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Workbook for Diagnostic Medical Sonography

A GUIDE TO CLINICAL PRACTICE, ABDOMEN

AND SUPERFICIAL STRUCTURES

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Workbook for Diagnostic Medical Sonography

Bridgette M. Lunsford, MAEd, RVT, RDMS Clinical Applications Specialist

GE Healthcare – Ultrasound Arlington, Virginia

Diane M. Kawamura, PhD, RT(R), RDMS Professor, Radiologic Sciences

Weber State University Ogden, Utah

A GUIDE TO CLINICAL PRACTICE,

ABDOMEN AND SUPERFICIAL STRUCTURES

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Publisher: Julie K. Stegman Senior Product Manager: Heather Rybacki Product Manager: Kristin Royer Marketing Manager: Shauna Kelley Design Coordinator: Joan Wendt Art Director: Jennifer Clements Manufacturing Coordinator: Margie Orzech Production Services: Absolute Service, Inc.

Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business

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Third Edition

All rights reserved. This book is protected by copyright. No part of it may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in the book prepared by individuals as part of their offi cial duties as U.S. government employees are not covered by the above-mentioned copyright.

Printed in China.

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Contents

1 Introduction ……………………………………………………………………………………………..1

PART 1 • ABDOMINAL SONOGRAPHY

2 The Abdominal Wall and Diaphragm …………………………………………………………..9

3 The Peritoneal Cavity ………………………………………………………………………………17

4 Vascular Structure ……………………………………………………………………………………27

5 The Liver ………………………………………………………………………………………………..37

6 The Gallbladder and Biliary System …………………………………………………………..49

7 The Pancreas …………………………………………………………………………………………..59

8 The Spleen ……………………………………………………………………………………………..69

9 The Gastrointestinal Tract …………………………………………………………………………79

10 The Kidneys ……………………………………………………………………………………………89

11 The Lower Urinary System ………………………………………………………………………101

12 The Prostate Gland ………………………………………………………………………………..111

13 The Adrenal Glands ……………………………………………………………………………….119

14 The Retroperitoneum …………………………………………………………………………….129

PART 2 • SUPERFICIAL STRUCTURE SONOGRAPHY

15 The Thyroid Gland, Parathyroid Glands, and Neck …………………………………….137

16 The Breast …………………………………………………………………………………………….147

17 The Scrotum …………………………………………………………………………………………159

18 The Musculoskeletal System ……………………………………………………………………169

PART 3 • NEONATAL AND PEDIATRIC SONOGRAPHY

19 The Pediatric Abdomen ………………………………………………………………………….177

20 The Pediatric Urinary System and Adrenal Glands ……………………………………..185

21 The Neonatal Brain ………………………………………………………………………………..193

22 The Infant Spine …………………………………………………………………………………….205

23 The Infant Hip Joint ……………………………………………………………………………….213

v

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vi CONTENTS

PART 4 • SPECIAL STUDY SONOGRAPHY

24 Organ Transplantation ……………………………………………………………………………221

25 Emergency Sonography …………………………………………………………………………227

26 Foreign Bodies ………………………………………………………………………………………233

27 Sonography-Guided Interventional Procedures …………………………………………237

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1

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Anechoic

2. Echogenic

3. Echopenic

4. Isoechoic

5. Heterogeneous

6. Homogeneous

7. Hyperechoic

8. Hypoechoic

9. Specifi city

10. Sensitivity

11. Accuracy

a. Describes portions of an image that are not as bright as surrounding tissues or are less bright than normal

b. How well an examination documents whatever disease or pathology is present

c. Describes tissues or organ structures that have several different echo characteristics

d. Describes a structure that is less echogenic or has few internal echoes

e. Describes the portion of an image that appears echo free

f. Ability of the examination to fi nd disease that is present and not fi nd disease that is not present

g. Describes image echoes brighter than surrounding tissues or brighter than is normal for that tissue or organ

h. Refers to imaged echoes of equal intensity i. Describes structures of equal echo density j. How well an examination documents normal

fi ndings or excludes patients without disease k. Describes an organ or tissue that is capable of

producing echoes by refl ecting the acoustic beam

1 Introduction

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2 1 — INTRODUCTION

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

A.

D.

C.

B.

1. Patient Positioning – What position is the patient in?

B.

C.

A. C.

2. Longitudinal Plane

B.

D.

A. C.

3. Coronal Plane

B.

D.

A. C.

4. Transverse Plane

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1 — Introduction 3

Sagittal Coronal

A. C.

D.

B.

H.

F.

G.E.

5. Endovaginal Planes

Sagittal Coronal or Transverse

D.

B.

H.

F.

A. C. G.E.

6. Endorectal Planes

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4 1 — INTRODUCTION

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. When performing a neurosonography examination, the top of the image represents which scanning surface? a. Anterior

b. Posterior

c. Superior

d. Inferior

2. When scanning in the longitudinal, sagittal plane, where is the transducer indicator located in relation to the organ of interest? a. At the 12:00 position

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

3. When scanning in the transverse plane, where is the transducer indicator located in relation to the organ of interest? a. At the 12:00 position

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

4. When performing a neonatal brain examination, where is the transducer indicator located in the sagittal plane? a. At the 12:00 position

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

5. When performing a neonatal brain examination, where is the transducer indicator located in the coronal plane? a. At the 12:00 position

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

6. When scanning in the longitudinal, sagittal plane, which of the following is NOT demonstrated in the image presentation? a. Anterior

b. Cephalic

c. Right

d. Caudal

Sagittal: Anterior Fontanelle Coronal: Anterior Fontanelle

A. C.

D. H.

B. F.

G.E.

7. Cranial Fontanelle Planes

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1 — Introduction 5

7. When scanning in the transverse plane on the anterior surface, which of the following is NOT demonstrated in the image presentation? a. Posterior

b. Superior

c. Right

d. Left

8. Which of the following structures would NOT normally produce acoustic enhancement? a. Urinary bladder

b. Simple kidney cyst

c. Gallbladder

d. Gallstone

9. Which of the following is NOT a sonographic criterion of a simple cyst? a. Posterior acoustic shadowing

b. Anechoic center

c. Well-defi ned posterior wall

d. Edge-shadowing artifact

10. If a kidney stone is diagnosed with an abdominal sonogram but further testing reveals that the kidney is normal, what is this result called? a. A true-positive result

b. A true-negative result

c. A false-positive result

d. A false-negative result

11. If a kidney stone is diagnosed with an abdominal sonogram and further testing also fi nds a kidney stone, what is this result called? a. A true-positive result

b. A true-negative result

c. A false-positive result

d. A false-negative result

12. The abdominal sonogram appears normal; however, a CT reveals a mass in the liver. What is this result called? a. A true-positive result

b. A true-negative result

c. A false-positive result

d. A false-negative result

13. If the number of false-negative examinations increases, what happens to the sensitivity of the examination? a. The sensitivity will increase

b. False-negative results do not affect the sensitivity

c. The sensitivity will decrease

d. The sensitivity will remain the same

14. The likelihood of disease actually being present if the sonogram is positive is called what? a. The negative predictive value

b. The positive predictive value

c. Sensitivity

d. Specifi city

15. Which term describes the ability of the examination to fi nd diseases that are present and not fi nd diseases that are not truly present? a. Sensitivity

b. Specifi city

c. Effi cacy

d. Accuracy

FILL-IN-THE-BLANK

1. The liver and spleen are located on opposite sides of

the body and are therefore .

2. In directional terms, the lungs are

to the liver.

3. The plane is a vertical plane that

runs through the body and divides it into right and

left sections.

4. The vertical plane that divides the body into equal right

and left halves is called the plane.

5. In the position, the patient is lying

supine on the examination table with his or her head

lower than his or her feet.

6. The plane is a horizontal plane

that is perpendicular to the sagittal plane and divides

the body into superior and inferior portions.

7. The plane is a vertical plane that

divides the body into anterior and posterior portions.

8. When performing an endovaginal examination, in both

the sagittal and coronal planes the

anatomy is located at the apex of the image.

9. An organ may appear to have an abnormal

echogenicity if disease is present or a poor

examination technique is used, such as incorrect

settings.

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6 1 — INTRODUCTION

10. Fluid-fi lled structures, such as the gallbladder, urinary

bladder, or simple cysts, appear .

11. The normal testicle is described as

whereas the normal kidney appears .

12. The reduced echo amplitude found beyond a highly

attenuating object such as a kidney stone is called an

acoustic .

13. An artifact called may be seen at

the near wall of a simple cyst.

14. A structure contains both solid

and fl uid components and will usually exhibit both

anechoic and echogenic areas on the sonogram.

15. The preliminary report, which is also referred to

as the , should

include the sonographic fi ndings but should not

include a diagnosis.

SHORT ANSWER

1. List the sonographic criteria that defi ne a simple cyst.

2. What information should the sonographer include in his or her preliminary report? What information should be avoided?

3. What terminology can be used to describe a solid mass?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What is the name of the artifact that the large white arrows are pointing to?

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1 — Introduction 7

2. What type of artifact are the large white arrows pointing to? The small arrows are pointing to a cyst in the kidney. What term could be used to describe this structure?

3. What term could you use to describe the echotexture of the kidney cortex (K) to the liver parenchyma (L)? What about the echotexture of the mass (M) to the kidney cortex? Would you describe the mass as heterogeneous or homogeneous?

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8 1 — INTRODUCTION

4. What one term would you use to describe the internal echo pattern of this mass?

CASE STUDIES

1. A 38-year-old woman with right upper quadrant pain presents for an abdominal sonogram. What steps must the sonographer take prior to starting the examination that will enable him or her to provide the best possible examination?

2. You have been working on a research study. You have scanned 73 patients. Out of the 73 patients, 35 had a true-positive result and 31 had a true-negative result. There were 6 false-negative results and 1 false-positive result. From these statistics, calculate the sensitivity, specifi city, and accuracy of the examination.

5. What term would be used to describe the echotexture of the mass (arrows) in comparison to the surrounding liver parenchyma?

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9

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Abscess

2. Ascites

3. Aponeurosis

4. Ecchymosis

5. Erythema

6. Fascia

7. Linea alba

8. Omphalocele

9. Peristalsis

10. Pleural effusion

11. Pneumothorax

12. Rectus abdominis

a. Redness of the skin due to infl ammation b. Long, vertical, paired abdominal muscles that run

from the xiphoid process to the symphysis pubis c. Skin discoloration caused by the leakage of blood

into the subcutaneous tissues d. Cavity containing dead tissue and pus that forms due

to an infectious process e. Fibrous tissue network that is richly supplied by

blood vessels and nerves located between the skin and the underlying structures

f. Accumulation of serous fl uid in the peritoneal cavity g. Rhythmic contraction of the GI tract that propels

food through it h. Fibrous structure that runs down the midline of the

abdomen from the xiphoid process to the symphysis pubis

i. Fluid accumulation in the pleural cavity j. Collapsed lung that occurs when air leaks into the

space between the chest wall and lung k. Layers of fl at fi brous sheets composed of strong

connective tissue, which serve as tendons to attach muscles to fi xed points

l. Congenital defect in the midline abdominal wall that allows abdominal organs to protrude through the wall into the base of the umbilical cord

PART 1 • ABDOMINAL SONOGRAPHY

2 The Abdominal Wall and Diaphragm

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10 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

E. A.

D.

(Boundary indefinite and overlapping)

Posterior

Left lateral (flank)

Antero-lateral

Anterolateral

B.

C.

1. Transverse section of the abdominal wall

A.

G.

B.

C. D. E. F.

2. Subcutaneous layers of the abdominal wall

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2 — The Abdominal Wall and Diaphragm 11

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following has the primary function of attaching muscles to fi xed points? a. Superfi cial fascia

b. Deep fascia

c. Subcutaneous tissue

d. Aponeuroses

2. Which of the following muscles is not a paired muscle? a. Pyramidalis muscle

b. External oblique

c. Rectus abdominis

d. Transverse abdominis

3. Which of the following is an anatomical area where vessels can enter and exit the abdominal cavity and is a potential site for hernias? a. Linea alba

b. Inguinal canal

c. Umbilicus

d. Rectus sheath

4. Which of the following is a true statement about the right crus of the diaphragm? a. It can be seen sonographically anterior to the

abdominal aorta

b. It is shorter than the left crus of the diaphragm

c. It can be seen anterior to the IVC

d. It appears anterior to the caudate lobe

5. Which of the following muscles is not part of the anterolateral abdominal wall? a. Pyramidalis muscle

b. Psoas muscle

c. Rectus abdominis

d. External oblique

6. Which statement regarding the diaphragm is FALSE? a. The right dome of the diaphragm is slightly

higher than the left

b. The diaphragmatic apertures allow the esophagus, blood vessels, and nerves to pass between the chest and abdomen

c. The central portion of the diaphragm descends during inspiration and ascends during expiration

d. Due to diaphragmatic contraction, the IVC dilates during inspiration

7. Which transducer is best suited for a sonographic examination of the superfi cial abdominal wall? a. 12 MHz linear array

b. 4 MHz curved array

c. 3 MHz phased array

d. 4 MHz linear array

8. Which of the following is an infl ammatory response? a. Hematoma

b. Hernia

c. Abscess

d. Lipoma

9. In order to determine if an abscess is intraperitoneal or extraperitoneal, what structure must the sonographer demonstrate? a. Linea alba

b. Peritoneal line

c. Rectus abdominus

d. Diaphragm

10. Which of the following may be a contraindication to sonography-guided aspiration? a. Septations within the abscess

b. Particulate debris fl oating within the abscess

c. An anechoic abscess with increased through transmission

d. An echogenic abscess

11. Which of the following statements regarding hematomas is FALSE? a. Postsurgical hematomas are usually retroperitoneal

b. The echogenicity and sonographic appearance of a hematoma will vary depending on its age

c. The most common superfi cial abdominal wall hematomas occur within the rectus sheath

d. Hematomas are associated with muscular trauma that results in hemorrhage

12. What is the most common content in an abdominal wall hernia? a. Liver

b. Bowel

c. Free fl uid

d. Fat

13. Which of the following is not a ventral hernia? a. Umbilical

b. Inguinal

c. Hypogastric

d. Epigastric

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12 PART 1 — ABDOMINAL SONOGRAPHY

14. What is the most common type of ventral hernia? a. Umbilical

b. Inguinal

c. Hypogastric

d. Epigastric

15. Which of the following is the most common benign tumor of the abdominal wall? a. Desmoid tumor

b. Sarcoma

c. Neuroma

d. Lipoma

16. Which of the following typically occurs when a nerve is damaged during surgery? a. Desmoid tumor

b. Sarcoma

c. Neuroma

d. Lipoma

17. Which of the following is another term for pleural effusion? a. Hydrothorax

b. Ascites

c. Eventration

d. Pneumothorax

18. Which of the following is an abnormal elevation of the diaphragm due to a developmental anomaly? a. Pleural effusion

b. Eventration

c. Diaphragmatic paralysis

d. Diaphragmatic hernia

19. Over half of infants born with a congenital diaphragmatic hernia die from what medical condition? a. Cardiac failure

b. Infection

c. Renal failure

d. Respiratory failure

20. Which of the following may be seen in the thoracic cavity in a fetus with a congenital diaphragmatic hernia? a. Liver

b. Spleen

c. Stomach

d. All of the above may be seen

FILL-IN-THE-BLANK

1. The human body is divided into the ventral and

dorsal cavities. The ventral cavity is separated by the

diaphragm into the cavity and the

cavity.

2. The superfi cial fascia inferior to the umbilicus is

divided into two layers: the fascia,

a fatty layer containing small vessels and nerves,

and the fascia, which is a deep

membranous layer.

3. The lines the

abdominopelvic cavity and is formed by a single layer

of epithelial cells and supporting connective tissue.

4. The is a fi brous

compartment that contains the rectus abdominis,

pyramidalis muscle, blood and lymphatic vessels,

and nerves.

5. The posterior abdominal wall is composed of

three paired muscles: the

, , and

.

6. When evaluating a superfi cial lesion in the abdominal

wall, a may be

used to eliminate the “main bang” artifact.

7. Sonographically, the diaphragm is seen as a thin

band in children and adults and a

band in fetuses.

8. Three main categories of disease that affect

the abdominal wall include ,

, and changes.

9. The four clinical indications of an infl ammatory

response are , ,

, and .

10. The shape of an abscess can vary but the typical

shape is or .

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2 — The Abdominal Wall and Diaphragm 13

11. If edema is present after an injury, a contused

abdominal muscle may appear and

more .

12. Superfi cial abdominal wall hematomas most commonly

occur within the .

13. Discoloration of the abdominal wall called

and a falling

value are often clinical signs of a rectus sheath

hematoma.

14. A is a collection of serum that

results from a surgical procedure or from the

liquefaction of a hematoma and typically appears

anechoic to hypoechoic sonographically.

15. The two main categories of abdominal wall hernias

are and .

16. Two complications that can occur with midline

hernias include , which can

compromise the blood supply and cause ischemia,

and , which occurs when the

contents of the sac cannot be pushed back into the

abdominal cavity.

17. When evaluating a hernia with sonography, the

can be used to

demonstrate widening of the hernia and movement

of the hernia contents.

18. Sonographically, a

is diagnosed when fl uid is

visualized superior to the diaphragm.

19. Paralysis of one hemidiaphragm can be detected

sonographically by showing

or motion on the affected side

and normal or motion on the

contralateral side.

20. A diaphragmatic hernia allows

contents such as , ,

and to enter the thoracic cavity.

SHORT ANSWER

1. Sonographically, how would one distinguish ascites from a pleural effusion?

2. Describe the process of abscess formation and resolution.

3. You receive a request to perform an examination of the anterior abdominal wall on a patient with a recent history of abdominal surgery. The area surrounding the incision is red and warm to the touch and the referring physician is concerned about the presence of an abscess. What techniques and precautions will you use to limit the spread of infection to this and subsequent patients?

4. A 68-year-old man presents with a clinical history of an umbilical hernia post aortic aneurysm repair. You scan over the area and are not sure that you can visualize the hernia. What technique will you use to hopefully make the hernia more visible and what fi ve things must you evaluate when performing an examination on an abdominal hernia?

5. You receive a request to perform a portable chest sonogram in the ICU on a patient with suspected right hemidiaphragmatic paralysis. Describe the exam protocol you will follow and what factors you will be looking for.

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14 PART 1 — ABDOMINAL SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. This image was taken at the level of the umbilicus and represents a periumbilical abscess (arrowheads). How would you describe the mass sonographically? What are the long arrows pointing to? Why does that occur?

2. What anatomic structure are the arrows pointing to? What does the number 1 represent? What does the number 2 represent?

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2 — The Abdominal Wall and Diaphragm 15

3. What anatomic structure are the arrows pointing to? What does the number 1 represent?

4. Describe the sonographic appearance of the lipoma seen within the anterior abdominal wall. What layer does the number 1 represent? Number 2? What structure do the arrows represent?

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16 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

Review the images and answer the following questions.

1. A neonate presents for an abdominal sonogram a few hours after delivery to follow up an abnormality seen on a prenatal sonogram. This image was taken in the right upper quadrant and demonstrates the diaphragm indicated by the letter D. Liver is seen both superior and inferior to the diaphragm. What is the likely diagnosis? What causes this abnormality and what is the most common complication associated with it?

2. A patient presents for a sonogram of the anterior abdominal wall. The patient has a recent history of abdominal surgery and now presents with pain, tenderness, and erythema around the incision site. This sagittal image was taken at the incision site. Describe the image and discuss the probable diagnosis based on the history and image. What is the likely treatment for this patient and is aspiration under sonographic guidance an option?

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17

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Abscess

2. Ascites

3. Bare area

4. Biloma

5. FAST scan

6. Hematoma

7. Hemoperitoneum

8. Hilum

9. Iatrogenic

10. Lymphocele

11. Mesentery

12. Peritoneal organs

13. Parietal peritoneum

14. Retroperitoneal organs

15. Seroma

16. Visceral peritoneum

a. Caused by treatment; either intentional or unintentional

b. Fluid collection composed of blood products located adjacent to or surrounding transplanted organs

c. Surface area of a peritoneal organ devoid of peritoneum

d. Peritoneum encasing peritoneal organs e. Pocket of infection containing pus, blood, and

degenerating tissue f. Solid organs within the peritoneal cavity that are

covered by visceral peritoneum g. Collection of bile that can occur with trauma or

rupture of the biliary tract h. Area of an organ where blood vessels, lymph, and

nerves enter and exit i. Free fl uid within the peritoneal cavity j. An extravasated collection of lymph k. Peritoneum lining the walls of the peritoneal cavity l. Two layers of fused peritoneum that conduct nerves,

lymph, and blood vessels between the small bowel/ colon and the posterior peritoneal cavity wall

m. Triage ultrasound examination performed to detect free fl uid that would indicate bleeding

n. Organs posterior to the parietal peritoneum, which are typically covered on their anterior surface or fatty capsule by parietal peritoneum

o. Extravasated collection of blood within the peritoneal cavity

p. Extravasated collection of blood localized within a potential space or tissue

3 The Peritoneal Cavity

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18 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

B.

C.

D. E.

F.

G.

Midclavicular lines

A.

Transpyloric plane Subcostal plane

I.

Intertubercular plane

H.

1. Addison’s lines – Label the nine abdominopelvic regions.

B.

C.

Median plane

A.

Ubmilicus

Transumbilical plane

D.

2. Quadrants of the abdominopelvic cavity – Label the four quadrants.

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3 — The Peritoneal Cavity 19

Transverse mesocolon

Left colic flexure

Transverse colon

Right colic flexure

A.

Ascending colon

Tenia coli

Descending colon

Root of mesentery of small intestine

B.C.E. D.

Phrenicocolic ligament

F.

3. Potential spaces – Label the potential spaces.

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following methods is used to divide the abdominopelvic cavity into nine regions by drawing two vertical and two horizontal lines? a. McBurney’s lines

b. Murphy’s lines

c. Xyphoid lines

d. Addison’s lines

2. Peritoneum that surrounds the abdominal organs is referred to as: a. Visceral peritoneum

b. Hilar peritoneum

c. Parietal peritoneum

d. Retroperitoneum

3. The lesser sac contains which of the following organs? a. Liver

b. Stomach

c. Pancreas

d. The lesser sac does not contain any organs

4. Which of the following spaces is most likely to contain a pancreatic pseudocyst? a. Lesser sac

b. Greater sac

c. Hepatorenal space

d. Left paracolic gutter

5. Which of the following is another name for the rectouterine space? a. Pouch of Douglas

b. Posterior cul-de-sac

c. Rectovaginal pouch

d. All of the above

6. Which of the following potential spaces is commonly referred to as Morrison’s pouch? a. The left anterior subphrenic space

b. The left posterior suprahepatic space

c. The hepatorenal space

d. The right subphrenic space

7. Which of the following potential spaces is located between the anterior wall of the urinary bladder and the pubic symphysis? a. Vesicorectal space

b. Uterovesicle space

c. Space of Retzius

d. Rectouterine space

8. Which of the following potential spaces is located between the posterior urinary bladder and the anterior uterus? a. Vesicorectal space

b. Uterovesicle space

c. Space of Retzius

d. Rectouterine space

Kawamura_WB_CH03.indd 19 12/1/11 3:56 PM

20 PART 1 — ABDOMINAL SONOGRAPHY

9. All of the following statements regarding the FAST examination are true EXCEPT: a. The FAST examination is very effective in

diagnosing causes of acute abdominal pain such as gallstones and kidney stones.

b. The FAST examination is used to search for free fl uid in cases of blunt abdominal trauma.

c. FAST is an acronym for Focused Assessment with Sonography in Trauma.

d. The FAST examination has proven to be sensitive in detecting as little as 200 mL of free fl uid within the peritoneal cavity and 20 mL of fl uid within the pleural cavity.

10. When evaluating the peritoneal cavity with sonography, all of the following are true EXCEPT: a. Ascites will demonstrate bowel moving freely

within it.

b. Cystic masses typically have sharp corners and angles as they fi ll the potential spaces.

c. Changing patient position can be used to demonstrate the movement of free fl uid.

d. Cystic masses may demonstrate a mass-effect on surrounding tissues and tend to have a round or oval shape.

11. Transudative ascites is typically associated with: a. Infl ammatory bowel disease

b. Ovarian cancer

c. Congestive heart failure

d. Peritonitis

12. Ascites typically collects in all of the following potential spaces EXCEPT: a. Morrison’s pouch

b. Pouch of Douglas

c. Paracolic gutters

d. Pleural space

13. Due to the high frequency of appendicitis and duodenal ulcers, the most common potential space for a peritoneal abscess is: a. Right subphrenic space

b. Hepatorenal space

c. Left anterior subphrenic space

d. Space of Retzius

14. All of the following statements regarding a peritoneal abscess are true EXCEPT: a. The abscess may appear as a thick walled fl uid

collection with internal debris.

b. Color Doppler will frequently demonstrate internal vascularity.

c. An abscess may be located in a potential space or next to an infl amed or perforated organ.

d. A peritoneal abscess may be the result of a surgical complication.

15. A large hematoma may be associated with a decrease in which laboratory value? a. Amylase

b. White blood count

c. Bilirubin

d. Hematocrit

16. The common sonographic appearance of a lymphocele is: a. Hypoechoic collection with thick septations

b. Simple anechoic collection with possible thin septations

c. Complex mass with calcifi cations

d. Thick-walled collection with internal septations

17. An interventional procedure performed to remove ascites from the peritoneal cavity is called: a. Thoracentesis

b. Fine-needle aspiration

c. Percutaneous abscess drainage

d. Paracentesis

18. A fl uid collection that contains urine and is associated with a rupture of the urinary tract is called a/an: a. Biloma

b. Urinoma

c. Seroma

d. Lymphocele

19. All of the following statements regarding omental caking are true EXCEPT: a. Omental caking is a thickening of the greater

omentum from malignant infi ltration.

b. Nodular masses may be seen sonographically deep to the anterior wall.

c. Simple transudative ascites is frequently associated with omental caking.

d. Omental caking is commonly associated with cancers of the ovary, stomach, and colon.

20. Which of the following organs is NOT located within the peritoneal cavity? a. Liver

b. Pancreas

c. Spleen

d. Gallbladder

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3 — The Peritoneal Cavity 21

FILL-IN-THE-BLANK

1. Addison’s lines divide the abdomen into nine regions.

Those regions are the right and left

right and left , right and left

, and the central regions

, ,

and .

2. The abdominopelvic cavity is also frequently

divided into four quadrants. Those quadrants

are the , ,

, and .

3. The largest body cavity is called the

, which encompasses the abdomen

and pelvis.

4. The thin sheet of tissues that divides the abdominal

cavity into the peritoneal and retroperitoneal

compartments is called the

.

5. The lesser sac lies immediately posterior to the

.

6. The greater omentum divides the greater sac into two

compartments: the ,

which means above the colon, and the

, which means below the colon.

7. The right and left

are potential spaces along the lateral borders of the

peritoneal cavity that allow fl uids to travel between

the supracolic and infracolic compartments.

8. When a patient is supine, the most gravity-

dependent portion of the abdominal cavity is the

. This potential

space should always be checked for free fl uid during

the sonographic examination.

9. When a female patient is in the supine position,

the is the most

gravity-dependent portion of the pelvic cavity.

10. When a male patient is in the supine position, the

is the most

gravity-dependent portion of the pelvic cavity.

11. ascites typically has a simple

appearance because it is characterized by a lack of

protein and cellular material.

12. ascites has a more complex and

echogenic appearance because fl uid seeps out from

blood vessels and contains a large amount of protein

and cellular material.

13. The presence of within an abscess

may cause a “dirty” posterior shadow.

14. Free blood within the peritoneal cavity is called

; once the blood organizes into a

focal area or clot, the collection is called

a .

15. results when a

benign appendiceal or ovarian adenoma ruptures,

spilling epithelial cells into the peritoneum, causing

to accumulate within the peritoneal

cavity.

16. Seromas typically occur in the

postsurgical period, whereas

are typically slower to develop and may present

4 to 8 weeks after surgery, helping to establish a

more defi nitive diagnosis between the two similar-

appearing fl uid collections.

17. Mesenteric cysts may occur anywhere along the

mesentery but are most commonly found originating

from the

mesentery.

18. The term describes the enlargement

of lymph nodes that can result from

diseases such as colitis or malignancies such as

lymphoma or colon cancer.

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22 PART 1 — ABDOMINAL SONOGRAPHY

19. Peritoneal mesothelioma is a rare malignant tumor

of the peritoneum that is associated with exposure to

.

20. A paracentesis may be done for

purposes to remove a small amount of fl uid for

laboratory testing or for purposes

to relieve pain and pressure that the patient may be

experiencing due to a large volume of ascites.

SHORT ANSWER

1. What purpose does the greater omentum serve?

2. Explain the protocol used during a FAST examination. When and where is this procedure performed?

3. What are three common causes of ascites? Where is ascites most likely to accumulate?

4. Describe the sonographic appearance of a peritoneal abscess. Where might an abscess be located?

5. What is the purpose of the peritoneal membrane?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Which potential space is the single arrow pointing to? Which potential space is the double arrow pointing to? What pathology is seen in this image?

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3 — The Peritoneal Cavity 23

3. What potential space is the arrow pointing to? Why is this space signifi cant?

2. What potential space are the arrows pointing to? What pathologies might collect here?

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24 PART 1 — ABDOMINAL SONOGRAPHY

4. What type of ascites is seen in this image? What pathologies could have resulted in this type of ascites? What structure are the arrows pointing to?

5. What type of ascites is seen in this image? How would you describe the ascites? What pathologies could have resulted in this type of ascites?

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3 — The Peritoneal Cavity 25

CASE STUDIES

1. A 62-year-old man with a history of liver disease presents for an abdominal sonogram with a history of abdominal distention and pain. Your examination reveals an echogenic, irregular shrunken liver consistent with cirrhosis. You also discover portal vein thrombosis (PV) as the portal vein is fi lled with echogenic material and no color fl ow is identifi ed. What pathology is the arrow pointing to? What is the double arrow pointing to? What procedure could be done to relieve the patient’s symptoms of abdominal distention?

Kawamura_WB_CH03.indd 25 12/1/11 3:56 PM

Kawamura_WB_CH03.indd 26 12/1/11 3:56 PM

27

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Anastomosis

2. Aneurysm

3. Arteriovenous fi stula

4. Ectasia

5. Endograft

6. Graft

7. Prosthesis

8. Pseudoaneurysm

9. Thrombosis

a. Any tissue or organ for implantation or transplantation

b. Dilatation, expansion, or distention c. Connection between two vessels d. Focal dilatation of an artery caused by a structural

weakness in the wall e. An artifi cial substitute for a body part f. A metallic stent covered with fabric and placed

inside an aneurysm to prevent rupture g. The formation of a clot in a blood vessel h. Connection allowing communication between an

artery and vein i. Caused by a hematoma that forms as a result of a

leaking hole in an artery

4 Vascular Structure

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28 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

A.

D.

E.

F.

K. G.

H.

I.J.

B. C.

1. Abdominal vasculature

2. Abdominal vasculature

Kawamura_WB_CH04.indd 28 12/1/11 3:56 PM

4 — Vascular Structure 29

3. Abdominal vasculature

4. Abdominal vasculature

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30 PART 1 — ABDOMINAL SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which is the innermost layer of a vessel wall? a. Tunica intima

b. Tunica media

c. Tunica adventitia

d. Tunica serosa

2. Which of the following statements regarding arteries and veins is FALSE? a. The walls of arteries and veins contain the same

three layers

b. Both arteries and veins contain valves to keep blood moving

c. Because the walls of veins contain less muscle, they are more easily compressed

d. Arteries have a thicker muscle layer and therefore maintain a constant shape

3. The compression of the left renal vein between the aorta and the SMA is referred to as the: a. Sandwich effect

b. Murphy’s phenomenon

c. Compartment syndrome

d. Nutcracker phenomenon

4. Which of the following veins does NOT drain into the IVC? a. Portal vein

b. Middle hepatic vein

c. Left renal vein

d. Right renal vein

5. Which vessel courses posterior to the SMA and anterior to the aorta? a. Superior mesenteric vein

b. Splenic vein

c. Left renal vein

d. Left gastric vein

6. Which vessel lies posterior to the bile duct and anterior to the portal vein? a. Hepatic vein

b. Hepatic artery

c. Gastroduodenal artery

d. Celiac axis

7. What do the superior mesenteric vein and the splenic vein join together to form? a. Celiac axis

b. Portal vein

c. Inferior vena cava

d. Main hepatic vein

8. The celiac axis is _________________ to the origin of the superior mesenteric artery. a. Cephalad

b. Caudal

c. Medial

d. Lateral

9. Which vessel lies posterior to the IVC? a. Left renal vein

b. Right renal vein

c. Left renal artery

d. Right renal artery

10. The portal vein carries blood to the liver from the: a. Aorta

b. IVC

c. Splenic artery

d. Intestines

11. What is an aneurysm that is uniform in nature called? a. Saccular

b. Fusiform

c. Dissecting

d. Congenital

12. How large must the Aortic diameter be to diagnose an aortic aneurysm? A. 2 cm

B. 3 cm

C. 4 cm

D. 5 cm

13. What is the typical sonographic appearance of an aortic dissection? a. A uniform dilation of the wall of the aorta

b. A dilation of one side of the aorta, typically the left

c. Discontinuity of the wall of the aorta with a large hematoma surrounding the vessel

d. Thin linear fl ap seen pulsating within the aortic lumen with blood fl ow visible on both sides of the fl ap

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4 — Vascular Structure 31

14. At what size does risk of rupture greatly increase in an abdominal aortic aneurysm? a. 3 cm

b. 5 cm

c. 7 cm

d. 9 cm

15. Which of the following is NOT a complication of aortic endografts? a. Endoleaks

b. Abscess

c. Dissecting aneurysm

d. Pseudoaneurysm

16. What is the most common clinical symptom of renal artery stenosis? a. Abdominal pain

b. Hypertension

c. Increased urinary output

d. Pulsatile abdominal mass

17. Mesenteric insuffi ciency results from a hemodynamically signifi cant stenosis or occlusion of two out of three of the vessels that supply the intestinal tract. Which vessels are they? a. Portal vein, inferior mesenteric vein, superior

mesenteric vein

b. Portal artery, inferior mesenteric artery, hepatic artery

c. Superior mesenteric artery, celiac axis, inferior mesenteric artery

d. Gastroduodenal artery, hepatic artery, splenic artery

18. What happens when blood fl ow in the IVC is obstructed? a. The entire IVC will become dilated

b. The IVC will dilate proximal to the obstruction

c. The IVC will dilate distal to the obstruction

d. The IVC has thick walls and does not change in diameter

19. What is the most common cause of IVC obstruction? a. Tumor due to renal cell carcinoma

b. Thrombus from extension of DVT

c. Right-sided heart failure

d. Portal hypertension

20. Which of the following vessels must be evaluated to rule out “Budd-Chiari” disease? a. Aorta and celiac axis

b. Renal veins and IVC

c. Portal veins and hepatic veins

d. IVC and hepatic veins

21. What is the most likely cause of portal hypertension? a. Congestive heart failure

b. Cirrhosis of the liver

c. Dehydration

d. Enlargement of the spleen

22. Which of the following is NOT characteristic of a vascular stenosis? a. Post-stenotic dilatation of the vessel

b. Vessel lumen visibly narrowed at the stenosis by calcifi ed plaque

c. Markedly decreased Doppler velocities at the level of the stenosis

d. Post-stenotic turbulence

23. Which type of aneurysm typically has a neck and demonstrates a swirling pattern on color Doppler? a. Dissecting

b. Pseudoaneurysm

c. Fusiform

d. Mycotic

24. When a patient has an abdominal aortic aneurysm, what is the greatest concern? a. The presence of thrombus

b. Dissection

c. Rupture

d. Extension into the iliac arteries

25. Which of the following statements regarding portal hypertension is FALSE? a. Portal hypertension is typically caused by

increased hepatic vascular resistance

b. The diameter of the portal vein is almost always decreased in cases of portal hypertension

c. Portal hypertension can also be caused by Budd- Chiari syndrome

d. Portal hypertension can result in collateral formation involving the coronary vein, gastroesophageal veins, and splenorenal veins

FILL-IN-THE-BLANK

1. Arteries and veins are composed of three layers: the

,

, and the

. The

is thicker in arteries and is largely

responsible for their elasticity and contractility.

Kawamura_WB_CH04.indd 31 12/1/11 3:56 PM

32 PART 1 — ABDOMINAL SONOGRAPHY

2. The aorta originates off of the

; once it penetrates the

diaphragm it is called the

, and fi nally bifurcates into the right

and left arteries.

3. The three branches of the celiac axis are

the , the

,

and the .

4. The CA, SMA, and IMA originate from the

aspect of the aorta, whereas

the right and left renal arteries arise from the

aspect of the aorta.

5. The inferior vena cava is formed by the junction of

the right and left

, courses through the abdominal

cavity, entering into the thoracic cavity to empty into

the of the heart.

6. The normal IVC will change caliber with respiratory

maneuvers; with inspiration

due to the decreased pressure within the thoracic

cavity, during expiration, and

with suspended respiration.

During the Valsalva maneuver the IVC lumen

.

7. The portal vein is formed by the junction of

the and the

at the ,

immediately posterior to the neck of the pancreas.

8. is a form of arteriosclerosis that

is characterized by an accumulation of lipids, blood

products, and sometimes calcium deposits along the

intimal lining of the arteries.

9. A aneurysm is a protrusion toward

one side or the other, unlike a fusiform aneurysm,

which is more uniform.

10. When an abdominal aortic aneurysm is diagnosed,

the arteries and

arteries should also be examined to evaluate for

extension of the aneurysm.

11. Aortic is a separation of the layers

of the aortic wall that typically presents with extreme

chest or abdominal pain.

12. Iliac artery aneurysms are most often a continuation

of an

and tend to be .

13. EVAR stands for .

14. A pulsatile anechoic mass at the anastomosis of

an endograft that demonstrates a swirling blood

fl ow pattern with color Doppler is most likely a

.

15. An incomplete seal between the endograft and wall

of the aorta may result in an . This

may result in or

of the aortic aneurysm.

16. Renal artery stenosis is most often a result of

and occurs at the

of the renal artery. Fibromuscular dysplasia causes

renal artery stenosis less frequently but these lesions

are typically located in the renal

artery.

17. results from a

lack of adequate blood supply to the intestinal tract

causing postprandial pain, weight loss, and change in

bowel habits.

18. Malignant invasion of the IVC most commonly occurs

from . Respiratory changes are

typically or below

the level of obstruction.

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4 — Vascular Structure 33

19. is a syndrome in which the IVC

and/or one or more of the hepatic veins are occluded.

In the primary form of the syndrome, the vessels

are occluded by a congenital

, and in the secondary form they are

occluded by or .

20. While performing an examination of the liver,

you have diffi culty identifying the main portal

vein; however, you do see multiple tortuous

vessels in the region of the porta hepatis. This

collateralization is called

of the portal vein.

21. The normal portal vein measures less than

in diameter. In a patient with an

acute portal vein thrombosis, the diameter of the

portal vein may . With chronic

thrombosis, the diameter may .

22. An increase in the portal venous pressure is called

. Common

signs and symptoms include and

.

23. Portal hypertension can result in many

sonographically visible changes including

varices, an enlarged

vein, and a patent

vein seen within the ligament.

24. Blood fl ow toward the liver is called

, whereas blood fl ow away from the

liver, as seen in some cases of portal hypertension, is

called .

25. A TIPS, which stands for , is

used to decompress the portal vein pressure by

connecting the with one of the

bypassing fl ow through the liver.

SHORT ANSWER

1. While performing an abdominal sonogram to rule out renal artery stenosis, your patient asks you what the risk factors for atherosclerosis are and what are the signs and symptoms of atherosclerotic disease. How would you answer?

2. You are asked to perform a sonogram of the aorta to rule out an abdominal aortic aneurysm. What images would your protocol include and if an aneurysm was present, what other vessels would you evaluate and why? What are some of the pitfalls to look out for when performing this examination?

3. What is the purpose of an aortic endograft? List the common complications of aortic endograft repair and describe the sonographic appearance of each complication.

4. Describe the two methods used to evaluate for renal artery stenosis sonographically. What measurements are taken for each method?

5. What are some of the common causes of portal hypertension in the United States? One of the common complications is the formation of collaterals. Where does this occur and why does it occur? What can be done to limit the symptoms of portal hypertension?

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34 PART 1 — ABDOMINAL SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

2. What is the arrow pointing to? What type of symptoms could this cause? What structure is the arrowhead pointing to?

3. This image was taken in a patient with a history of alcoholic cirrhosis and portal hypertension. This tortuous vessel was noted in the liver in the region of the ligamentum teres. What vessel is represented in this image?

1. What vessels are the arrows pointing to? What vessels are the arrowheads pointing to? In what plane would this image have to be acquired in order to view these vessels in this manner?

Kawamura_WB_CH04.indd 34 12/1/11 3:56 PM

4 — Vascular Structure 35

4. This image was taken in the region of the porta hepatis. What pathology is seen in this transverse view of the portal vein? What is the normal measurement for the portal vein?

5. This image of the abdominal aorta was taken in the midline abdomen just above the level of the umbilicus in an asymptomatic patient. What pathology is seen here? What are the arrows pointing to?

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36 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

1. A 48-year-old man presented to the emergency room with extreme chest and abdominal pain, hypertension, nausea, and vomiting. A chest and abdomen CT revealed an aortic dissection. Review the following images of the aorta and right common iliac artery. What are the arrows pointing to? How would you confi rm this diagnosis and ensure that the fi ndings were not artifactual in nature?

2. A 72-year-old man presents for a sonogram of the abdominal aorta. He was previously diagnosed with a large abdominal aortic aneurysm. Review the following images. What are the arrows pointing to within the lumen of the aorta? The calipers are measuring the transverse diameter of the aorta. What is the measurement? What is the normal measurement of the abdominal aorta?

Kawamura_WB_CH04.indd 36 12/1/11 3:56 PM

37

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. AFP

2. ALT

3. AST

4. Falciform ligament

5. Glisson’s capsule

6. Hepatofugal

7. Hepatomegaly

8. Hepatopetal

9. Jaundice

10. Ligamentum venosum

11. Ligamentum teres

12. Main lobar fi ssure

13. Porta hepatis

14. Reidel’s lobe

a. Remnant of ductus venosus seen as echogenic line separating caudate lobe from the left lobe

b. Fissure where the portal vein and hepatic artery enter the liver and the common hepatic duct exits

c. Tumor marker frequently elevated in cases of hepatocellular carcinoma and certain testicular cancers

d. Anatomic variant in which right lobe is enlarged and extends inferiorly

e. Blood fl ow toward the liver f. Enlarged liver g. Divides the right and left lobes of the liver; seen in

sagittal plane as an echogenic line between the neck of the gallbladder and the main portal vein

h. Liver enzyme most specifi c to hepatocellular damage i. Yellowish pigmentation of the skin and whites of the

eyes caused by increased levels of bilirubin in the blood

j. An enzyme found in all tissues but in largest amounts in the liver; increases with hepatocellular damage

k. Remnant of the left umbilical vein, seen in the transverse plane as a triangular echogenic foci dividing the medial and lateral segments of the left lobe of the liver

l. Fibroelastic connective tissue layer that surrounds the liver

m. Fold in the parietal peritoneum that extends from the umbilicus to the diaphragm and contains the ligamentum teres

n. Blood fl ow away from the liver

5 The Liver

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38 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

Right Common Carotid Artery

Superior Vena Cava Right Pulmonary Artery

Right Pulmonary Vein

Right Atrium Foramen Ovale

Valve of Inferior Vena Cava (Valve of Eustachii)

Inferior Vena Cava

Hepatic Vein

A. Liver Circulation

Liver Portal Vein

Renal Vein

Superior Mesenteric Vein

B.

Placenta

Umbilical Arteries

Internal Iliac Artery Internal Iliac Vein

Gut

Renal Artery

Aorta

Superior Mesenteric Artery

Celiac Trunk

Right Ventricle

Left Ventricle

Left Atrium

Left Pulmonary Vein

Left Pulmonary Artery

Ductus Arteriosus Aorta

Left Common Carotid Artery

1. Fetal circulation

Kawamura_WB_CH05.indd 38 12/1/11 4:01 PM

5 — The Liver 39

2. Liver anatomy

3. Liver anatomy

Kawamura_WB_CH05.indd 39 12/1/11 4:01 PM

40 PART 1 — ABDOMINAL SONOGRAPHY

4. Liver anatomy

5. Vascular anatomy

Kawamura_WB_CH05.indd 40 12/1/11 4:01 PM

5 — The Liver 41

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. What is the normal liver length along the right surface? a. 10 to 12 cm

b. 11 to 14 cm

c. 15 to 17 cm

d. 19 to 22 cm

2. What separates the left lobe from the caudate lobe? a. Ligamentum teres

b. Ligamentum venosum

c. Falciform ligament

d. Coronary ligament

3. Which of the following lies within the main lobar fi ssure? a. Main portal vein

b. Right hepatic vein

C. Middle hepatic vein

d. Left hepatic vein

4. Based on the segmental division of the liver, the quadrate lobe is the: a. Lateral segment of the left lobe

b. Medial segment of the left lobe

c. Anterior segment of the right lobe

d. Posterior segment of the right lobe

5. You are asked to locate a mass found within the right posterior segment of the liver. Which vessel separates the right anterior segment of the liver from the right posterior segment? a. Left hepatic vein

b. Middle hepatic vein

c. Right hepatic vein

d. Main portal vein

6. Which of the following statements regarding the differences between hepatic and portal veins is FALSE? a. Hepatic veins are intersegmental while portal

veins are intrasegmental

b. The portal veins have highly echogenic walls

c. Portal veins decrease in caliber as they course away from the porta hepatis

d. Hepatic veins decrease in caliber as they course toward the diaphragm

7. Which of the following are both interlobar and intersegmental? a. Portal veins

b. Bile ducts

c. Hepatic veins

d. Hepatic arteries

8. Which of the following supplies oxygenated blood to the liver? A. Portal vein

B. Hepatic artery

C. Hepatic veins

D. Hepatoduodenal artery

9. Which of the following functions does the liver NOT perform? a. Formation of bile

b. Production of clotting factors

c. Production of digestive enzymes amylase and lipase

d. Storage of vitamins A, B 12

, and D

10. An echogenic mass consistent with a hemangioma is seen just anterior to the middle hepatic vein. In which liver segment is this mass located? a. Posterior segment right lobe

b. Anterior segment right lobe

c. Medial segment left lobe

d. Lateral segment left lobe

11. Which of the following laboratory tests CANNOT evaluate liver function? a. ALT

b. AST

c. ALP

d. BUN

12. You receive an order for an abdominal sonogram with an indication of an elevated AFP. Based on these results, what pathology are you looking for? a. Fatty infi ltration

b. Polycystic liver disease

c. Hepatocellular carcinoma

d. Cavernous hemangioma

13. An intrahepatic mass will typically: a. Cause an anterior displacement of the right kidney

b. Display internal displacement of the liver capsule

c. Cause an anterior shifting of the IVC

d. Displace hepatic vessels

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42 PART 1 — ABDOMINAL SONOGRAPHY

14. Which of the following is NOT a diffuse liver disease? a. Fatty infi ltration

b. Hepatoma

c. Cirrhosis

d. Hepatitis

15. Which of the following is FALSE regarding fatty infi ltration of the liver? a. Fatty infi ltration may be focal or diffuse

b. Visualization of the intrahepatic vessels becomes more diffi cult

c. Focal fatty infi ltration may be mistaken for a liver mass

d. The cortex of the right kidney will appear hyperechoic compared to the liver parenchyma

16. A 65-year-old man presents with elevated liver function tests. Your examination reveals a shrunken, echogenic right lobe and a relatively enlarged caudate lobe. The liver contour is irregular. What is the most likely diagnosis? a. Acute hepatitis

b. Cirrhosis

c. Chronic hepatitis

d. Hepatocellular carcinoma

17. Which benign liver tumor commonly occurs in patients with glycogen storage disease? a. Adenoma

b. Hepatoma

c. Hemangioma

d. Lipoma

18. If you are having trouble visualizing the posterior portion of the liver in a patient with fatty infi ltration, which of the following may help? a. Increasing the TGCs in the near fi eld

b. Decreasing the overall gain

c. Decreasing the depth

d. Lowering the frequency

19. In focal fatty sparing, normal tissue appears more hypoechoic than the surrounding liver tissue and may be mistaken for a mass. Where does this typically occur? a. Dome of the liver

b. Posterior liver near the right kidney

c. Region of the porta hepatis near the gallbladder

d. Lateral segment of the left lobe

20. What does a person with cirrhosis have a higher incidence of developing? a. Hepatoma

b. Cavernous hemangioma

c. Hepatic adenoma

d. Hepatic hemangiosarcoma

21. All of the following may be seen in patients with late stage cirrhosis EXCEPT: a. Ascites

b. Caudate lobe enlargement

c. Shrunken atrophic spleen

d. Hepatofugal fl ow in the portal vein

22. What is the sonographic appearance of a mother cyst containing multiple daughter cysts diagnostic of? A. Hepatic abscess

B. Echinococcal cyst

C. Polycystic liver disease

D. Chronic hematoma

23. A 38-year-old woman presents post-cholecystectomy with RUQ pain, fever, and an elevated white count. Your examination reveals an irregular, hypoechoic mass with posterior enhancement in the region of the porta hepatis. What is the most likely diagnosis? a. Hematoma

b. Focal fatty sparing

c. Pyogenic abscess

d. Hepatocellular carcinoma

24. Patients with AIDS are at greater risk for all of the following liver fi ndings EXCEPT: a. Kaposi’s sarcoma

b. Fatty liver infi ltration

c. Candidiasis

d. Schistosomiasis

25. A 30-year-old woman presents for an abdominal sonogram to rule out the presence of gallstones. The examination reveals a well-defi ned, 2 cm, solitary, echogenic mass in the posterior right lobe. What is the most likely diagnosis? A. Hepatic metastases

B. Hepatocellular carcinoma

C. Cavernous hemangioma

D. Amebic abscess

Kawamura_WB_CH05.indd 42 12/1/11 4:01 PM

5 — The Liver 43

26. An examination of the liver reveals a well- defi ned, highly echogenic mass in the posterior liver. An artifact is present, causing the portion of the diaphragm directly posterior to the mass to appear discontinuous with the remainder of the diaphragm. What is the most likely diagnosis of the mass? a. Hepatic adenoma

b. Hepatic lipoma

c. Cavernous hemangioma

d. Hepatoma

27. A 60-year-old man with a history of alcoholic cirrhosis presents with increasing abdominal girth and jaundice. The sonographic examination reveals ascites and multiple hyperechoic lesions seen throughout the liver. Tumor is noted within the portal vein. What is the most likely diagnosis? a. Hepatic metastases

b. Hepatic adenomas

c. Hepatocellular carcinoma

d. Karposi’s sarcoma

28. Cystic lesions of the liver could include all of the following EXCEPT: a. Congenital cysts

b. Polycystic liver disease

c. Resolving hematoma

d. All of the above

29. While performing an abdominal sonogram for RUQ pain, you notice a single, well-circumscribed anechoic lesion in the right lobe of the liver. The lesion exhibits posterior enhancement. The remainder of the examination is normal. What is the most likely diagnosis? a. Simple liver cyst

b. Polycystic liver disease

c. Hematoma

d. Cavernous hemangioma

30. What is a recanalized paraumbilical vein typically the result of? a. Hepatitis

b. Portal hypertension

c. Liver metastases

d. Amebic abscess

FILL-IN-THE-BLANK

1. The liver is surrounded by a fi brous capsule

called and is located within the

cavity.

2. After birth, the ductus venosus closes to become

the and the

left umbilical vein becomes the

. Both are important as they can

become recanalized with certain disease processes,

most commonly .

3. The anatomy of the liver can be classifi ed by

different methods. The anatomic division divides

the liver into four lobes: the lobe,

lobe, lobe, and

lobe, based on

. The segmental division is based on

the liver’s .

4. The left intersegmental fi ssure divides the

lobe into and

segments. The left

vein is a sonographic landmark of the left

intersegmental fi ssure.

5. The lobe may be enlarged in

patients with a history of cirrhosis or Budd-Chiari

syndrome. Enlargement of the caudate lobe may

cause compression of the .

6. A 28-year-old woman presents for an abdominal

sonogram and you notice that the right lobe appears

enlarged and extends inferiorly toward the pelvis.

The texture appears homogenous and is continuous

with the remainder of the right lobe. The most likely

diagnosis is a .

7. The basic functional unit of the liver is the

. These cells carry out most of the

metabolic functions of the liver. The

cells, macrophages that are part of the reticuloendothelial

system, help break down red blood cells.

8. An anatomical variation in which the liver and

gallbladder are found on the left side of the abdomen

and the spleen is found on the right side is called

.

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44 PART 1 — ABDOMINAL SONOGRAPHY

9. The portal triad is made up of the

vein, artery, and .

10. A array transducer is typically used

to evaluate the liver but a array

transducer can be used to evaluate the anterior liver

capsule for surface nodularity in suspected cases of

cirrhosis.

11. Fatty infi ltration is also called

and is commonly caused in the United States by

and .

12. With fatty infi ltration, the echogenicity of the liver is

, while the acoustic penetration is

.

13. Infl ammation of the liver is called .

In the acute form, the liver appears ,

causing the portal vessels to appear more

.

14. The most common cause of cirrhosis in the United

States is .

15. Patients with autosomal dominant polycystic

kidney disease may also develop cysts in the

, , and

.

16. The majority of liver cysts are .

Acquired cystic lesions of the liver may be the

result of , , or

reactions.

17. The appearance of a liver hematoma will vary

depending on the of the bleed.

Immediately following the injury, the hematoma will

typically appear . Within a day, the

hematoma may become ; eventually

clot forms and the hematoma becomes organized

and complex. Chronic hematomas can become

.

18. Hematomas are usually contained by the liver

, although rupture can occur.

A subcapsular hematoma will displace the liver

and have a shape.

19. Echinococcal cysts are commonly referred to as

cysts. Rupture of an echinococcal

cyst can result in .

20. An amebic abscess is typically the result of parasites

travelling to the liver from the via

the .

21. Patients with HIV and AIDS are commonly infected

by the organism .

When the liver is infected, sonographically the liver

demonstrates a

pattern.

22. The most common benign liver tumor is the

.

23. Two benign liver lesions typically occur in women of