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ABDOMINAL SONOGRAPHY ARDMS EXAM
2024 WITH ACTUAL CORRECT QUESTIONS
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what is the sonographic appearance of an intussusception? an intussusception usually presents as an oval, pseudokidney mass, with central echoes on longitudinal imaging, and a sonolucent doughnut or target configuration on cross-sectional imaging name the four zones of the prostate peripheral zone transition zone central zone fibromuscular stroma what zone of the prostate is the source of most prostate cancers? the peripheral zone is the location for approx. 70% of all prostate cancers. the classic appearance of prostate cancer on ultrasound is a hypoechoic, peripherally-oriented lesion what zone of the prostate is not affected by cancer? the fibromuscular stroma is a non-glandular, anterior portion of the prostate. therefore, it is not affected by cancer, prostatitis, or hyperplasia describe benign prostatic hyperplasia (BPH) enlargement of the inner gland. BPH priginates exclusively from the inner gland. 95% of all BPH arises in the transition zone, and only 5% form the periurethral glands or tissue the ejaculatory ducts pass through the _____ and empties into the urethra
central zone seminal vesicles are two sac-like out-pouchings of the vas deferens situated adjacent to the ____ aspect of the prostate between the urinary bladder and rectum. superior/posterior the base of the prostate is the _____ portion of the gland superior the apex of the prostate is the ____ portion of the gland inferior the demarcation between the inner gland and the outer gland is called the _____ surgical capsule the prostate is situated in the retroperitoneum and is bordered:
- anteriorly by the ____
- posteriorly by the ___
- superiorly by the ____
- inferiorly by the _____
- pubic bone
- rectum
- bladder
- urogenital diaphragm describe prostate-specific antigen (PSA). PSA is produced exclusively by prostatic acinar cells, and rises in relationship to the amount of benign and/or malignant tissue when do PSA levels rise? PSA will rise with patient age, prostate volume, benign prostatic hyperplasia, and or prostate cancer. prostate cancer will elevate the PSA level approximately 10x that of benign prostatic hyperplasia. what is the name of the anatomical point where the posterior sheath of the rectus muscle ends? arcuate line describe the sonographic appearance of an abscess abscesses are complex collections containing cystic and solid componenets. in most cases, debris, septations, and gas are seen within the abscess. the borders of an abscess are typically irregular, and may be quite thick. depending on their cystic component, abscesses typically demonstrate posterior enhancement. clinically, patients with abscesses should present with fever and leukocytosis what is the etiology of a lymphocele?
and/or anemia. the sonographic appearance of adrenal hemorrhage is variable depending on the age of the hematoma what does the presence of portal venous gas indicate? portal venous gas in an indication of bowel infarction, as seen in ulcerative colitis or necrotizing enterocolitis what is the sonogrpahic appearance of portal venous gas? the sono appearance of portal venous gas is that of linear echogenic branches in the periphery of the liver. echogenic foci within the lumen of the portal vein is also seen does the sonographic portal venous gas differ from that of biliary gas? yes, the sono appearance of portal venous gas differs from that of biliary gas. portal venous gas is seen within the periphery of the liver, while biliary gas is located closer to the liver hilum what is nutcracker syndrome? Nutcracker syndrome is compression of the left renal vein between the superior mesenteric artery and the aorta. it is evident by the markedly dilated left renal vein as compared to the right renal vein. associated symptoms include : left-sided hematuria, abd pain, varicocele formation, and possibly infertility. what pathology is described by the terms mantle sign and sandwich sign? Diffuse lymphadenopathy of the abd will create a layered or mantle appearance around vessels of the abd. lymphadenopathy is visualized anterior and posterior to vessels of the abd, thus creating the sandwich sign what are the symptoms of Graves Disease? thyroid hyperfunctioning, causing diffuse glandular hyperplasia. Patients with Graves disease may present with exophthalmos, palpable lymph nodes, muscle atrophy, localized myxedema, weight loss, tremors, and nervousness. describe the sono features of Graves disease sonographically, the thyroid is diffusely enlarged and appears identical to a multinodular goiter. color flow Doppler will show increased vascularity due to hyperfunctioning of the gland a 6-year old patient presents with a lateral neck mass. the mass is anterior to the SCM muscle and lateral to the thyroid near the angle of the mandible. the mass is predominantly cystic, with enhanced through-transmission. what is the most likely diagnosis for this mass? this mass is a branchial cleft cyst. a branchial cleft cyst arises in the lateral aspect of the neck, commonly from epithelial remnants of the second branchial cleft. this is the most common explanation for a cyst in the lateral aspect of the neck a patient presents with hypoglycemia and a hypoechoic mass in the tail of the pancreas. what is the mass in the pancreas?
the mass is most likely an islet cell tumor. this tumor, which is usually seen in the body or tail of the pancreas, causes hypersecretions of insulin, which causes hypoglycemia. name and describe two cystic masses associated with the pancreas in patients without a history of autosomal dominant polycystic kidney disease pseudocysts- formed in association with acute or chronic pancreatitis. they are encapsulated collections of pancreatic enzymes. sonographically, pseudocysts are predominantly anechoic masses that may or may not contain dependent debris. pseudocysts commonly displace or invade adjacent structures such as the liver, lesser sac, stomach, left kidney, or spleen cystadenomas- rare fluid collections that arise from the epithelium of the pancreatic duct. they are primarily cystic, with septations and thick walls. cystadenomas are easily confused with pseudocysts. both are associated with increased levels of serum amylase describe the sono characteristics of emphysematous cholecystitis acute infection of the gb wall. due to vascular compromise, bacteria produces gas within the wall of the gb. sonographically, emphysematous cholecystitis appears as a thickened gb wall. gas within the wall produce comet-tail or reverberation artifacts. this may be described as a "ring of air" what are the presenting symptoms in a patient with emphysematous cholecystitis? high mortality a large percentage of these patients are diabetics. patients present with right upper quadrant pain, fever, and peukocytosis what two vessels form the main portal vein? the splenic vein and the SMV at the confluence adjacent to the head of the pancreas to form the MPV what are the two methods of renal artery evaluation? direct- renal artery velocity evaluation indirect- inrarenal waveform evaluation name five techniques to access a renal artery stenosis? main renal artery peak systolic velocity renal artery/ aorta velocity ratio pulsus parvus et tardus absent early systolic peak acceleration(intrarenal waveform) describe the use of the renal artery to aortic ratio in determining renal artery stenosis to determine the degree of stenosis in the renal arteries, peak systolic velocities of the main renal arteries are compared with the peak systolic velocity of the aorta. the ratio is computed by dividing the peak systolic velocity of the renal artery by the peak systolic velocity of the aorta renal artery to aortic ratios greater than or equal to 3.5 indicate a hemodynamically significant stenosis
name 5 reasons for enlarged gallbladder prolonged fasting hydrops of gb choledocholithiasis Courvoisier gb diabetes name and describe three causes of jaundice
- Hepatocellular disease, which is destruction of hepatocytes that interfere with excretion of bilirubin
- hemolytic disease, which occurs when the hepatocytes can not conjugate bilirubin fast enough to keep up with an increase in red blood cell destruction. this creates an increase in indirect or unconjugated bilirubin
- surgical jaundice, which is the mechanical obstruction of the biliary tree causing increases in direct or conjugated bilirubin ultrasound findings of malignant tumors can lead to further ultrasound evaluation. describe the area of further evaluation when presented with the following primary malignancies:
- solid testicular mass
- solid renal mass
- solid mass filling gb
- solid pancreatic mass
- solid testicular mass- the periaortic region should be evaluated for lymphadenopathy
- solid renal mass- the IVC and the renal veins should be evaluated for tumor extension
- solid mass filling the gb-the liver should be evaluated for mets, to verify the malignant nature of the gb mass
- solid pancreatic mass- additional areas of eval should include the liver for mets, the biliary tree and pancreatic duct for dilatation, regional lymphadenopathy, and the portal vein and splenic vein for thrombosis the pancreas is divided into endocrine and exocrine functions. what is the product of the endocrine gland? what cells carry out the endocrine function of the pancreas? the endocrine function of the pancreas is to produce insulin. the cells that produce insulin are the islets of Langerhans. what is the product of the exocrine gland? what cells carry out the exocrine function of the pancreas? the exocrine function of the pancreas is to produce amylase, lipase, carboxypeptidase, trypsin, and chymotrypsin. the cells that product these enzymes are called acinar cells multiple endocrine neoplasia is a familial autosomal dominant, adenomatous hyperplasia. name four tumors associated with multiple endocrine neoplasia that can be visualized sonographically parathyroid adenoma medullary thyroid carcinoma
pancreatic islet cell tumor pheochromocytoma name 3 lab values that will elevate in association with a biliary obstruction conjugated bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase will elevate in the presence of a biliary tree obstruction name two lab values utilized as tumor markers and will elevate in association with a malignancy alpha-fetoprotein and carcinoembryonic antigen are tumor makers associated with various malignancies name the pathology associated with the sonographic sign:
- pseudokidney sign
- water lily sign
- parallel channel sign
- double bubble sign
- olive sign
- inflammatory bowel
- echinococcal cysts
- intrahepatic duct dilatation
- duodenal atresia
- hypertrophic pyloric stenosis name 3 abdominal examples that produce a comet-tail or reverberation artifact adenomyomatosis emphysematous cholecystitis pneumobilia name three masses that produce a propagation speed artifact
- hepatic lipoma
- angiomyolipoma
- adrenal myelolipoma name two structures posterior to the IVC right renal artery and right adrenal gland name two structures posterior to the first portion of the duodenum CBD and GDA name the structure posterior to the third portion of the duodenum passes between the SMA and AO. AO is imaged posterior to 3rd portion name the structure posterior to the head of the pancreas IVC
Wilm's Tumor (nephroblastoma) is the most common renal tumor in children. the mean age at diagnosis is 3.5 years what are the ultrasound findings associated with significant acute pyelonephritis? ultrasound findings associated with acute pyelonephritis include: renal enlargement hypoechoic parenchyma absence of sinus echoes What is pyonephrosis? the presence of pus in a dilated renal collecting system, secondary to infected hydronephrosis. What are the three sonographic features of pyonephrosis?
- dependent echoes within a dilated pelvocaliceal system
- shifting urine-debris level
- gas shadowing from infection what malignant tumor is associated with the urinary collecting system ( renal pelvis, ureter, and bladder)? transitional cell carcinoma, although typically occurring in the bladder, can arise in the ureter and renal pelvis what are the sonographic findings associated with renal vein thrombosis?
- dilated thrombus-filled renal vein
- absent intrarenal venous flow
- enlarged hypoechoic kidney
- high-resistance renal artery waveform ( increased RI) what is the sonographic appearance of a renal mycetoma? Myctoma( Fungal Ball) appear as hyperechoic, nonshadowing masses. Angiomyolipomas, blood clots, pyogenic debris, sloughed papilla, and nonshadowing renal stones have a similar sonographic appearance list four sonographic features of multicystic dysplastic kidney disease
- cysts of varying shape and size
- absence of communication between cysts
- absence of renal sinus
- absence of renal parenchyma what contralateral renal abnormalities are found when multicystic dysplastic kidney disease is unilateral?
- ureteropelvic junction obstruction
- renal agenesis or hypoplasia
- pelvovalectasis name 3 anatomic anomalies that appear as pseudotumors of the kidney
- column of Bertin
- dromedary hump
- fetal lobation what is the term which refers to patients on chronic hemodialysis that develop bilateral renal cysts acquired cystic disease is seen with patients on chronic hemodialysis. on occasion, these cyst may hemorrhage resulting in flank pain, hematuria and intracystic echogenic collections. acquired cystic disease is associated with a slightly higher incidence of renal cell carcinoma what would a sonographer look for in a patient with a history of tuberous sclerosis? tuberous sclerosis is a multisystemic disorder associated with renal cyst formation and multiple renal angiomyolipomas what are the other names for a renal cell carcinoma? hypernephromas, adenocarcinomas, von Growitz tumor renal cell carcinoma is associated with what four diseases?
- adult polycystic kidney disease
- acquired cystic disease
- Von Hippel-Lindau syndrome
- Tuberous Sclerosis renal cell carcinoma sonographically appears as an encapsulated, solid mass that is hypoechoic relative to normal, adjacent renal parenchyma. what additional areas should be evaluated whenever a solid renal mass is detected?
- ipsilateral renal vein and IVC for tumor invasion
- contralateral kidney and renal vein
- retroperitoneum for lymphadenopathy
- liver for METS describe the appearance of a dromedary hump the dromedary hump is a common variant of cortical thickening of the lateral aspect of the left kidney describe the appearance of a junctional parenchymal defect the junctional parenchymal defect is a triangular echogenic area in the anterior aspect of the right upper pole of the kidney
due to the dysplastic collecting tubules of the medullary pyramids, calcium tends to deposit within them. thus sonographically, medullary sponge kidney appears as equally spaced hyperechoic medullary pyramids what is the most common cause of an abdominal mass in the newborn? multicystic dysplastic kidney disease is the most common cause of an abdominal mass in the newborn what are the four functions of the spleen?
- breakdown of hemoglobin
- formation of bile pigment
- formation of antibodies
- a reservoir for blood the stomach is _______ to the splenic hilum medial and anterior the tail of the pancreas is _______ to the stomach posterior the left kidney is ________ to the spleen inferior and medial the tail of the pancreas is _______ to the upper pole of the left kidney anterior name four structures that appear as cystic splenic masses
- cystic degeneration of infarcts or hematomas
- cysts associated with adult polycystic kidney disease
- parasitic cysts of the spleen
- pancreatic pseudocysts describe the sonographic appearance of a splenic infarct the typically appearance of a splenic infarct is a peripheral wedge-shaped hypoechoic lesion what type of hematoma is the result of splenic trauma in which the splenic capsule remains intact an intraparenchymal or subscapular hematoma occurs with splenic trauma in which the splenic capsule remains intact what type of hematoma is the result of splenic trauma in which the splenic capsule ruptures a perisplenic or intraperitoneal hematoma occurs with splenic trauma in which the splenic capsule ruptures true pancreatic cysts are uncommon. multiple pancreatic cysts are associated with what two syndromes?
autosomal dominant ( adult) polycystic kidney disease Von Hippel-Lindau syndrome cystic fibrosis is characterized by viscous secretions leading to pancreatic insufficiency. when severely affected, what is the sonographic appearance of the pancreas in a patient with cystic fibrosis the chronic appearance of the pancreas in a patient with cystic fibrosis is increased echogenicity of the pancreatic parenchyma name four sonographic indications of portal vein thrombosis
- echogenic thrombus within vessel lumen
- an increase in portal vein diameter
- portosystemic collateral circulation
- cavernous transformation name three notable structures posterior to the kidneys diaphragm Quadratus Lumborum muscle psoas muscle what is the orientation of structures that enter and exit the renal hilum? the vein exits anteriorly the artery enters between the vein and ureter the ureter exits posteriorly trace the branches of the renal artery the main renal artery branches from the aorta. upon entering the hilum of the kidney, it divides into five segmental arteries, which in turn divide into interlobar arteries. the interlobar arteries are seen between the medullary pyramids. at the base of the medullary pyramids, the arcuate arteries branch perpendicular from the interlobar arteries. the arcuate arteries are seen running parallel to the renal capsule the interlobar arteries branch off the arcuate arteries and run perpendicular to the renal capsule name the fascia which encloses the kidneys, adrenal glands, and perinephric fat the sheath that encloses the kidneys and adrenal glands is Gerota's Fascia or the perirenal space what renal structure is a concentrated area of collecting tubules which is sonographically seen in newborns and infants as hypoechoic equally spaced triangles medullary pyramids are collecting tubules which appear as hypoechoic triangles in newborns and infants. in adults, they are not commonly imaged, but this depends on patients body habitus bilateral renal agenesis associated with oligohydramnios and pulmonary hypoplasia is incompatible with life. what is associated with unilateral renal agenesis?
choledochal cyst parasitic infestations what is the name of the cholangiocarcinoma located at the hepatic hilum? Cholangiocarcinoma is commonly located in the CHD and CBD. A klatskin tumor is a specific type of cholangiocarcinoma located at the hepatic hilum. with a Klatskin tumor intrahepatic bile duct dilatation should be seen without extrahepatic bile duct dilatation the head of the pancreas is _______ to the IVC anterior the head of the pancreas is ________ to the second portion of the duodenum medial the CBD is ______ to the head of the pancreas posterolateral the GDA is _______ to the head of the pancreas anteriolateral the SMA and SMV are ______ to the neck of the pancreas posterior the uncinate process is ______ to the SMA and SMV posterior the aorta is _____ to the body of the pancreas posterior the celiac axis arises from the aorta ______ to the pancreas superior the GDA and CBD run ________ to the first portion of the duodenum posterior the splenic vein is ______ to the pancreas posterior the SMA arises from the aorta _____ to the pancreas inferior the SMA and SMV are _____ to the uncinate process of the pancreas anterior
the SMA and SMV are _____ to the third portion of the duodenum anterior the SMV is to the _____ of the SMA right the portal vein is the result of the combination of the ____ and the ______ SMV and Splenic vein what are the two most common causes of pancreatitis? alcohol abuse and biliary calculi what is the sonographic appearance of acute pancreatitis? mild- normal appearing with increasing severity, decreased echogenicity and increased gland size are noted what are the sonographic signs of chronic pancreatitis?
- small, echogenic gland
- calcifications
- pancreatic duct dilatation
- pseudocyst formation pancreatic adenocarcinoma is sonographically seen as a solid focal hypoechoic mass typically (70%) In the head of the pancreas. what additional findings are associated with pancreatic adenocarcinoma?
- diated biliary system
- dilated pancreatic duct
- liver mets
- ascited
- lymphadenopathy
- pseudocyst formation what sign is associated with an adenocarcinoma of the pancreatic head resulting in extrinsic compression of the common bile duct and an enlarged gallbladder? a Courvoisier's sign is a palpable, nontender gallbladder due to an adenocarcinoma of the pancreatic head obstructing the biliary tract resulting in jaundice the pancreas is a nonencapsulated, retroperitoneal structure located between the second portion of the second duodenum and the splenic hilum. what space in the retroperitoneum is the pancreas located? located in the anterior pararenal space of the retroperitoneum name the 5 different parts of the pancreas head, neck, body, tail, and uncinate process
- acute pancreatitis
- chronic pancreatitis
- trauma
- pancreatic cancer what is the most common location of a pancreatic pseudocyst commonly located within the anterior pararenal space of the retroperitoneum and the lesser sac of the peritoneum what is emphysematous cholecystitis? an infection associated with gas-forming bacteria within the wall of the gallbladder describe the sonographic appearance of emphysematous cholecystitis appears as gas shadowing from the wall of the gallbladder describe the mechanism of hydrops of the gallbladder distended, non-inflamed gallbladder due to total obstruction of the cystic duct. the trapped bile is reabsorbed and the gallbladder is filled with a clear mucinous secretion derived from the mucosa. this condition is asymptomatic and may present as a palpable, RUQ mass. the diagnosis should be suspected on ultrasound when an obstructing stone is noted in an enlarged, but non-tender, gallbladder what are Rokitansky-Ascholff sinuses (RAS)? diverticula within the wall of the gallbladder what pathology is associated with Rokitansky-Aschoff sinuses? adenomyomatosis. sludge and stones accumulate within the sinuses, and present as focal wall thickening. echogenic foci are visible within the thickened wall. this accumulation causes a characteristic comet tail reverberation artifact what is the sonographic presentation of gallbladder carcinoma? intraluminal mass, asymmetric wall thickening or a mass-filled gallbladder what three other findings should be investigated to confirm the diagnosis of gallbladder carcinoma?
- liver METS
- lymphadenopathy
- bile duct dilatation what are the two most common causes of biliary tract obstruction?
- gallstones(choledocholithiasis
- carcinoma of the pancreas what lab values are most likely to be elevated due to biliary tract obstruction?
- alkaline phosphatase
- conjugated (direct) bilirubin
- gamma glutyml transpeptidase what are the two signs that indicate intrahepatic bile duct dilatation? shotgun sign and parallel channel sign both describe the appearance of a dilated bile duct adjacent to a portal vein. other features that characterize intrahepatic bile duct dilatation is the irregular path of dilated bile ducts as compared to portal veins, the stellate or star-shape configuration of bile ducts and acoustic enhancement associated with bile ducts what is Mirizzi's syndrome? an extrahepatic bile duct obstruction due to a stone within the cystic duct. the stone causes extrinsic mechanical compression of the common hepatic duct describe sonographic findings associated with Mirizzi's syndrome intrahepatic bile duct dilatation, a normal-sized CBD, and a large stone in the cystic duct of the gallbladder name three extrahepatic biliary ducts
- common hepatic duct
- cystic duct
- common bile duct what pathology causes intrahepatic biliary dilatation without extrahepatic biliary dilatation? Klatskin tumor causes intrahepatic biliary dilatation without extrahepatic biliary dilatation. a Klatskin tumor is a specific type of cholangiocarcinoma. it is located at the hepatic hilum at the junction of the right and left hepatic ducts describe the sonographic appearance of pneumobilia ( air in the biliary tree) variable length echogenic foci in the distribution of the biliary tree, resulting in acoustic shadowing and reverberation ( comet tail artifacts) commonly seen in the hilum of the liver what is the most common reason for pneumobilia? most commonly seen after an endoscopic retrograde cholangiopancreatiogram (ERCP.) however, it can also be due to surgically created biliary-enteric anastomosis, incompetence of the Sphincter of Oddi, wall erosion by a gallstone or ulcer into the common bile duct choledochal cysts usually occur in Asian women. Symptoms of pain, jaundice, and an abdominal mass may be present. what are the sonographic features associated with a choledochal cyst?
- two cyst-like structures in the RUQ. these are the gallbladder and the dilated common bile duct
- dilated intrahepatic biliary tree what is the sonographic appearance of Caroli's Disease?
