface is covered. (7:35-37)

127. A normal functioning transplanted kidney will appear sonographically as which of the following?

127. (C) A normally functioning transplanted kidney will have the same sonographic appearance as a normal kidney located in the renal fossa. (7:400)

128. When performing a gallbladder examination, why is the patient asked to be NPO (nothing by mouth) for approximately 6 hours before the examination?

128. (D) When food containing fat enters the small intestines, cholecystokinin is released into the bloodstream, which activates the contraction of the gallbladder and the relaxing of the sphincter of Oddi. (7:198)

224. The laboratory findings of renal failure include which of the following?

224. (B) Increased levels of creatinine and blood urea nitrogen are seen in renal failure. (2:251)

225. The head of the pancreas is located to the right of which of the following?

225. (E) The head of the pancreas is to the right of the portal splenic confluence, anterior to the inferior vena cava, and medial to the c-loop of the duodenum. (2:196)

226. What is Crohn's disease?

226. (C) Crohn's disease is chronic inflammation of the bowel. It usually affects the ileum but may affect both the small and the large intestines. It is most often seen in young adults. (7:296)

227. A resistive index (RI) >0.70 in a kidney is consistent with early

227. (B) An early sign of obstructive hydronephrosis is the intrarenal vessels having an RI >0.70. The RI returns to normal after 72 hours. (2:285)

228. A postrenal transplant perirenal fluid collection can be all of the following except

228. (A) A parapelvic cyst is located in the renal hilum. A hematoma, lymphoma, abscess, and urinoma are perirenal fluid collections that can readily be identified on ultrasound. (2:269, 292)

229. Which of the following describes the Doppler characteristic of the venous blood flow in a varicocele?

229. (A) Increased blood flow within the dilated vessels can be seen with a Valsalva maneuver. Varicoceles are more common on the left side. (4:750)

23. The gastroduodenal artery is a branch of which of the following?

23. (C) The gastroduodenal artery is a branch of the common hepatic artery. It is a landmark for the anterior lateral aspect of the head of the pancreas. (7:241)

233. Fatty infiltration of the liver can be assessed sonographically by visualizing which of the following?

233. (C) In cases of moderate to severe fatty infiltration, the echogenicity of the liver will be increased. The diaphragm and intrahepatic vessel borders may be difficult to see because of the increased attenuation of the liver parenchyma. (2:134, 135)

129. Where are transplanted kidneys usually placed?

129. (B) A transplanted kidney is usually placed in the pelvis along the iliopsoas margin and anterior to the psoas muscle. The ureter of the donor kidney is anastomosed to the bladder. The donor renal artery is anastomosed to the external iliac artery, while the renal vein is connected to the internal iliac vein. (7:399)

13. What is the most common location of pancreatic pseudocyst?

13. (A) The most common location of a pancreatic pseudo-cyst is in the lesser sac, which is located anterior to the pancreas and posterior to the stomach. (2:216)

130. What do Klatskin tumors cause?

130. (A) Klatskin tumors arise at the junction of the right and left hepatic ducts and causes dilation of the intrahepatic ducts with no dilatation of the extrahepatic ducts. (6:141, 142)

131. Which of the following is not located in the peritoneal cavity?

131. (D) Pancreas. The liver, spleen, hepatic veins, and gallbladder are located in the peritoneal cavity. The great vessels, pancreas, adrenal glands, and kidneys are not surrounded by peritoneum; therefore, they are located in the retroperitoneal cavity. (2:328)

132. The splenic artery

132. (C) The splenic artery originates from the celiac axis and courses along the superior aspect of the pancreas body and tail. (6:72)

133. Artifactual echoes may occur within cysts owing to each of the following except

133. (C) Artifacts result from a variety of sources including thickness and side-lobe artifacts, reverberation artifacts, electronic noise, and range in ambiguity effects. Edge effects cause acoustic shadowing owing to reflection and refraction of sound. (6:12, 13)

134. In which of the following ways does ascites sonographically affect the liver?

134. (B) When ascites is present, it acts as an acoustic window. Therefore, the liver will appear more echogenic. There is always posterior acoustic enhancement when the sound travels through fluid. (6:11)

135. If the ultrasound beam passes through a fatty tumor within the liver, and we know that the speed of sound in fat is lower than in soft tissue, where will this fatty tumor be placed?

135. (A) All ultrasound equipment is calibrated at 1,540 m/s, the speed of sound in soft tissue. When the ultrasound beam goes through a fatty tumor with a lower propagation speed, the tumor will appear farther away than its actual distance. (6:13)

136. Which of the following is representative of a post-trauma fluid collection located between the diaphragm and the spleen?

136. (D) A fluid collection located between the diaphragm and the spleen may represent a subphrenic abscess. (2:348)

137. Which of the following can be displaced by a retroperitoneal sarcoma?

137. (B) If a mass is solid, displacement of adjacent organs will aid in helping to evaluate the origin of the mass. In a retroperitoneal sarcoma, the kidney, spleen, and pancreas would be displaced anteriorly. (2:348, 349)

138. Splenomegaly may be caused by all of the following except which one?

138. (C) Splenomegaly may be caused by congestion, i.e., portal thrombosis, trauma, infection, Hodgkin's disease, lymphoma, neoplasms, storage diseases, and polycythemia vera. (2:318, 319)

139. The causes of a large gallbladder include all of the following except

139. (A) Adenomyomatosis is a benign infiltrative disease that causes a diffuse thickening of the gallbladder wall. It does not cause enlargement of the gallbladder. (6:134, 135)

14. Which of the following is true about the extrahepatic portion of the falciform ligament?

14. (B) The extrahepatic portion of the falciform ligament can be visualized when there is massive ascites. The falciform ligament contains the ligamentum of teres and will appear sonographically as an echogenic linear band attaching the bare area of the liver to the anterior abdominal wall. (2:114)

140. Where are the quadratus lumborum muscles located?

140. (D) Posterior to the kidneys are the quadratus lumborum muscles, diaphragm, psoas muscle, and twelfth rib. (6:248)

141. All of the following are associated with cirrhosis except

141. (D) Patients with chronic cirrhosis will have a small nodular fibrotic liver, which impedes blood flow through the liver causing collateral vessel development and portal hypertension. Ascites, peripheral edema, and splenomegaly are usually secondary to the increase in pressure in the portal vein. Liver failure causes jaundice and an increase in the clotting time. Sonographically, the liver is small and echogenic. (7:151)

142. Which of the following is absence of a ureteral jet consistent with?

142. (C) Ureteral jets are not present if there is an obstructive hydronephrosis. A bladder tumor or posterior urethra valves may obstruct urine from exiting the body. In cases of severe obstruction, the increased pressure in the urinary bladder may cause the ureters and renal collecting system to dilate. A parapelvic cyst usually does not cause hydronephrosis. (2:285)

143. A cystic mass that extends from the renal pelvis to outside the renal capsule is

143. (B) An extrarenal pelvis extends from the renal pelvis to outside the renal capsule. One way to differentiate an extrarenal pelvis from hydronephrosis is to place the patient prone. The pressure will collapse the extrarenal pelvis. (6:285, 284)

15. The superior mesenteric artery arises 1 cm below the celiac trunk and courses

15. (C) Anterior and parallel to the aorta. (7:55)

198. Sonographically, one can recognize fatty infiltration of the liver by all of the following except

198. (E) Fatty infiltration of the liver usually causes a diffuse hyperechoic pattern, not a focal pattern. (7:145)

199. Obstruction of the common bile duct by a mass in the head of the pancreas will lead to which of the following?

199. (A) Courvoisier's law states that obstruction of the common bile duct due to pressure from outside the biliary system will lead to an enlarged gallbladder with dilatation of the biliary radicles. (2:218)

2. A 4-year-old boy presents with high blood pressure, hematuria, and a palpable left flank mass. An ultrasound examination is performed, and a solid renal mass is identified. This finding is most characteristic of which of the following?

2. (D) Wilms' tumor, also known as nephroblastoma, is the most common type of renal cancer in children between the ages of 2 and 4 years. The most common symptoms for Wilms' tumor are hematuria and hypertension. (1:1926)

20. Which of the following describes adenomyomatosis of the gallbladder?

20. (D) Adenomyomatosis is a benign proliferation and thickening of the muscle layer and glandular layer of the gallbladder with formation of intramural diverticula called Rokitansky-Aschoff sinuses (RAS). There are three forms: diffuse, segmental, and localized. It is more common in women, with increasing incidence after the age 40 years. (6:134, 135)

235. A patient who has blunt trauma to the abdomen earlier in the day presents with left-upper-quadrant pain and a decrease in hematocrit. An echogenic mass is seen in the spleen. What is this consistent with?

235. (D) The spleen is a common site of blunt abdominal trauma. The hematoma will be contained in the spleen if there is no rupture of the splenic capsule. A decrease in hematocrit is an indication that there is blood loss from the cardiovascular system. (2:321)

202. What is the most common medical disease that causes acute renal failure?

202. (A) Acute tubular necrosis is the most common medical cause of renal disease. Renal infarction is occlusion of a vessel caused by thrombus; it usually occurs in the periphery of the kidney. Patients with diabetes may have small echogenic kidneys, which is the sonographic appearance of chronic renal disease. Nephrocalcinosis disease sonographically appears as echogenic renal pyramids with or without shadowing. (2:289)

207. What term is used to describe onset of pain while scanning over the gallbladder?

207. (C) Sonographic Murphy's sign is pain over the gallbladder region upon palpation on physical examination. Kehr's sign is pain in the left upper quadrant radiating to the left shoulder. It is associated with a ruptured spleen. (6:127)

209. Which one of the following statements concerning the sonographic patterns of periaortic lymph nodes is not correct?

209. (B) Periaortic nodes will displace the superior mesenteric artery anteriorly, not posteriorly. (2:338, 339)

21. What is the most common cause of acute pyelonephritis?

21. (B) The most common cause for acute pyelonephritis is Escherichia coli a Gram-negative rod-shaped bacterium, which invades the renal tissue. It is more common in women than men. (10:142)

236. Which of the following tests can be used to diagnose hemangiomas?

236. (E) A hemangioma has the same sonographic appearance as a live cell adenoma, focal nodular hyperplasia, hepa-tocellular carcinoma, and metastases to the liver. All of these are benign neoplasms that may appear echogenic on ultrasound. Other diagnostic tests can be used to make a definitive diagnosis. (2:148)

239. Which of the following may a jaundiced male child with a hemolytic disorder be found to have?

239. (B) In hemolytic disease associated with abrupt breakdown of large amounts of red blood cells, the reticulo-endothelial cells receive more bilirubin than they can detoxify. Therefore, one would present with an elevated indirect or unconjugated bilirubin. (2:154-155)

24. Identify the vessel that is seen anterior to the aorta and posterior to the superior mesenteric artery.

24. (E) The left renal vein courses transversely across the body to enter into the inferior vena cava. It may be identified sonographically as a tubular anechoic structure between the aorta and superior mesenteric artery. (9:183)

240. Which of the following statements are true?

240. (B) Bowman's capsule and the glomerulus together are termed the renal corpuscle. Extending from Bowman's capsule is a renal tubule. Each tubule has three sections: a proximal tubule, a distal convoluted tubule, and a loop of Henle. Together the Bowman's capsule, glomerulus, and renal tubules constitute a nephron. (7:333-335)

248. Which of the following terms describes a normal variant of the liver in which the right lobe of the liver extends below the lower pole of the right kidney?

248. (D) Riedel's lobe is a normal variant of the right lobe of the liver. There is a tongue-like inferior projection of the right lobe. It extends below the lower pole of the right kidney during normal respiration. (9:86)

25. The liver is covered by a thick membrane of collagenous fibers intermixed with elastic elements. What is this membrane called?

25. (A) Glisson's capsule is a dense fibroelastic membrane that completely surrounds the liver and encloses the portal vein, hepatic artery, and bile ducts within the liver. (4:117)

252. Hydrops of the gallbladder may be secondary to all of the following except which one?

252. (A) Sludge in the gallbladder does not cause hydrops of the gallbladder. Same causes of hydrops include muco-cutaneous lymph node syndrome (Kawasaki's disease), prolonged biliary status, hyperalimentation, and hepatitis. (10:69)

26. Which of the following can cause anterior displacement of the splenic vein?

26. (C) Left adrenal hyperplasia may cause anterior displacement of the splenic vein and posterior or inferior displacement of the left kidney. (7:489)

261. Which of the following conditions may affect the adrenal gland?

261. (E) All of the above are conditions that may affect the adrenal gland. The primary malignancy that metastasize to the adrenal gland can be from the lungs, breast, liver, bones, lymphoma, melanoma, and the gastrointestinal tract. A decrease in oxygen during delivery may cause hemorrhage to the adrenal glands during the neonatal period. (7:489-491)

267. What portion of the pancreas is anterior to the formation of the portal vein?

267. (B) The main portal vein is formed posterior to the neck of the pancreas. (2:201)

268. What is the most common islet cell tumor?

268. (D) The most common functioning islet cell tumor is an insulinoma. Islet cell tumors can either be functional or nonfunctional, benign or malignant. (2:219)

27. Which one of the following vessels originates from the celiac axis and is very tortuous?

27. (A) The celiac axis has three branches, the common hepatic artery, left gastric artery, and splenic artery. Sonographically, only a short section of the splenic artery can be seen because of its tortuous course. (6:72, 73)

10. Where does the pancreatic head lie?

10. (C) The pancreatic head lies caudad to the portal vein and anterior to the inferior vena cava. (2:208)

100. The head of the pancreas is located anterior to which of the following vessels?

100. (A) The head of the pancreas is located anterior to the inferior vena cava. (2:196)

101. What is the lesser sac located between?

101. (B) The lesser sacs are located between the stomach and pancreas. (2:216)

102. Where are the renal pyramids found?

102. (B) The renal pyramids are located in the medulla of the kidney. (2:248)

103. Which of the following is chronic renal disease associated with?

103. (C) In chronic renal disease, both kidneys are small and echogenic. (2:268)

104. A 50-year-old woman with a long history of alcoholism presents with increased abdominal girth. Which of the following is the most probable finding on a sonogram of the abdomen?

104. (B) A long history of alcoholism is a major cause of cirrhosis and ascites often is seen secondarily to cirrhosis. (7:149, 152)

105. Chronic active hepatitis is a progressive destructive liver disease that eventually leads to which of the following?

105. (C) Chronic active hepatitis may progress to cirrhosis. The etiology of chronic active hepatitis is usually idiopathic but may be viral or immunological. (2:148)

106. A 6-year-old child presents with recurrent fever, right-upper-quadrant pain, and jaundice. An abdominal sonogram is performed. The liver and gallbladder appear normal, but a 2-cm cyst is seen communicating with the common bile duct. What does this cystic structure most likely represent?

106. (A) Choledochal cyst is a rare focal cystic dilatation of the common bile duct caused by an anomalous junction of the common bile duct with the main pancreatic duct. The reflux of the pancreatic enzymes causes a weakness of the common bile duct wall and an outpouching of the wall. Choledochal cysts may be associated with gallstones, cirrhosis, and pancreatitis. Clinically, the patient presents with pain, fever, abdominal mass, or jaundice. (2:177)

121. One method to diagnosis renal obstruction is to document a resistive index (RI) of greater than

121. (E) According to Platt et al. an RI of the renal artery greater than 0.70 is 90% accurate in diagnosing renal obstruction. (6:211)

122. Identify the syndrome that is associated with an adrenal mass.

122. (C) Cushing's syndrome is an adrenal disease where there is oversecretion of glucocorticoids. (2:343)

107. A 35-year-old woman presents with a tender neck, and on physical exam, an enlarged thyroid is found. An enlarged inhomogeneous thyroid with irregular borders is seen on the sonogram. What is this most characteristic of?

107. (E) Hashimoto's thyroiditis is chronic inflammation of the thyroid. It is a common cause of hypothyroidism in regions where there is a lack of iodine. The entire thyroid gland is involved, and sonographically, the thyroid is enlarged with irregular borders with decreased heterogeneous echoes. People with Graves' disease present with hyperthyroidism, bulging eyes, and skin thickening. The thyroid is enlarged with increased vascularity. Malignant tumors of the thyroid are rare and have varied appearance on ultrasound, from a single small solid nodule to hypoechoic to being isoechoic with the thyroid tissue. In 50% of cases, there will be calcification. (2:402)

108. What is calcification of the gallbladder wall called?

108. (D) Calcification of part or the entire wall of the gallbladder is called a porcelain gallbladder. It is associated with chronic cholecystitis and gallstones. These patients have a higher risk of carcinoma of the gallbladder. (2:185)

109. A 60-year-old man presents with an abdominal pulsatile mass and high blood pressure. What is this most characteristic of?

109. (A) Patients typically are diagnosed with an aortic aneurysm by a pulsatile mass noted on physical examination. They usually have a history of smoking and vascular disease, such as hypertension. On ultrasound, it is important to measure the diameter of the lumen and the location of the aneurysm in reference to the renal arteries. (2:90, 91)

11. Identify the sonographic pattern that best describes hydronephrosis.

11. (C) Hydronephrosis is a fluid-filled pelvocaliceal collecting system. Sonographically, hydronephrosis has varied appearances from a mildly distended pelvocaliceal collecting system to moderately distended fluid-filled pelvocaliceal collecting system, and in the most severe form, the kidneys appear cystic with very little renal cortical tissue. (2:284, 285)

110. Identify the vessel that may be imaged posterior to the inferior vena cava.

110. (B) The right renal artery courses posterior to the inferior vena cava and may be imaged as a round anechoic structure posterior to the inferior vena cava on a longitudinal scan. (2:84)

111. The retroperitoneal space is defined as the area between which of the following?

111. (A) The retroperitoneal space is the area between the posterior portion of the parietal peritoneum and the posterior abdominal wall muscle. (2:238)

112. An abdominal sonogram is performed, and there is a suggestion of a mass in the head of the pancreas. Identify the other structures that should be evaluated.

112. (A) When there is extrinsic pressure and obstruction of the common bile duct (i.e., a mass in the head of the pancreas), the gallbladder and biliary tree will be enlarged. (6:159-162)

113. Identify the laboratory values that are most consistent for a patient with acute pancreatitis.

113. (C) The serum amylase and lipase both elevate upon the onset of pancreatitis, but amylase reaches its maximum value within 24 hours. Lipase remains elevated for a longer period of time. (7:249)

114. When hypertrophic pyloric stenosis is imaged in the short axis, what is the least measurement of the muscle wall?

114. (B) Hypertrophic pyloric stenosis (HPS) is more commonly seen in males between the ages of 1 week and 6 months. The pylorus is the channel between the stomach and duodenum. When the muscle of the pylorus is thickened, it prevents food from entering the stomach. The child typically presents with projectile vomiting, dehydration, and a palpable olive-size mass in the epigastric region. The diagnosis of HPS is made if the length of the pylorus is greater than 18 mm, the anterior to posterior diameter is greater than 15 mm, or the muscle thickness is greater than 4 mm. (7:587, 588)

115. What is a malignant tumor of the adrenal gland found in children called?

115. (B) Neuroblastoma is a malignant tumor of the adrenal medulla that is found in children. (7:503)

116. Lymph nodes may be confused sonographically with all of the following except

116. (B) Chronic pancreatitis. Enlarged lymph nodes are hypoechoic with no increase in through transmission. Aortic aneurysm, crus of the diaphragm, and bowel may all appear sonographically as hypoechoic. Chronic pancreatitis is imaged as echogenic. (7:512)

117. An abdominal sonogram is performed on a 35-year-old man with a history of primary cancer of the liver who now presents with abdominal pain and increasing abdominal girth. What is this most consistent with?

117. (D) Budd-Chiari syndrome is caused by thrombus in the hepatic veins or in the inferior vena cava causing obstruction of blood flow to the heart. The obstruction may be congenital or acquired. Budd-Chiari is associated with renal cell carcinoma, primary carcinoma of the liver, or prolonged usage of oral contraceptives. It is characterized by abdominal pain, massive ascites, and hepatomegaly. Sonographically, the right lobe of the liver may be small with normal or enlarged caudate lobe. There will either be absence of blood flow in the hepatic veins and inferior vena cava or abnormal blood flow pattern on Doppler. (7:160, 161)

118. During an abdominal sonogram, recanalization of the umbilical vein is identified. What could this be associated with?

118. (E) In response to the increased pressure in the portal vein, which is associated with portal hypertension, there may be recanalization of the umbilical vein, which is located within the ligamentum of teres. (2:154, 155)

119. Which of the following is characteristic of a pelvic kidney?

119. (B) A pelvic kidney is a kidney that has failed to ascend to the renal fossa. It is located in the pelvis but has the same sonographic appearance as a kidney located in the renal fossa. (6:173)

12. A patient presents with a dilated interhepatic duct, dilated gallbladder, and a dilated common bile duct. This is most characteristic of which one of the following levels of obstruction?

12. (B) On a sonographic examination dilatation of the interhepatic ducts, common bile duct, and gallbladder (the gallbladder enlarges before the biliary tree because it has the greatest surface area) is imaged, one should expect the obstruction to be at the distal common bile duct. (2:189)

120. The ureteropelvic junction is located between which of the following?

120. (A) The ureteropelvic junction is where the renal pelvis narrows and joins the proximal portion of the ureter. (6:172)

158. A 1-week-old male infant presents with a left flank mass. An IVP demonstrates a normal right kidney, but there is no visualization of the left kidney. A sonogram is performed and numerous noncommunicating round cystic structures are demonstrated in the left renal fossa, the largest of which is located laterally. No renal parenchyma is identified. The right kidney is normal. This most probably represents which of the following?

158. (C) A multicystic (dysplastic) kidney is a common cause of a palpable neonatal mass. It is usually unilateral. Bilateral multicystic pathology is not compatible with life. (2:270)

159. Which of the following is an echogenic linear line extending from the portal vein to the neck of the gallbladder?

159. (D) The main lobar fissure is a landmark used to document the gallbladder fossa when there is nonvisualization of the gallbladder. It appears sonographically as an echogenic linear structure that extends from the portal vein to the neck of the gallbladder. (2:114)

16. The division by using Couinaud's sections into right and left lobes of the liver is

16. (A) The division by using Couinaud's sections into right and left lobes of the liver is by the imaginary plane, the main lobar fissure. (6:94)

160. What is the most common primary neoplasm of the pancreas?

160. (A) The most common primary neoplasm of the pancreas is an adenocarcinoma. (2:218)

17. Which of the following is the portion of the pancreas that lies posterior to the superior mesenteric artery and vein?

17. (C) A prominent uncinate process of the pancreas lies posterior to the superior mesenteric artery and vein. (2:208; 7:55)

174. The common bile duct is formed by which of the following?

174. (C) The common bile duct is formed from the confluence of the common hepatic duct and the cystic duct. (9:92)

175. Which of the following is usually the cause of an aneurysm?

175. (B) Atherosclerosis is the most common cause of an aneurysm. (2:90)

18. Which vessel courses along the posterior surface of the body and tail of the pancreas?

18. (E) The splenic vein courses transversely across the body along the posterior portion of the body and tail of the pancreas. (6:151)

180. Sonographers are sometimes asked to assist in sonographic-guided needle thoracentesis. What is the recommended position for the patient?

180. (B) Sitting upright. The correct positioning for the patient undergoing needle thoracentesis is significant for successful procedure. (12:118)

181. Patients with hyperthyroidism caused by Graves' disease is most likely to have which of the following biochemical markers?

181. (A) Graves' disease is an autoimmune disease that affects the thyroid gland, eyes, and the skin. The name derives from Robert Graves, MD, and Irish physician who was the first to describe this type of hyperthyroidism. The biochemical abnormality is decreased thyroid-stimulating hormone and increased T3 and T4. (2:520; 7:665, 666)

182. What is the sonographic characteristic of Hashimoto's thyroiditis?

182. (B) Multiple hypoechoic micronodules. Hashimoto's thy-roiditis is a chronic lymphocytic thyroiditis. The disease is autoimmune and most frequently caused by hypothyroidism. The typical sonographic appearance is enlargement of the thyroid glands with multiple hypoechoic micronodules. (1:762)

183. Which of the following is associated with an increase with the biochemical marker CEA?

183. (D) CEA stands for carcinoembryonic antigen, a type of protein molecule found in tumor cells and the developing fetus. Both benign and malignant conditions can increase CEA. Types of cancer that can cause an increase in CEA are pancreas, liver, stomach, breast, and lungs. An increase in CEA-125 is associated with ovarian cancer. Increased levels are also seen in non-cancer conditions, such as inflammation, peptic ulcers, and ulcerative colitis. Smokers can have higher CEA values than nonsmok-ers. A consistent increase in CEA after surgical removal of a cancerous tumor is suggestive of relapse. (13:490)

184. A 35-year-old man was found to have an abdominal mass, and a sonographically guided fine needle aspiration biopsy is required. What kind of anesthesia is normally used for this type of procedure?

184. (D) Fine needle biopsies are typically performed with local anesthesia. (1:2072; 2:436-442)

185. Pneumobilia is most likely seen after which of the following procedures?

185. (D) Pneumobilia (air within the biliary tree) is commonly seen after previous biliary intervention: common bile duct stents, choledochoduodenal fistula, emphyse-matous cholecystitis, and gallstone ileus with endoscopic retrograde cholangiopancreatography (ERCP) are the most common. (1:180; 4:30, 31)

186. Which of the following anatomical structures is not seen anterior to the inferior vena cava in the abdomen?

186. (E) The right artery arises from the anterolateral aorta and courses posterior to the inferior vena cava (IVC) to the right renal hilum. The pancreas, duodenum, hepatic veins, caudate lobe, and main lobar fissure are located anterior to the IVC. (2:111; 4:193)

187. Hashimoto's disease is a chronic disease of which of the following glands?

187. (B) Hashimoto's disease is an autoimmune disease that affects the thyroid. It is also known as Hashimoto thyroiditis and is the most common cause for hypothyroidism. (2:522; 4:297)

188. What is the most common cause for acute pancreatitis in the United States?

188. (D) The most common cause for acute pancreatitis in the United States are gallstones (cholelithiasis) and alcohol abuse; other less common causes include abdominal trauma, peptic ulcer, pancreatic carcinoma, and use of certain medications. (2:255; 4:90)

19. Sonographically, where can the gastroesophageal junction be visualized?

19. (B) The gastroesophageal junction can sonographically be visualized anterior to the aorta and posterior to the left lobe of the liver. (2:231)

197. A 35-year-old man presents with right-upper-quadrant pain and recurrent attacks of pancreatitis. His laboratory results would be expected to indicate which of the following?

197. (C) A rise in lipase level indicates acute pancreatitis or pancreatic carcinoma. Amylase levels will also rise with acute pancreatitis but do not stay as elevated as or as specific as lipase levels. (2:204, 205)