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You are scanning a patient with a known mass in the left medial segment of the liver. What anatomic landmark can you use to identify the left medial segment from the right anterior segment of the liver? - CORRECT ANSWER>>Middle Hepatic Vein You suspect enlargement of the caudate lobe in a patient with liver disease. What structure located at the anterior border of the caudate lobe will help you identify this lobe of the liver? - CORRECT ANSWER>>Fissure for the ligamentum venosum You are asked to rule out the presence of a recanalized paraumbilical. Which anatomic structure is a useful landmark in location of this structure? - CORRECT ANSWER>>Ligamentum Teres *The left portal vein is in contact with the ligamentum teres. A paraumbilical vein begins at the left portal vein and exits the liver at the ligamentum teres. Which vessel courses within the main lobar fissure? - CORRECT ANSWER>>Middle Hepatic Vein Oxygenated blood is supplied to the liver via the: - CORRECT ANSWER>>Portal Vein and Hepatic Artery You are performing a sonogram on a slender female and notice a long, thin extension of the inferior aspect of the right lobe of the liver. This most likely represents: - CORRECT ANSWER>>Reidel's lobe Which of the following forms the caudal border of the left portal vein? 2 | P a g e A. Ligamentum venosum B. Hepatoduodenal ligament C. Main Lobar Fissure D. Coronary Ligament E. Ligamentum teres - CORRECT ANSWER>>Ligamentum teres What ligament divides the left lobe of the liver into medial and lateral segments? - CORRECT ANSWER>>Ligamentum teres You are asked to perform a Doppler study on the hepatic veins in the liver. What differentiates the hepatic veins from the portal veins? - CORRECT ANSWER>>The portal veins are accompanied by branches of the biliary tree and hepatic artery You have detected a mass anterior and to the left of the ligamentum venosum. This mass is located in what lobe of the liver? - CORRECT ANSWER>>Left Lobe of the Liver The thin capsule surrounding the liver is known as: - CORRECT ANSWER>>Glisson's capsule Which of the following course interlobar and intersegmental within the liver? A. Bile ducts B. Portal veins C. Hepatic arteries D. Lymphatics E. Hepatic veins - CORRECT ANSWER>>E. Hepatic Veins You are performing an ultrasound exam of the liver on a small patient with a 5 MHz curved linear array. Although you have increased the overall gain to its
maximum setting, the posterior border of the liver and diaphragm are not visualized. What should you do? - CORRECT ANSWER>>Rescan the liver with a lower frequency transducer *Lower frequency transducers provide greater penetration than higher frequency transducers. Another way to increase the penetration is to increase the transmit power. Decreasing the transmit power will decrease penetration. Moving the focal zone into the near field will not improve penetration. 3 | P a g e How would you correctly describe the probe placement and imaging plane you would use to demonstrate the 3 hepatic veins and IVC in one view? - CORRECT ANSWER>>Subcostal oblique approach with the probe angled superiorly and to the patients right You are performing a follow-up sonogram on a patient in which a 5-mm cyst was previously identified at the anterior border if the left lobe of the liver. Although you are using a 3.5 MHz curved linear array transducer, you do not see the cyst. What would be most helpful in improving the visibility of this cyst? - CORRECT ANSWER>>Rescan the left lobe with a higher frequency transducer *Visibility of small cysts is limited by spatial resolution. To improve resolution, the best option is to increase the imaging frequency. You are imaging a patient with a high liver. Subcostal images do not clearly demonstrate the liver tissue. What should you do? - CORRECT ANSWER>>Scan the patient in deep inspiration A patient is referred for ultrasound evaluation of a questionable mass in the dome of the liver seen on a CAT scan. What method would improve visualization in this area of the liver? - CORRECT ANSWER>>Perform a subcostal scan with the probe angled superior and the patient in deep inspiration A patient is referred for a liver ultrasound with a clinical history of elevated alpha fetoprotein level. What should you look for? - CORRECT ANSWER>>Hepatocellular Carcinoma (HCC)
- A non-pregnant patient with elevated levels of AFP may have hepatocellular carcinoma. However, low levels of AFP do not rule out the presence of HCC. Other abnormalities associated with high levels of AFP include germ cell tumor of gonadal, retroperiotoneal, or mediastinal origin. Occasionally, serum AFP levels may be abnormally high with cancer of the pancreas, stomach, or biliary system. Hepatitis and Cirrhosis may produce modest serum AFP. You are reviewing lab work prior to performing an abdominal ultrasound exam. Elevated lab values include Gamma-glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP). Which statement below is true? 4 | P a g e A. Elevation of both GGT and ALP suggests the source of elevated ALP is due to metastatic bone cancer B. Elevation of both GGT and ALP is a sensitive indicator of pancreatitis C. If both GGT and ALP are elevated, the lab work is invalid and must be repeated D. Concomitant elevation of both GGT and ALP indicates the source of the elevated ALP in the liver - CORRECT ANSWER>>D. Concomitant elevation of both GGT and ALP indicates the source of the elevated ALP in the liver *ALP may be elevated with multiple conditions including skeletal disease, hyperparathyroidism, and acute hepatocellular disease. GGT is used with ALP to suggest the source of elevated ALP levels. If both ALP and GGT levels are elevated, the source of the ALP is probably of the liver, indicating hepatocellular dysfunction. Which of the following lab tests is NOT used in evaluation of liver function? A. Gamma-glutamyl transpeptidase (GGT) B. Aspartate aminotransferase (AST) C. Direct bilirubin D. Indirect bilirubin E. Lipase - CORRECT ANSWER>>E. Lipase
A patient is referred to rule out hepatomegaly. What are useful indicators of hepatomegaly? - CORRECT ANSWER>>*Rounding of the inferior border of the liver *Longitudinal measurement of the right lobe exceeding 15.5 cm *Extension of the right lobe inferior to the lower pole of the right kidney *Increased anteroposterior measurement of the right lobe You have identified a single homogeneous hyperechoic lesion measuring 2.4 cm in the posterior aspect of the right lobe of the liver. What is the most common etiology of a mass fitting this description? - CORRECT ANSWER>>Cavernous Hemangioma A patient is referred for a sonogram of the liver to rule out metastatic disease. What describes the sonographic appearance of liver metastasis? - CORRECT ANSWER>>Single hypoechoic mass Multiple hyperechoic masses Masses of mixed echogenicity Cystic masses Which of the following is NOT a feature of hepatic cysts? A. Thin wall B. Posterior Acoustic Enhancement C, Anechoic D. Increased Attenuation 7 | P a g e E. Increased through transmission - CORRECT ANSWER>>D. Increased Attenuation *Attenuation through a cyst is decreased rather than increased A single, well-defined mass with smooth walls and homogeneous low-level echoes is seen within the anterior right lobe of the liver in a 48 year old female. No Doppler signals could be obtained within the mass. Which of the following conditions is the most likely etiology of this mass? A. Kaposi's sarcoma B. Focal nodular hyperplasia C. Hemorrhagic cyst D. Portal vein aneurysm E. Hepatocellular carcinoma - CORRECT ANSWER>>C. Hemorrhagic cyst You are scanning a patient with history of fever, abnormal liver function tests, and right upper quadrant tenderness. The liver is enlarged with decreased echogenicity, the gallbladder wall is thickened and thick echogenic bands are noted surrounding the portal veins. What condition is this? - CORRECT ANSWER>>Hepatitis *With hepatitis, the liver parenchyma may appear normal or have a decreased echogenicity of the portal veins. Bright bands seen surrounding the portal veins are known as "periportal cuffing." Hepatomegaly may be present as well as thickening of the gallbladder wall. You are evaluating a suspicious lesion to look for gas bubbles to confirm the presence of a liver abscess in a patient with fever and increased white blood cell count. What is the sonographic appearance of the gas bubbles? - CORRECT ANSWER>>Brightly echogenic foci associated with echogenic ringdown artifact Which of the following is associated with infestation by a parasite and is most prevalent in sheep and cattle-raising countries? - CORRECT ANSWER>>Hydatid disease You are scanning the liver and notice irregularity of the surface. A nodular liver surface is associated with which of the following abnormalities? A. Cirrhosis 8 | P a g e B. Acute Hepatitis C. Fatty liver D. Polycystic liver disease E. Hepatomegaly - CORRECT ANSWER>>A. Cirrhosis Which of the following is NOT true regarding fatty liver?
A.It is an irreversible disorder B.Fatty liver may be caused by obesity C. It may be diffuse or focal D. It may show a rapid change in appearance with time E. It commonly causes increased attenuation of the sound beam through liver - CORRECT ANSWER>>A. It is an irreversible disorder. *It is a reversible disorder You are scanning through the liver and notice a luminal narrowing of the hepatic veins. Color and spectral Doppler reveal high velocities through the strictures. These findings are most commonly associated with which of the following? A. Diffuse fatty liver B. Acute hepatitis C. Cirrhosis D. Focal fatty infiltration E. Glycogen storage disease - CORRECT ANSWER>>C. Cirrhosis *Since the walls of the hepatic veins are thin, they may be compressed as cirrhosis progresses. Gray-scale imaging may reveal tapering of the veins with color and spectral Doppler confirming increased velocities through the narrowed lumens. The most common benign tumor in the liver is: - CORRECT ANSWER>>Cavernous hemangioma Which of the following is most commonly associated with invasion of the portal vein? A. Hepatocellular carcinoma B. Cavernous hemangioma C. Liver metastases 9 | P a g e D. Hepatic adenoma E. Focal nodular hyperplasia - CORRECT ANSWER>>A. Hepatocellular carcinoma (HCC) *HCC has a propensity for venous invasion, which involves the portal venous system more commonly than the hepatic venous system. Tumor invasion of the portal vein can be differentiated from portal vein thrombosis by the presence of low-resistance arterial flow located in a fine network of vessels within the tumor filled vein. A thrombus-filled vein will not show flow within the thrombus. Although metastatic disease may lead to invasion of the portal vein, it occurs less commonly than with hepatocellular carcinoma. You have been asked to perform a liver sonogram on a patient with AIDS. What tumor is most commonly associated with this history? - CORRECT ANSWER>>Kaposi's sarcoma You are scanning a 53 year old female with a history of recent weight loss and vague abdominal pain. The liver is markedly heterogenous and contains numerous calcified lesions. This most likely represents metastatic disease from with primary? A.Non-Hodgkin lymphoma B. Cystadenocarcinoma of the ovary C. Lung D. Adenocarcinoma of the colon E. Breast - CORRECT ANSWER>>D. Adenocarcinoma of the colon *Although there are a variety of appearances of metastatic liver disease, calcified metastases is most commonly associated with mucinous adenocarcinoma of the colon. Metastasis from the breast, lung, and lymphoma tend to be hypoechoic. Cystic metastasis may occur from cystadenocarcinoma of the ovary or pancreas During ultrasound evaluation of the liver, a bull's eye or target lesion is identified in the anterior right lobe. The most likely etiology of this mass is: A. Liver abscess B. Hepatic adenoma C. Focal nodular hyperplasia D. Hepatocellular carcinoma
D. Portal vein thrombosis E. Pseudoaneurysm - CORRECT ANSWER>>A. Rejection Graft rejection is extremely common following liver transplantation. Unfortunately, there have been no imaging findings that have sufficient sensitivity or specificity to rule out rejection. Complications of biopsy, including pseudoaneurysm and hematoma, may be detected sonographically. You are scanning a patient with a history of liver transplantation. What should you search for following complications of this surgery? - CORRECT ANSWER>>Biliary sludge 12 | P a g e *Portal vein stenosis *Hepatic artery thrombosis *Liver malignancy You have been asked to provide ultrasound imaging during liver surgery. What transducer would be best suited for this purpose? A. 3.5 MHz curved linear array B. 10 MHz linear array C. 2.25 MHz phased array D. 7 MHz linear array E. 12 MHz curved linear array - CORRECT ANSWER>>D. 7 MHz linear array *During intraoperative scanning, the sterile transducer is placed directly on the exposed liver. For this reason, a transducer with higher than usual frequency can be used to image the liver nonsurgically. Typically, a 5 MHz linear array is used. Frequencies higher than 7 MHz, however, may not allow adequate penetration through the exposed liver. Some specialized transducers are available with small footprints and side cable inserts that allow the surgeon to place the probe underneath the liver. You are scanning through the right lobe of the liver and notice that although you have maximized the far field TGC, the parenchyma in the far field and diaphragm are not clearly visualized. What should you do? A. Decrease transmit power B. Increase compression curve C. Decrease transmit frequency D. Decrease overall gain E.Increase dynamic range - CORRECT ANSWER>>C. Decrease transmit frequency *Lowering the transmit frequency will increase penetration and improve visibility in the far field. This may require selection of a different transducer with a lower frequency, or, with some wideband transducers, multiple frequencies may be selectable depending on the need for either greater penetration or greater resolution. Hepatofugal flow in the portal vein is a sign of: 13 | P a g e A. Normalcy B. Hepatic artery thrombosis C. Portal hypertension D. Acute cholecystitis E. Hepatocellular carcinoma - CORRECT ANSWER>>C. Portal Hypertension *The normal flow direction of the portal vein is cranially directed toward the liver and is termed hepatopetal. Hepatofugal flow is retrograde portal vein flow directed away from the liver. It is a sign of severe portal hypertension. A patient is referred for abdominal ultrasound with a high fever and RUQ pain. You document the presence of a large, rounded, homogeneous mass with low-level internal echoes and poorly defined borders. The mass is located in the right lobe of the liver, adjacent to the capsule and shows increased through transmission. This most likely represents: A. Hemorrhagic cyst B. Abscess
C. Hematoma D. Choledochal cyst E. Loculated ascites - CORRECT ANSWER>>B. Abscess *These characteristics describe an amebic abscess within the liver. A hemorrhagic cyst could have a similar appearance, but the wall would be clearly defined rather than poorly distinguished. You are scanning a patient with a known mass in the left medial segment of the liver. What anatomic landmark can you use to identify the left medial segment separate from the right anterior segment of the liver? - CORRECT ANSWER>>Middle Hepatic Vein Which organ is the largest visceral organ in the body? - CORRECT ANSWER>>Liver Where is the major portion of the liver, the right lobe located? - CORRECT ANSWER>>in the right upper quadrant of the abdomen What organ is covered in large part by the peritoneum , except for a small area posterior to the dome known as the bare area? - CORRECT ANSWER>>the Liver 14 | P a g e Which organ is covered in a layer of fibrous tissue, glisson's capsule? - CORRECT ANSWER>>the Liver You suspect enlargement of the caudate lobe in a patient with liver disease. What structure located at the anterior border of the caudate lobe will help you to identify this lobe of the liver? - CORRECT ANSWER>>Fissure for the ligamentum venosum You are asked to rule out the presence of a recannalized paraumbilical. Which anatomic structure is a useful landmark in location of this structure? - CORRECT ANSWER>>Ligamentum teres What is the left portal vein in contact with? - CORRECT ANSWER>>Ligamentum teres Where does the paraumbilical vein begins? - CORRECT ANSWER>>begins at the left portal vein and exits the liver at the ligamentum teres Which vessel course within the main lobar fissure? - CORRECT ANSWER>>middle hepatic vein Oxygenated blood is supplied to the liver via the: - CORRECT ANSWER>>Portal vein and hepatic artery You are performing a sonogram on a slender female and notice a long, thin extension of the inferior aspect of the right lobe of the liver. The most likely represents: - CORRECT ANSWER>>Reidel's lobe What forms the caudal border of the left portal vein? - CORRECT ANSWER>>Ligamentum teres What ligament divides the left lobe of the liver into medial and lateral segments? - CORRECT ANSWER>>Ligamentum teres You are asked to perform a Doppler study on the hepatic veins in the liver. What differentiates the hepatic veins from the portal veins? - CORRECT ANSWER>>the portal veins are accompanied by branches of the biliary tree and hepatic artery 15 | P a g e You have detected a mass anterior and to the left of ligamentum venosum. This mass is located in what lobe of the liver? - CORRECT ANSWER>>Left Lobe The thin capsule surrounding the liver is known as: - CORRECT ANSWER>>Glisson's capsule What courses interlobar and intersegmental within the liver? - CORRECT ANSWER>>Hepatic veins You are performing an ultrasound exam of the liver on a small patient with a 5MHz curved linear array. Although you have increased the overall gain to its maximum setting, the posterior border of the liver and diaphragm are not visualized. What should you do? - CORRECT ANSWER>>Rescan the liver with a lower frequency transducer. Correctly describe the probe placement and imaging plane you would use to demonstrate the three hepatic veins and inferior vena cava in the one view? -
adenomas has increased in the united states since the 1970s. And are associated with use of oral contraceptives. A liver ultrasound on a 49-year-old obese male demonstrates diffuse increased echogenicity with a focal hypoechoic area anterior to the portal vein. This most likely represents: - CORRECT ANSWER>>Fatty metamorphosis of the liver with focal sparing What is commonly seen as a hypoechoic mass anterior to the portal vein? - CORRECT ANSWER>>Focal fatty sparring A 52-year-old male with known liver cirrhosis presents for an abdominal ultrasound. You will carefully evaluate the liver to rule out the presence of any focal mass because of what? - CORRECT ANSWER>>Patients with liver cirrhosis are at increased risk for hepatocellular carcinoma You are scanning a patient with suspected liver cirrhosis. All of the following, 1. Surface nodularity, 2. Shrunken caudate lobe, 3. Altered echo texture, 4. Ascites, 5. Regenerative nodules are sonographic feature of cirrhosis Except: - CORRECT ANSWER>>Shrunken caudate lobe The caudate lobe is most commonly enlarged compared to the right lobe due to sparing in what disease? - CORRECT ANSWER>>Liver cirrhosis An ultrasound evaluation of liver cirrhosis should include a search for which associated complication? - CORRECT ANSWER>>Portal hypertension 18 | P a g e What is the most common cause of intrahepatic portal hypertension in the United States? - CORRECT ANSWER>>Cirrhosis Ultrasound findings of an abdominal study on a 51-year-old female include enlargement of the hepatic veins and inferior vena cava in an otherwise normal appearing liver. These findings are most consistent with what? - CORRECT ANSWER>>Right-sided heart failure Focal fatty liver is most commonly found in which location? - CORRECT ANSWER>>Anterior to the portal vein at the porta hepatis You have performed an ultrasound study on a patient with an enlarged caudate lobe, shrunken right lobe and splenomegaly. The hepatic veins could not be identified. No other abnormalities were discovered. What should you do? - CORRECT ANSWER>>Evaluate the hepatic veins and IVC with color Doppler to confirm patency The thin-walled hepatic veins may become compressed and difficult to identify by B-mode imaging with what disease? - CORRECT ANSWER>>Liver cirrhosis A patient is referred to rule out hepatomegaly. What is a not useful indicators of hepatomegaly? - CORRECT ANSWER>>NOT USEFUL: Increased diameter of the main portal vein greater than 1cm What is useful indicator to rule out hepatomegaly? - CORRECT ANSWER>>Rounding of inferior border of the liver, longitudinal measurement of the right lobe exceeding 15.5cm, extension of the right lobe inferior to the lower pole of the right kidney, and increased anteroposterior measurement of the right lobe. You have identified a single homogeneous hyperechoic lesion measuring 2.4cm in the posterior aspect of the right lobe of the liver. What is the most common etiology of a mass fitting this description? - CORRECT ANSWER>>Cavernous hemangioma A patient is referred for a sonogram of the liver to rule out metastatic disease. What describes the sonographic appearance of liver metastasis? - CORRECT ANSWER>>Single hypoechoic mass, multiple hyperechoic masses, masses of mixed echogenicity, cystic masses. 19 | P a g e Which of the following is NOT a feature of hepatic cysts? a. Thin wall b. Posterior acoustic enhancement c. Anechoic
d. increased attenuation e. increased through transmission - CORRECT ANSWER>>Increase attenuation - Attenuation through a cyst is decreased rather than increased. A single large, well-defined mass with smooth walls and homogeneous low-level echoes is seen within the anterior right lobe of the liver in a 48-year-old female. No Doppler signals could be obtained within the mass. What condition is the most likely etiology of this mass? - CORRECT ANSWER>>Hemorrhagic cyst You are scanning a patient with a history of fever, abnormal liver function tests, and right upper quadrant tenderness. The liver is enlarged with decreased echogenicity, the gallbladder wall is thickened and thick echogenic bands are noted surrounding the portal veins. What condition is it most likely? - CORRECT ANSWER>>Hepatitis What is the appearance under ultrasound of hepatitis? - CORRECT ANSWER>>the liver parenchyma may appear normal or have a decreased echogenicity with increased echogenicity of the portal veins. bright bands seen surrounding the portal veins known as "periportal cuffing". Hepatomegaly may be present or gallbladder wall. You are evaluating a suspicious lesion to look for gas bubbles to confirm the presence of liver abscess in a patient with fever and increased white blood cell count. What is the sonographic appearance of the gas bubbles? - CORRECT ANSWER>>Brightly echogenic foci associated with echogenic ringdown artifact Which of the following is associated with infestation by a parasite and is most prevalent in sheep and cattle-raising countries? - CORRECT ANSWER>>Hydatid disease You are scanning the liver and notice irregularity of the surface. A nodular liver surface is associated with what abnormality? - CORRECT ANSWER>>Cirrhosis Is a fatty liver a reversible disorder? - CORRECT ANSWER>>Yes 20 | P a g e What is true about fatty livers? - CORRECT ANSWER>>Fatty liver may be caused by obesity. It may be diffuse or focal. It may show a rapid change in appearance with time. It commonly causes increased attenuation of the sound beam through liver. You are scanning through the liver and notice luminal narrowing of the hepatic veins. Color and spectral Doppler reveal high velocities through the strictures. These findings are most commonly associated with which of the following? - CORRECT ANSWER>>Cirrhosis The most common benign tumor in the liver is: - CORRECT ANSWER>>Cavernous Hemangioma What is most commonly associated with invasion of the portal vein? - CORRECT ANSWER>>Hepatocellular carcinoma
- CORRECT ANSWER>> You have been asked to perform a liver sonogram on a patient with AIDS. Which of the following tumors, hepatocellular carcinoma, Kaposi's sarcoma, budd-chiari syndrome, hemangiosarcoma, or hepatic adenoma, is most commonly associated with this history? - CORRECT ANSWER>>Kaposi's sarcoma You are scanning a 53-year-old female with a history of recent weight loss and vague abdominal pain. The liver is markedly heterogeneous and contains numerous calcified lesions. This most likely represents metastatic disease from which primary? - CORRECT ANSWER>>Adenocarcinoma of the colon What is most commonly associated with mucinous adenocarcinoma of the colon? - CORRECT ANSWER>>Calcified metastases During ultrasound evaluation of the liver, a bull's eye or target lesion is identified in the anterior right lobe. The most likely etiology of this mass is: - CORRECT ANSWER>>Liver metastasis from lung cancer The appearance of a bull's eye lesion within the liver is nonspecific , but when is it frequently seen? - CORRECT ANSWER>>with metastases from the lung cancer 21 | P a g e
You are scanning a patient with liver cirrhosis and suspected portal hypertension. In this study, assessment of the size of which of the following is most important? - CORRECT ANSWER>>Spleen 23 | P a g e A recannalized paraumbilical vein may be seen as a result of which of the following? - CORRECT ANSWER>>Portal hypertension Which of the following describes the best sonographic window to view a recannalized paraumbilical vein? - CORRECT ANSWER>>Sagittal subcoastal view through the left lobe at the level of the ligamentum teres The portal triad consists of the following three structures: - CORRECT ANSWER>>Portal vein, bile duct, hepatic artery The ligamentum venosum forms the anterior border of what lobe of the liver? - CORRECT ANSWER>>Caudate lobe You are scanning a patient with portal hypertension. Enlargement of which of the following structures is diagnostic of this condition? - CORRECT ANSWER>>Coronary vein Which measurement below is the diagnostic cutoff for portal vein enlargement? - CORRECT ANSWER>>13mm Regenerating nodules are a feature associated with: - CORRECT ANSWER>>Cirrhosis You are performing an ultrasound exam in a patient with a history of alcoholic liver cirrhosis. You have documented the presence of splenomegaly and dilated veins at the splenic hilum. Considering the patient's history and findings, what else should you look for? - CORRECT ANSWER>>Search for the presence of portosystemic collaterals The best view for ultrasound demonstration of the coronary vein is: - CORRECT ANSWER>>A sagittal view of the splenic vein near the midline You are performing a follow-up study on a patient with a history of cavernous transformation. Where should you look to evaluate this condition? - CORRECT ANSWER>>Porta hepatis You are scanning a patient with an enlarged caudate lobe and shrunken right lobe. What diffuse liver process should you suspect? - CORRECT ANSWER>>Cirrhosis 24 | P a g e You are scanning an obese patient to rule out fatty liver. What is the common sonographic appearance this condition? - CORRECT ANSWER>>Increased echogenicity of the liver compared to the normal kidney You are having difficulty locating the gallbladder in a patient with right upper quadrant pain. What anatomic landmark will help you identify the gallbladder fossa? - CORRECT ANSWER>>Interlobar hepatic fissure In what anatomic variant is the fundus of the gallbladder folded over the body? - CORRECT ANSWER>>Phrygian cap A patient is referred from the emergency room to rule out acute cholecystitis. You think the gallbladder wall may be thickened. What is the normal diameter of the gallbladder wall? - CORRECT ANSWER>>less than 3 mm You are scanning the gallbladder and notice some smudgy echoes within it. You suspect the echoes are due to artifact. What is a common cause of artifactual echoes within the gallbladder? - CORRECT ANSWER>>Reverberation, side lobes, slice thickness artifact You have a patient scheduled for a gallbladder sonogram. What preparation is required? - CORRECT ANSWER>>The patient should be fasting for 8-12 hours prior to study. You have been requested to perform a gallbladder ultrasound to rule out cholelithiasis. What is cholelithiasis? - CORRECT ANSWER>>Gallstones You are scanning the gallbladder and notice that the wall is abnormally thickened, would this be associated with malignant ascites? - CORRECT ANSWER>>NO A referring physician has asked you about the accuracy of gallbladder sonography. The diagnostic accuracy of gallbladder sonography is: - CORRECT ANSWER>>more
than 90% During gallbladder sonography, you notice echogenic foci within the gallbladder but do not detect distal acoustic shadowing. What changes below will improve the detectability of stone shadowing? - CORRECT ANSWER>>Increase transducer frequency, increase transducer focusing 25 | P a g e You are scanning a patient with a porcelain gallbladder. What does this term mean? - CORRECT ANSWER>>The gallbladder wall contains varying amounts of calcification Where exactly is the location of the distal common bile duct? - CORRECT ANSWER>>Posterior and slightly lateral to the pancreatic head. The patient you are scanning has eaten breakfast prior to your study. What is the appearance of the gallbladder in the postprandial state? - CORRECT ANSWER>>Contraction of the gallbladder with diffuse wall thickening A patient presents to the ultrasound department for a sonogram to rule out biliary obstruction. Which lab test would best indicate the presence of bile duct obstruction? - CORRECT ANSWER>>Serum direct bilirubin What is the most common cause of acute cholecystitis? - CORRECT ANSWER>>Calculus obstruction of the gallbladder neck or cystic duct Tenderness over the gallbladder with probe pressure is termed: - CORRECT ANSWER>>Murphy's sign You are performing an abdominal ultrasound study and detect a dilated, nontender gallbladder. What should you look for? - CORRECT ANSWER>>Mass in the head of the pancreas What are symptoms associated with acute cholecyctitis? - CORRECT ANSWER>>Nausea, vomiting, epigastric pain, right upper quadrant pain You are performing an ultrasound examination on a patient with acute cholecyctitis. Complications that you should look for include, Pancreatitis, pancreatic carcinoma, gallbaladder perforation, gangrenous cholecytitis, or emphysematous cholecyctitis, EXCEPT? - CORRECT ANSWER>>Pancreatic carcinoma You have been asked to rule out the presence of choledocholithiasis. What are you looking for? - CORRECT ANSWER>>Stones within the common bile duct Identification of what anatomic structure would most help a sonographer locate a contracted gallbladder? - CORRECT ANSWER>>Main lobar fissure 26 | P a g e The transverse diameter measurements of the gallbladder in a fasting patient measure 5.3 cm. This measurement is: - CORRECT ANSWER>>Consistent with a hydropic gallbladder You are scanning a patient in ICU and notice low-level echoes within the gallbladder consistent with sludge. The gallbladder wall is not thickened. What could the sludge be due to? - CORRECT ANSWER>>The patient has sludge most likely due to bile stasis Ultrasound images obtained on a 48-year-old male show a comet-tail or V-shaped reverberation artifact originating from the anterior wall of the gallbladder. This artifact most likely results from: - CORRECT ANSWER>>Adenomyomatosis You are performing an ultrasound study to rule out the presence of cholelithiasis. A small echogenic foci is seen in the posterior aspect of the gallbladder fundus. How can you determine if this foci represents a poly or a stone? - CORRECT ANSWER>>Shadowing is not present with polyps but is present with stones What is the sonographic appearance of tumefactive sludge within the gallbladder?
- CORRECT ANSWER>>An avascular mass with low-level echoes You are scanning a 34-year-old multiparous woman with symptoms of severe right upper quadrant pain, nausea and vomiting. The gallbladder is thick-walled with stones and an adjacent complex fluid collection is seen. These findings most likely represent: - CORRECT ANSWER>>Acute cholecystitis complicated by gallbladder perforation
gas. What would be the most helpful in improving visualization of the CBD? - CORRECT ANSWER>>Roll the patient into a right posterior oblique position The most common anatomic variant of the gallbladder is: - CORRECT ANSWER>>Gallbladder folds What is the most accurate test for acute cholecystitis? - CORRECT ANSWER>>Cholescintigraphy You are scanning a patient with a Procelain gallbladder. You must carefully evaluate the gallbladder because these patients are at increased risk for: - CORRECT ANSWER>>Gallbladder carcinoma A patient is referred for gallbladder ultrasound with a history of right upper quadrant pain and nausea. You suspect the presence of a stone in the region of the gallbladder neck, but are not sure. What would be helpful in confirming the 29 | P a g e presence of a stone? - CORRECT ANSWER>>Roll the patient into a left lateral decubitus position. You have been asked to administer cholecystokinin to a patient. What is expected to occur if the study is normal? - CORRECT ANSWER>>The gallbladder will contract You are attempting to locate the common hepatic duct at the porta hepatis. What is the most common anatomic relationship of the portal triad at this location? - CORRECT ANSWER>>The common duct is anterior to the hepatic artery and portal vein A patient is referred for ultrasound with jaundice, pain, nausea, and vomiting and a history of cholecystectomy. What is the most likely finding? - CORRECT ANSWER>>Choledocholithiasis You have detected a stone impacted in the distal common bile duct in a patient with jaundice and abdominal pain. You will tailor your exam to evaluate what complication of this condition? - CORRECT ANSWER>>Pancreatitis You are requested to perform an ultrasound evaluation of the gallbladder and biliary tree on an elderly female with a small frame. What transducer is the most suited to this task? - CORRECT ANSWER>>5.0 MHz curved linear array A patient is referred for an abdominal ultrasound. You notice a yellow discoloration of the eyes and skin. This condition is called: - CORRECT ANSWER>>Jaundice You are asked to perform an ultrasound study on a patient with suspected cholangiocarcinoma. What associated findings should you look for? - CORRECT ANSWER>>Dilatation of the biliary tree What is the etiology of the low-level echoes seen in the near field of this gallbladder? - CORRECT ANSWER>>Reverberation artifact You are scanning a patient in the emergency room with severe nausea and abdominal pain. When you press with the transducer over the gallbladder, the patient has increased pain. What did you do? - CORRECT ANSWER>>Elicited a sonographic Murphy's sign 30 | P a g e You are scanning a patient with sickle cell anemia and note the presence of gallstones and gallbladder wall thickening. What else should you do to determine if acute cholecystitis is present? - CORRECT ANSWER>>Press with the ultrasound probe over the gallbladder to determine if it is painful, look carefully to see if a gallstone is lodged in the gallbladder neck, & check for the presence of pericholecystic fluid. What is the purpose of obtaining images in the left lateral decubitus position during ultrasonography of the gallbladder? - CORRECT ANSWER>>Evaluate mobility of gallstones You are scanning a patient with symptoms of cholelithiasis. Although you cannot clearly identify a gallbladder, you detect a bright band of echoes with posterior shadowing in the right upper quadrant. How can you determine if this represents a contracted gallbladder filled with stones? - CORRECT ANSWER>>Connection of the shadowing echoes to the interloper fissure confirms identification of the
gallbladder, the WES wall-echo-shadow sign confirms identification of the gallbladder, "dirty" shadowing from bowel gas can be differentiated from "clean" shadowing from stones by the presence of ringdown artifact in the bowel gas shadow A tumor that may be located in an intrahepatic or extra hepatic bile duct is known as: - CORRECT ANSWER>>Cholangiocarcinoma Ultrasound you obtained on an 81-year-old man with acute right upper quadrant pain show gallstones and bright echoes in the gallbladder wall with bringdown artifacts. What is the most likely finding? - CORRECT ANSWER>>Emphysematous cholecystitis - gas forming bacteria are present within the gallbladder lumen. You are attempting to image the head of the pancreas in a patient referred for abdominal sonography. How should you align the probe on the body to obtain a long axis view of the head and body of the pancreas? - CORRECT ANSWER>>Obtain a midline transverse scan plane with the left side of the probe slightly caudal compared to the right side of the probe. Your department protocol requires you to measure the main pancreatic duct whenever it is visible by ultrasound. What is the name of the duct you are measuring? - CORRECT ANSWER>>Duct of Wirsung 31 | P a g e The accessory pancreatic duct, which is sometimes visible sonographically, is known as: - CORRECT ANSWER>>duct of Santorini What is the anatomic relationship of the common bile duct (CBD) to the pancreas?
- CORRECT ANSWER>>The CBD is posterior to the head of the pancreas You are reviewing a CT report on a patient referred for abdominal sonography. The report states that pancreatic divisor is present. What does this mean? - CORRECT ANSWER>>The two pancreatic ducts have not fused What structure can you use to identify the anterior aspect of the head of the pancreas? - CORRECT ANSWER>>Gastroduodenal artery What structure can be used to identify the posterior aspect of the head of the pancreas? - CORRECT ANSWER>>Common Bile duct What structure can be seen coursing transversely at the level of the upper pancreatic head? - CORRECT ANSWER>>Gastroduodenal artery A thin patient has been referred for ultrasound evaluation of the pancreas. What is the best transducer for this examination? - CORRECT ANSWER>>5.0 MHz curved linear array You are performing an ultrasound exam on a patient with a history of repeated bouts of pancreatitis. What would you most likely use color Doppler for in this study? - CORRECT ANSWER>>Improve detectability of possible pseudoaneurysms What is color Doppler used in evaluation of patient with pancreatitis to confirm? - CORRECT ANSWER>>Confirm patency of the splenic, portal, superior mesenteric, and hepatic vessels and to improve detectability of possible pseudoaneurysms During insonation of the pancreas, you notice a prominent vessel just posterior to the pancreatic neck. What vessel are you imaging? - CORRECT ANSWER>>Portal Splenic confluence You are having difficulty imaging the entire pancreas in a patient referred for abdominal ultrasound. What part of the pancreas is least commonly visualized by ultrasound? - CORRECT ANSWER>>Tail 32 | P a g e What frequency transducer would most commonly be used for endoscopic ultrasound of the pancreas? - CORRECT ANSWER>> 10 MHz - Megahertz You are performing an ultrasound study to rule out the presence of a pancreatic tumor. What is the most commonly occurring malignant tumor of the pancreas? - CORRECT ANSWER>>Adenocarcinoma What is a risk factor for the development of pancreatic cancer? - CORRECT ANSWER>>Smoking, High-fat diet, diabetes, and chronic pancreatitis You are scanning a 52-year-old male with a history of alcohol abuse. Ultrasound findings include a hyperechoic mass in the head of the pancreas, dilation of the pancreatic and common bile duct, and diffuse calcification within the pancreas.
Which part of the pancreas does the duodenum encircle? - CORRECT ANSWER>>head of the pancreas What is the relationship of the splenic vein to the pancreas? - CORRECT ANSWER>>Posterior and caudal Which vessel is located at the superior border of the pancreas? - CORRECT ANSWER>>Celiac trunk When imaging the pancreas, which vessel do you routinely visualize at the posterior border of the pancreatic head? - CORRECT ANSWER>>Inferior vena cava During insonation of the pancreas, you routinely image a vessel coursing anterior to the uncinate process. What is this vessel? - CORRECT ANSWER>>Superior mesenteric vein You have obtained a sagittal image of the pancreatic head and detect a small, tubular structure coursing cephalocaudad anterior to the pancreas. What is this structure? - CORRECT ANSWER>>Gastroduodenal artery What part of the pancreas generally has the largest dimensions? - CORRECT ANSWER>>head Part of your routine protocol for pancreatic imaging is to comment on the echogenicity of the organ. What is the normal echogenicity of the normal pancreas? - CORRECT ANSWER>>Either isoechoic or hyperechoic competed to the liver 35 | P a g e The tail of the pancreas is in contact with what structures? - CORRECT ANSWER>>Left kidney, splenic flexure of the colon and the spleen You are examining the inferior vena cava to rule out obstruction. Within the liver, the IVC lies along the posterior surface of what lobe? - CORRECT ANSWER>>Caudate lobe Which renal tumor is common? - CORRECT ANSWER>>renal cell carcinoma You are imaging the spleen of a 27 year old male with AIDS. What is the most common finding in the spleen in patients with AIDS? - CORRECT ANSWER>>Moderate splenomegaly You detect a wedge-shaped, hypo echoic lesion within the spleen. What would increase diagnostic confidence the most? - CORRECT ANSWER>>Evaluate the lesion with color doppler. You are scanning a patient and notice that the right and left kidneys are attached at their lower poles. What anomaly is present? - CORRECT ANSWER>>Horseshoe kidney You have detected compensatory hypertrophy of the right kidney in a 35 year old male. This finding is associated with what? - CORRECT ANSWER>>Nephrectomy, renal agenesis,renal hypoplasia, and renal atrophy What is the normal waveform for the main renal artery? - CORRECT ANSWER>>low resistance Do cysts decrease or increase attenuation? - CORRECT ANSWER>>they show decrease sound attenuation that results in the sonographic appearance of posterior acoustic enhancement Progression of which of the following abnormalities flattens the portal veins? - CORRECT ANSWER>>Biliary obstruction The wall thickness in a normal fasting gallbladder should not exceed - CORRECT ANSWER>>3 mm 36 | P a g e This color Doppler sonogram is most likely demonstrating which of the following abnormalities? - CORRECT ANSWER>>Pseudoaneurysm This color Doppler image demonstrates turbulent swirling blood flow within a fluid collection, classic sonographic findings of a common femoral artery pseudoaneurysm. A patient presents with sudden onset of upper abdominal pain. Ultrasound demonstrates prominence in the stomach rugae. These findings are most suspicious for which of the following conditions? - CORRECT ANSWER>>Gastritis
Prominence of the stomach rugae in a patient with upper abdominal pain is most suspicious for gastritis. Hypervascular, thick gastric walls are sonographic findings associated with gastric ulcers. Which of the following is a complication of acute pancreatitis? - CORRECT ANSWER>>Duodenal obstruction Complications of acute pancreatitis may include abscess formation, duodenal obstruction, hemorrhage, phlegmon, and pseudocyst formation. Cholecystitis is a possible etiology of acute pancreatitis. A patient presents with a history of hematuria. The findings in this duplex image are most suspicious for which of the following pathologies? - CORRECT ANSWER>>Carcinoma A vascular echogenic mass is identified protruding from the posterior wall of the urinary bladder. Bladder carcinoma commonly presents with a history of painless hematuria. Based on the clinical history, the sonographic findings are suspicious for a malignant mass. A sagittal sonogram medial to the porta hepatis is demonstrating which of the following abnormalities? - CORRECT ANSWER>>Dilated common bile duct A hypoechoic mass identified by the calipers is obstructing the common bile duct resulting in dilatation. The mass is most likely a malignancy in the head of the pancreas. 37 | P a g e The pathology in this sonogram is most likely a/an - CORRECT ANSWER>>Pseudocyst A complex fluid collection is identified posterior to the tail of the pancreas. This is most likely a pancreatic pseudocyst. Phlegmons and islet cell tumors appear as hypoechoic masses on ultrasound. A pancreatic hemorrhage is a differential consideration but not the most likely pathology. Which of the following abnormalities is demonstrated in this transverse sonogram? - CORRECT ANSWER>>Stones in the duct of Wirsung Multiple stones are located in main pancreatic duct (duct of Wirsung). Which of the following is a clinical symptom of hypothyroidism? - CORRECT ANSWER>>Muscle cramps Muscles cramping is a symptom of hypothyroidism. Other symptoms may include weight gain, mental and physical lethargy, arthritis, skin dryness, feeling cold, slow metabolic rate, and decreased heart rate. Symptoms commonly associated with hyperthyroidism include weight loss, palpitations, nervousness, exophthalmos, constant hunger, tremors, increased heart rate, and intolerance to heat. A 20-year-old patient presents with a palpable left scrotal mass. The sonographic findings are most suspicious for which of the following pathologies? - CORRECT ANSWER>>Malignant neoplasm A malignant neoplasm is the most likely diagnosis in a young adult demonstrating a hypoechoic intratesticular mass. The patient is afebrile excluding a testicular abscess from the differential considerations. A patient presents with a history of a palpable neck mass. Which of the following terms best describes the sonographic findings? - CORRECT ANSWER>>Heterogeneous thyroid gland The sonographer's technical report should describe the right thyroid lobe as demonstrating an irregular and heterogeneous echo texture. A patient presents with a history of cirrhosis. The arrows are identifying the - CORRECT ANSWER>>coronary ligament 38 | P a g e A hyperechoic linear structure is identified dividing the right subphrenic space from the subhepatic space. This is consistent with the right coronary ligament. The right coronary ligament serves as a barrier between these two peritoneal spaces. This color Doppler sonogram is most likely demonstrating which of the following abnormalities? - CORRECT ANSWER>>Patent umbilical vein The sonogram is demonstrating a patent paraumbilical vein. Note the liver
