Abdomen Ardms Exam Questions and Complete Solutions Graded A+, Exams of Medicine

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Abdomen Ardms Exam Questions and Complete Solutions Graded A+ [Document subtitle] Denning [Date] [Course title]

Intersegmental vessels - Answer: Hepatic veins Intrasegmental - Answer: Portal triad Hepatic veins - Answer: Course between the lobes and segments. Hepatic veins have non-echogenic walls. Portal triad - Answer: The vessels of the portal triad course to the center of each segment. The portal triad is encased by a fibrofatty sheath(glissons capsule) giving it hyperechoic walls. Portal triad vessels include:MPV, proper hepatic artery, & CHD. main lobar fissure - Answer: Divides the right and left hepatic lobes by an oblique plane between the ivc and the gb fossa. This fissure can be identified between the gb neck and the junction of right and left portal veins. The main lobar fissure also divides the anterior segment of the right lobe from the medial segment of the left. Right intersegmental fissure - Answer: Divides the right lobe into medial and lateral segments. Landmark:RHVNN left intersegmental fissure - Answer: Divides the left lobe into medial and lateral segments. Landmarks: LHV,ascending LPV, falciform ligament, ligamentum teres Ligamentum venosum - Answer: Remnant of the ductus venosus. Seperates the left lobe from the caudate lobe. Ligamentum teres - Answer: Is a remnant of the umbilical vein which runs from the umbilicus to the left portal vein. With portal hypertention it recanalizes to form a portosystemic venous collateral. Ligamentum venosum - Answer: Is a remnant of the ductus venosus. It runs from the LPV to the IVC seperating the left lobe from the caudate lobe of the liver. Hepatopetal - Answer: Flow toward the liver.

Hepatofugal - Answer: Flow away from the liver. Portal vein - Answer: Low-velocity continuous flow. Flow velocity can increase after eating. The MPV is a vessel of the portal triad. Portal triad - Answer: MPV,CHD,HAP. Hepatic blood flow in ml/min - Answer: 1500Ml/min. 25% is proper hepatic artery and 75% portal vein. Hepatic oxygenation - Answer: 50% proper HA. 50% portal vein Portal vein O2 sat - Answer: 85% Upper limits of portal vein diameter - Answer: 13mm. A larger diameter suggests portal hypertension. Hepatic vein waveforms - Answer: Have phases above and below the baseline. Described as Triphasic reflecting right atrial filling, ctx, & relaxation. hepatic artery proper - Answer: Runs parallel to the MPV. It is located anterior and to the left of the MPV. hepatic artery waveforms - Answer: Demonstrates flow throughout diastole indicating a low resistance system. Hepatic ligaments - Answer: Ligamentum teres, falciform ligament,coronary ligament, rt & lt triangular ligament. Ligamentum teres - Answer: A remnant of the umbilical vein extending from the umbilicus to the left PV. Recanalizes with cirrhosis to function as a venous collateral.

Falciform ligament - Answer: Peritoneal reflection or fold created by the passage of the embryonic umbilical vein from the umbilicus to the left branch of the PV. coronary ligament - Answer: Peritoneal reflections which suspend the liver from the diaphram. The coronary ligaments surround the bare area. Right & left triangular Ligament - Answer: Peritoneal reflections to the far right and left of the bare area. Rhv - Answer: divides ant and post segments of right lobe MHV - Answer: seperates right and left lobes LHV - Answer: Divides medial and lateral segments of the left lobe. RPV (Anterior branch) - Answer: courses centrally in anterior segment of right lobe. RPV (posterior branch) - Answer: Courses centrally in posterior segment of right lobe. LPV horizontal segment - Answer: Seperates caudate lobe from medial segment of the left lobe Left portal vein ascending segment - Answer: Divides medial from lateral segment of left lobe. Gb fossa - Answer: Seperates rt and left lobes Ligamentum teres - Answer: Divides caudal aspect of left lobe into medial and lateral segments Ligamentum venosum - Answer: Seperates caudate lobe from left lobe Liver measurement - Answer: Is measured in the sup-inf dimension on the mid-clavicular sagittal or coronal mid-axial plane. Organ size will vary with ht, wt, and bsa.

Hepatomegaly - Answer: Is indicated in 75% of the population with a greater than 15.5cm sup-inf dimension. Riedels lobe - Answer: Is an inferior projection of the rt lobe commonly seen in women. May be mistaken for hepatomegaly. Liver echogenicity - Answer: The normal liver is homogeneous and is slightly hyperechoic compared to the normal renal cortex. Echogenicity - Answer: Is a term used to compare signal amplitudes. Hyperechoic - Answer: Echoes greater than Hypoechoic - Answer: Echoes less than. Isoechoic - Answer: Echoes equal Anechoic - Answer: Without echoes Sonolucent - Answer: Without echoes Hepatic granulomas - Answer: Small organized collection of macrophages that appear as calcifications in the liver and spleen. Caused by histoplasmosis or tuberculosis infection. Histoplasmosis - Answer: Is caused by spores(fungus) that float in the air. The fungus grows in droppings of birds and bats. Common in ckn coops, old barns, & caves.

Hepatitis - Answer: Liver infection resulting from infectious(viral, bacterial,fungal,& parasitic organisms) or noninfectious (meds,toxins,& autoimmune disorders) agents. May result in elevation of ALT,AST,conjugated and unconjugated bili Hepatitis was commonly spread through blood transfusions and organ transplants. Hepatitis route of transmission - Answer: HEP A(HAV): fecal/oral HEP B (HBV): blood/body fluids HEP C (HCV): blood/body fluids Hep C Virus (HCV) - Answer: Is the most common today by sharing needles to inject drugs. Acute hepatitis - Answer: -"Starry night"(periportal cuffing) -hypoechoic liver parenchyma -liver enlargement -hyperechoic PV walls Chronic hepatitis - Answer: -Hyperechoic liver parenchyma -small liver -decreased echogenicity of PV walls Pyogenic (bacterial) abscess - Answer: The most common cause is biliary tract disease. Obstruction of bile flow allows for bacterial proliferation. The right hepatic lobe is affected more often than the left hepatic libe by a factor of 2:1.

Sono findings: complex mass,gas ,reverb artifact Symptoms: ruq pain, leukocytosis, fever, & elevated lft's Aspiration is needed to confirm dx. Major forms of liver abscesses - Answer: -Pyogenic 80% -amebic 10% -fungal 10% Amebic abscess - Answer: Occurs when a parasite(amoeba) from the intestines reaches the PV. Most common extraintestinal complication of amoebic dysentery. Occurs almost exclusively in immigrants and travelers. Onset of symptoms are usually 8-12w from date of travel Symptoms & findings: -Ruq pain- hepatomegaly -diarrhea -fever -leukocytosis -elevated lft's Sono features: -round hypoechoic/ complex mass -typically occurs in rt lobe (dome)

-contiguous with the liver capsule. Fungal abscess(candidiasis) - Answer: A mycotic (fungal) infection of the blood that results in a small abscess in the liver. Appearance of lesion can change over the course of the disease process. Wheel within a wheel (Fungal abscess) - Answer: Is a lesion with a peripheral hypoechoic zone, an inner echogenic wheel and a hypoechoic ctr. This is the earliest manifestation of a fungal infection and most recognizable. Bulls eye (fungal abscess) - Answer: Lesion appears like this when the hypoechoic center calcifies. Uniformly hypoechoic focus (fungal abscess) - Answer: Most common presentation of lesion. Echogenic focus (fungal abscess) - Answer: Calcification representing scar formation seen late in the disease process. Echinococcal cyst(hydatid disease) - Answer: Adult tapeworms (3-6mm long) inhabit the small intestine. The appearance can vary although it is sonographically described as a cyst within cyst. It can be a -simple cyst -cyst with detached Endocyst

• cyst with multiple Daughter cysts
• calcifiesd mass Echinococcal cyst lab studies - Answer: Casoni skin test(70% sensitivity) Echinococcal Arc 5- detection of.

antibodies Indirect hemagglutination Schistosomiasis - Answer: Is one of the most common parasitic infections in humans. It is a major cause of portal hypertension. Endemic areas are to tropical zones. Eggs reach the liver throught the PV then causes periportal fibrosis. Then the intrahepatic PV's become occluded causing portal hypertension. Schistosomiasis sono findings - Answer: -Occluded intrahepatic PV's -thickening of PV walls Sonographic findings related to AIDS - Answer: -hepatomegaly -splenomegaly -lymphadenopathy -pneumocystis (carinii) jiroveci -fatty liver infiltration -non-hodgkins lymphoma -candidiasis -cholangitis -kaposi's sarcoma -nephropathy(echogenic kidneys) Pneumocystic (carinii) jiroveci - Answer: The most common opportunistic infection in persons with HIV. Sono findings: involvement of the liver are that of diffuse, nonshadowing,hyperechoic foci. Sclerosing & AIDS. Cholangitis - Answer: Sonographically appear as thickened biliary ducts. Thickening may compromise the lumen causing biliary obstruction.

Fatty infiltration (steatosis) - Answer: Is the accumulation of triglycerides with the hepatocytes. The most common association with fatty liver disease is metabolic syndrome(type II DM, obesity, hypertriglyceridemia). Also drugs, alcohol. 30% incidence in the US. Fatty liver sono findings - Answer: Appears as increased echogenicity and decreased acoustic penetration. There are 2 patterns of fatty infiltration:

1. Focal fatty infiltration-commonly occurs at porta hepatis. 2.Focal sparing infiltration: commonly occurs adjacent to the gb, in the porta hepatis, in the caudate lobe and at the liver margins. Glycogen storage disease (GSD) - Answer: A genetically acquired disorder that results in the excess deposition of glycogen in the liver. GSD's are associated with fatty infiltration and hepatic adenomas. There are 11 types od GSD's Cirrhosis - Answer: Is a diffuse process of fibrosis and distortion of normal liver architecture. Cirrhosis is the major cause of Portal htn. Causes of cirrhosis - Answer: Hep c Alcoholic liver disease NAFLD NASD HEP B autoimmune hep Primary biliary cirrhosis Primary sclerosing cholangitis Hemochromatosis (iron deposition)

Wilson disease (copper deposition) Drug induced liver disease Venous outflow liver disease (Budd-chiari) Rt side heart failure/tricuspid regurg Cirrhosis abnormal increased lfts include - Answer: AST(sgot) ALT(SGPT) LDH _lactate dehydrogenase) Conjugated bili Cirrhosis sono findings - Answer: Hepatomegaly (acute) Liver atrophy (chronic) Caudate lobe enlargement Surface nodularity (regenerative nogules) Fatty infiltration- increased echoes Increased incidence of hepatocellular CA Hep C - Answer: Is the nations leading cause of cirrhosis and cheonic hepatitis. Portal htn - Answer: Is increased pressure in the portal venous system. Normal portal pressure is 5 to 10 mmHg Portal vein diameter >13mm suggests portal htn. Asymptomatic. Patients usually present with upper GI hemorrhage due to rupture of esophageal varices 4 types of portal htn - Answer: 1. Extrahepatic presinusoidal Ex. PV thrombosis

2. Intrahepatic presinusoidal

Ex. Schistosomiasis

3. Intrahepatic Ex. Cirrhosis
4. Intrahepatic postsinusoidal Ex.HV thrombosis Sonographic findings of portal HTN: - Answer: include the secondary signs of: Splenomegaly Ascites Portal systemic venous collaterals Surgical technique to lower portal pressure - Answer: Portacaval shunt Splenorenal shunt/linton shunt Distal splenorenal shunt/ warren shunt TIPS Portal systemic collaterals - Answer: Connecting the portal system to the IVC bypassing the liver. Ex. 1.gastroesophageal varices 2.recanalized umbilical vein 3.splenorenal varices 4.intestinal varices 5.rectal varices Gastroesophageal varices - Answer: Are supplied primarily by the left. Gastric (coronary) vein (due to flow reversal) that branches from the main portal vein and typically drain into the azygos hemiazygos venous system. Recanalized umbilical vein - Answer: Re-opening of the umbilical vein (ligamentum teres) to act as a collateral from the LPV to epigastric veins to the IVC.

Splenorenal varices - Answer: Tortuous collateral veins seen in the splenic and left renal hilum. Intestinal varices - Answer: The veins of retroperitoneal structures such as the colon,duodenum, and pancreas anastomose with systemic trubutaries. Rectal varices (hemorrhoids) - Answer: A collateral path in which the inferior mesenteric vein drains into the rectal veins which connect with systemic tributaries. Caput medusa - Answer: Tortuous collaterals around umbilicus Physical signs of collaterals - Answer: -dilated veins -caput medusa -hemorrhoids -ascites TIPS transjugular Intrahepatic portal systemic Shunting - Answer: Are created to lower portal pressure(phtn). Shunt is placed by using a jugular access. It is placed between a heoatic vein and portal vein. With a patent TIPS the RPV and the LPV Should deminstrate hepatofugal flow. Criteria for TIPS malfunction - Answer: -low shunt velocity (<50cm/sec) -high focal shunt velocity (>190cm/sec) -hepatopetal LPV or RPV -hepatofugal MPV -absent shunt flow GORE Viatorr endoprosthesis - Answer: This shunt is a wire reinforced PTFE.

Orhotopic liver transplantation - Answer: Approx 5000 liver transplants are performed in the US each year. Indication for liver transplant in adults - Answer: -cirrhosis of many etiologies:hep c is the leading cause of chronic hepatitis and cirrhosis. Indication for liver transplant in children - Answer: Biliary atresia Liver transplant sonographic evaluation - Answer: .biliary tree .PV patency .hepatic artery patency .IVC. Patency Presence of venous collaterals .Post-op collections(hematoma, ,biloma) MELD - Answer: The Model for End-Stage Liver disese, is a scoring system for assessing the severity of chronic liver disease. It is used in determining prognosis and prioritizing for receipt of a liver transplant. The MELD score uses a formula with the patients values for bilirubin, creatinine, and the international, normalized ratio for prothombin time (INR). PV thrombosis - Answer: Are caused by Conditions that cause stasis and less commonly hypercoagulability. Sonographic findings of PV thrombosis - Answer: -Hypoechoic thrombus within the PV -increased PV caliper -cavernous transformation -portal systemic collaterals

Causes of PV thrombosis - tumoral - Answer: -hepatocelullar carcinoma -metastatic liver disease -pancreatic carcinoma Causes of portal vein thrombosis- non-tumoral - Answer: .Pancreatitis .cirrhosis/hep .Inflammatory bowel disease .splenectomy .hypercoagulation .portal lymphadenopathy cavernous transformation of the portal vein - Answer: Numerous wormlike venous collaterals that oarallel the chronically thrombosed PV. cavernous transformation is typically seen with bengin causes of PV thrombosis. Budd-Chiari syndrome - Answer: A disorder characterized by hepatic vein obstruction. Pt presentd with signs associated with portal htn: ascited, hepatomegaly, and Splenomegaly. Causes of budd chiari - Answer: -Freq. Idiopathic -congenital:ivc membraneous HV steatosis or hypoplasia -hypercoagulable states: Polycythemia vera Paraxysmal nocturnal hemoglobiuria Factor V leiden deficiency Protein C & S deficiency Antithrombin III deficiency Antiphospholipid antibody syndrome

Sickle cell syndrome Sickle cell disease Oral contraceptives -infections -pregnancy/postpartum

• tumors: hepatocelullar carcinoma Renal cell carcinoma Adrenal carcinoma Portal vein gas - Answer: Is an uncommon ominous condition with a high mortality rate where air is noted within the intrahepatic portal veins. Associted with ischemic and non-ischemic conditions. In infants, intrahepatic PV gas is due to necrotizing entercolitis. Liver cysts - Answer: Is defined as a fluid filled space lined vy biliary epithelium. Liver cysts sonographic criteria include: - Answer: -Anechoic -thin walled -acoustic enhancement Estimated to occur in 5% of the population. Typically dont appear till the 5th decade of life. If liver cysts are seen at an earlier age check the kidneys for pckd. Hemorrhagic cyst - Answer: Will appear as a cyst with internal echoes acconpanied by RUQ pain and a decreasing hematocrit.

Liver cysts differential dx. - Answer: -simple cyst -PCLD -hydatid cyst -cystic tumors -abscess Cavernous hemagioma - Answer: Most common benign tumor of the liver. The majority are asymptomatic and discovered incidentally. Hemangiomas consist of multiple vascular channels that create multiple sonographic interfaces. May enlarge with pregnancy or the administration of estrogen. Cavernous hemangioma sono findings - Answer: -Hyperechoic -posrerior enhancement -may appear hypoechoic within thr background of a fatty infiltrated liver. -no flow within the hemangioma -contrast enhanced imaging shows centripetal flow. Focal nodular Hyperplasia - Answer: A benign solid liver mass that is believed to be a developmental hyperplastic lesion rather than a true neoplasm. FNH consists of hyperplastic hepatocytes with fibrous tissue.the mass contains proliferating bile ducts,Kupffer cells,connective tissue and a central stellate scar. FNH produces a mass effect displacing intrahepatic blood vessels. Focal nodular hyperplasia sono findings - Answer: -Solid mass with varying echogenicity

-solitary lesion(80-95%) -central fibrous scar(20%)(hallmark) -stellate vascularity "Stealth lesion" - Answer: FNH that have an echogenicity equal to the surrounding liver parenchyma. Hepatic adenoma - Answer: Associated with the use of orql contraceptive. Associated with glycogen storage disease Surgical resection recommended due to the risk of malignant transformation Hepatic adenoma sono findings - Answer: -Nonspecific echogenicity -tumor hemorrhage Hepatic lipoma - Answer: Extremely rare fatty tumors. tuberous sclerosis is associated with hepatic lipomas and angiomyolipomas. Hepatic lipoma sono findings - Answer: -Hyperechoic mass -_propagation speed artifact Propagation speen artifact - Answer: Decreased speed of sound in fat(1450)results in a prolonged sound return time. Hyperechoic hepatic masses - Answer: -hepatic lipoma -hemangioma -echogenic metastasis -focal fatty infiltration

HCC sono findings - Answer: Variable appearance Most are hypoechoic HCC hepatocellular carcinoma - Answer: Is the most common primary malignancy of the liver. Primary cancer of the liver & occurs predominantely in patients with underlying chronic liver disease & cirrhosis. Tumors may present as a single mass lesion or as diffuse growth which can be difficult to differentiate from surrounding cirrhotic liver tissue & regenerating liver nodules on imaging studies. Without sx resection, ablative therapy, or liver transplant it results in liver failure and death. HCC occurs in 10-25% of pts with cirrhosis. HCC commonly invades venous structures(pv, hv,& IVC) Assoc with increased: Alpha fetoprotein AST(sgot) ALT(SGOT) Metastatic disease - Answer: Easily established in the liver due to its dual blood supply. The fenestrations in the sinusoidal endothelium allow malignant cells tobe trapped in the space of Disse. Most liver mets are multiple. Growing mets compresses adjacent liver parenchyma causing atrophy & forming a connective tissue rim. Large mets often outgrow their blood supply causing hypoxia. & necrosis at the center of the lesion. Metastasis sono patterns - Answer: Hyperechoic mets = gi tract

Hypoechoic mets = lymphoma Bulls eye or target mets= lung Calcified mets= mucinous adenocarcioma of the colon Cysric mets= leiomyosarcoma Estimated CA deaths in 2014 - Answer: Lung. 159000 Breast. 50000 Pancreatic. 40000 Prostate. 39000 Non-hodgkins lymphoma 18000 Bladder. 15000 Kidney. 14000 Thyroid. 1900 Hepatoblastoma - Answer: Is an uncommon malignant liver neoplasm occuring in infamts and children. Most occur prior to 2y of age. Approx. 100 cases in the Us per yr. Patient presents with an enlarging asymptomatic abd mass (10-12cm at dx) Increased serum AFP Associated lung mets and PV invasion Hepatoblastoma assoc genetic conditions - Answer: -Beckwith-wiedemann syndrome -familial adenomatous polyposis Hepatoblastoma sono appearance - Answer: Nonspecific Liver chemistry - Answer: 1.Aminotransferases (transaminases) 2.Aspartate aminotransferase (AST)

AST=SGOT

3.Alanine aminotransferase (ALT) ALT=SGPT 4.Gamma Glutamyl Transpeptidase. (GGT)

5. Lactic dehydrogenase (LDH) 6.Alfa fetoprotein (AFP) 7.Prothrombin time (PT)
6. Partial thromboplastin time (PTT) Aminotransferases (transaminases) - Answer: The liver uses these enzymes to metabolize amino acids & to make proteins. When liver cells are damaged they spill these enzymes (AST & ALT) into the blood stream. The level of aminotranserases doesnt correlate with extent of damage or prognosis. Reasons for liver exzyme elevation: - Answer: Fatty liver Meds and herbs Excessive alcohol intake HF HAV HBV HCV Autoimmune hep Inherited disorders-hemachromatosis Wilsons disease Alfa 1 antitrypsin def AST=SGOT - Answer: AKA serum glutamic oxaloacetic transaminase.

Ast has a wide tissue distribution. It is present in the liver,hrt,skeletal muscle, kidney, & brain. Elevation of AST by itself. Is non-specific for liver disease. It is very sensitive being elevated in almost all significant hepatocelullar diseases. An increase in AST without ALT is seen with MI, hf,muscle injury, CNS disease. AST & ALT are elevated in almost all liver diseases. Highest elevations occur with viral hep. ALT=SGPT - Answer: AKA serum glutamic pyruvic transaminase (SGPT) ALT is present in high concentration within the liver tissue therefore ALT is more specific for liver disease than AST. Elevated AST and LDH with a normal ALT r/o hepatic disease. GGT - Answer: Is present in hepatocytes and bile duct epithelium therefore an elevation indicates hepatocellar disease and biliary obstruction. GGT is increased in most diseases that cause acute damage to the liver or the bile ducts. GGT is also elevated in patients with acute and chronic alcohol abuse. Incrsed GGT + ALP=biliary obstruction Incrsed GGT + ALT=hepatocellular disea LDH - Answer: Enzymes found in the cells of many body tissues. Because LDH is widely spread throughout the body, cellular damage causes an elevation of the total serum LDH. The dx usefulness of this enzyme by itself is not a valuable as determination of its 5 isoenzymes. Individual isoenzyme elevations can indicate specific organ or tissue damage. LDH levels can be used to monitor treatment of some cancers. AFP - Answer: Is a protein synthesized by the fetal liver andlevels decrease during the 1st yr of life. Elevated levels occur with: --hepatocellular carcinoma(hepatoma)

Germ cell tumors (teztes and ovaries) Metastatic liver cancer Hepatoblastoma(childhood) Moderate levels of AFP can be seen with non-cancerous liver disease. High levels of AFP (>500 ng/ml) are very suggestive of HCC. PT - Answer: Screen for abnormalities in the extrinsic & common pathways of coagulation. PT is reported as the international normalized ration (INR) Normal range 10 and 13sec. INR - Answer: Is valuable in screening for abnormal coagulation in various acquired conditions (vit k def., liver disease, disseminated intravascular coagulation. It is also used to mintor warfarin therapy. PTT - Answer: PTT tests for deficiencies of clotting factors. Prolonged PTT may indicate prolonged heparin use, coagulation factor dificiency a condition such as antiphospholipid antibody syndrome or lupus anticoagulant syndrome in which the immune system makes antibodies attck blood clotting factors and sepsis. Tumor markers - Answer: 1.AFP -HCC -Acute & chronic hepatitis -testicular cancer (nonseminoma) 2.chromogranin A -neoendocrine tumors (carcinoid tumo

3.CA 15-3 and CA 27.29

• Breast CA
• can be evaluated in other CA's 4.Beta-2 microglobulin (B2M) -multiple myeloma -lymphoma

5. Serum gamma globulin -bone marrow CA's <multiple myelona <macroglobulinemia
6. human chorionic gonadotropin (HCG) -testicular CA (seminima & non seminoma) -choriocarcinoma 7.CA 125 -OVA CA -endometriosis -lung CA 8.Neuro-specific enolase (NSE) -Lung CA (small cell lung CA)
7. Prostate specific antigen(PSA) -Prostate CA -Benign prostatic hypertrophy(BPH)

10. CA 72-4

-OVA CA

-gastrointestinal cáncers

11. Prostatic acid phosphatase(PAP) -prostate CA 12.CA 19-9 -Pancreatic CA -Can be elevated with colorectal and. bile duct CA's 13.s-100 and TA-90 -malignant melanoma 14.calcitonin -medullary thyroid CA 15.Bladder tumor antigen and NMP22 -BL CA(transitional cell carcinoma) 16.carcinoembryonic antigen (CEA)

• colorectal CA -elevated with other CA's The rt and lt hepatic ducts join to form the - Answer: CHD