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ARDMS Abdominal Sonography Review
Study Guide
The prostate is located in the (retroperitoneum or peritoneum) layer. - ✔retroperitoneum What borders the prostate gland? (A-P & S-I) - ✔Ant = pubic bone Post = rectum Sup = bladder Inf = urogenital diaphragm What artery supplies the prostate gland & has branches from the internal iliac artery? - ✔Inferior vesical artery Apex - ✔Inferior portion just superior to the urogenital diaphragm Base - ✔Superior portion just below the inferior margin of the bladder Seminal vesicles - ✔2 sac-like out-pouchings of the vas deferens b/t the bladder and rectum & adjacent to the superior/posterior prostate Ejaculatory ducts - ✔pass thru the central zone & empties into urethra Verumontanum - ✔longitudinal ridge in the urethra that the ejaculatory ducts are adjacent to Corpora amylacea - ✔calcifications commonly seen in the inner gland of the prostate Surgical capsule - ✔demarcation b/t the inner(central/transitional) & outer(peripheral) gland Eiffel tower sign - ✔shadowing created by calcifications in the urethra/verumontanum area Name the 4 zones of the prostate - ✔1.peripheral 2.central 3.transitional 4.fibromuscular stroma
Peripheral Zone - ✔Posterior portion 70% of organ's tissue Most common area for cancers Extends to apex Central Zone - ✔Superior portion 25% of organ's tissue Ejaculatory ducts pass thru here Transitional Zone - ✔5% of organ's tissue Site of origin of BPH Fibromuscular stroma - ✔Anterior portion Non-glandular tissue Not affected by cancers, infections, hyperplasia Gleason score - ✔grading of prostate cancer Orientation for prostate study: In transverse view, what is at the top, bottom, left, & right of screen? (In that order) - ✔Anterior, posterior, right, left Orientation for prostate study: In sagittal view, what is at the top, bottom, left, & right of screen? (In that order) - ✔Anterior, posterior, superior, inferior What does TRUS stand for? - ✔TransRectal UltraSound What age & percentage of men are diagnosed with prostate cancer? - ✔>65 yo
80% What race is 2x more likely to develop prostate cancer than white males? - ✔African American What does the genetic make-up of a patient have to do with prostate cancer likelihood?
- ✔1st degree relative = 2-3 x greater risk of developing cancer
What is the role of Color Doppler in a TRUS? - ✔allows improved perception of pathologic vessels in association with cancer What is the most common appearance of the seminal vesicles by TRUS? - ✔Hypoechoic, symmetrical, irregularly shaped structures You are performing a TRUS in a patient with acute prostatitis. An anechoic mass is seen within the prostate. This most likely represents _______. - ✔abscess. They appear as an anechoic mass w/ or w/out internal echoes. Name the retroperitoneal organs - ✔"SADPUCKER" Suprarenal glands AO/IVC Duodenum (2nd, 3rd, 4th part) Pancreas (head, neck, body) Ureters Colon (Ascending/Descending) Kidneys Esophagus (Ant. & L. covered) Rectum(portion) Renal vessels SMV Gonadal vessels Lymphatics Prostate The spleen is a (retroperitoneal/peritoneal) organ. - ✔peritoneal What does an average adult spleen measure? - ✔4 x 8 x 12 cm At what size is splenomegaly indicated? - ✔When measured >12 cm or inferior to the lower pole of the left kidney Location: What is located medial/anterior to the splenic hilum? - ✔stomach fundus, lesser sac, pancreatic tail LUQ Anatomy: List the anatomy from anterior -> posterior in the LUQ. -
✔1. stomach
- splenic artery
- pancreas
- splenic vein
- Lt kidney/adrenal Accessory spleen - ✔- normal variant
- < 5 cm round, same echogenicity/texture as spleen
- found near splenic hilum
- mistaken for enlarged lymph nodes What are the most common causes for granulomas? - ✔histoplasmosis tuberculosis What are granulomas? - ✔- splenic calcifications from previous infections
- focal bright lesions, w/ or w/out shadowing
- also found in liver and lungs What also causes calcifications in the spleen? - ✔- splenic artery wall calcifications
- splenic artery aneurysms calcifications
- pneumocystis carinii infection
- splenic infarcts What cysts may be found in the spleen? - ✔- Epidermoid cysts
- Pancreatic pseudocysts
- Auto-Dom polycystic disease
- Hydatid cysts
- Hematomas/Liquified infarcts Epidermoid cysts (in spleens) - ✔In spleens, lined by squamous epithelium, solitary, about 10 cm, wall may be calcified, & internal echogenicity. Pancreatic pseudocysts - ✔- May erode into spleen due to close proximity.
- May weaken vessels causing pseudoaneurysms/bleeding into pseudocyst. What is the most common primary, benign splenic tumor? - ✔hemangioma Malignant tumors are (common/uncommon) in the spleen -
✔disruption of normal asymmetrical development of organs/vessels Polysplenia - ✔- left-sided prominence
- biliary atresia/no GB
- multiple LUQ spleens
- azygos continuation of interrupted IVC
- cardiac defects
- intestinal malrotation Asplenia - ✔- right-sided prominence
- no spleen
- AO/IVC reversed
- midline liver/GB
- cardiac defects
- intestinal malrotation Subcapsular/Intraparenchymal hematomas occur when.... - ✔splenic capsule remains intact. Perisplenic/Intraperitoneal hematomas occur when... - ✔capsule ruptures w/ loculated fluid around spleen. F.A.S.T. - ✔Focused Assessment w/ Sonography for Trauma
- documents the presence of free fluid in the peritoneal cavity What does the appearance of intraperitoneal blood depend on? - ✔Age Amount Physcial state of the clot Posttraumatic Splenosis - ✔ectopic spleen due to repeated splenic rupture/surgery causing cells to implant throughout peritoneal cavity (autotransplantation) What can be used to give a more definitive diagnosis of splenic infarction? - ✔Color Doppler will be absent in an area of infarction & be differentiated from surrounding parenchyma. While scanning a spleen, you detect splenomegaly & dilated, tortuous vessels near the hilum, what condition do you suspect? - ✔Portal hypertension, which commonly causes dilated varices at the hilum & splenomegaly is almost always present.
What vein does the splenic vein drain into? - ✔Portal vein What is Wilson's disease? - ✔An inherited disorder that causes too much copper to accumulate in the liver, brain and other vital organs. Also called hepatolenticular degeneration. Causes fatty changes & fibrosis in the liver. Peritoneum - ✔serous membrane that lines abd cavity
- Parietal (Outer): lines abd wall
- Visceral (Inner): covers abd organs Space b/t = peritoneal cavity Peritoneal Cavity - ✔Space b/t parietal & visceral peritoneum
- Lesser sac: space where the liver, pancreas, & stomach are
- Greater sac: where ascites & floating bowel are imaged Epiploic foramen - ✔entrance to the lesser sac Pouch of Douglas - ✔Female: (Rectouterine pouch), space b/t rectum & uterus Male: (Rectovesical pouch), space b/t rectum & bladder Intraperitoneal structures (11) - ✔"SAC J FLUDROSC" Stomach Appendix Cecum Jejunum Fallopian tubes Liver Uterus Duodenum (1st part) Rectum (Portion) Ovaries Spleen Colon (Transverse & Sigmoid) Retroperitoneum is between which layers? - ✔Transversalis fascia & posterior parietal peritoneum 2 layers of Gerota's fascia creates which 3 compartments? - ✔Anterior renal fascia
Hepatic Veins - ✔3 Branches: Right, Middle, Left Drain into IVC Renal Veins - ✔Right RV: Short, drains into IVC Left RV: Long, passes b/t SMA & AO to the L. kidney Left renal vein courses ________ to the AO. - ✔anteriorly Gonadal Veins - ✔Right GV: drains into IVC Left GV: drains into L. renal vein Nutcracker Syndrome - ✔the engorgement of the L renal vein due to compression b/t the SMA & AO Cardiac failure & fluid overload will cause the IVC to ____. - ✔dilate The most common tumor to involve the IVC is the _______. - ✔renal cell carcinoma Name 5 reasons the IVC is commonly displaced: - ✔Liver mass R. renal artery aneurysm Lymphadenopathy Tortuous AO R renal/adrenal mass Greenfield Filter is used for what? How is it done? - ✔To prevent the ascent of lower ext vein thrombus Inserted using catheters thru the femoral vein/internal jugular vein & placed inferior to renal veins. What kind of mass causes an arc of the IVC on ultrasound? - ✔Retrocaval lymphadenopathy Retroperitoneal fibrosis - ✔- (Ormond's Disease or Inflammatory Aneurysm)
- Dense fibrous tissue growth in the paravertebral region near the AO bifurcation.
- Sonographically, hypoechoic midline mass
- Assoc w/ bilateral ureteral obstruction as it envelopes structures
- IVC & lymphatic compression leads to LE edema & scrotal swelling
- Most are idiopathic Azygous/Hemiazygous Veins - ✔Azygous: right-sided vein Hemiazygous: left-sided vein Alternate venous return when there is IVC obstruction Ascending Lumbar Vein - ✔- Branches of common iliac veins
- R. ascending joins w/ R. subcoastal vein to form azygous vein.
- L. ascending joins w/ L. subcoastal vein to for hemiazygous vein. Adrenal Glands - ✔Right:
- Triangle/pyramid shaped
- Located superior, anterior, & medial to upper pole
- Crus of the diaphragm lies medial & posterior to gland Left:
- Cescent shaped
- Located anteriomedial to upper pole
- Crus of diaphragm & AO lies medial to gland
- Pancreas tail lies anterior to gland Crus of Diaphragm - ✔Location:
- Anterior to AO
- Superior to CA
- Posterior to IVC It is located medial & posterior to all structures except AO. What's the sonographic appearance of the adrenal cortex? - ✔Hypoechoic, less echogenic than surrounding retroperitoneal fat What's the sonographic appearance of the adrenal medulla? - ✔Echogenic linear structure in adrenal gland What vessels supply blood to each adrenal gland? - ✔3 arteries: Suprarenal branch of the inferior phrenic art, AO, & renal art. 1 vein: R. suprarenal into IVC and L. suprarenal into L. renal vein What 2 glands function together to regulate hormone production, like aldosterone, cortisol, & androgen? - ✔adrenal gland anterior pituitary gland The adrenal cortex produces _______. -
- most common childhood adrenal mass
- increased urine & blood catecholamines
- maintains normal, bilateral renal contour What's the difference b/t adrenal neuroblastoma & Wilm's tumor? - ✔Adrenal neuroblastoma displaces the ipsilateral kidney inferiorly into pelvis. Wilm's tumor originates from & destroys the kidney. Myelolipoma - ✔- benign
- hyperechoic in adrenal bed
- associated with propagation speed artifact due to fat composition Adrenal lymphoma - ✔- common
- bilateral
- most common cell type = Non-Hodgkin disease Adrenal metastases is the ____ most common metastatic site. - ✔4th What is the most common adrenal mass in a newborn? - ✔Adrenal hemorrhage What is the most likely diagnosis in a newborn with an abd mass & decreasing hematocrit? A) Wilm's tumor B) Adrenal neuroblastoma C) Hepatoblastoma D) Adrenal hemorrhage - ✔D) Adrenal hemorrhage With lymphadenopathy which direction is the IVC & SMA displaced? - ✔anteriorly What direction will the splenic vein be displaced by a left adrenal mass? - ✔anteriorly What direction will the bladder be displaced by a hematoma in the Pouch of Douglas? - ✔anteriorly With a gastric outlet obstruction & dilation of the stomach, what direction will the pancreatic tail be displaced? - ✔posteriorly What direction will a mass in the uncinate process displace the SMV? -
✔anteriorly What direction will a neuroblastoma displace the ipsilateral kidney? - ✔inferiorly What direction will a mass in the left lobe of the liver displace the gastroesophageal junction? - ✔posteriorly Which direction will the IVC be displaced with a ... ... right liver mass? ... right renal artery aneurysm? ... tortuous aorta? ... right adrenal mass? ... right renal mass? - ✔posterior anterior right medial/anterior medial/left What are the 3 types of aneurysms? - ✔1. True
- False (Pseudoaneurysms)
- Dissecting Berry Aneursym - ✔small saccular aneurysm commonly in the cerebrum Mycotic aneurysm - ✔infected aneurysm Atherosclerotic aneurysm - ✔results from weakening of the media in severe atherosclerosis Fusiform aneurysm - ✔spindle-shaped dilatation where the stretching affects the entire circumference Saccular aneurysm - ✔localized spherical out-pouching of the vessel wall List layers of the artery walls from outer to inner. - ✔1. Adventitia
- Media
- Intima
✔1. Adventitia/serosa
- Muscularis externa (ext muscle layer)
- Submucosa
- Mucosa Gastroesophageal Junction - ✔- The esophagus that's between the diaphragm and stomach
- In sagittal, looks like "target" sign posterior to left lobe of liver Acute appendicitis - ✔- most common acute abd pain
- non-compressible appendix
6 mm diameter
- appendicolith (fecalith)
- Hyperemia
- Located at McBurney's point McBurney's Point - ✔the most tender area in the early appendicitis in the RLQ Hypertrophic Pyloric Stenosis - ✔- hypertrophy of the circular muscle causing elongation of the pylorus & contstriction of the canal
- (+) pylorus wall > 4 mm
- (+) pylorus diameter > 11-15 mm Carcinoembryonic Antigen (CEA) - ✔- Tumor marker for colorectal cancers, but elevated in both benign/malignant
- Used to monitor patient after removal of malignancy Diverticulitis - ✔- inflammation of diverticulum (colonic outpouchings)
- commonly the sigmoid
- bowel wall > 4 mm, abscess, inflammation (rough echogenic structures)
- fever, LLQ pain, leukocytosis Bowel Obstruction - ✔- causes: intraluminal (food bolus), lesion (tumor, Crohn's), extrinsic (hernia-most common)
- demonstrate loops of distended bowel, level of obstruction, & peristalsis Intussusception - ✔- segment of intestine telescopes into adjoining intestine
- most common in infants under 1 yr
- abd pain, rectal bleeding
- transverse, concentric rings of folded bowel What are the functions of the pancreas? - ✔Exocrine: secretes trypsin, lipase, & amylase (ductal system) Endocrine: secretes insulin via the islets of Langerhans (non-ductal system) What does the normal pancreas measure? - ✔< 3 cm (A-P) Describe the technique used to better visualize the pancreas. - ✔In LLD, water in the stomach creates the acoustic window In supine/RLD, water in stomach/duodenum creates the acoustic window Head of pancreas is ________ to the IVC & ________ to the duodenum. - ✔anterior; medial CBD is ______ to the pancreatic head. GDA is ______ to the pancreatic head. - ✔posterior/lateral; anterior/lateral SMA & SMV are _______ to the neck of the pancreas & _______ to the uncinate process. - ✔posterior; anterior AO is _______ to the body of the pancreas. - ✔posterior CA arises from the AO at the ________ border of the pancreas. - ✔superior SMA arises from the AO at the ________ border of the pancreas. - ✔inferior What are the branches starting from the CA? - ✔CA -> L gastric artery -> common hepatic artery & splenic artery What are the branches of the common hepatic artery? - ✔common hepatic artery -> proper hepatic artery & gastroduodenal arteries What is a branch of the proper hepatic artery? - ✔proper hepatic artery -> right gastric artery The proper hepatic artery courses ________ towards the liver ________ to the portal vein & ________ of the bile duct. - ✔superiorly; anterior; left
Duodenal C loop (2nd portion) Sonographically, what does an acute pancreatitis look like? - ✔enlarged & hypoechoic What are the 2 most common causes of acute pancreatitis? - ✔1. biliary tract disease (~40%)
- chronic alcohol abuse (~35%) Phlegmon - ✔a spreading inflammatory rxn to an infection which forms a suppurative lesion Pancreatic phlegmon - ✔(also focal pancreatitis) an inflammatory mass formed by edema & leakage of pancreatic enzymes, a result from acute pancreatitis complications Sonographically, what does a chronic pancreatitis look like? - ✔- small & hyperechoic
- calcifications
- pancreatic duct dilatation What is the most common cause of chronic pancreatitis? - ✔alcoholism Pancreatic cyst - ✔rare associated w/ adult poly-cystic kidney disease & von Hippel-Lindau syndrome Cystic Fibrosis - ✔- exocrine gland disorder resulting in viscous secretions causing pancreatic dysfunction
- sonographically, cysts due to ductal obstruction
- the most common cause of a hyperechoic pancreas in a child Pancreatic pseudocysts - ✔- accumulation of pancreatic fluid confined by the retroperitoneum
- common causes: pancreatitis, trauma, ductal obstruction, neoplasms Which space is the pancreas located in within the retroperitoneum? - ✔anterior pararenal space After disruption of the parietal peritoneum, overlying the anterior border of the pancreas, fluid enters the _______________. - ✔lesser peritoneal sac
In children, what is the most common cause for a pancreatic pseudocysts? What else should you look for? - ✔- abdominal trauma (child abuse)
- look for bruising Pancreas divisum - ✔failure of the dorsal & ventral pancreatic ductal systems to fuse causing a smaller Santorini's duct which drains the pancreas Annular pancreas - ✔uncommon congenital anomaly where a ring of normal pancreatic tissue encircles the duodenum secondary to abnormal migration of the ventral pancreas Pancreatic adenocarcinoma - ✔- Symptoms: abd/back pain, jaundice, weight loss
- 90% present w/ lymphatic & metastatic spread of the tumor Whipple procedure - ✔- also pancreaticoduodenectomy
- remove head, part of bile duct, GB, & duodenum Pancreatic Serous Cystadenoma - ✔- associated w/ von Hippel-Lindau disease
- benign, grape-like cysts
- also microcystic cystadenomas Mucinous Cystic Neoplasms - ✔- also macrocystic cystadenomas
- uncommon, malignant, large multicyst w/ septations Islet Cell Tumor - ✔- assoc w/ Von Hippel-Lindau (VHL) & Multiple Endocrine Neoplasia (MEN-1)
- uncommon, endocrine tumors
- commonly in body & tail Insulinoma - ✔- most common islet cell tumor
- benign
- hyperinsulinemia -> hypoglycemia Gastrinoma - ✔- 2nd most common islet cell tumor
- malignant
- gastric acid hypersecretion
- also Zollinger-Ellison syndrome
