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Workbook for Diagnostic Medical Sonography

A GUIDE TO CLINICAL PRACTICE, ABDOMEN

AND SUPERFICIAL STRUCTURES

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Kawamura_WB_FM.indd iiKawamura_WB_FM.indd ii 12/2/11 12:54 AM12/2/11 12:54 AM

Workbook for Diagnostic Medical Sonography

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

GE Healthcare - Ultrasound Arlington, Virginia

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

Weber State University Ogden, Utah

A GUIDE TO CLINICAL PRACTICE,

ABDOMEN AND SUPERFICIAL STRUCTURES

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

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Third Edition

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Printed in China.

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Contents

1 Introduction ...........................................................................................................1

PART 1 • ABDOMINAL SONOGRAPHY

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

3 The Peritoneal Cavity ..........................................................................................17

4 Vascular Structure ................................................................................................27

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

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

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

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

9 The Gastrointestinal Tract ....................................................................................79

10 The Kidneys .........................................................................................................89

11 The Lower Urinary System .................................................................................101

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

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

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

PART 2 • SUPERFICIAL STRUCTURE SONOGRAPHY

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

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

17 The Scrotum ......................................................................................................159

18 The Musculoskeletal System ..............................................................................169

PART 3 • NEONATAL AND PEDIATRIC SONOGRAPHY

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

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

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

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

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

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vi CONTENTS

PART 4 • SPECIAL STUDY SONOGRAPHY

24 Organ Transplantation .......................................................................................221

25 Emergency Sonography ....................................................................................227

26 Foreign Bodies ...................................................................................................233

27 Sonography-Guided Interventional Procedures ................................................237

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REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Anechoic

2. Echogenic

3. Echopenic

4. Isoechoic

5. Heterogeneous

6. Homogeneous

7. Hyperechoic

8. Hypoechoic

9. Specifi city

10. Sensitivity

11. Accuracy

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

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

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

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

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

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

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

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

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

producing echoes by refl ecting the acoustic beam

1 Introduction

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2 1 — INTRODUCTION

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

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

A. C.

2. Longitudinal Plane

A. C.

3. Coronal Plane

A. C.

4. Transverse Plane

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1 — Introduction 3

Sagittal Coronal

A. C.

G.E.

5. Endovaginal Planes

Sagittal Coronal or Transverse

A. C. G.E.

6. Endorectal Planes

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4 1 — INTRODUCTION

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

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

b. Posterior

c. Superior

d. Inferior

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

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

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

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

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

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

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

b. At the 3:00 position

c. At the 6:00 position

d. At the 9:00 position

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

b. Cephalic

c. Right

d. Caudal

Sagittal: Anterior Fontanelle Coronal: Anterior Fontanelle

A. C.

D. H.

B. F.

G.E.

7. Cranial Fontanelle Planes

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1 — Introduction 5

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

b. Superior

c. Right

d. Left

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

b. Simple kidney cyst

c. Gallbladder

d. Gallstone

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

b. Anechoic center

c. Well-defi ned posterior wall

d. Edge-shadowing artifact

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

b. A true-negative result

c. A false-positive result

d. A false-negative result

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

b. A true-negative result

c. A false-positive result

d. A false-negative result

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

b. A true-negative result

c. A false-positive result

d. A false-negative result

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

b. False-negative results do not affect the sensitivity

c. The sensitivity will decrease

d. The sensitivity will remain the same

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

b. The positive predictive value

c. Sensitivity

d. Specifi city

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

b. Specifi city

c. Effi cacy

d. Accuracy

FILL-IN-THE-BLANK

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

the body and are therefore .

2. In directional terms, the lungs are

to the liver.

3. The plane is a vertical plane that

runs through the body and divides it into right and

left sections.

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

and left halves is called the plane.

5. In the position, the patient is lying

supine on the examination table with his or her head

lower than his or her feet.

6. The plane is a horizontal plane

that is perpendicular to the sagittal plane and divides

the body into superior and inferior portions.

7. The plane is a vertical plane that

divides the body into anterior and posterior portions.

8. When performing an endovaginal examination, in both

the sagittal and coronal planes the

anatomy is located at the apex of the image.

9. An organ may appear to have an abnormal

echogenicity if disease is present or a poor

examination technique is used, such as incorrect

settings.

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6 1 — INTRODUCTION

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

bladder, or simple cysts, appear .

11. The normal testicle is described as

whereas the normal kidney appears .

12. The reduced echo amplitude found beyond a highly

attenuating object such as a kidney stone is called an

acoustic .

13. An artifact called may be seen at

the near wall of a simple cyst.

14. A structure contains both solid

and fl uid components and will usually exhibit both

anechoic and echogenic areas on the sonogram.

15. The preliminary report, which is also referred to

as the , should

include the sonographic fi ndings but should not

include a diagnosis.

SHORT ANSWER

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

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

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

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

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

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1 — Introduction 7

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

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

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8 1 — INTRODUCTION

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

CASE STUDIES

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

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

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

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REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Abscess

2. Ascites

3. Aponeurosis

4. Ecchymosis

5. Erythema

6. Fascia

7. Linea alba

8. Omphalocele

9. Peristalsis

10. Pleural effusion

11. Pneumothorax

12. Rectus abdominis

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

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

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

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

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

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

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

abdomen from the xiphoid process to the symphysis pubis

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

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

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

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

PART 1 • ABDOMINAL SONOGRAPHY

2 The Abdominal Wall and Diaphragm

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10 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

E. A.

(Boundary indefinite and overlapping)

Posterior

Left lateral (flank)

Antero-lateral

Anterolateral

1. Transverse section of the abdominal wall

C. D. E. F.

2. Subcutaneous layers of the abdominal wall

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2 — The Abdominal Wall and Diaphragm 11

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

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

b. Deep fascia

c. Subcutaneous tissue

d. Aponeuroses

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

b. External oblique

c. Rectus abdominis

d. Transverse abdominis

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

b. Inguinal canal

c. Umbilicus

d. Rectus sheath

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

abdominal aorta

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

c. It can be seen anterior to the IVC

d. It appears anterior to the caudate lobe

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

b. Psoas muscle

c. Rectus abdominis

d. External oblique

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

higher than the left

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

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

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

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

b. 4 MHz curved array

c. 3 MHz phased array

d. 4 MHz linear array

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

b. Hernia

c. Abscess

d. Lipoma

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

b. Peritoneal line

c. Rectus abdominus

d. Diaphragm

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

b. Particulate debris fl oating within the abscess

c. An anechoic abscess with increased through transmission

d. An echogenic abscess

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

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

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

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

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

b. Bowel

c. Free fl uid

d. Fat

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

b. Inguinal

c. Hypogastric

d. Epigastric

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12 PART 1 — ABDOMINAL SONOGRAPHY

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

b. Inguinal

c. Hypogastric

d. Epigastric

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

b. Sarcoma

c. Neuroma

d. Lipoma

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

b. Sarcoma

c. Neuroma

d. Lipoma

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

b. Ascites

c. Eventration

d. Pneumothorax

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

b. Eventration

c. Diaphragmatic paralysis

d. Diaphragmatic hernia

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

b. Infection

c. Renal failure

d. Respiratory failure

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

b. Spleen

c. Stomach

d. All of the above may be seen

FILL-IN-THE-BLANK

1. The human body is divided into the ventral and

dorsal cavities. The ventral cavity is separated by the

diaphragm into the cavity and the

cavity.

2. The superfi cial fascia inferior to the umbilicus is

divided into two layers: the fascia,

a fatty layer containing small vessels and nerves,

and the fascia, which is a deep

membranous layer.

3. The lines the

abdominopelvic cavity and is formed by a single layer

of epithelial cells and supporting connective tissue.

4. The is a fi brous

compartment that contains the rectus abdominis,

pyramidalis muscle, blood and lymphatic vessels,

and nerves.

5. The posterior abdominal wall is composed of

three paired muscles: the

, , and

6. When evaluating a superfi cial lesion in the abdominal

wall, a may be

used to eliminate the “main bang” artifact.

7. Sonographically, the diaphragm is seen as a thin

band in children and adults and a

band in fetuses.

8. Three main categories of disease that affect

the abdominal wall include ,

, and changes.

9. The four clinical indications of an infl ammatory

response are , ,

, and .

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

shape is or .

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2 — The Abdominal Wall and Diaphragm 13

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

abdominal muscle may appear and

more .

12. Superfi cial abdominal wall hematomas most commonly

occur within the .

13. Discoloration of the abdominal wall called

and a falling

value are often clinical signs of a rectus sheath

hematoma.

14. A is a collection of serum that

results from a surgical procedure or from the

liquefaction of a hematoma and typically appears

anechoic to hypoechoic sonographically.

15. The two main categories of abdominal wall hernias

are and .

16. Two complications that can occur with midline

hernias include , which can

compromise the blood supply and cause ischemia,

and , which occurs when the

contents of the sac cannot be pushed back into the

abdominal cavity.

17. When evaluating a hernia with sonography, the

can be used to

demonstrate widening of the hernia and movement

of the hernia contents.

18. Sonographically, a

is diagnosed when fl uid is

visualized superior to the diaphragm.

19. Paralysis of one hemidiaphragm can be detected

sonographically by showing

or motion on the affected side

and normal or motion on the

contralateral side.

20. A diaphragmatic hernia allows

contents such as , ,

and to enter the thoracic cavity.

SHORT ANSWER

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

2. Describe the process of abscess formation and resolution.

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

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

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

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14 PART 1 — ABDOMINAL SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

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

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

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2 — The Abdominal Wall and Diaphragm 15

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

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

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16 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

Review the images and answer the following questions.

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

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

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REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Abscess

2. Ascites

3. Bare area

4. Biloma

5. FAST scan

6. Hematoma

7. Hemoperitoneum

8. Hilum

9. Iatrogenic

10. Lymphocele

11. Mesentery

12. Peritoneal organs

13. Parietal peritoneum

14. Retroperitoneal organs

15. Seroma

16. Visceral peritoneum

a. Caused by treatment; either intentional or unintentional

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

c. Surface area of a peritoneal organ devoid of peritoneum

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

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

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

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

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

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

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

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

o. Extravasated collection of blood within the peritoneal cavity

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

3 The Peritoneal Cavity

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18 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

D. E.

Midclavicular lines

Transpyloric plane Subcostal plane

Intertubercular plane

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

Median plane

Ubmilicus

Transumbilical plane

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

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3 — The Peritoneal Cavity 19

Transverse mesocolon

Left colic flexure

Transverse colon

Right colic flexure

Ascending colon

Tenia coli

Descending colon

Root of mesentery of small intestine

B.C.E. D.

Phrenicocolic ligament

3. Potential spaces – Label the potential spaces.

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

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

b. Murphy’s lines

c. Xyphoid lines

d. Addison’s lines

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

b. Hilar peritoneum

c. Parietal peritoneum

d. Retroperitoneum

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

b. Stomach

c. Pancreas

d. The lesser sac does not contain any organs

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

b. Greater sac

c. Hepatorenal space

d. Left paracolic gutter

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

b. Posterior cul-de-sac

c. Rectovaginal pouch

d. All of the above

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

b. The left posterior suprahepatic space

c. The hepatorenal space

d. The right subphrenic space

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

b. Uterovesicle space

c. Space of Retzius

d. Rectouterine space

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

b. Uterovesicle space

c. Space of Retzius

d. Rectouterine space

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

20 PART 1 — ABDOMINAL SONOGRAPHY

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

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

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

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

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

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

within it.

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

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

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

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

b. Ovarian cancer

c. Congestive heart failure

d. Peritonitis

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

b. Pouch of Douglas

c. Paracolic gutters

d. Pleural space

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

b. Hepatorenal space

c. Left anterior subphrenic space

d. Space of Retzius

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

collection with internal debris.

b. Color Doppler will frequently demonstrate internal vascularity.

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

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

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

b. White blood count

c. Bilirubin

d. Hematocrit

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

b. Simple anechoic collection with possible thin septations

c. Complex mass with calcifi cations

d. Thick-walled collection with internal septations

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

b. Fine-needle aspiration

c. Percutaneous abscess drainage

d. Paracentesis

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

b. Urinoma

c. Seroma

d. Lymphocele

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

omentum from malignant infi ltration.

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

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

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

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

b. Pancreas

c. Spleen

d. Gallbladder

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3 — The Peritoneal Cavity 21

FILL-IN-THE-BLANK

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

Those regions are the right and left

right and left , right and left

, and the central regions

, ,

and .

2. The abdominopelvic cavity is also frequently

divided into four quadrants. Those quadrants

are the , ,

, and .

3. The largest body cavity is called the

, which encompasses the abdomen

and pelvis.

4. The thin sheet of tissues that divides the abdominal

cavity into the peritoneal and retroperitoneal

compartments is called the

5. The lesser sac lies immediately posterior to the

6. The greater omentum divides the greater sac into two

compartments: the ,

which means above the colon, and the

, which means below the colon.

7. The right and left

are potential spaces along the lateral borders of the

peritoneal cavity that allow fl uids to travel between

the supracolic and infracolic compartments.

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

dependent portion of the abdominal cavity is the

. This potential

space should always be checked for free fl uid during

the sonographic examination.

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

the is the most

gravity-dependent portion of the pelvic cavity.

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

is the most

gravity-dependent portion of the pelvic cavity.

11. ascites typically has a simple

appearance because it is characterized by a lack of

protein and cellular material.

12. ascites has a more complex and

echogenic appearance because fl uid seeps out from

blood vessels and contains a large amount of protein

and cellular material.

13. The presence of within an abscess

may cause a “dirty” posterior shadow.

14. Free blood within the peritoneal cavity is called

; once the blood organizes into a

focal area or clot, the collection is called

a .

15. results when a

benign appendiceal or ovarian adenoma ruptures,

spilling epithelial cells into the peritoneum, causing

to accumulate within the peritoneal

cavity.

16. Seromas typically occur in the

postsurgical period, whereas

are typically slower to develop and may present

4 to 8 weeks after surgery, helping to establish a

more defi nitive diagnosis between the two similar-

appearing fl uid collections.

17. Mesenteric cysts may occur anywhere along the

mesentery but are most commonly found originating

from the

mesentery.

18. The term describes the enlargement

of lymph nodes that can result from

diseases such as colitis or malignancies such as

lymphoma or colon cancer.

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22 PART 1 — ABDOMINAL SONOGRAPHY

19. Peritoneal mesothelioma is a rare malignant tumor

of the peritoneum that is associated with exposure to

20. A paracentesis may be done for

purposes to remove a small amount of fl uid for

laboratory testing or for purposes

to relieve pain and pressure that the patient may be

experiencing due to a large volume of ascites.

SHORT ANSWER

1. What purpose does the greater omentum serve?

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

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

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

5. What is the purpose of the peritoneal membrane?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

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

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3 — The Peritoneal Cavity 23

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

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

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24 PART 1 — ABDOMINAL SONOGRAPHY

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

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

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3 — The Peritoneal Cavity 25

CASE STUDIES

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

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

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

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Anastomosis

2. Aneurysm

3. Arteriovenous fi stula

4. Ectasia

5. Endograft

6. Graft

7. Prosthesis

8. Pseudoaneurysm

9. Thrombosis

a. Any tissue or organ for implantation or transplantation

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

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

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

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

leaking hole in an artery

4 Vascular Structure

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28 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

K. G.

I.J.

B. C.

1. Abdominal vasculature

2. Abdominal vasculature

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

4 — Vascular Structure 29

3. Abdominal vasculature

4. Abdominal vasculature

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30 PART 1 — ABDOMINAL SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

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

b. Tunica media

c. Tunica adventitia

d. Tunica serosa

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

three layers

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

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

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

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

b. Murphy’s phenomenon

c. Compartment syndrome

d. Nutcracker phenomenon

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

b. Middle hepatic vein

c. Left renal vein

d. Right renal vein

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

b. Splenic vein

c. Left renal vein

d. Left gastric vein

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

b. Hepatic artery

c. Gastroduodenal artery

d. Celiac axis

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

b. Portal vein

c. Inferior vena cava

d. Main hepatic vein

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

b. Caudal

c. Medial

d. Lateral

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

b. Right renal vein

c. Left renal artery

d. Right renal artery

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

b. IVC

c. Splenic artery

d. Intestines

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

b. Fusiform

c. Dissecting

d. Congenital

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

B. 3 cm

C. 4 cm

D. 5 cm

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

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

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

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

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4 — Vascular Structure 31

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

b. 5 cm

c. 7 cm

d. 9 cm

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

b. Abscess

c. Dissecting aneurysm

d. Pseudoaneurysm

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

b. Hypertension

c. Increased urinary output

d. Pulsatile abdominal mass

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

mesenteric vein

b. Portal artery, inferior mesenteric artery, hepatic artery

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

d. Gastroduodenal artery, hepatic artery, splenic artery

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

b. The IVC will dilate proximal to the obstruction

c. The IVC will dilate distal to the obstruction

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

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

b. Thrombus from extension of DVT

c. Right-sided heart failure

d. Portal hypertension

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

b. Renal veins and IVC

c. Portal veins and hepatic veins

d. IVC and hepatic veins

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

b. Cirrhosis of the liver

c. Dehydration

d. Enlargement of the spleen

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

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

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

d. Post-stenotic turbulence

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

b. Pseudoaneurysm

c. Fusiform

d. Mycotic

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

b. Dissection

c. Rupture

d. Extension into the iliac arteries

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

increased hepatic vascular resistance

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

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

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

FILL-IN-THE-BLANK

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

, and the

. The

is thicker in arteries and is largely

responsible for their elasticity and contractility.

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32 PART 1 — ABDOMINAL SONOGRAPHY

2. The aorta originates off of the

; once it penetrates the

diaphragm it is called the

, and fi nally bifurcates into the right

and left arteries.

3. The three branches of the celiac axis are

the , the

and the .

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

aspect of the aorta, whereas

the right and left renal arteries arise from the

aspect of the aorta.

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

the right and left

, courses through the abdominal

cavity, entering into the thoracic cavity to empty into

the of the heart.

6. The normal IVC will change caliber with respiratory

maneuvers; with inspiration

due to the decreased pressure within the thoracic

cavity, during expiration, and

with suspended respiration.

During the Valsalva maneuver the IVC lumen

7. The portal vein is formed by the junction of

the and the

at the ,

immediately posterior to the neck of the pancreas.

8. is a form of arteriosclerosis that

is characterized by an accumulation of lipids, blood

products, and sometimes calcium deposits along the

intimal lining of the arteries.

9. A aneurysm is a protrusion toward

one side or the other, unlike a fusiform aneurysm,

which is more uniform.

10. When an abdominal aortic aneurysm is diagnosed,

the arteries and

arteries should also be examined to evaluate for

extension of the aneurysm.

11. Aortic is a separation of the layers

of the aortic wall that typically presents with extreme

chest or abdominal pain.

12. Iliac artery aneurysms are most often a continuation

of an

and tend to be .

13. EVAR stands for .

14. A pulsatile anechoic mass at the anastomosis of

an endograft that demonstrates a swirling blood

fl ow pattern with color Doppler is most likely a

15. An incomplete seal between the endograft and wall

of the aorta may result in an . This

may result in or

of the aortic aneurysm.

16. Renal artery stenosis is most often a result of

and occurs at the

of the renal artery. Fibromuscular dysplasia causes

renal artery stenosis less frequently but these lesions

are typically located in the renal

artery.

17. results from a

lack of adequate blood supply to the intestinal tract

causing postprandial pain, weight loss, and change in

bowel habits.

18. Malignant invasion of the IVC most commonly occurs

from . Respiratory changes are

typically or below

the level of obstruction.

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4 — Vascular Structure 33

19. is a syndrome in which the IVC

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

In the primary form of the syndrome, the vessels

are occluded by a congenital

, and in the secondary form they are

occluded by or .

20. While performing an examination of the liver,

you have diffi culty identifying the main portal

vein; however, you do see multiple tortuous

vessels in the region of the porta hepatis. This

collateralization is called

of the portal vein.

21. The normal portal vein measures less than

in diameter. In a patient with an

acute portal vein thrombosis, the diameter of the

portal vein may . With chronic

thrombosis, the diameter may .

22. An increase in the portal venous pressure is called

. Common

signs and symptoms include and

23. Portal hypertension can result in many

sonographically visible changes including

varices, an enlarged

vein, and a patent

vein seen within the ligament.

24. Blood fl ow toward the liver is called

, whereas blood fl ow away from the

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

called .

25. A TIPS, which stands for , is

used to decompress the portal vein pressure by

connecting the with one of the

bypassing fl ow through the liver.

SHORT ANSWER

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

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

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

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

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

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34 PART 1 — ABDOMINAL SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

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

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

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

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

4 — Vascular Structure 35

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

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

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36 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

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

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

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

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. AFP

2. ALT

3. AST

4. Falciform ligament

5. Glisson’s capsule

6. Hepatofugal

7. Hepatomegaly

8. Hepatopetal

9. Jaundice

10. Ligamentum venosum

11. Ligamentum teres

12. Main lobar fi ssure

13. Porta hepatis

14. Reidel’s lobe

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

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

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

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

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

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

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

eyes caused by increased levels of bilirubin in the blood

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

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

l. Fibroelastic connective tissue layer that surrounds the liver

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

n. Blood fl ow away from the liver

5 The Liver

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38 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

Right Common Carotid Artery

Superior Vena Cava Right Pulmonary Artery

Right Pulmonary Vein

Right Atrium Foramen Ovale

Valve of Inferior Vena Cava (Valve of Eustachii)

Inferior Vena Cava

Hepatic Vein

A. Liver Circulation

Liver Portal Vein

Renal Vein

Superior Mesenteric Vein

Placenta

Umbilical Arteries

Internal Iliac Artery Internal Iliac Vein

Gut

Renal Artery

Aorta

Superior Mesenteric Artery

Celiac Trunk

Right Ventricle

Left Ventricle

Left Atrium

Left Pulmonary Vein

Left Pulmonary Artery

Ductus Arteriosus Aorta

Left Common Carotid Artery

1. Fetal circulation

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5 — The Liver 39

2. Liver anatomy

3. Liver anatomy

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

40 PART 1 — ABDOMINAL SONOGRAPHY

4. Liver anatomy

5. Vascular anatomy

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

5 — The Liver 41

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

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

b. 11 to 14 cm

c. 15 to 17 cm

d. 19 to 22 cm

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

b. Ligamentum venosum

c. Falciform ligament

d. Coronary ligament

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

b. Right hepatic vein

C. Middle hepatic vein

d. Left hepatic vein

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

b. Medial segment of the left lobe

c. Anterior segment of the right lobe

d. Posterior segment of the right lobe

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

b. Middle hepatic vein

c. Right hepatic vein

d. Main portal vein

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

veins are intrasegmental

b. The portal veins have highly echogenic walls

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

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

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

b. Bile ducts

c. Hepatic veins

d. Hepatic arteries

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

B. Hepatic artery

C. Hepatic veins

D. Hepatoduodenal artery

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

b. Production of clotting factors

c. Production of digestive enzymes amylase and lipase

d. Storage of vitamins A, B12, and D

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

b. Anterior segment right lobe

c. Medial segment left lobe

d. Lateral segment left lobe

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

b. AST

c. ALP

d. BUN

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

b. Polycystic liver disease

c. Hepatocellular carcinoma

d. Cavernous hemangioma

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

b. Display internal displacement of the liver capsule

c. Cause an anterior shifting of the IVC

d. Displace hepatic vessels

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42 PART 1 — ABDOMINAL SONOGRAPHY

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

b. Hepatoma

c. Cirrhosis

d. Hepatitis

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

b. Visualization of the intrahepatic vessels becomes more diffi cult

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

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

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

b. Cirrhosis

c. Chronic hepatitis

d. Hepatocellular carcinoma

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

b. Hepatoma

c. Hemangioma

d. Lipoma

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

b. Decreasing the overall gain

c. Decreasing the depth

d. Lowering the frequency

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

b. Posterior liver near the right kidney

c. Region of the porta hepatis near the gallbladder

d. Lateral segment of the left lobe

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

b. Cavernous hemangioma

c. Hepatic adenoma

d. Hepatic hemangiosarcoma

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

b. Caudate lobe enlargement

c. Shrunken atrophic spleen

d. Hepatofugal fl ow in the portal vein

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

B. Echinococcal cyst

C. Polycystic liver disease

D. Chronic hematoma

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

b. Focal fatty sparing

c. Pyogenic abscess

d. Hepatocellular carcinoma

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

b. Fatty liver infi ltration

c. Candidiasis

d. Schistosomiasis

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

B. Hepatocellular carcinoma

C. Cavernous hemangioma

D. Amebic abscess

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5 — The Liver 43

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

b. Hepatic lipoma

c. Cavernous hemangioma

d. Hepatoma

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

b. Hepatic adenomas

c. Hepatocellular carcinoma

d. Karposi’s sarcoma

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

b. Polycystic liver disease

c. Resolving hematoma

d. All of the above

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

b. Polycystic liver disease

c. Hematoma

d. Cavernous hemangioma

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

b. Portal hypertension

c. Liver metastases

d. Amebic abscess

FILL-IN-THE-BLANK

1. The liver is surrounded by a fi brous capsule

called and is located within the

cavity.

2. After birth, the ductus venosus closes to become

the and the

left umbilical vein becomes the

. Both are important as they can

become recanalized with certain disease processes,

most commonly .

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

different methods. The anatomic division divides

the liver into four lobes: the lobe,

lobe, lobe, and

lobe, based on

. The segmental division is based on

the liver’s .

4. The left intersegmental fi ssure divides the

lobe into and

segments. The left

vein is a sonographic landmark of the left

intersegmental fi ssure.

5. The lobe may be enlarged in

patients with a history of cirrhosis or Budd-Chiari

syndrome. Enlargement of the caudate lobe may

cause compression of the .

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

sonogram and you notice that the right lobe appears

enlarged and extends inferiorly toward the pelvis.

The texture appears homogenous and is continuous

with the remainder of the right lobe. The most likely

diagnosis is a .

7. The basic functional unit of the liver is the

. These cells carry out most of the

metabolic functions of the liver. The

cells, macrophages that are part of the reticuloendothelial

system, help break down red blood cells.

8. An anatomical variation in which the liver and

gallbladder are found on the left side of the abdomen

and the spleen is found on the right side is called

Kawamura_WB_CH05.indd 43 12/1/11 4:01 PM

44 PART 1 — ABDOMINAL SONOGRAPHY

9. The portal triad is made up of the

vein, artery, and .

10. A array transducer is typically used

to evaluate the liver but a array

transducer can be used to evaluate the anterior liver

capsule for surface nodularity in suspected cases of

cirrhosis.

11. Fatty infi ltration is also called

and is commonly caused in the United States by

and .

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

, while the acoustic penetration is

13. Infl ammation of the liver is called .

In the acute form, the liver appears ,

causing the portal vessels to appear more

14. The most common cause of cirrhosis in the United

States is .

15. Patients with autosomal dominant polycystic

kidney disease may also develop cysts in the

, , and

16. The majority of liver cysts are .

Acquired cystic lesions of the liver may be the

result of , , or

reactions.

17. The appearance of a liver hematoma will vary

depending on the of the bleed.

Immediately following the injury, the hematoma will

typically appear . Within a day, the

hematoma may become ; eventually

clot forms and the hematoma becomes organized

and complex. Chronic hematomas can become

18. Hematomas are usually contained by the liver

, although rupture can occur.

A subcapsular hematoma will displace the liver

and have a shape.

19. Echinococcal cysts are commonly referred to as

cysts. Rupture of an echinococcal

cyst can result in .

20. An amebic abscess is typically the result of parasites

travelling to the liver from the via

the .

21. Patients with HIV and AIDS are commonly infected

by the organism .

When the liver is infected, sonographically the liver

demonstrates a

pattern.

22. The most common benign liver tumor is the

23. Two benign liver lesions typically occur in women of

childbearing age and have an association with oral

contraceptive use. Those lesions are

and .

24. Hepatocellular carcinoma is also known as

and is the most common primary

malignant liver tumor. In the United States, the most

common predisposing factor is .

25. The liver function tests AST and ALT will be

with hepatocellular carcinoma and

the tumor marker is elevated in

70% of cases.

26. Hepatocellular carcinoma may invade the vasculature

of the liver, including the and

veins. Tumors may also cause

biliary tract .

27. Liver are much more common than

primary liver tumors and can result from primary

cancers of the .

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5 — The Liver 45

28. Although liver metastases can have a wide range

of sonographic appearances, metastases from colon

cancer are typically , metastases

from lung cancer typically have a

appearance, and lesions from lymphoma are typically

29. Although not yet approved by the FDA in the United

States, ultrasound

can aid in the evaluation of liver lesions.

30. Portosystemic shunts are placed to help alleviate

the symptoms of portal hypertension. Sonography

can help monitor for complications that include

of the shunt or stent, neointimal

, and obstruction.

SHORT ANSWER

1. Couinaud’s anatomy divides the liver into eight segments. How are these segments divided and what is the importance of this segmentation?

2. Imaging the entire liver sonographically sometimes requires creative techniques. Describe some of the techniques used to adequately image the liver.

3. In cases of cirrhosis, the caudate lobe is typically spared or enlarged. Why does this occur? In what other pathology is the caudate lobe enlarged?

4. You are asked to perform an abdominal sonogram to rule out cirrhosis in a patient with a history of alcohol abuse. What sonographic features will you look for to confi rm your diagnosis?

5. You are evaluating a patient with a recent diagnosis of hepatocellular carcinoma. What are the clinical signs and symptoms of hepatocellular carcinoma? What might you see sonographically?

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46 PART 1 — ABDOMINAL SONOGRAPHY

2. A 42-year-old woman presents for an abdominal sonogram with a history of gallbladder disease. While evaluating the right lobe of the liver, you locate the fi nding seen in this image. How would you describe this mass sonographically? What is the most likely diagnosis?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. A 38-year-old man with a history of diabetes and obesity presents for an abdominal sonogram due to elevated LFTs. While performing the examination, you are having diffi culty penetrating through the liver. Describe the liver seen in this image. What is the most likely diagnosis?

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5 — The Liver 47

3. Provide a sonographic description of this mass. List three differential diagnoses for a mass with this appearance.

5. This image represents a large pyogenic liver abscess. What are the arrows pointing to? What type of clinical symptoms might this person be experiencing?

4. Identify the vessels labeled A, B, and C. In which segment of the liver is this simple cyst located based on the vasculature?

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48 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

1. A 25-year-old woman presented with RUQ pain and a palpable midline abdominal mass. Her laboratory workup was normal. Her medical history is signifi cant only for an 8-year history of oral contraceptive use. These images were taken over the palpable area. Describe what you see in the images and give a possible diagnosis.

A B

2. A 57-year-old man presents with a history of alcoholism, hepatitis C, and cirrhosis. He is currently complaining of abdominal distention and pain. Describe what you see in this image. The double arrows are pointing to the portal vein. What pathology is seen there?

Kawamura_WB_CH05.indd 48 12/1/11 4:01 PM

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Cholangitis

2. Cholecystectomy

3. Cholecystitis

4. Cholecystokinin

5. Choledocholithiasis

6. Common bile duct

7. Cystic duct

8. Cholelithiasis

9. Gallbladder

10. Pneumobilia

11. Sludge

12. Phyrgian cap

13. Murphy’s sign

14. Junctional fold

a. Calculi located within the bile duct b. Air within the bile ducts c. Formation or presence of stones within the

gallbladder d. Hormone which stimulates gallbladder contraction e. Fold within the neck or body of the gallbladder f. Pain in the area of the gallbladder when pressure is

applied by the ultrasound transducer g. Infl ammation of the bile ducts h. Fold within the gallbladder fundus i. Surgical removal of the gallbladder j. Solid, semisolid, or thickened bile within the

gallbladder or bile duct k. Pear-shaped sac responsible for storing bile until it is

released through the cystic duct l. Duct which carries bile from the cystic and hepatic

ducts to the duodenum m. Acute or chronic infl ammation of the gallbladder n. Duct of the gallbladder which joins with the hepatic

duct to form the common bile duct

6 The Gallbladder and Biliary System

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50 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

I H G

1. Biliary system

2. Anatomy

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6 — The Gallbladder and Biliary System 51

3. Porta hepatis

4. Gallbladder

5. Anatomical variant

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52 PART 1 — ABDOMINAL SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. What is the upper limit of normal for the measurement of the gallbladder wall? a. 2 mm

b. 3 mm

c. 4 mm

d. 5 mm

2. Which of the following is NOT included in the portal triad? a. Hepatic vein

b. Hepatic artery

c. Portal vein

d. Bile duct

3. What is the normal measurement for an intrahepatic bile duct? a. Less than 1 mm

b. Less than 2 mm

c. Less than 3 mm

d. Less than 4 mm

4. What is a fold or kinking of the gallbladder fundus onto the body commonly called? a. Hartman’s pouch

b. Valve of Heister

c. Phrygian cap

d. Ampulla of Vater

5. Which of the following is the hormone that causes the gallbladder to contract and the sphincter of Oddi to relax, allowing bile to fl ow from the gallbladder to the small intestine? a. Alkaline phosphatase

b. Bilirubin

c. Lactic dehydrogenase

d. Cholecystokinin

6. Which anatomical landmark can help locate a gallbladder that is diffi cult to visualize? a. Main lobar fi ssure

b. Ligamentum venosum

c. Ligamentum teres

d. Coronary ligament

7. Which of the following is NOT a laboratory test that can be used to evaluate the biliary system? a. Lipase

b. Alkaline phosphatase

c. Bilirubin

d. Lactic dehydrogenase

8. A 2-month-old infant presents with persistent jaundice and a palpable RUQ mass. The sonogram demonstrates a normal gallbladder and a cystic mass in the porta hepatis that appears to be separate from the gallbladder. The CBD appears to be entering the cystic mass. What is the most likely diagnosis? a. Choledochal cyst

b. Interposition of the gallbladder

c. Biliary atresia

d. Multiseptate gallbladder

9. A 2-week-old infant presents with a sudden onset of jaundice. The sonogram demonstrates intrahepatic ductal dilatation but does not demonstrate a gallbladder or CHD. Which congenital biliary anomaly is the most likely cause? a. Choledochal cyst

b. Interposition of the gallbladder

c. Biliary atresia

d. Mulitseptate gallbladder

10. Which of the following is NOT a symptom of gallbladder disease? a. Nausea and vomiting

b. Epigastric or RUQ pain

c. Pain that radiates to the right shoulder

d. Hematuria

11. Which of the following statements regarding gallstones is FALSE? a. The prevalence of gallstones is higher in females

than males

b. The majority of stones in the U.S. are made up of cholesterol

c. The majority of gallstones cause symptoms

d. Abnormal gallbladder emptying and altered absorption are precursors to stone formation

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6 — The Gallbladder and Biliary System 53

12. Which of the following statements regarding gallbladder polyps is FALSE? a. Polyps will move to the dependent portion of the

gallbladder with change in patient position

b. Polyps are attached to the gallbladder wall by a stalk

c. Polyps typically do not shadow

d. Polyps are typically adenomatous or made of cholesterol

13. What is the most common malignancy to metastasize to the gallbladder? a. Breast

b. Lung

c. Colon

d. Melanoma

14. A comet-tail reverberation artifact is seen originating from the anterior gallbladder wall. What gallbladder pathology is most likely causing this artifact? a. Gallbladder carcinoma

b. Adenomyomatosis

c. Gallstone

d. Sludge

15. With a distal obstruction such as a mass in the head of the pancreas, which part of the biliary tree is the fi rst to dilate? a. Common bile duct

b. Common hepatic duct

c. Gallbladder

d. Intrahepatic duct

16. Which of the following will cause a thin-walled gallbladder? a. Chronic cholecystitis

b. Acute cholecystitis

c. A fatty meal

d. Hydrops

17. An abdominal sonogram demonstrates a large hypoechoic mass in the head of the pancreas. The gallbladder is enlarged with a thin wall. Murphy’s sign is negative. No gallstones are seen and the bile ducts are normal in caliber. What is the most likely diagnosis? a. Cholelithiasis

b. Choledocholithiasis

c. Cholecystitis

d. Courvoisier gallbladder

18. A 76-year-old patient presents for an abdominal sonogram with chronic abdominal pain. An irregular mass is seen projecting into the gallbladder lumen. Color Doppler detects fl ow within the mass. Gallstones are also seen. What is the most likely diagnosis? a. Adenomyomatosis

b. Gallbladder carcinoma

c. Courvoisier gallbladder

d. Gallbladder sludge and stones

19. Which of the following increases a patient’s risk of developing gallbladder malignancy? a. Gallstones

b. Chronic cholecystitis

c. Porcelain gallbladder

d. All of the above raise the risk

20. Which of the following would cause intrahepatic dilation with a normal gallbladder and CBD? a. Carcinoma in the pancreatic head

b. Gallstone in the gallbladder neck

c. Stone in the distal CBD

d. Klatskin tumor

FILL-IN-THE-BLANK

1. The normal distended gallbladder measures

cm in length and less than

cm in the AP and transverse

dimensions.

2. Because the gallbladder lies within the

between the right and left hepatic lobes, this structure

can be used as a landmark to locate a contracted

gallbladder.

3. The gallbladder is divided into three sections:

the , , and

Kawamura_WB_CH06.indd 53 12/1/11 4:02 PM

54 PART 1 — ABDOMINAL SONOGRAPHY

4. The right and left hepatic ducts join in the

porta hepatis to form the

, which is joined

by the to form the

common bile duct.

5. The purpose of the gallbladder is to

and bile.

6. An infundibulum at the neck of the gallbladder

where stones may collect is a variant called a

7. bilirubin is typically elevated in

cases of obstructive jaundice as can occur with

choledocholithiasis; bilirubin is

typically elevated with liver disease and hemolytic

anemia.

8. Low-level, nonshadowing echoes are seen layering

along the dependent portion of the gallbladder. The

echoes move along with a change in patient position.

The most likely diagnosis is .

9. Care must be taken not to misdiagnose a polyp as

a gallstone. Unlike gallstones, polyps should not

produce an acoustic and should not

when the patient changes position.

10. are seen in up to 95% of cases of

gallbladder carcinoma. Other risk factors include

chronic and

gallbladder, or calcifi cation of the gallbladder wall.

11. may be used to

look for internal vascularity in a suspected gallbladder

mass and to distinguish sludge from a malignant mass.

12. The two most common hyperplastic cholecystoses are

and .

13. A gallbladder that is enlarged, thin-walled, and not

tender that is caused by a mass in the pancreatic

head obstructing the common bile duct is called

14. A is a distended

gallbladder caused by an obstruction of the

gallbladder neck or cystic duct.

15. Patients with biliary system obstruction typically

present with symptoms of ,

, , and

elevated or

16. Bile ducts should be measured from the

wall to the

wall, with a CBD measurement greater than

mm considered abnormal.

17. can help

distinguish dilated ducts from hepatic vessels.

18. Stones within the bile ducts, called ,

are the most common pathology of the biliary tree.

19. Primary malignancy of the bile ducts is called

20. The most common location for cholangiocarcinoma

to occur is at the porta hepatis. This type of

cholangiocarcinoma is called a

SHORT ANSWER

1. List two pitfalls that might cause a false-positive gallbladder examination and two pitfalls that could cause a false-negative gallbladder examination. Explain how your each of your examples could cause an incorrect diagnosis.

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6 — The Gallbladder and Biliary System 55

2. Describe the protocol for a sonographic examination of the biliary tree. Include the patient preparation, patient positioning, and required images.

3. What techniques can the sonographer utilize to demonstrate acoustic shadowing with small gallstones?

4. Explain the difference between intrinsic and extrinsic gallbladder wall thickening and list three examples of each.

5. Describe the sonographic appearance, clinical symptoms, and cause of both Courvoisier gallbladder and gallbladder hydrops.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What pathology is the arrow pointing to in this image? What could you do to differentiate this pathology from a gallbladder mass?

2. What pathology is demonstrated in this image? What criteria must be met for this pathology to be confi rmed?

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56 PART 1 — ABDOMINAL SONOGRAPHY

3. What pathology is seen in this image? Describe what you are seeing in this image.

4. What are the arrows pointing to in this image? What is the normal measurement for this structure? What is the most likely diagnosis?

5. Describe the gallbladder seen in this image. What are some common causes of this pathology?

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6 — The Gallbladder and Biliary System 57

CASE STUDIES

1. A 37-year-old woman presents for an abdominal sonogram with a history of RUQ pain and intolerance to fatty foods. This sagittal image is taken of her gallbladder. What pathology do you see? What artifact is the arrow pointing to? How would you distinguish this pathology from gallstones?

2. A 45-year-old man presents with a history of acute hepatitis, jaundice, and right upper quadrant pain. An examination of the upper abdomen is ordered to evaluate the liver and biliary system. This image was taken in the right upper quadrant. No gallstones were seen. What is the most likely diagnosis? What type of clinical symptoms does this pathology typically cause?

Kawamura_WB_CH06.indd 57 12/1/11 4:02 PM

Kawamura_WB_CH06.indd 58 12/1/11 4:02 PM

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Acini cells

2. Alpha cells

3. Amylase

4. Beta cells

5. Delta cells

6. Endocrine

7. Exocrine

8. Glucagon

9. Insulin

10. Islets of Langerhans

11. Lipase

12. Pseudocyst

13. Phlegmon

14. Somatostatin

a. Secreting into a duct b. Performs endocrine function, secreting insulin c. Fat-digesting enzyme d. Performs exocrine function, secreting digestive

enzymes e. An abnormal cavity resembling a true cyst but not

lined with epithelium f. Performs endocrine function, secreting glucagon g. Hormone secreted by delta cells, functions to

regulate insulin and glucagon production h. Enzyme that digests carbohydrates i. Endocrine portion of the pancreas made up of alpha

and beta cells that produce insulin and glucagon j. Diffuse infl ammatory reaction to infection spreading

along fascial pathways, producing edema k. Hormone secreted by the alpha cells, functions to

increase activity of phosphorylase l. Secreting into blood or tissue m. Performs endocrine function, secreting somatostatin n. Hormone secreted by beta cells, functions to increase

uptake of glucose and amino acids

7 The Pancreas

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60 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

B C

1. Pancreatic anatomy

2. Surrounding anatomy

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7 — The Pancreas 61

3. Pancreatic divisions

4. Vascular anatomy

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following statements regarding the pancreas is FALSE? a. The pancreas is retroperitoneal

b. The pancreas is surrounded by a rigid capsule

c. The pancreas is made up of a head, neck, body, and tail

d. The pancreas is frequently obscured by bowel gas during sonographic examination

2. Which portion of the pancreas is found anterior to the IVC and posterior to the superior mesenteric vein? a. Uncinate process

b. Head

c. Neck

d. Body

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62 PART 1 — ABDOMINAL SONOGRAPHY

3. Which portion of the pancreas lies just anterior to the portal confl uence? a. Uncinate process

b. Head

c. Neck

d. Body

4. Which of the following is a congenital anomaly of the pancreas in which the head of the pancreas surrounds the duodenum, frequently causing complete or partial duodenal stenosis or atresia? a. Pancreatic divisum

b. Ectopic pancreas

c. Pancreatic pseudocyst

d. Annular pancreas

5. Which of the following produces insulin? a. Alpha cells

b. Beta cells

c. Delta cells

d. Acini cells

6. Which laboratory values are used most often to diagnose pancreatic disease? a. BUN and creatinine

b. WBC and RBC

c. AST and ALT

d. Amylase and lipase

7. A normal main pancreatic duct should not exceed: a. 1 mm

b. 2 mm

c. 3 mm

d. 1 cm

8. In a transverse view of the pancreatic head, which vessel can be seen anterior to the CBD? a. Gastroduodenal artery

b. Splenic vein

c. Hepatic artery

d. Superior mesenteric artery

9. Which of the following provides the best acoustic window to the pancreas? a. Right lobe of the liver

b. Left lobe of the liver

c. Duodenum

d. Stomach

10. Which of the following techniques can aid in sonographic visualization of the pancreas? a. Having the patient drink water to displace gas

in the stomach

b. Imaging the pancreas at the start of the examination to reduce air in the stomach

c. Rotating the patient into the RLD position to visualize the tail of the pancreas

d. All of the above may be used to image the pancreas

11. Which of the following statements regarding cystic fi brosis is FALSE? a. Cystic fi brosis can result in pancreatic

insuffi ciency

b. Sonographically, the pancreas will appear hypoechoic and small

c. Liver and gallbladder disease are also common in children with cystic fi brosis

d. Children with cystic fi brosis may experience acute and chronic pancreatitis

12. What are the two most common causes of acute pancreatitis? a. Biliary tract disease and diabetes

b. Annular pancreas and cystic fi brosis

c. Alcohol abuse and diabetes

d. Biliary tract disease and alcohol abuse

13. In comparison to the normal pancreas, how does the pancreas in a patient with acute pancreatitis typically appear? a. Smaller and more echogenic

b. Larger and more echogenic

c. Larger and more hypoechoic

d. Smaller and more hypoechoic

14. Where are pancreatic pseudocysts most often found? a. Anterior to the pancreatic head

b. Posterior to the pancreatic body

c. Near the pancreatic tail

d. Lateral to the pancreatic head

15. Which of the following describes the sonographic appearance of chronic pancreatitis? a. A heterogeneously echogenic gland with

calcifi cations seen throughout the parenchyma

b. An enlarged hypoechoic gland with cystic formation

c. A small hypoechoic gland with calcifi cations seen in the parenchyma

d. Chronic pancreatitis never affects the sonographic appearance of the pancreas

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7 — The Pancreas 63

16. What is the most common malignant pancreatic tumor? A. Cystadenocarcinoma

B. Adenocarcinoma

C. Squamous cell carcinoma

D. Insulinoma

17. Pancreatic adenocarcinomas typically occur in the pancreatic: a. Head

b. Neck

c. Body

d. Tail

18. The most common islet cell tumor is the: a. Gastrinoma

b. Insulinoma

c. Glucogonoma

d. Cystadenoma

19. If a mass is detected in the pancreatic head what other organ should be evaluated? a. Stomach

b. Duodenum

c. Gallbladder

d. Left kidney

20. What is the most common cystic lesion found within or near the pancreas? a. Mucinous cystic adenoma

b. Microcystic adenoma

c. Polycystic disease of the pancreas

d. Pancreatic pseudocyst

FILL-IN-THE-BLANK

1. The body of the pancreas lies anterior to the

artery, and vein.

2. The tail of the pancreas is bordered posteriorly

by the vein, anteriorly by

the , and laterally by the left

3. The main pancreatic duct is also called the

of . Enzymes

secreted by the pancreas are transported through this

duct, which joins with the distal

to empty into the

4. The Islets of are part of the

system, which releases hormones

directly into the bloodstream.

5. Insulin is released by a feedback

mechanism, meaning that as blood glucose levels

above a certain level, insulin is

secreted by the beta cells and as blood glucose levels

, insulin secretion is decreased.

6. An imbalance between insulin secretion and the

metabolic needs of the human body will result in

7. The pancreas secretes enzymes which are essential

to digestion and the absorption of vital nutrients.

These enzymes include amylase, which breaks down

; , which breaks

down fats; and trypsinogen and chymotrypsinogen,

which break down into amino

acids.

8. In children, the normal pancreas is more

than the adult pancreas because

children tend to have less pancreatic fat than adults.

9. In most sonographic examinations the

and of the

pancreas can be adequately visualized; however,

the pancreatic is more diffi cult to

visualize.

10. Water can be given to increase visualization of the

pancreas during the sonographic examination. If

water is given to the patient, the patient should be

examined in the position so that air

in the stomach will rise above the fl uid.

11. Clinically, a patient with acute pancreatitis will

present with pain, radiating to

the . This pain is characteristically

relieved when the patient .

Kawamura_WB_CH07.indd 63 12/1/11 4:03 PM

64 PART 1 — ABDOMINAL SONOGRAPHY

12. In patients with acute pancreatitis, serum

increases quickly and returns to

normal within 3 to 10 days after onset of symptoms,

whereas serum remains elevated

longer.

13. In acute pancreatitis, the echotexture of the pancreas

is due to edema and the borders

of the gland may appear . The

may dilate due

to obstruction.

14. Pancreatic , a common complication

of acute pancreatitis, are encapsulated collections of

the by products of the tissue destruction that occurs

in severe disease.

15. is the result of

repeated attacks of acute pancreatitis and leads to

fi brosis, destruction, and atrophy of functioning

pancreatic tissue.

16. Pancreatic cancer is the leading

cause of cancer-related deaths in the United States

because early detection is .

17. Adenocarcinoma of the pancreas arises from the

tissues, whereas islet cell tumors

are in origin.

18. Islet cell tumors typically occur in the

or of the pancreas

and are often in size.

19. adenomas are benign cystic lesions

that occur most frequently in the pancreatic head

and contain multiple cysts of varying sizes, whereas

adenomas are

malignant lesions composed of larger cystic areas

that are frequently found within the pancreatic tail.

20. disease is an autosomal dominant

disease that is characterized by multiple small cysts in

the liver, kidneys, and, less commonly, the pancreas.

SHORT ANSWER

1. Describe the technique used to evaluate the pancreas sonographically. Include probe selection, probe placement, patient preparation, and tricks used to image a diffi cult-to-visualize pancreas.

2. Which portion of the pancreas is part of the endocrine system? What is the endocrine function of the pancreas? Which portion of the pancreas is part of the exocrine system? What is the exocrine function of the pancreas?

3. A 45-year-old patient presents with symptoms of acute pancreatitis. What laboratory values would help with this diagnosis and what changes would you expect in these values?

4. List four causes of acute pancreatitis. What complications can occur with acute pancreatitis?

5. A 60-year-old patient presents with a large hypoechoic mass in the head of the pancreas consistent with an adenocarcinoma. The gallbladder is noted to be extremely dilated. What is the mechanism for gallbladder dilation in this patient? What is this condition called?

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7 — The Pancreas 65

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. In this image, what are the calipers measuring? Where did this likely come from? The arrow is pointing to the main pancreatic duct. What is the normal measurement for this structure? Does this duct appear normal?

2. A 48-year-old patient with acute pancreatitis presents with worsening epigastric and left upper quadrant pain. The patient also has a fever and elevated amylase and lipase. This image is taken from the left upper quadrant. Describe what is seen in this image. What is the most likely diagnosis?

3. A 58-year-old patient presents with a history of indigestion and epigastric discomfort. This image was taken in the region of the pancreas. Describe the mass seen. Which solid pancreatic malignancy is more common in the pancreatic head?

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66 PART 1 — ABDOMINAL SONOGRAPHY

4. Describe the pancreas seen in this image. What is the most likely diagnosis? What are the most common causes of this pathology?

5. Describe the mass indicated by the arrow. Where in the pancreas is this mass located? What is the most likely diagnosis?

CASE STUDIES

1. A 38-year-old patient with a history of chronic alcoholism presents with severe pancreatitis. This mass is seen in the left upper quadrant. Describe the mass. List some of the other possible complications from acute pancreatitis.

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7 — The Pancreas 67

2. A 55-year-old patient presents with jaundice, weight loss, and diffi culty eating. These sonographic images are taken of the pancreas. In the fi rst image, what structures are indicated by the arrows A, B, and C? The next two images are sagittal images of the pancreatic head. Describe what is seen. What is the most likely diagnosis? What other structures will you evaluate for pathology based on these fi ndings?

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Kawamura_WB_CH07.indd 68 12/1/11 4:03 PM

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Erythrocyte

2. Erythropoiesis

3. Hematocrit

4. Infarct

5. Leukocyte

6. Leukocytosis

7. Leukopenia

8. Phagocytosis

9. Splenomegaly

a. Tissue death caused by an interruption of the blood supply

b. Decreased white blood cell count, possibly the result of viral infection or leukemia

c. Red blood cell; contains hemoglobin d. White blood cell; protects and fi ghts against infection

in the body e. Elevated white blood cell count, usually due to

infection f. Process used by the red pulp to destroy old red blood

cells g. Enlarged spleen h. Laboratory value of the percentage of blood volume

made up of red blood cells i. Process of red blood cell production

8 The Spleen

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70 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

G HI

1. Relational anatomy

2. Splenic anatomy

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8 — The Spleen 71

3. Anatomy of the left upper quadrant

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following statements regarding the anatomy of the spleen is FALSE? a. The spleen is surrounded by a fi brous capsule

b. The spleen is a retroperitoneal organ

c. The spleen is located in the left hypochondrium

d. The spleen lies posterior to the stomach

2. Which of the following ligaments does NOT help stabilize the spleen? a. Falciform ligament

b. Lienorenal ligament

c. Gastrosplenic ligament

d. Phrenicocolic ligament

3. The spleen is considered enlarged when its length is greater than: a. 9 cm

b. 11 cm

c. 13 cm

d. 15 cm

4. The spleen receives its blood supply from the splenic artery, which is a branch of the: a. Aorta

b. Superior mesenteric artery

c. Pancreatic artery

d. Celiac axis

5. While scanning the spleen, you notice a small round mass that appears to be separate from the spleen in the region of the splenic hilum. The echotexture of the mass is similar to that of the spleen. What is the most likely diagnosis? a. Splenic metastases

B. Accessory spleen

c. Splenic hemangioma

d. Ruptured spleen

6. While performing an abdominal ultrasound, you are having diffi culty locating the spleen in its normal location in the left upper quadrant. As you scan the entire left side, you locate what appears to be the spleen in the left lower quadrant. What is the most likely explanation for this fi nding? a. Asplenia

b. Accessory spleen

c. Situs inversus

d. Wandering spleen

7. What is a wandering spleen at an increased risk for? a. Splenic rupture

b. Torsion and infarction

c. Splenomegaly

d. Leukemia and lymphoma

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72 PART 1 — ABDOMINAL SONOGRAPHY

8. Which of the following statements regarding the function of the red pulp is FALSE? a. The red pulp is responsible for erythropoiesis

throughout our lives

b. In cases of severe hemorrhage, the red pulp may release its reservoir into the bloodstream

c. Red pulp is responsible for the removal of worn-out red blood cells

d. The red pulp removes defective cells such as sickle and thalassemic cells from circulation

9. What is leukocytosis typically the response to? a. Lupus erythematosus

b. Chemotherapy

c. Bacterial infection

d. Hemorrhage

10. What is leukopenia? a. A normal fi nding

b. The result of severe infl ammation

c. Frequently a side effect of chemotherapy

d. An increase in the number of white blood cells in circulation

11. What is the normal echogenicity of the spleen? a. Heterogeneous

b. Isoechoic to the liver

c. Hyperechoic to the liver

d. Hypoechoic to the liver

12. What is the most common sonographically visualized abnormality of the spleen? a. Splenic rupture

b. Splenic abscess

c. Splenomegaly

d. Lymphoma

13. What is the most common cause of splenomegaly? a. Mononucleosis

b. Lymphoma

c. Sickle cell anemia

d. Portal hypertension

14. While scanning the spleen, you notice multiple enlarged tortuous vessels in the splenic hilum. Color Doppler confi rms that they are vascular in nature. Dilated vessels are also noted within the splenic parenchyma. What is the most likely cause of these fi ndings? a. Portal hypertension with collateral varices

b. Lymphoma with metastases

c. Splenic rupture with bleeding outside the capsule

d. Accessory spleen near the splenic hilum

15. Sonographically, when splenomegaly occurs, the echogenicity of the spleen: a. Does not change

b. Always becomes more hypoechoic

c. Always becomes more hyperechoic

d. Could be hyperechoic or hypoechoic but does not correlate with the cause of the enlargement

16. Focal lesions of the spleen include all of the following EXCEPT: a. Cysts

b. Infarcts

c. Splenomegaly

d. Granulomas

17. A patient with sickle cell disease presents for an abdominal sonogram complaining of recent left upper quadrant pain. A hypoechoic wedge shaped lesion is seen in the spleen. What is this typical of? a. Lymphoma

b. Splenic rupture

c. Splenomegaly

d. Splenic infarct

18. A 10-year-old patient presents for an abdominal sonogram following blunt abdominal trauma that occurred during a bicycle accident. Which of the following would be an unusual fi nding in this patient? a. Subcapsular hematoma

b. Free fl uid in the peritoneum

c. Hematoma within the splenic parenchyma

d. Varices in the splenic hilum

19. What may splenic calcifi cations be the result of? a. Pneumocystis jiroveci

b. Histoplasmosis

c. Resolved hematoma

d. All of the above may cause splenic calcifi cations

20. Which of the following may cause a small, shrunken spleen? a. Mononucleosis

b. Acquired immunodefi ciency syndrome

c. Sickle cell anemia

d. Portal hypertension

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8 — The Spleen 73

FILL-IN-THE-BLANK

1. The spleen is located in the cavity

and is covered by peritoneum except at the splenic

2. The spleen is located posterior to the

, lateral to the ,

, and tail, and

anterior to the .

3. Three ligaments help hold the spleen in its position

in the left upper quadrant. The

ligament attaches the spleen to the left kidney. The

ligament attaches the spleen to the

stomach and the ligament, although

not directly attached to the spleen, helps support its

inferior end.

4. The average spleen measures cm

in length, cm in width, and

cm in thickness.

5. A fi brous capsule surrounds the spleen and

project from the capsule into the

organ, dividing the spleen into several compartments.

6. The spleen is made up of and

pulp. The

pulp is composed of lymphatic tissue and the

pulp is composed of venous sinuses

capable of storing more than 300 mL of blood.

7. The splenic vein joins with the

and can be seen posterior to the tail and body of

the pancreas. Posterior to the

of the pancreas, the splenic vein joins with the

to form the main portal vein.

8. is a very rare condition that leads to

a congenital absence of the spleen.

9. Following a splenectomy, an

may enlarge and assume the

functions of the removed spleen.

10. The red pulp is responsible for the

peripheral blood. These functions include removal of

or blood cells and

the storage of .

11. The removal of defective and worn-out red blood cells

occurs in the cords of .

12. The white pulp is part of the

system as it is a source of lymphocytes, macrophages,

and antibodies. In addition, the white pulp can

bacteria that have bypassed the

lymph nodes.

13. When imaging the spleen in the sagittal plane, views

should always include the left to

evaluate for ascites or pleural fl uid and the interface

with the .

14. The most common varice to occur in cases of portal

hypertension is the collateral,

which diverts blood from the splenic vein to

the vein and fi nally into the

15. The most common malignant disease that affects

the spleen is . Sonographically,

may be present if the spleen is

diffusely infi ltrated.

16. Acquired splenic cysts are ,

, or in origin.

17. Patients who are are more

susceptible to fungal and bacterial abscesses of the

spleen.

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74 PART 1 — ABDOMINAL SONOGRAPHY

18. Patients with splenic infarcts are at risk for

splenic . Signs to watch out for

include increasing hemorrhage,

free blood, and expanding

area within the infarct.

19. In patients with both Hodgkin’s disease and non-

Hodgkin’s lymphoma, the spleen may contain focal

or masses, may

exhibit diffuse , or may appear

sonographically .

20. The most common benign vascular lesion of the

spleen is the .

SHORT ANSWER

1. The red pulp and white pulp that make up the spleen each have different functions. Describe the function of each and how they can be affected by pathological processes.

2. You are asked to perform an abdominal sonogram to rule out splenomegaly. What are the most common causes of splenomegaly and how does the anatomy of the spleen allow for such an increase in size?

3. Your patient presents with a history of bacterial endocarditis now complaining of left upper quadrant pain, fever, and leukocytosis. Splenic abscess is suspected. Describe the sonographic appearance of splenic abscess. What characteristics can help confi rm the diagnosis?

4. The spleen is the most frequently damaged organ in blunt abdominal trauma. Why is the spleen so commonly injured? Describe the appearance of spleen in a trauma situation.

5. The spleen is commonly affected in patients with sickle cell anemia. Describe the variation in sonographic appearance that can occur with this disease.

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8 — The Spleen 75

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

2. A 10-year-old girl presents for a sonogram of the spleen following a bicycle accident. Describe what is seen in this sagittal image of the spleen. What is the most likely diagnosis? What other areas in the abdomen will you evaluate based on these fi ndings? Which lab value may be associated with this fi nding?

1. What structure is the arrow pointing to in this image? What is the signifi cance of this structure?

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76 PART 1 — ABDOMINAL SONOGRAPHY

4. Describe what is seen in this image of the spleen. List three of the most common causes of this splenic pathology.

3. A 12-year-old patient with a history of sickle cell disease presents in a sickle cell crisis with severe left upper quadrant pain. Describe what is seen in this image of the spleen. What is the most likely diagnosis?

5. A 54-year-old patient presents with a history of lymphoma. Describe what is seen in this image of the spleen. What is the typical appearance of the spleen in a patient with lymphoma?

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8 — The Spleen 77

CASE STUDIES

1. A 47-year-old man presents for an abdominal sonogram with a history of chronic alcohol abuse and cirrhosis. What pathology is seen in this image of the spleen? What is the normal measurement of the spleen? Why does the spleen enlarge in cases of liver cirrhosis? You are asked to evaluate the splenic hilum with color Doppler. What are you looking for?

2. A 56-year-old woman presents with a history of pancreatic cancer. Describe what is seen in this image of the spleen. What is the most likely diagnosis? What other pathology may cause multiple target or hypoechoic lesions in the spleen?

Kawamura_WB_CH08.indd 77 12/1/11 4:04 PM

Kawamura_WB_CH08.indd 78 12/1/11 4:04 PM

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Appendicolith

2. Dysphagia

3. Ileus

4. Peristalsis

5. Ulcer

6. Volvulus

a. Failure of the intestine to propel its contents due to diminished motility

b. Abnormal twisting of the intestines that can lead to obstruction, gangrene, perforation, and peritonitis

c. Diffi culty swallowing d. Fecalith or calcifi cation found in the appendiceal

lumen e. An erosion in the mucosal layer of the wall of the

GI tract f. Rhythmic dilatation and contraction that propels the

contents of the GI tract

9 The Gastrointestinal Tract

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80 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Gastrointestinal tract

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9 — The Gastrointestinal Tract 81

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is NOT a layer of the bowel wall? a. Lamina propria

b. Intima media

c. Muscularis mucosa

d. Serosa

2. What is the innermost layer of the bowel wall? a. Epithelium

b. Serosa

c. Intima

d. Muscularis

3. What has more recently become the most common malignancy of the esophagus? a. Squamous cell

b. Lymphoma

c. Adenocarcinoma

d. Leiomyosarcoma

4. Which of the following describes the location of the esophagogastric junction? a. Posterior to the left lobe and to the right of the

abdominal aorta

b. Posterior to the left lobe and posterior to the abdominal aorta

c. Posterior to the left lobe and anterior to the aorta

d. The esophagogastric junction can never be visualized sonographically

Lumen

Peritoneum

2. Wall layers

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82 PART 1 — ABDOMINAL SONOGRAPHY

5. Where are the layers of the GI tract wall thickest? a. Esophagus

b. Stomach

c. Small intestine

d. Large intestine

6. What should the bowel wall measure when the stomach is not distended? a. 1 to 4 mm

b. 1 to 4 cm

c. 2 to 6 mm

d. 3 to 8 mm

7. Where does infl ammation start in Crohn’s disease? a. Muscularis mucosa

b. Muscularis propria

c. Serosa

d. Submucosa

8. Your patient has been referred for an abdominal sonogram with a history of abdominal pain and Crohn’s disease. Which of the following does Crohn’s disease primarily affect? a. Ileum

b. Duodenum

c. Stomach

d. Cecum

9. Which of the following statements regarding the jejunum and ileum is FALSE? a. The jejunum and ileum lie to the right and left of

the abdomen, respectively

b. The valvulae conniventes of the mucosa can usually be seen if fl uid is present within the loops

c. The diameter of the jejunum and ileum should measure less than 3 cm

d. Peristalsis should be visualized in the normal small bowel

10. Which of the following CANNOT cause an ileus? a. Surgery

b. Spinal fracture

c. Intussusception

d. Acute pancreatitis

11. A 2-year-old patient presents with abdominal pain and a palpable abdominal mass. Sonographically, an echogenic mass is seen in the midline and in the transverse plane it appears to demonstrate multiple concentric rings. What is the most likely diagnosis? a. Duodenal ulcer

b. Pyloric stenosis

c. Crohn’s disease

d. Intussusception

12. What is the most common benign tumor of the small bowel? a. Adenoma

b. Lipoma

c. Leiomyoma

d. Lymphoma

13. When evaluating the appendix sonographically, what structure will help you locate it? a. Cecum

b. Duodenum

c. Jejunum

d. Urinary bladder

14. Rebound tenderness and pain located over the area of the appendix is referred to as a positive: a. Murphy’s sign

b. McBurney’s sign

c. McDowell’s sign

d. McGinnty’s sign

15. Which of the following statements regarding appendicitis is FALSE? a. A calcifi ed appendicolith can help identify an

infl amed appendix

b. An infl amed appendix will demonstrate hyperemic fl ow with color or power Doppler

c. A noncompressible appendix greater than 6 mm is considered abnormal

d. Sonography cannot visualize a normal appendix

16. A 20-year-old patient presents with right lower quadrant pain. The sonogram demonstrates an 8-mm noncompressible target shaped lesion at the area of maximum tenderness. A calcifi cation is seen within the lesion. What is the most likely diagnosis? a. Crohn’s disease

b. Appendicitis with appendicolith

c. Intussusception with bowel tumor

d. Ileus with bowel distention

17. Where do the majority of colon cancers occur? a. Sigmoid colon

b. Ascending colon

c. Cecum

d. Rectum and rectosigmoid colon

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9 — The Gastrointestinal Tract 83

18. Your patient complains of abdominal pain; while scanning over the area of tenderness, you locate a loop of bowel with visible haustra. This is characteristic of which part of the GI tract? a. Stomach

b. Small intestine

c. Large intestine

d. All parts of the GI tract display this characteristic feature

19. Which part of the GI tract can be seen curving around the pancreatic head? a. Stomach

b. Duodenum

c. Jejunum

d. Ileum

20. A patient presents with abdominal pain and your evaluation reveals multiple dilated fl uid fi lled small bowel loops with markedly increased peristalsis. What is the most likely diagnosis? a. Intussusception

b. Crohn’s disease

c. Bowel obstruction

d. Diverticulitis

FILL-IN-THE-BLANK

1. Sonography is not often the examination of choice for

evaluating the GI tract due to the diffi culty caused by

the presence of in the GI tract.

2. Both and

approaches may be used to evaluate the GI tract

sonographically.

3. Sonographically, the bowel wall is described as

layers. The layers are the innermost

echogenic layer representing the

interface. Next is a hypoechoic layer made up of

the , , and

. Next is the echogenic

, followed by the hypoechoic

, and fi nally the echogenic

4. Squamous cell carcinoma can present with the

clinical symptom of , or diffi culty

swallowing.

5. The fundus of the stomach lies

to the spleen and to the left

kidney. The body and antrum lie anterior to the

6. Chronic gastritis may present with generalized

thickening of the hypoechoic layer

of the stomach wall.

7. Gastric peptic ulcers are much less common than

ulcers in the United States,

typically appearing along the antral portion of the

8. The folds that can sometimes be seen projecting into

the fl uid-fi lled lumen of the small bowel are called

9. Sonographically, the small bowel is typically more

distended with an than with an

ileus.

10. With ileus, the small bowel is distended with

or , and peristalsis

can be normal to .

11. A volvulus will appear as a dilated,

-shaped loop containing only

and no air.

12. Intussusception is more common in

than in . When it does occur in

adults, it is almost always secondary to a bowel

Kawamura_WB_CH09.indd 83 12/1/11 4:05 PM

84 PART 1 — ABDOMINAL SONOGRAPHY

13. Crohn’s disease is a common cause of bowel wall

infl ammation and presents sonographically as

of the bowel wall and surrounding

. The typical sonographic

appearance is a lesion.

14. The normal appendix extends from the

and should measure no more

than mm in diameter with a wall

thickness of mm or less.

15. The appendix is located under

point, which is located by drawing an imaginary line

from the right anterosuperior to

the umbilicus. The appendix is usually found at the

midpoint of this line.

16. When evaluating the appendix, the sonographer

should use the technique to

displace gas- or fl uid-fi lled bowel loops and locate the

area of maximum tenderness.

17. Complications of appendicitis include

formation, , or .

18. Lymphadenopathy in the right lower quadrant

surrounding the cecum is termed

. Lymph nodes greater than

mm are considered abnormal.

19. The colon lies along the of the

abdomen, is larger in diameter than the small bowel,

and contains characteristic folds.

When the colon is not distended, the wall should

measure mm thick.

20. Ulcerative colitis is an infl ammatory disease that

affects the and

layers of the colon. Infl ammation starts in the

and may extend throughout the

colon.

SHORT ANSWER

1. Although the majority of evaluations of the GI tract are performed transabdominally, endoluminal examinations can provide useful information. What structures can be evaluated with an endoluminal examination, and how does it compare to a transabdominal examination?

2. What techniques may be used to evaluate the stomach and duodenum sonographically?

3. You are asked to perform an abdominal sonogram to rule out appendicitis in a 10-year-old patient. Describe the technique used to locate and evaluate the appendix for appendicitis.

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9 — The Gastrointestinal Tract 85

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. A 45-year-old patient presents with acute pancreatitis, abdominal pain, and distention. Peristalsis is noted within the bowel and is mildly increased. Describe the image shown. What is a possible diagnosis? What normal structures are the arrows pointing to?

2. A 59-year-old patient presents for an abdominal sonogram with severe epigastric pain. The patient is able to demonstrate an area that is the most painful. This image is taken at that area. Multiple concentric rings are demonstrated within the visualized bowel. This is diagnostic of what bowel pathology? In adults, what is the most common cause of this pathology?

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86 PART 1 — ABDOMINAL SONOGRAPHY

3. A 24-year-old patient presents with a history of Crohn’s disease. Describe the bowel seen in this image. Which part of the bowel is most commonly affected by Crohn’s disease?

4. A 14-year-old patient presents with severe RLQ pain, nausea and vomiting, and leukocytosis. Your examination of the RLQ reveals this image. What are the arrows pointing to? What is the normal measurement for the wall of the appendix? What is the normal diameter of the appendix?

5. Describe what is seen in this image of the stomach. In what layer of the stomach wall do gastric carcinomas typically occur?

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9 — The Gastrointestinal Tract 87

CASE STUDIES

1. A 6-year-old patient presents with RLQ pain and fever. These images are taken in the RLQ. Describe what is seen. What is the diagnosis? What complications may occur with this pathology?

2. A 64-year-old patient presents with abdominal pain and a history of diverticulosis. What are the arrows in this image pointing to? Where does this pathology most commonly occur? What complications may arise?

Kawamura_WB_CH09.indd 87 12/1/11 4:05 PM

Kawamura_WB_CH09.indd 88 12/1/11 4:05 PM

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms wtith their defi nitions.

Key Terms Defi nititons

1. Azotemia

2. BUN

3. Creatinine

4. Diuresis

5. Dysuria

6. Gerota’s fascia

7. Hematuria

8. Hypernephroma

9. Nephrectomy

10. Nephropathy

11. Oliguria

12. Proteinuria

13. Pyuria

14. Urosepsis

a. Blood in the urine b. Blood test along with BUN used to measure the

kidneys’ ability to remove waste in the blood c. Bacterial infection in the bloodstream as a result of a

urinary tract infection d. An overload of nitrogenous wastes such as blood

urea nitrogen, uric acid, and creatinine, which occur with renal failure

e. Pus in the urine f. Painful urination g. Kidney disease h. Blood test that evaluates the amount of nitrogenous

waste in the blood and serves as a measure of kidney function

i. Low output of urine that is the result of many possible causes including dehydration, renal failure, or urinary obstruction

j. Increased production of urine that can occur with diabetes mellitus, acute renal failure, or increased fl uid intake

k. Another term for renal cell carcinoma l. Also known as the renal fascia; dense connective

tissue that surrounds and helps anchor the kidney, adipose capsule, and the adrenal gland

m. Surgical removal of the kidney n. Protein in the urine; sign of kidney disease

10 The Kidneys

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90 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

B C

EFG

I H

1. Retroperitoneal anatomy

2. Urinary systsem

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10 — The Kidneys 91

G H

3. Renal anatomy

4. Renal anatomy

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92 PART 1 — ABDOMINAL SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is sonography of the kidneys NOT used for? a. Assess the size of the kidney, including length,

width, and thickness

b. Evaluate the echogenicity of the renal cortex, medulla, and sinus

c. Evaluate the function of the kidneys

d. Differentiate between cystic and solid lesions

2. What is the functional unit of the kidney? a. Mesonephros

b. Nephron

c. Hepatocyte

d. Pronephros

3. Approximately when do the kidneys begin to function? a. 4 weeks

b. 6 weeks

c. 8 weeks

d. 10 weeks

4. What is the normal length of the adult kidney? a. 6 to 8 cm

b. 8 to 10 cm

c. 10 to 12 cm

d. 12 to 14 cm

5. Which of the following surrounds the kidney and the adrenal gland and serves to anchor them to the surrounding structures? a. Renal capsule

b. Gerota’s fascia

c. Adipose capsule

d. Glisson’s capsule

6. Which of the following is TRUE regarding the renal vasculature? a. The renal arteries arise off of the anterior aspect of

the aorta

b. The right renal artery courses anterior to the IVC before entering the renal hilum

c. The left renal vein crosses posterior to the aorta before entering the IVC

d. Because the aorta lies to the left of midline, the right renal artery is typically longer than the left

7. What are the extensions of cortex that lie between the renal pyramids called? a. Columns of Bertin

b. Cortical columns

c. Fetal lobulation

d. Dromedary hump

5. Congenital anomaly

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10 — The Kidneys 93

8. What is a common renal variation in which a local bulge is seen at the lateral border of the kidney called? a. Hypertrophied column of Bertin

b. Extrarenal pelvis

c. Fetal lobulation

d. Dromedary hump

9. What is excessive fatty infi ltration of the renal pelvis called? a. Hypertrophied column of Bertin

b. Extrarenal pelvis

c. Renal sinus lipomatosis

d. Nephrocalcinosis

10. Which of the following is NOT a laboratory test used to evaluate renal function? a. Blood urea nitrogen

b. Creatinine

c. Urinalysis

d. Amylase

11. An RI in the adult kidney is considered normal if it is below: a. 1

b. 0.8

c. 0.7

d. 0.5

12. What is the most common congenital anomaly of the genitourinary tract? a. Duplicated collecting system

b. Unilateral renal agenesis

c. Bilateral renal agenesis

d. Pelvic kidney

13. You are asked to evaluate a patient with a complaint of a pulsatile midline abdominal mass. Which renal condition may be responsible for this complaint? a. Pyelonephritis

b. Pelvic kidney

c. Duplicated collecting system

d. Horseshoe kidney

14. While performing an abdominal sonogram on a 62-year-old patient, you discover a 2-cm cystic area in the lower pole cortex. What is the most likely diagnosis? a. Adult polycystic kidney disease

b. Simple renal cyst

c. Von Hippel-Lindau disease

d. Medullary sponge kidney

15. Which of the following is NOT associated with adult polycystic kidney disease? a. Bilaterally enlarged kidneys with numerous

discrete cysts visible

b. Associated cysts in the liver, pancreas, and spleen

c. Small echogenic kidneys

d. Cerebral artery aneurysms located within the circle of Willis

16. What is the sonographic appearance of medullary sponge kidney? a. Bilaterally enlarged kidneys with numerous large

cysts in the region of the pyramids

b. Small, echogenic kidneys with a loss of corticomedullary junction

c. Normal-sized kidneys with echogenic cortex

d. Normal-sized kidneys with highly echogenic medullary pyramids without associated shadowing

17. What is a cyst that originates in the renal parenchyma and protrudes into the renal sinus called? a. Simple cyst

b. Parapelvic cyst

c. Milk of calcium cyst

d. Extrarenal pelvis

18. Which of the following is NOT associated with renal cortical cysts? a. Tuberous sclerosis

b. Von Hippel-Lindau disease

C. Adult polycystic kidney disease

D. Amyloidosis

19. Which of the following is NOT a benign tumor of the kidney? a. Hypernephroma

b. Angiomyolipoma

c. Oncocytoma

d. Adenoma

20. A small, well-defi ned, highly echogenic mass is seen in the renal cortex of a 38-year-old woman. What is this a characteristic of? a. Hypernephroma

b. Oncocytoma

c. Angiomyolipoma

d. Adenoma

21. Which of the following pathologies does NOT have an increased risk of renal cell carcinoma? a. Von Hippel-Lindau disease

b. Medullary sponge kidney

c. Adult polycystic kidney disease

d. Tuberous sclerosis

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94 PART 1 — ABDOMINAL SONOGRAPHY

22. A 25-year-old pregnant patient presents in her third trimester with mild right fl ank pain. Which of the following would you expect to fi nd in this patient? a. Multiple angiomyolipomas

b. Large renal cyst

c. Mild-to-moderate hydronephrosis

d. Renal cell carcinoma

23. Which of the following CANNOT cause hydronephrosis? a. Hyperplasia of the prostate

b. Ureterocele

c. Fibroid uterus

d. Renal artery stenosis

24. What is the medical term for kidney stones? a. Nephrolithiasis

b. Cholelithiasis

c. Nephrocalcinosis

d. Fecolithiasis

25. A patient presents with a history of medullary nephrocalcinosis. What is the typical sonographic appearance of medullary nephrocalcinosis? a. Bilateral small echogenic kidneys

b. Enlarged kidneys with multiple distinct cystic areas

c. Normal kidney cortex with highly echogenic pyramids bilaterally

d. Bilateral hydronephrosis with thinning of the renal cortex

26. What is a common cause of acute pyelonephritis? a. Lower urinary tract infection

b. Renal artery stenosis

c. Renal cell carcinoma

d. Colitis

27. Which of the following is FALSE regarding upper urinary tract infections? a. Incomplete bladder emptying or stasis may lead to

a UTI

b. Only respiratory infections are more common than UTIs

c. People with diabetes or immunocompromise are more likely to have a UTI

d. The incidence of UTIs is much higher in men

28. What is acute pyelonephritis most commonly caused by? a. Staphylococcus aureus

b. Escherichia coli

c. Pseudomonas

d. Klebsiella

29. What is the presence of purulent material or pus in the collecting system called? a. Hydronephrosis

b. Urosepsis

c. Pyonephrosis

d. Urolithiasis

30. A patient is referred for an abdominal sonogram with a history of chronic medical renal disease. What is typical sonographic appearance of this condition? a. Bilaterally enlarged hypoechoic kidneys

b. Bilaterally enlarged kidneys with multiple discrete cysts

c. Small hypoechoic kidneys

d. Small echogenic kidneys

FILL-IN-THE-BLANK

1. The urinary system is made up of two

, two , the

, and the

2. The kidneys are located in the

cavity.

3. During embryological development, three pairs

of kidneys are formed at successive intervals: the

, the , and the

and ducts.

4. In the male, the duct persists and

develops into the male ,

the , and the

ejaculatory duct. In the female, the mesonephric

duct develops into the duct,

which develops into the and

5. At the renal hilus, the renal and

renal , , nerves,

and the enter or exit the kidney.

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10 — The Kidneys 95

6. The kidney is surrounded by three layers

of supportive tissues: the innermost fi brous

, which protects

against and ; the

middle layer, called the capsule;

and the outermost layer, called

fascia.

7. The right kidney is lower than the

left due to the presence of the .

The length of the kidneys should be within

cm of each other.

8. The renal extends from the renal

capsule to the bases of the renal

and the spaces between them. The renal or

pyramids are visualized

sonographically as hypoechoic, triangular structures

deep to the cortex.

9. In a normal adult, the renal cortex is

or to the liver parenchyma. In

neonates, the renal cortex is or

to the liver parenchyma. The

cortex in an adult should measure greater than

in thickness over the pyramids.

10. The main function of the kidneys is to remove

from the and

regulate the and

content of the blood.

11. A urine specimen or urinalysis can be used to detect

the presence of , ,

and , which could indicate

or .

12. Bilateral renal agenesis is not compatible with

and can be detected in utero by the

absence of a and ,

or decreased amniotic fl uid.

13. In the case of ureteral duplication, the upper

pole ureter typically enters in the bladder below

the trigone and may be obstructed, leading to

14. Complex cysts include cysts,

cysts, and or

cysts.

15. Calcifi cations in the wall of a cyst may be due to

previous or .

Mural calcifi cations can also be associated with

, so they may need to be evaluated

by other means.

16. Milk of calcium may be found in a

or calyceal and often forms after

or .

17. Tuberous sclerosis is a multisystemic disorder

associated with bilateral renal and

renal .

18. Von Hippel-Lindau disease is an inherited disorder

that can present with multiple renal .

The cysts can contain neoplastic elements that may

evolve into .

19. The most common benign kidney tumor is the

and is thought to be the benign

counterpart of .

20. Angiomyolipomas are typically solitary and are more

common in .

angiomyolipomas occur in patients with tuberous

sclerosis complex.

21. Renal cell carcinoma is also known as

or , and is the

most common malignant tumor of the kidney.

22. Renal cell carcinoma can spread into the perinephric

and renal . It can

also spread to the kidney.

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96 PART 1 — ABDOMINAL SONOGRAPHY

23. Urothelial tumors include and

and become clinically apparent due

to painless .

24. Hydronephrosis is a urine of the

renal , structures,

and . Hydronephrosis makes kidneys

susceptible to , ,

and permanent .

25. Clinical symptoms of urolithiasis include

or blood in the urine,

if obstruction occurs, and

as stones are passed. Stones in the

right ureter may mimic symptoms of .

26. Trauma to the kidneys can occur during blunt or

penetrating trauma. A linear absence of echoes is

suggestive of a renal . Focal areas

of hemorrhage are typically . A

collection of blood that lies between the cortex and

the renal capsule is called a .

27. Symptoms of UTI include elevated

and the possibility of the presence of ,

, and in the urine.

28. When evaluating kidneys for medical renal disease,

a diffuse in cortical echogenicity is

typically seen. The kidneys become

and the medulla becomes .

29. is a leading cause

of chronic renal failure and the cause of diabetic

morbidity and mortality.

30. The most common cause of acute renal failure is

Renal failure is the inability of the kidneys to

remove accumulated from the

blood. Azotemia is an overload of

, such as

, and

in the blood.

SHORT ANSWER

1. Common renal anatomic variants include a hypertrophied column of Bertin and an extrarenal pelvis. Describe the sonographic appearance of each of these variants and describe how you would differentiate these normal variants from a pathological condition.

2. List the main functions of the kidney. What laboratory values are used to evaluate renal function?

3. While performing a renal sonogram, the right kidney is visualized and appears normal. The left kidney is not seen in its normal position in the left upper quadrant. What are the possible causes of this and where else would you focus your examination?

4. Renal cell carcinoma is the most common malignant tumor of the kidney. List the risk factors for developing RCC and describe what other areas should be evaluated if a renal mass is found during a sonographic examination of the abdomen.

5. List three intrinsic and three extrinsic causes of hydronephrosis. List three possible reasons for a false- positive diagnosis of hydronephrosis.

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10 — The Kidneys 97

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What pathology is seen in this image? What age does this pathology typically present? What complications may be seen with this disease?

2. Describe the mass defi ned by the arrows. What is the most likely diagnosis? What disorder is associated with multiple masses of this type?

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98 PART 1 — ABDOMINAL SONOGRAPHY

3. What condition is seen in these images? Describe the kidney seen in the images. Is this condition typically seen unilaterally or bilaterally? Are there any associated complications?

4. Describe the lesion shown in this image. What are some possible diagnoses? What further testing could be done to confi rm the diagnosis?

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10 — The Kidneys 99

5. What pathology are the arrows pointing to? What symptoms are commonly associated with this pathology? How could color Doppler help with this pathology?

CASE STUDIES

1. A 42-year-old man presents with severe right fl ank pain and hematuria. He has a history of bilateral kidney stones. What is seen in this image of the right kidney? If a kidney stone is causing an obstruction at the right ureteropelvic junction, what structure(s) will be dilated? What if the stone is at the right ureterovesical junction?

2. A 58-year-old man presents with gross hematuria and mild left fl ank discomfort. Describe what is seen in this image. What is the most likely diagnosis? Describe other possible sonographic appearances of this pathology.

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101

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Cystitis

2. Cystoscopy

3. Exstrophy

4. Hematuria

5. Diverticula

6. Trabeculated bladder

7. VCUG

a. Presence of red blood cells in the urine b. Out-pouching of the bladder wall c. Procedure in which a scope is used to evaluate the

urethra, bladder, and pelvic ureters d. Irregular bladder wall frequently seen in patients

with longstanding obstruction or neurogenic bladder e. Fluoroscopic exam used to evaluate for urinary refl ux f. Congenital anomaly in which part of the urinary

bladder is located outside the abdominal wall g. Infl ammation of the urinary bladder

11 The Lower Urinary System

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102 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Female pelvis

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11 — The Lower Urinary System 103

2. Male pelvis

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104 PART 1 — ABDOMINAL SONOGRAPHY

3. Lateral view of the male pelvis

4. Color Doppler of the urinary bladder

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11 — The Lower Urinary System 105

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. The bladder is lined with a mucous membrane made of what? a. Squamous epithelium

b. Transitional epithelium

c. Intimal epithelium

d. Urogenital epithelium

2. Which of the following statements regarding the urethra is FALSE? a. The female urethra is 3 to 4 cm long and

transports urine from the body

b. The male urethra is longer than the female urethra and has a dual function

c. The internal urethral sphincter is formed by a thickening of the detrusor muscle

d. The external urethral sphincter is formed of skeletal muscle and is under involuntary control

3. The involuntary emptying of the bladder is called: a. Micturition

b. Incontinence

c. Retention

d. Voiding

4. The inability to empty the bladder even when it is full of urine is called: a. Micturition

b. Incontinence

c. Retention

d. Voiding

5. While evaluating the urinary bladder in a patient with a history of lower urinary tract infection, you suspect the bladder wall may be thickened. What is the normal measurement of the bladder wall when the bladder is distended? a. Less than 7 mm

b. Less than 5 mm

c. Less than 3 mm

d. Less than 2 mm

6. A 26-year-old woman presents with dysuria, fever, and pelvic pain. The bladder wall is diffusely thickened and hypoechoic. The kidneys appear normal. What is the most likely cause of these fi ndings? a. Bladder neoplasm

b. Bladder outlet obstruction

c. Cystitis

d. Ureterocele

7. While evaluating the bladder with color Doppler, you visualize ureteral jets on the left side but are unable to detect a jet on the right. What might this indicate? a. Hydronephrosis

b. Urinary tract infection

c. Bladder outlet obstruction

d. Ureteral obstruction

8. Which of the following statements regarding bladder diverticula is FALSE? a. A bladder diverticula will always empty

completely with voiding

b. A diverticula may be the result of a chronic bladder obstruction

c. Stones or tumor may occur in a bladder diverticula

d. A large bladder diverticula may mimic an ovarian cyst

9. You receive a request to evaluate the urinary system in a male newborn with suspected bladder outlet obstruction. What is the most common cause of bladder outlet obstruction? a. Bilateral renal agenesis

b. Ectopic ureterocele

c. Vesicoureteral refl ux

d. Posterior urethral valves

10. Which of the following CANNOT cause bladder outlet obstruction? a. Congenital urethral stricture

b. Stone at the ureteropelvic junction

c. Ureterocele

d. Posterior urethral valves

11. What is a condition in which the bladder is herniated through a defect in the anterior abdominal wall called? a. Bladder exstrophy

b. Complete duplication of the bladder

c. Bladder diverticula

d. Ureterocele

12. A female infant presents with a low-grade fever and palpable abdominal mass just superior to the urinary bladder. Sonographically, a cystic mass is seen in this area. A connection to the bladder cannot be identifi ed. What does this structure likely represent? a. Duplicated bladder

b. Bladder diverticula

c. Ureterocele

d. Urachal cyst

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106 PART 1 — ABDOMINAL SONOGRAPHY

13. You are performing an examination of the urinary tract on a male infant with a history of urinary tract infections. You visualize a round cystic structure within the bladder lumen. With color Doppler you are able to detect a consistent ureteral jet coming from the area. What is the most likely diagnosis? a. Foley catheter in the bladder

b. Bladder diverticula

c. Ureterocele

d. Bladder mass

14. A patient presents with a history of lower urinary tract infections. The bladder wall appears normal; however, a small echogenic area is seen along the posterior wall of the bladder. Acoustic shadowing is present posterior to the area and the echogenic foci moves with a change in patient position. What does this echogenic foci represent? a. A bladder calculi

b. A calcifi ed bladder mass

c. Foley catheter in the urinary bladder

d. Ectopic ureterocele

15. Which of the following statements regarding refl ux is FALSE? a. The vesicoureteral junction normally protects the

kidney from the backfl ow of infected urine

b. The vesicoureteral junction normally allows the fl ow urine both into and out of the bladder

c. High-pressure refl ux is a major cause of chronic renal failure

d. When refl ux is in process, dilation of the ureter may be seen with sonography

16. The ureterovesical junction describes the area where the: a. Proximal ureter joins the renal pelvis

b. Distal ureter joins the urinary bladder

c. Distal urethra joins the urinary bladder

d. Proximal urethra joins the urinary bladder

17. A patient presents with a history of right ureterovesical junction obstruction. Which of the following would NOT be an expected fi nding? a. Right megaureter

b. Right-sided hydronephrosis

c. Ectopic ureterocele

d. Left-sided hydronephrosis

18. On sonographic examination, your patient is noted to have a thickened bladder wall. Which of the following CANNOT cause bladder wall thickening? a. Bladder outlet obstruction

b. Neurogenic bladder

c. Overhydration

d. Cystitis

19. A fl uid collection that occurs as a result of bladder trauma is called a: a. Urinoma

b. Lymphocele

c. Ureterocele

d. Diverticula

20. What is the most common type of bladder malignancy? a. Adenocarcinoma

b. Squamous cell carcinoma

c. Lymphoma

d. Transitional cell carcinoma

FILL-IN-THE-BLANK

1. The lower urinary tract consists of the pelvic

, , and

2. Initially, the bladder is contiguous with the

, which eventually becomes the

, which extends from the apex of

the bladder to the .

3. The bladder wall is composed of four layers:

the innermost transitional epithelium, the

, the muscle layer, which is called

the muscle, and the fi brous

4. The ureters are constricted in three places:

at the junction, as they

cross the vessels, and at the

junction.

5. The is the terminal portion

of the urinary tract. The

is an muscle that keeps

the urethra closed and prevents leaking.

Contraction this sphincter and

closes it.

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11 — The Lower Urinary System 107

6. The thickness of the bladder wall should measure

less than when it is distended and

less than when empty or partially

distended.

7. On transverse sections, the shape of the bladder

superiorly is , whereas more

inferiorly, the shape is . On

longitudinal sections, the bladder shape is more

8. If the ureters are dilated, they can be visualized as

round structures to the urinary

bladder in the plane.

9. Bladder volume is calculated using the

formula for an . The formula

is � �

� .

10. or scanning

techniques may be used to evaluate the female

urethra. , or small defects in the

urethral wall, may be identifi ed.

11. A posterior urethral valve is a mucosal fl ap

originating from the that obstructs

urine fl ow and causes bladder .

Sonographically, the urethra is

elongated and dilated. The bladder wall is typically

12. An ureter does not insert into

the typical location in the bladder trigone. This

ureter typically arises from the

pelvis of a kidney and inserts

and more

towards the bladder base.

13. A is a cyst-like enlargement of the

lower end of the ureter. If the ureteral opening is

narrowed, and

may be present. If the ureterocele obstructs the

opening to the urethra, may occur.

14. If the fails to close properly, an

open channel between the bladder and umbilicus

may form. Complications include ,

, or formation.

15. Infl ammation of the bladder is called

. This infection is typically caused

by the bacteria . If the infection

travels to the kidneys, it can cause .

16. Predisposing factors to bladder stone formation

include increased of salts in the

urine, of the urinary tract, and

urinary tract or .

17. A patient with a bladder has lost

voluntary control of voiding due to a disturbance

somewhere along the neural pathway. The bladder

may be either or ,

depending on the nature of the damage.

18. During a cesarean section, a potential space

is created between the bladder and the uterus

known as a . A

can form in this potential space

following surgery. A fever and leukocytosis can

indicate that this area has become .

19. The most common symptom of a bladder neoplasm

is . Sonography typically displays

wall thickening. Metastatic bladder

tumors may occur by direct extension from primary

tumors of the , ,

, and .

20. Any condition that causes urinary stasis or

obstruction predisposes a patient to

formation and .

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108 PART 1 — ABDOMINAL SONOGRAPHY

SHORT ANSWER

1. Describe two possible patient preparations used for a transabdominal sonographic evaluation of the urinary bladder. What other methods besides the transabdominal approach are used to evaluate the lower urinary tract?

2. What role does color Doppler play in the evaluation of the urinary bladder? Discuss three examples.

3. What is an ectopic ureterocele? How does this pathology cause hydronephrosis? Describe the sonographic appearance of this pathology.

4. What mechanism is in place to protect the kidneys from infected urine in the bladder? What problems can occur when this mechanism malfunctions?

5. Describe the sonographic appearance of a neurogenic bladder. What causes these changes?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What structure is the arrow pointing to?

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11 — The Lower Urinary System 109

2. What are the arrows pointing to? Does this structure appear normal? What can cause thickening of the bladder wall?

3. What is the arrow pointing to in this image? List two predisposing factors for this pathology. What complications may occur?

4. Describe what is seen in this image. What is the likely diagnosis? What could mimic this pathology?

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110 PART 1 — ABDOMINAL SONOGRAPHY

CASE STUDIES

1. A 26-year-old woman presents with a recent history of a lower urinary tract infection with symptoms of urinary frequency and dysuria. What do you see in this image? How does this pathology predispose the patient to urinary tract infections?

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111

REVIEW OF GLOSSARY TERMS

MATCHING

Match the key terms with their defi nitions.

Key Terms Defi nitions

1. Apex

2. Base

3. Corpora amylacea

4. Eiffel Tower sign

5. Ejaculatory ducts

6. Endogenous calculi

7. Exogenous calculi

8. Seminal vesicles

9. Surgical capsule

10. Vas deferens

11. Verumontanum

a. Reproductive duct that extends from the epididymis to the ejaculatory duct

b. Superior portion of the prostate gland, which is located below the inferior margin of the urinary bladder

c. Calculi found within the urethra d. Calcifi cations commonly seen in the inner gland of

the prostate e. Inferior portion of the prostate gland, which is

located superior to the urogenital diaphragm f. A longitudinal ridge within the prostatic urethral wall

where the orifi ces of the ejaculatory ducts are located on either side

g. Calculi formation within the substance of the prostate

h. Shadowing created by calcifi cation in the area of the urethra and verumontanum

i. A pair of tubular glands which extend from out- pouching of the vas deferens

j. Demarcation between the inner gland and the outer gland, which normally appears hypoechoic

k. Duct that passes through the central zone and empties into the urethra; originates from the combination of the vas deferens and the seminal vesicle

12 The Prostate Gland

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112 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

F GD

CAB

1. Male pelvis

2. Sagittal view of the male pelvis

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12 — The Prostate Gland 113

D C

3. Zonal anatomy

4. Normal prostate anatomy

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which structure travels within the central zone of the prostate gland and joins the urethra? a. Ejaculatory duct

b. Seminal vesicle

c. Vas deferens

d. Verumontanum

2. Which of the following is NOT a zone within the glandular tissue of the prostate gland? a. Peripheral zone

b. Epithelial zone

c. Central zone

d. Periurethral zone

3. Which of the glandular zones of the prostate is the largest? a. Peripheral zone

b. Periurethral zone

c. Central zone

d. Transition zone

4. In which zone does prostate cancer and prostatitis most often occur? a. Peripheral zone

b. Periurethral zone

c. Central zone

d. Transition zone

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114 PART 1 — ABDOMINAL SONOGRAPHY

5. Your patient presents for a sonogram to evaluate for benign prostatic hypertrophy. Which zone is most affected by BPH? a. Peripheral zone

b. Periurethral zone

c. Central zone

d. Transition zone

6. Which blood test is used to identify men at increased risk of prostate cancer? a. AFP

b. CA-125

c. PSA

d. AST

7. The apex of the prostate is located inferior to the verumontanum and is made up predominantly of the: a. Peripheral zone

b. Periurethral zone

c. Central zone

d. Transition zone

8. The base of the prostate is located superior to the verumontanum and is made up predominantly of the: a. Peripheral zone

b. Periurethral zone

c. Central zone

d. Transition zone

9. Which of the following cysts is associated with genital anomalies such as hypospadias? a. Müllerian duct cyst

b. Utricle cyst

c. Seminal vesicle cyst

d. Prostatic cyst

10. Which of the following cysts will contain spermatozoa? a. Müllerian duct cyst

b. Utricle cyst

c. Seminal vesicle cyst

d. Prostatic cyst

11. A diabetic patient presents with fever, urinary frequency, low back pain, and hematuria. While scanning the prostate the gland, you notice a focal complex area that has increased blood fl ow. What is the most likely diagnosis given the patient’s history? a. BPH

b. Prostate cancer

c. Prostatic cyst

d. Prostatic abscess

12. What is the most common symptomatic condition to affect the prostate gland? a. BPH

b. Prostate cancer

c. Prostatic cyst

d. Prostatitis

13. Your patient states that he has had a transurethral resection or TURP procedure. What condition does this procedure treat? a. Prostate cancer

b. Prostatic abscess

c. Prostatitis

d. BPH

14. Which of the following statements regarding BPH is FALSE? a. BPH is commonly seen in men over the age of 40

with a peak incidence around 60

b. BPH causes the prostate to appear more rounded than normal

c. BPH affects the central zone of the prostate

d. BPH causes urinary symptoms of frequency, nocturia, and diffi culty starting a stream

15. What is the sonographic appearance of the prostate gland in patients with benign prostatic hypertrophy? a. Hypoechoic

b. Hyperechoic

c. Heterogeneous

d. The appearance of BPH could include all of the above

16. Where does corpora amylacea occur most often? a. Superior segment of the prostate

b. Inferior segment of the prostate

c. Posterior segment of the prostate

d. Anterior segment of the prostate

17. Patients with prostate cancer may present with which of the following: a. An abnormal PSA level

b. An abnormal DRE

c. Bladder outlet obstruction

d. Patients may present with all of the above symptoms

18. A defi nitive diagnosis of prostate cancer can be made by: a. DRE

b. TRUS

c. Ultrasound-guided biopsy

d. PSA level

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12 — The Prostate Gland 115

19. TRUS alone has a predictive value of: a. Less than 10 percent

b. 25 percent

c. 50 percent

d. 75 percent

20. Which of the following statements regarding ultrasound-guided prostate biopsy is TRUE? a. Prostate biopsy is only performed if a discrete

lesion can be identifi ed with ultrasound

b. The method of choice is the transperineal approach

c. Prostate biopsy is commonly done at known sites of anatomic weakness

d. Prostate biopsy is routinely done from a transabdominal approach with a full urinary bladder

FILL-IN-THE-BLANK

1. TRUS is an acronym for .

2. TRUS of the prostate can be used to evaluate

the prostate in cases of ,

, , and

abnormalities. It can also be used

to guide and treatment procedures.

3. The ducts are responsible for

development of the male reproductive system,

whereas the form the female

reproductive system.

4. The prostate is shaped like a and

measures on average.

5. The cephalic portion of the gland is the

, whereas the caudal portion is

the . The travels

through the center of the prostate gland.

6. Sonographically, the peripheral zone tissue is

and . The

separates the peripheral zone from

the central zone. The echogenicity of the central

zone is than the peripheral zone.

7. Sonographic characteristics of prostate disease include

changes in , of the

gland, and a distorted .

8. When performing an examination of the prostate,

the image is typically with the

near fi eld at the of the image and

the far fi eld at the of the image. In

the transverse plane, the right lobe of the gland is at

the side of the image and the left

lobe of the gland is on the side of

the image.

9. The capsule of the prostate gland should appear

and without .

10. The most common of the pelvic cystic masses are the

duct and cysts.

11. A utricle cyst is in origin and is

typically associated with genital anomalies such as

, testicles, and

anomalies.

12. The majority of patients with seminal vesicle cyst

also have ipsilateral .

13. The most common cysts are typically the result of

BPH and are seen in the zone of

the prostate.

14. Prostatic calculi are divided into

calculi and calculi.

calculi are found within the

prostate gland and form from

fl uid. calculi are found within the

urethra and are derived from .

15. calculi can produce what is known

as the “Eiffel Tower” appearance.

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116 PART 1 — ABDOMINAL SONOGRAPHY

16. Patients with acute bacterial prostatitis present with

a , along with

and pain. Large numbers of

will be present within the urine.

17. The prostate is infected by organisms ascending from

the . There is a greater incidence of

prostatitis within the zone.

18. The most common sonographic fi nding in patients

with a history of prostatitis is a in

the periurethral area. The peripheral zone may also

have a echo pattern.

19. The most common cancer in American men is

. The majority are diagnosed in

men over the age of .

20. The most common type of prostate cancer is

and occurs most commonly in the

zone. Most are ,

as opposed to solitary lesions.

SHORT ANSWER

1. What are the most common indications for sonography of the prostate? Is TRUS of the prostate typically used for screening purposes?

2. Describe the sonographic technique used to evaluate the prostate gland, including patient preparation, positioning, image orientation, and any contraindications to the study.

3. Calcifi cations are commonly seen in the prostate gland. What conditions can cause calcifi cations within the prostate?

4. Prostate cancer is the second most deadly male cancer, making its diagnosis an important one. Describe the sonographic appearance of prostate cancer. Is ultrasound a good screening tool for prostate cancer? Why or why not?

5. Describe the method most commonly used for ultrasound-guided prostate biopsy, including patient preparation and technique.

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12 — The Prostate Gland 117

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. This image was taken lateral to the base of the prostate. What structure is imaged here? Does this structure appear normal? If not, what could cause this?

2. A cystic structure is demonstrated in this male pelvis between the bladder and the rectum. What is the likely diagnosis? What type of symptoms might the patient experience?

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118 PART 1 — ABDOMINAL SONOGRAPHY

3. This image demonstrates cystic structures in the base of the prostate gland in an asymptomatic patient. What is a possible diagnosis?

4. This 55-year-old patient has a history of severe BPH. What could cause the changes seen in the center of this prostate gland? How does this work?

CASE STUDIES

1. A 54-year-old patient presents with symptoms of urinary frequency and nocturia. What is seen in this image of the prostate gland? In what age range does this typically occur? Which zone is typically affected?

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119

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. ACTH

2. Adrenal cortex

3. Adrenal medulla

4. Endoscopic ultrasound

5. MEN

a. An ultrasound transducer that is inserted in the mouth or anus to visualize the walls of the digestive tract and surrounding organs

b. Inner portion of the adrenal gland that secretes the catecholamines epinephrine and norepinephrine

c. A group of autosomal dominant disorders characterized by benign and malignant tumors of the endocrine glands

d. Hormone secreted by the pituitary gland that causes the adrenal gland to produce and release corticosteroids

e. Outer parenchyma of the adrenal gland that secretes corticoids, including cortisol and aldosterone

13 The Adrenal Glands

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120 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Adrenal anatomy

G B

D E

2. Retroperitoneal anatomy

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13 — The Adrenal Glands 121

LEFT

RIGHT

PO STER

IO R

E B

D AN

TER IO

3. Right scan plane

LEFT

RIGHT

PO STER

IO R

AN TER

IO R

4. Left scan plane

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122 PART 1 — ABDOMINAL SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. The adrenal gland is really two glands in one organ. What is the adrenal gland composed of? a. Two endocrine glands

b. Two exocrine glands

c. One exocrine gland and one endocrine gland

d. None of the above

2. The adrenal cortex is made up of all of the following zones EXCEPT: a. Zona glomerulosa

b. Zona fasciculata

c. Zona muscularis

d. Zona reticularis

3. Which of the following regarding the anatomy of the adrenal glands is FALSE? a. The right adrenal gland lies posterior and lateral

to the IVC

b. The right adrenal gland has a triangular shape

c. The right adrenal gland is larger than the left

d. The left adrenal gland has a crescent or semilunar shape

4. Which of the following is NOT a cortical hormone? a. Cortisol

b. Adrenalin

c. Androgen

d. Estrogen

5. Which of the following statements regarding the medulla is FALSE? a. The medulla synthesizes epinephrine and

norepinephrine

b. Release of the hormones is stimulated through the sympathetic nervous system

c. The medullary hormones are essential to life and must be replaced if the adrenal glands are removed

d. The anticipation of stress or pain causes the release of the medullary hormones

6. Which of the following statements regarding sonographic evaluation of the adrenal gland is FALSE? a. The liver can frequently be used as an acoustic

window when evaluating the right adrenal gland

b. The right adrenal gland can be visualized posterior to the crus of the diaphragm

c. The left adrenal gland can be visualized between the left kidney and the aorta

d. The left adrenal gland may be imaged with the patient in the cava-suprarenal line position

7. Which of the following statements regarding adrenal pathology is TRUE? a. A right-sided adrenal mass may displace the

kidney anteriorly

b. A left-sided adrenal mass may displace the splenic vein anteriorly

c. A left-sided adrenal mass may displace the kidney superiorly

d. A right-sided adrenal mass may displace the right renal vein posteriorly

8. In hypoadrenalism, patients have a decreased steroid output. Which of the following conditions is a form of hypoadrenalism? a. Conn’s syndrome

b. Cushing’s syndrome

c. Aldosteronism

d. Addison’s disease

9. Which of the following is NOT a form of hyperadrenalism? a. Conn’s syndrome

b. Cushing’s syndrome

c. Aldosteronism

d. Addison’s disease

10. A patient presents with elevated serum glucose levels, hyperpigmentation of the skin, and thinning of the abdominal tissue with red striations seen on the abdominal wall. Which of the following could cause these symptoms? a. Addison’s disease

b. Cushing’s syndrome

c. Pheochromocytoma

d. Conn’s syndrome

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13 — The Adrenal Glands 123

11. A patient presents with hyperpigmentation of the skin, decreased kidney function, fatigue, and hypotension. The patient also complains of gastrointestinal concerns such as diarrhea and weight loss. Which of the following could cause these symptoms? A. Addison’s disease

B. Cushing’s syndrome

C. Pheochromocytoma

D. Conn’s syndrome

12. What is the most common cause of Cushing’s syndrome? a. Long-term use of insulin

b. Tuberculosis infection

c. Alcoholism

d. Long-term use of steroids such as prednisone

13. What is the most common cause of Conn’s syndrome? a. Long-term use of steroids such as prednisone

b. Tuberculosis infection

c. Aldosterone-producing adrenal adenoma

d. Pheochromocytoma

14. What are the principle clinical symptoms of Conn’s syndrome? a. Diabetes

b. Hypernatremia and hypokalemia

c. Hypertension and headaches

d. Hypercalcemia and hypovolemia

15. A patient presents with a history of highly elevated blood pressure, headache, and rapid heartbeat. What are these symptoms common with? a. Conn’s syndrome

b. Cushing’s syndrome

c. Pheochromocytoma

d. Cortical adenoma

16. Which of the following tumors occurs in the adrenal medulla? a. Adenoma

b. Pheochromocytoma

c. Myelolipoma

d. Adenocarcinoma

17. Which of the following describes the most common appearance of the adrenal adenoma? a. Small, round, homogeneous hypoechoic lesions

b. Large hyperechoic lesion with irregular borders

c. Complex lesion of varying size with increased through transmission

d. Small hypoechoic lesion with a calcifi ed rim

18. Which of the following may be seen in patients with MEN syndrome? a. Pheochromocytoma

b. Cortical adenoma

c. Adrenal myelolipoma

d. Both A and B

19. A patient presents for an abdominal sonogram to rule out a pheochromocytoma. Which of the following increases a person’s risk of developing a pheochromocytoma? a. MEN syndrome

b. Von Hippel-Lindau disease

c. Tuberous sclerosis

d. All of the above are associated with pheochromocytoma

20. Which of the following statements regarding pheochromocytoma is FALSE? a. All pheochromocytomas are malignant

b. Pheochromocytomas may be unilateral or bilateral

c. Pheochromocytomas occur more frequently in patients with hereditary endocrine tumor syndromes

d. Patients with a pheochromocytoma have elevated levels of urinary catecholamines

FILL-IN-THE-BLANK

1. Transabdominal as well as and

approaches can be used to evaluate

the adrenal glands.

2. The adrenal gland is made up of the

and the and is combined within a

common .

3. Initially, the fetal adrenal gland is

than the kidney.

4. The adrenal glands lie ,

, and to the

kidneys.

5. fascia surrounds both the kidney

and adrenal gland. tissue also

surrounds each gland and separates it from the

kidney.

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124 PART 1 — ABDOMINAL SONOGRAPHY

6. The adrenal cortex makes up

percent of the gland. The cortical hormones

are , , and

7. Hormone secretion in the adrenal gland is controlled

by a mechanism.

blood levels of hormones trigger the hypothalamus to

secrete , which triggers the pituitary

to release , which works to increase

adrenal hormone activity.

8. The medulla secretes hormones,

similar to the and

glands. Hormones are produced in the

or cells.

9. The adult adrenal glands are cm

long, cm wide, and

mm thick.

10. The right adrenal gland is seen

to the kidney and to the right

crus of the diaphragm. The left adrenal gland is

to the left crus of the diaphragm and

or to the aorta.

1 1. With right adrenal gland disease, the

, , and

may be displaced anteriorly, while

the right kidney is displaced or

12. An enlarged left adrenal gland may displace the

splenic vein and the left kidney

or .

13. Adrenal hemorrhage is most common in

after a diffi cult delivery.

are common with resolving

hematoma and may shadow.

14. Chronic primary hypoadrenalism, or

disease, causes an increase in the

pituitary’s production of , which

causes changes in color.

15. Acute hypoadrenalism, or ,

occurs due to widespread ,

, or septicemia.

16. The term for an unexpected mass found during an

imaging procedure is . In patients

without a history of cancer, the majority of these

masses were , whereas in patients

with a history of cancer the majority of the masses

were found to be .

17. Adrenal adenomas may be part of the

syndrome. They may be

, and in that case may cause

syndrome.

18. Adenocarcinomas often produce .

The tumors are typically large and may show

anechoic zones of and

. Cortical cancers may invade

the vein, , and

19. Patients with pheochromocytoma typically

present with , ,

, and . Symptoms

result from an increased secretion.

20. The adrenal gland is the most

common site for metastases. Metastases tend to

be . The masses may indent the

posterior wall of the and displace

the kidneys .

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13 — The Adrenal Glands 125

SHORT ANSWER

1. CT is the imaging modality of choice for primary imaging of the adrenal glands, although sonography can also play a role. In what instances would sonography be used instead of CT? List four indications for sonography of the adrenal glands.

2. Chronic primary hypoadrenalism, or Addison’s disease, results in insuffi cient secretion of the adrenocortical hormones. What causes Addison’s disease and what are the common symptoms?

3. What causes Cushing’s syndrome? What are the common clinical symptoms of Cushing’s syndrome?

4. What is an incidentaloma? What might an adrenal incidentaloma represent?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. The mass (M) seen in this sagittal image represents an adrenal hemorrhage. Where is the mass located in relationship to the right kidney? What helps distinguish this extrarenal mass from a renal mass?

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126 PART 1 — ABDOMINAL SONOGRAPHY

2. Describe the lesion located between the arrows in this image. What symptoms would you expect from this type of lesion?

3. Describe the mass indicated by the arrows in this transverse image. Describe the location of the mass in reference to the right kidney. What is the most likely diagnosis?

4. Describe the mass seen between the calipers in this image. This mass was diagnosed as an adenoma. Are adrenal adenomas typically symptomatic and, if so, what symptoms do they cause?

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13 — The Adrenal Glands 127

CASE STUDIES

Review the images and answer the following questions.

1. A 57-year-old patient with a history of lung cancer presents for an abdominal ultrasound. Describe the mass seen in these images. How is the mass distinguished from a liver or renal mass? Where is the mass located in relation to the right kidney? Where else in the abdomen would you focus your examination after identifying this mass?

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129

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Abscess

2. Adenopathy

3. Extravasate

4. Fascia

5. Great vessels

6. Hematoma

7. HIV

8. Mass effect

9. Metastasis

10. Orthogonal

11. Primary neoplasm

12. Urinoma

a. Distortion or displacement of normal anatomy due to a mass, neoplasm, or fl uid collection

b. Fluid such as blood, bile, or urine that is forced out or leaks out of its normal vessel into the surrounding tissues or potential spaces

c. A thin, sheet-like tissue that separates muscles d. A pocket of infection typically containing pus, blood,

and degenerating tissue e. Planes that are perpendicular, or 90 degrees, to each

other f. The spread of cancer from the site at which it fi rst

arose to a distant site g. Enlargement of lymph nodes due to infl ammation,

primary neoplasia, or metastasis h. A term used to describe the aorta and IVC together i. An extravasated urine collection due to a tear of the

urinary collecting system j. An extravasated collection of blood localized within

a potential space or tissues k. A new growth of benign or malignant origin l. A blood-borne virus that attacks T-lymphocytes,

resulting in their destruction or impairment, eventually leading to AIDS

14 The Retroperitoneum

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130 PART 1 — ABDOMINAL SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

K K

RF IVC A

1. Retroperitoneal compartments

2. Retroperitoneum

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14 —The Retroperitoneum 131

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is NOT a retroperitoneal compartment? a. Anterior pararenal space

b. Perirenal space

c. Posterior parietal space

d. Posterior pararenal space

2. Which retroperitoneal space contains no organs? a. Anterior pararenal space

b. Perirenal space

c. Posterior parietal space

d. Posterior pararenal space

3. Which of the following is NOT found within the anterior pararenal space? a. Pancreas

b. Adrenal glands

c. Ascending colon

d. Distal CBD

4. Which of the following is NOT found within the perirenal space? a. Kidneys

b. Great vessels

c. Adrenal glands

d. Pancreas

5. What are lymph nodes that are found surrounding the major blood vessels of the retroperitoneum called? a. Visceral lymph nodes

b. Parietal lymph nodes

c. Superfi cial abdominal nodes

d. Axillary lymph nodes

6. Parietal nodes can be found in the retroperitoneum surrounding all of the following vessels EXCEPT: a. Portal vein

b. Celiac axis

c. Internal iliac artery

d. Superior mesenteric artery

7. What are the lymph nodes found along the small bowel and mesentery called? a. Chyle cistern nodes

b. Parietal nodes

c. Visceral nodes

d. Lacteals

8. Lymph nodes affected by lymphadenitis typically have all of the following characteristics EXCEPT: a. Ovoid shape

b. Loss of the fatty hilum

c. Hyperemia

d. Larger than normal

9. Primary malignant lymph nodes have all of the following characteristics EXCEPT: a. More hypoechoic

b. Round shape

c. Loss of the fatty hilum

d. Hyperemia

10. Which of the following statements regarding lymphadenopathy and AIDS is FALSE? a. Enlarged lymph nodes appear hyperechoic with a

loss of the fatty hilum

b. Enlarged lymph nodes appear hypoechoic and bowel wall thickening may also be seen

c. Lymph nodes in patients with tuberculosis may appear anechoic due to necrosis

d. Patients with AIDS may develop Kaposi sarcoma and lymphoma

11. Which of the following is NOT a malignant tumor of the retroperitoneum? a. Liposarcoma

b. Rhadomyosarcoma

c. Myxosarcoma

d. Retroperitoneal fi brosis

12. What is the most common primary malignancy of the retroperitoneum? a. Liposarcoma

b. Rhadomyosarcoma

c. Myxosarcoma

d. Retroperitoneal fi brosis

13. Sonographically, how do liposarcomas appear? a. Extremely large, poorly marginated,

complex retroperitoneal mass

b. Large, well-defi ned hyperechoic mass

c. Small, well-defi ned hyperechoic mass

d. Large echogenic mass that tends to infi ltrate surrounding structures such as the IVC

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132 PART 1 — ABDOMINAL SONOGRAPHY

14. What is the most common site for retroperitoneal infections? a. Anterior pararenal space

b. Posterior pararenal space

c. Perirenal space

d. Perinephric space

15. What is the most common cause of posterior pararenal fl uid collections? a. Urinoma from urinary system rupture

b. Abscess or hemorrhage from aortic disease

c. Abscess from appendicitis or Crohn’s disease

d. Lymphocele from renal transplant

16. Your patient presents with a history of pancreatitis to rule out the presence of a pseudocyst. Which retroperitoneal compartment would contain a pseudocyst? A. Anterior pararenal space

B. Posterior pararenal space

C. Perirenal space

D. Perinephric space

17. A patient presents with a history of left ureteropelvic junction obstruction. A fl uid collection is seen surrounding the left kidney. What is the likely diagnosis of the fl uid collection? a. Hematoma

b. Urinoma

c. Lymphocele

d. Abscess

18. While performing an abdominal examination on a patient, you suspect the lymph nodes surrounding the great vessels are enlarged. What is the normal measurement for the lymph nodes in this location? a. Less than 5 mm

b. Less than 7 mm

c. Less than 10 mm

d. Less than 20 mm

19. Which retroperitoneal compartment contains the psoas and quadratus lumborum muscles? A. Anterior pararenal space

B. Posterior pararenal space

C. Perirenal space

D. Perinephric space

20. While performing an abdominal sonogram you notice multiple rounded hypoechoic structures in the splenic and left renal hilum. These structures appear to be distorting the surrounding blood vessels. What is the most likely diagnosis? a. Abscess

b. Lymphocele

c. Lymphadenopathy

d. Retroperitoneal fi brosis

FILL-IN-THE-BLANK

1. The area that lies behind the

is referred to as the retroperitoneum. The

retroperitoneum lies between the

and anterior to the .

2. The retroperitoneum is divided into three major

compartments by the and

fascia.

The anterior renal fascia is also referred to as

fascia and the posterior renal fascia

is referred to as fascia.

3. The anterior pararenal space is bordered anteriorly

by the posterior

and posteriorly by the anterior

4. The perirenal space is bordered anteriorly by the

and posteriorly by the

5. The posterior pararenal space lies between the

fascia and

the fascia. The

muscles and the

muscles are located within this space.

6. The is a

dilated collecting area that is located in the

mid-retroperitoneum and collects lymph from the

lower extremities and pelvis before ascending to the

duct.

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14 —The Retroperitoneum 133

7. Lymph nodes are located 360 degrees around

the great vessels. The nodes that lie posterior to

the great vessels may displace the aorta and IVC

when enlarged.

8. is the term for enlargement

of the lymph nodes due to ,

, or .

9. An enlargement of lymph nodes due to an

infl ammatory process is called .

10. Retroperitoneal fi brosis, also called

disease, can encase the ,

, and of the

retroperitoneum. If the ureters are affected,

can occur.

11. Malignant tumors tend to be

and more than their benign

counterparts. Retroperitoneal tumors demonstrate a

on surrounding structures.

12. The second most common primary retroperitoneal

malignancy is . Differential

diagnoses include ,

, and malignancy.

13. Retroperitoneal fl uid collections include

, ,

, and .

14. Fluid collections within the perirenal space are

generally associated with

abnormalities. Sonographically, fl uid is contained

within the borders of the renal .

15. A is a fl uid collection that may

occur following lymph node dissection for cancer

staging.

SHORT ANSWER

1. List the major functions of the lymphatic system. What role do the lymph nodes play?

2. The psoas and quadratus lumborum muscles can be mistaken for a fl uid collection in certain patients. What techniques can be used to ensure that these structures are normal?

3. If a mass or fl uid collection is identifi ed within the retroperitoneum, what should the sonographer document in a complete examination?

4. Sonographically, how can one distinguish between lymph nodes enlarged from infl ammation and those enlarged due to malignancy?

5. Why do retroperitoneal masses typically go undiagnosed for so long?

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134 PART 1 — ABDOMINAL SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. A 44-year-old patient presents with abdominal pain and distention. Describe the mass seen in the retroperitoneal cavity of this patient. List the possible differential diagnoses for a solid retroperitoneal mass that appears separate from the kidneys and adrenal glands.

2. This patient had a left renal biopsy done earlier today and complains of worsening left fl ank pain. Describe what is seen in this image. What is the likely diagnosis?

3. A 52-year-old patient presents with a history of bladder outlet obstruction, fever, and hydronephrosis. The patient complains of bilateral fl ank pain and nausea. This image was taken in the left upper quadrant. What are the arrows pointing to? What is the most likely diagnosis?

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14 —The Retroperitoneum 135

CASE STUDIES

Review the images and answer the following questions.

1. This image was taken in a 45-year-old man who has a long-standing history of AIDS. What are the arrows in this image pointing to? Do the structures appear normal? Where are the structures located? What is the likely diagnosis?

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137

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Adenoma

2. Adenopathy

3. Anaplasia

4. Cold nodule

5. Euthyroid

6. Fine-needle aspiration

7. Goiter

8. Graves’ disease

9. Hashimoto thyroiditis

10. Heterotopic

11. Hyperparathyroidism

12. Hypophosphatasia

13. Hypothyroidism

14. Indolent

15. Isthmus

16. Longus colli muscles

17. Microcalcifi cations

18. Papillary carcinoma

19. Parathyroid hormone

20. Primary hyperparathyroidism

21. Sternocleidomastoid muscles

22. Strap muscles

a. Focal or diffuse thyroid gland enlargement due to iodine defi ciency

b. Most common form of thyroid cancer c. Infl ammation of the thyroid d. Underactive thyroid hormones e. Thyroid gland is producing the right amount of

thyroid hormone f. Increase in color Doppler vascular fl ow in the thyroid g. Enlargement of the glands h. Wedge-shaped muscle posterior to the thyroid lobes i. Occurring at an abnormal place or upon the wrong

part of the body j. Sternohyoid and sternothyroid muscles located

anterior to the thyroid k. Invasive procedure using a small gauge needle to

obtain a tissue specimen from a specifi c lesion l. Hyperechoic foci that may or may not shadow m. Low phosphatase level that can be seen with

hyperparathyroidism n. Benign solid tumor o. Loss of differentiation of cells, which is characteristic

of tumor tissue p. Hormone produced by the parathyroid glands that

regulates serum calcium and phosphorus q. Congenital anomaly located anterior to trachea,

extending from the base of the tongue to the isthmus of the thyroid

r. Hormone secreted by the anterior pituitary gland that stimulates the thyroid gland to secrete T4 and T3

s. Large muscles located anterolateral to the thyroid t. Area seen on nuclear medicine study as a region of

thyroid where the radioisotope has not been taken up u. An autoimmune hyperthyroidism caused by

antibodies that continuously activate TSH receptors v. Oversecretion of parathyroid hormones

15 The Thyroid Gland, Parathyroid Glands, and Neck

PART 2 • SUPERFICIAL STRUCTURE SONOGRAPHY

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138 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

w. Disorder associated with elevated serum calcium levels, usually caused by benign parathyroid adenoma

x. Causing little pain or slow growing y. The band of thyroid tissue connecting the right and

left lobes z. Most common infl ammatory disease of the

thyroid gland

23. Thyroiditis

24. Thyroglossal duct cyst

25. Thyroid inferno

26. Thyroid-stimulating hormone

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ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Anterior view of the neck

D C

2. Anterosuperior view of the neck

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140 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

3. Arterial vasculature of the neck

F G H

I J

4. Musculature of the neck

5. Sonographic anatomy

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CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following transducers would be appropriate for evaluation of the thyroid gland and neck on an average patient? a. 7.5 MHz curvilinear

b. 5 MHz phased array

c. 5 MHz linear array

d. 12 MHz linear array

2. The thyroid and parathyroid are both what? a. Endocrine glands

b. Exocrine glands

c. Sebaceous glands

d. Apocrine glands

3. What is the main function of the thyroid gland? a. The production of calcium

b. The storage of fats and vitamins

c. Regulation of the basal metabolic rate

d. Production of antibodies

4. Which of the following regarding the anatomy of the neck and thyroid gland is FALSE? a. The strap muscles are anterolateral to the thyroid

gland

b. The longus colli muscle is seen posterior to the thyroid gland

c. The trachea forms the lateral border of the thyroid gland

d. The common carotid artery and internal jugular vein are posterolateral to the thyroid gland

5. Which of the following is NOT a strap muscle? a. Sternothyroid muscle

b. Sternohyoid muscle

c. Sternocleidomastoid muscle

d. Omohyoid muscle

6. A radioiodine scintigraphy examination can be used to evaluate thyroid nodules. Which of the following statements regarding this examination is FALSE? a. Nodules may be classifi ed as either hot or cold

nodules

b. A hot nodule traps an excessive amount of isotope and is hyperfunctioning

c. A cold nodule does not absorb the isotope and demonstrates an area of decreased or absent activity

d. All cold nodules are malignant

7. Which of the following is NOT a typical symptom of Graves’ disease? a. Hyperthyroidism

b. Elevated levels of T3 and T4

c. A shrunken echogenic thyroid gland

d. Bulging of the eyes

8. What is the most common functional disorder of the thyroid gland? a. Hyperthyroidism

b. Thyrotoxicosis

c. Graves’ disease

d. Hypothyroidism

9. A patient presents for evaluation of the thyroid gland with a history of Hashimoto thyroiditis. Which of the following is NOT a common symptom of this condition? a. Weight loss

b. Cold intolerance

c. Menstrual irregularities

d. Fatigue

10. On sonographic examination, your patient presents with an enlarged heterogeneous thyroid gland. The patient’s lab work is normal and the patient is not experiencing any symptoms besides the palpable, enlarged gland. What is the most likely diagnosis? a. Multinodular goiter

b. Graves’ disease

c. Hashimoto thyroiditis

d. Thyrotoxicosis

11. What is the most common form of thyroid cancer? a. Follicular

b. Papillary

c. Medullary

d. Anaplastic

12. Which of the following characteristics increases the suspicion for malignancy in a thyroid nodule? a. Eggshell calcifi cations

b. Hyperechogenicity

c. Microcalcifi cations

d. Peripheral calcifi cations

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13. Which of the following is NOT a characteristic of benign thyroid nodules? a. A uniform hypoechoic halo

b. Avascularity

c. Well-defi ned, regular margins

d. Taller-than-wide shape

14. Which of the following is NOT a characteristic of a metastatic lymph node? a. Increasing size on serial examinations

b. Microcalcifi cations

c. Prominent fatty hilum

d. Rounded, bulging shape

15. A patient presents with a personal history of multiple endocrine neoplasia type 2 syndrome for an examination of the thyroid gland. Which type of thyroid cancer is seen in patients with this disorder? a. Papillary carcinoma

b. Medullary carcinoma

c. Follicular carcinoma

d. Anaplastic carcinoma

16. Which aggressive form of thyroid cancer has a tendency to compress and destroy the local structures of the neck? a. Papillary carcinoma

b. Medullary carcinoma

c. Follicular carcinoma

d. Anaplastic carcinoma

17. Fine needle aspiration is effective for diagnosing all of the following forms of thyroid carcinoma EXCEPT: a. Papillary carcinoma

b. Medullary carcinoma

c. Follicular carcinoma

d. Anaplastic carcinoma

18. How many parathyroid glands do most adults have? a. 2

b. 4

c. 6

d. 8

19. What is the most common cause of primary hyperparathyroidism? a. Breast or prostate cancer

b. Chronic renal insuffi ciency

c. Parathyroid carcinoma

d. Parathyroid adenoma

20. While performing an examination of the thyroid gland, a small, solid, oval, homogeneously hypoechoic mass is seen posterior to the mid- lateral lobe of the thyroid gland. This appears to be separate from the thyroid gland. What is the most likely diagnosis? a. Hyperplasia of the parathyroid glands

b. Parathyroid adenoma

c. Papillary carcinoma

d. Multinodular goiter

FILL-IN-THE-BLANK

1. The thyroid is an gland that is

made up of a and

lobe, connected by a thin of tissue.

2. The mean length of the thyroid gland is

, mean AP diameter is

, and mean thickness of the

isthmus is .

3. The thyroid gland receives a rich blood supply

from four arteries: the paired ,

which arise from the external carotids, and

the , which originate at the

thyrocervical trunk of the subclavian artery.

4. The and thyroid

veins drain into the IJV, whereas the

thyroid veins drain into the brachiocephalic veins.

5. The common carotid artery and internal jugular

vein form the border of the

thyroid gland. The muscle is seen

posterior to the gland.

6. The thyroid gland secretes three hormones:

, , and

. is needed to

properly synthesize the hormones.

7. Maintenance of the concentrations of T3 and T4 is

controlled by a regulatory system that involves the

, the , and the

thyroid gland.

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8. A condition that is associated with excessive release

of thyroid hormones is called ,

whereas one associated with a thyroid hormone

defi ciency is referred to as .

9. The echotexture of the normal thyroid gland is

, and when

compared to the adjacent musculature.

10. Congenital cysts of the neck include

, which tend to be midline, and

, which tend to lie lateral to the

carotid artery.

11. Thyroid adenomas are benign nodules contained within

a . A minority of adenomas are toxic

and cause . Typically, an adenoma

will demonstrate a surrounding

the nodule. Sonographically, large adenomas have the

characteristics of a .

12. A nontoxic goiter refers to an enlargement of

the entire gland without evidence of discrete

and without

disturbance. Simple goiters may convert into

goiters, demonstrated by a

multilobulated, asymmetrically enlarged gland.

13. is a hypermetabolic state caused

by elevated levels of free and

. The majority of patients with

hyperthyroidism have disease,

which is an disease.

14. The most common cause of primary hypothyroidism

is .

15. Malignant thyroid nodules are typically solid

and when compared to the

normal thyroid parenchyma. The presence of

is one of the most specifi c

sonographic features of thyroid malignancy. They are

commonly found in thyroid cancer.

16. Papillary carcinoma most commonly occurs between

the ages of , and is three times

more common in .

17. A defi nitive diagnosis of papillary carcinoma can be

made by . The overall survival rate

of this type of thyroid cancer is ,

making it the least aggressive form of thyroid cancer.

18. Most adults have parathyroid

glands: two , which are located

to the mid-portion of the thyroid

gland, and two , which are located

or to the lower

thyroid.

19. The parathyroid glands are responsible for producing

, which regulates the concentrations

of and .

20. Primary hyperplasia is enlargement of

and should be expected when

nodules are identifi ed, whereas

should be suspected when a

solitary nodule is identifi ed.

SHORT ANSWER

1. Give three causes of primary hyperthyroidism. List fi ve clinical symptoms of hyperthyroidism.

2. What is the most common cause of primary hypothyroidism? List fi ve clinical symptoms of hypothyroidism.

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3. Describe the technique used to perform a fi ne-needle aspiration of a suspicious thyroid nodule.

4. You are asked to evaluate the parathyroid glands during a sonographic examination of the neck. What landmarks will you use to locate the parathyroid glands?

5. What is the most common cause of hyperparathyroidism? List fi ve clinical symptoms of hyperparathyroidism.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Identify the structure labeled “A.” Describe the mass labeled “B.”

2. Describe the three nodules indicated by arrows in this sagittal image of the thyroid gland. What two characteristics in these lesions are suspicious for malignancy?

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3. Describe the three lesions seen in this transverse image of the thyroid gland. List two characteristics in these lesions that are associated with a low risk for malignancy.

4. This patient presents with an enlarged thyroid on physical examination. Her laboratory values revealed hypothyroidism. Describe the thyroid gland seen in this image. What is the most common cause of hypothyroidism and the most likely diagnosis?

5. Describe the mass measured in this image. This mass is inferior to the thyroid gland and appears to be separate from the thyroid tissue. What is the most likely diagnosis? What symptoms might this cause?

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CASE STUDIES

Review the images and answer the following questions.

2. This patient presents with a tender palpable neck mass. This image was taken lateral and superior to the left thyroid gland. What structures are the arrows pointing to? What can cause this appearance?

1. This patient presents with a large palpable mass in the right neck. The patient’s laboratory workup was normal. Describe the thyroid seen in this sagittal image. How would a defi nitive diagnosis for this lesion be made?

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147

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Adenopathy

2. Areola

3. Axilla

4. BIRADS

5. Cooper’s ligaments

6. Desmoplastic reaction

7. Echopalpation

8. Elastography

9. In situ

10. Multicentric breast cancer

11. Multifocal breast cancer

12. Sentinel node

13. Spiculation

14. TDLU

a. Fingerlike extension of a malignant tumor b. Technique used to locate a palpable mass with

sonography c. Pigmented skin surrounding the nipple d. Coexistent caners within different quadrants or

separated by more than 5 cm within the breast e. First node in the drainage basin and at most risk for

metastasis f. Enlarged lymph nodes g. Technique that compares the relative stiffness of a

mass compared to the adjacent tissues h. Armpit, signifi cant because it contains the lymph

nodes that drain the breast tissue i. Functional unit of the breast, composed of a lobule

and its draining extralobular terminal duct j. Thin connective tissue bands that connect breast

tissue to the skin and provide structural support to the breast

k. Breast imaging and reporting data system published by the ACR in an effort to promote the use of more consistent terminology

l. Noninvasive breast cancer m. The presence of additional malignant lesions within

a breast quadrant or within 5 cm of the primary tumor, indicating the spread of cancer via the ducts

n. Fibroelastic, reactive fi brosis that occurs in the tissues surrounding many malignant breast lesions

16 The Breast

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ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

F G

1. Breast anatomy

2. Functional unit of the breast

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16 — The Breast 149

3. Zonal anatomy of the breast

A D C

A B

4. Transducer scan planes

C K

5. Quadrant and clock face annotation

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CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following statements regarding mammography is FALSE? a. Mammography cannot determine whether a mass

is cystic or solid

b. Mammography can be diffi cult in patients who have infl ammatory conditions or trauma to the breast

c. Mammography can easily detect lesions in a dense breast

d. Mammography can detect microcalcifi cations, which may be the fi rst sign of a malignancy

2. Which of the following statements regarding breast sonography is FALSE? a. Sonography is useful for differentiating cystic

from solid lesions

b. Sonography is often used to guide interventional and therapeutic procedures

c. Sonography can be used to evaluate the male breast

d. Sonography is as good as mammography in detecting microcalcifi cations

3. What is the functional unit of the breast? a. Radial ductal unit

b. Terminal ductal lobular unit

c. Stromal ductal unit

d. Glandular ductal unit

4. Where is the majority of the glandular tissue of the breast found? a. Upper outer quadrant

b. Upper inner quadrant

c. Lower outer quadrant

d. Lower inner quadrant

5. The breast tissue is attached to the skin by what? a. TDLUs

b. Lactiferous ligaments

c. Cooper’s ligaments

d. Thoracic ligaments

6. Lymphatic drainage from the breast occurs mostly through what? a. Internal mammary nodes

b. Axillary nodes

c. Rotter’s nodes

d. Thoracic nodes

7. Which breast layer is located between the anterior and posterior mammary fascia? a. Subcutaneous fat layer

b. Mammary layer

c. Retromammary fat layer

d. Axilla

8. An intramammary lymph node is identifi ed during a breast sonogram. What is the normal measurement of an intramammary lymph node? a. Less than 5 mm

b. Less than 1 cm

c. Less than 2 cm

d. Normal lymph nodes are not visualized within the breast

9. According to ACR and AIUM guidelines, which of the following transducers is appropriate to use for breast sonography? a. 7.5 MHz linear array

b. 7.5 MHz phased array

c. 12 MHz linear array

d. 15 MHz curvilinear array

10. Which of the following can help improve contrast and spatial resolution during breast sonography? a. Harmonic imaging

b. Spatial compounding

c. Broad bandwidth transducers

d. All of the above are used to improve image quality

11. What is the most common cause of breast lumps in women 35 to 50 years of age? a. Breast cancers

b. Fibroadenomas

c. Lipomas

d. Breast cysts

12. A patient with a simple cyst seen on both mammography and sonography would be given which classifi cation? a. BI-RADS 1

b. BI-RADS 2

c. BI-RADS 3

d. BI-RADS 4

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13. A patient presents for breast sonography after a lesion was seen on a mammogram. A cyst that does not meet all the criteria for a simple cyst is found that correlates to the area seen on mammography. Which of the following characteristics would NOT be worrisome for malignancy or neoplastic changes? a. Thickened cyst wall >5 mm

b. A mixed cystic or solid lesion

c. A fl uid-debris level that changes with patient positioning

d. Echoes along the wall of the cyst that do not change with patient positioning

14. What is a retention cyst that may develop in pregnant or lactating women called? a. Papillary apocrine metaplasia

b. Sebaceous cyst

c. Epidermal inclusion cyst

d. Galactocele

15. A patient presents with a history of breast surgery to remove a benign lesion. While scanning over the incision site, you suspect you are imaging the postsurgical scar. What is the typical sonographic appearance of a scar? a. Hypoechoic area with acoustic shadowing that is

reduced or eliminated with transducer pressure

b. Hyperechoic area with acoustic shadowing that is reduced or eliminated with transducer pressure

c. Hypoechoic area with acoustic shadowing that remains constant regardless of transducer pressure or angulation

d. Hypoechoic area with hyperemia seen with color Doppler

16. What is the most common benign solid tumor of the female breast? a. Phyllodes tumor

b. Intraductal papilloma

c. Lipoma

d. Fibroadenoma

17. What is the most common noninvasive breast cancer? a. LCIS

b. DCIS

c. IDC NOS

d. ILC

18. Which of the following is an uncommon cancer that presents with redness and eczema-like crusting of the nipple and areola, nipple discharge, and itching? a. Mondor’s disease

b. Ormond disease

c. Paget’s disease

d. Medullary disease

19. What is the most common breast cancer? a. LCIS

b. DCIS

c. IDC NOS

d. ILC

20. What is the most common male breast abnormality? a. Fibroadenoma

b. Simple cyst

c. Breast cancer

d. Gynecomastia

21. Which of the following statements regarding elastography of the breast is TRUE? a. Hard lesions tend to show more deformation or

strain than soft tissues

b. A cancer will tend to be larger on the elastogram than on the conventional 2D image

c. Most benign masses tend to be stiffer on elastography

d. A cancer will tend to be smaller on the elastogram than on the conventional 2D image

22. Which of the following is NOT a sonographic characteristic of a benign mass? a. A benign mass displaces rather than invades

surrounding tissues

b. A benign mass is typically well-circumscribed

c. A benign mass is typically taller than wide

d. A benign mass typically has an oval shape

23. Which of the following characteristics make a mass suspicious for malignancy? a. Angular or spiculated margins

b. Nipple retraction

c. Shadowing

d. All of the above are suspicious fi ndings

24. A mass that is highly suggestive of malignancy on both mammography and sonography with multiple suspicious features would be classifi ed as what? a. BI-RADS 2

b. BI-RADS 3

c. BI-RADS 4

d. BI-RADS 5

25. Which type of breast cancer begins in the ducts and does not invade the basement membrane? a. LCIS

b. DCIS

c. IDC NOS

d. ILC

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FILL-IN-THE-BLANK

1. is the most commonly used

imaging modality to evaluate the breast and remains

the only widely used screening tool proven to reduce

breast cancer mortality.

2. Mammography is capable of detecting suspicious

patterns of , which is typically

the fi rst imaging sign of a developing malignancy.

Lesions are more readily detected in a radiolucent

or breast than in a radiopaque or

breast.

3. Sonography can help differentiate

from lesions. Sonography can also

be useful in patients who are ,

, or , because

these patients tend to have increased breast density

that can limit the radiographic examination.

4. The breast is subdivided by fascial planes into three

layers: the layer,

the layer, and the

layer.

5. Within the mammary layer are

overlapping lobes arranged in a

fashion around the nipple. Each lobe contains

TDLUs.

6. The major muscle lies beneath the

upper two-thirds of the breast. The

muscle lies beneath the major

muscle.

7. Normal skin thickness in the breast is

or less, but it can be

slightly thicker near the and

8. The layer lies

between the posterior mammary fascia and the

pectoralis major muscle.

9. When evaluating the breast, sagittal and transverse

planes can be used as well as and

planes.

10. Image annotations should include the side being

examined, in the breast, and

transducer .

Distance from the is also

recommended by the ACR.

11. In mammography, the CC or

view demonstrates the , central,

and breast. The MLO or

view demonstrates the breast in profi le from the

to the fold and

includes a portion of the muscle.

12. The most common benign diffuse breast condition

is . Symptoms

include breast , fullness, and

. With sonography, multiple breast

are commonly seen.

13. Infl ammation of the breast is called

and it most commonly occurs in women who are

or . Without

treatment, an may develop.

14. A condition that is the result of infl ammatory and

ischemic processes, frequently the consequence

of breast trauma, is called

. Sonographically, initially there

may be echogenicity at the

palpable area. An

may form as a result displaying a fat-fl uid level.

15. A palpable, oval, well-circumscribed, solid mass that

is enlarging in pregnancy is commonly a secretory or

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16. An intraductal papilloma typically occurs within

a major . This

lesion may cause of the duct,

leading to cyst formation.

17. Approximately one in women will

develop breast cancer in their lifetime. The majority

occur in women over the age of .

Most cancers originate in a .

Because it has the highest percentage of glandular

and epithelial tissue, the

quadrant is the most likely location

for a breast cancer to develop.

18. Noninvasive breast cancer is called carcinoma

. Types include

and .

19. Invasive cancer describes cases when malignant cells

breach the of the

duct and/or lobule and extend into adjacent tissues.

is the most common breast cancer.

20. When IDC NOS is palpable, it typically is

, , and

. Lesions with

can feel larger on palpation

than their actual size due to the response of the

surrounding tissues.

21. Invasive lobular carcinoma is more often

, , and bilateral

than invasive ductal carcinoma. is

not a typical feature with ILC, as it is with IDC.

22. A clinical symptom of papillary carcinoma

23. carcinoma occurs when a

highly invasive cancer infi ltrates the lymphatics

of the skin. The skin becomes ,

, and with an

orange peel appearance.

24. The fi rst site of metastatic spread from a primary

breast cancer is usually to the

lymph nodes. The

node is the fi rst node in the drainage basin at most

risk for metastasis. Distant sites for metastasis

include , ,

, and .

25. Vocal is a technique using power

Doppler in which a patient is asked to hum during

real-time imaging. Abnormal tissues will tend

to show a of color during this

technique.

SHORT ANSWER

1. Mammography remains the most widely used screening tool in breast imaging. Discuss the advantages and drawbacks of mammography.

2. Sonography plays an important role in evaluating the breast as well. List four indications for breast sonography and four advantages of breast sonography.

3. Describe the common patient positioning techniques used during breast sonography. How are the images typically labeled?

4. Describe the sonographic characteristics that make a mass suspicious for malignancy.

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5. Breast sonography can be used to evaluate breast implants. List three common complications that occur with breast implant surgery and describe their sonographic appearance.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. List the sonographic characteristics of a simple breast cyst, seen here in this image.

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16 — The Breast 155

2. This image of a galactocele was seen in a 32-year- old woman who was breast-feeding. Describe the mass. What is the arrow pointing to? According to the annotation on the image, what quadrant of the breast is this mass located in?

3. This image was taken over a surgical scar. What characteristics are seen that are suspicious for malignancy? What characteristic is seen that is indicative of a surgical scar? What techniques can help distinguish a scar from a recurrent tumor?

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4. This palpable mass was found in a 32-year-old female. Describe the characteristics of the mass. What is the likely diagnosis?

5. Describe the mass marked by the calipers. If this palpable mass is located in the left breast at 11:00, which quadrant is it located in?

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CASE STUDIES

Review the images and answer the following questions.

1. A 49-year-old woman presented for her routine mammogram and a suspicious area was noted in the left breast. A follow-up sonogram was ordered and this lesion was noted at 1:00. What technique was used to create this image? What suspicious characteristics are noted? What quadrant is the mass located in?

2. A 44-year-old patient with a history of breast augmentation with silicone implants presents with a palpable lump in the left outer quadrant. What does the large arrow represent? What is this sign called? Is this an intracapsular or extracapsular rupture?

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159

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. AFP

2. Beta-hCG

3. Cryptorchidism

4. Hyperemia

5. Infarction

6. Orchiopexy

7. Pampiniform plexus

8. Valsalva maneuver

a. Surgical procedure done to fasten an undescended testicle into the scrotum or repair an acute testicular torsion

b. Undescended testicle c. Alpha fetoprotein level that may be elevated with

hepatocellular carcinoma and certain testicular cancers

d. A technique in which the patient is asked to bear down to increase the intra-abdominal pressure and aid in the diagnosis of varicocele and scrotal hernia

e. An increase in blood fl ow to the tissue f. Tissue death that occurs due to a lack of blood fl ow g. A network of veins that drains the epididymis and

testis h. Human chorionic gonadotropin is produced during

pregnancy but is also secreted by certain testicular cancers

17 The Scrotum

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ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

H I

1. Scrotal anatomy

2. Scrotal anatomy

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3. Scrotal anatomy

4. Scrotal anatomy

5. Scrotal anatomy

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. You receive a request to evaluate a child with a history of undescended testis. Where are the majority of undescended testes located? a. In the contralateral scrotum

b. In the fl ank area near the kidney

c. In the abdominal cavity

d. In the inguinal canal

2. Which of the following is not located within the scrotum? a. Testes

b. Seminal vesicles

c. Spermatic cord

d. Epididymis

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3. While performing a sonographic examination of the scrotum, you suspect a varicocele is present. What is the normal measurement of the veins in the pampiniform plexus? a. Less than 1 mm

b. Less than 2 mm

c. Less than 5 mm

d. Less than 1 cm

4. Which of the following is NOT part of the anatomical division of the epididymis? a. Tail

b. Body

c. Neck

d. Head

5. While obtaining a patient’s history, you learn that he has had a vasectomy. Which of the following scrotal pathologies is NOT more common in patients who have had a vasectomy? a. Spermatocele

b. Epididymal cyst

c. Seminoma

d. Dilatation of the rete testis

6. Which of the following is the fi brous sheath that covers and protects the testis and also makes up the mediastinum testis? a. Tunica albuginea

b. Tunica vaginalis

c. Tunica gubernaculum

d. Tunica parietalis

7. Dilatation of the seminiferous tubules is associated with epididymal cysts and spermatoceles and is referred to as tubular ectasia of the: a. Mediastinum testis

b. Rete testis

c. Tunica vaginalis

d. Tunica albuginea

8. Which of the following statements regarding the testicular veins is FALSE? a. The testis is drained by the veins of the

pampiniform plexus

b. The veins of the pampiniform plexus empty into the testicular veins

c. The right testicular vein drains directly into the IVC

d. The left testicular vein drains directly into the IVC

9. A patient with a history of undescended testis is at an increased risk for which of the following? a. Seminoma

b. Testicular torsion

c. Infertility

d. All of the above

10. What is the most common cause of acute scrotal pain? a. Testicular torsion

b. Testicular malignancy

c. Epididymitis and epididymo-orchitis

d. Scrotal hernia

11. Between what ages is testicular torsion most common? a. 6 to 12 years of age

b. 12 to 18 years of age

c. 22 to 30 years of age

d. 40 to 50 years of age

12. In young men, what is epididymitis most often caused by? a. Sexually transmitted disease

b. Scrotal trauma

c. Torsion

d. Infertility

13. What is a collection of serous fl uid located between the layers of the tunica vaginalis called? a. Tunica albuginea cyst

b. Spermatocele

c. Ascites

d. Hydrocele

14. A patient presents for a scrotal sonogram with a history of vasectomy and scrotal discomfort. Multiple cystic structures are seen in both testes along the mediastinum testis. Color Doppler does not demonstrate any fl ow in these cystic structures. What is the likely diagnosis? a. Tubular ectasia of the rete testis

b. Bilateral spermatoceles

c. Simple intratesticular cysts

d. Bilateral seminoma

15. A 26-year-old man presents with fever, scrotal pain, and swelling. The sonogram shows an enlarged hypoechoic epididymis with hyperemia. A small hydrocele is noted. The testis appears normal. What is the likely diagnosis? a. Orchitis

b. Epididymitis

c. Epididymo-orchitis

d. Testicular torsion

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17 — The Scrotum 163

16. What is the most common correctable cause of male infertility? a. Undescended testis

b. Spermatocele

c. Varicocele

d. Hydrocele

17. A 42-year-old patient presents with a painless right scrotal mass. Sonographically, a 2.5-cm, irregular, hypoechoic mass is seen in the mid-right testis. Color Doppler demonstrates hyperemia. The remainder of the scrotum, including the scrotal wall, appears normal. What is the most likely diagnosis? a. Isolated orchitis

b. Testicular abscess

c. Seminoma

d. Intratesticular varicocele

18. A patient presents for a scrotal sonogram with a history of infertility. The testes appear normal bilaterally. Superior to the testes, multiple cystic structures are seen. The largest of these structures measures 4 mm. Color Doppler demonstrates fl ow within these structures and increased fl ow is seen when the patient is asked to perform the Valsalva maneuver. What is the likely diagnosis? a. Spermatoceles

b. Epididymal cysts

c. Varicocele

d. Tubular ectasia of the rete testis

19. What is the most common sonographic appearance of a malignant testicular mass? a. Hyperechoic with diffuse calcifi cations

b. Complex mass with thick septations

c. Cystic mass with ring calcifi cations

d. Hypoechoic mass

20. Which of the following lab values may be elevated with a testicular malignancy? a. PSA

b. AFP

c. ALP

d. AST

FILL-IN-THE-BLANK

1. Most intratesticular masses are considered

until proven otherwise,

whereas the majority of extratesticular masses are

2. The major structures located within the scrotum

are the , , and

. The normal measurement of

the scrotal wall is in thickness.

The divides

the scrotum into two compartments.

3. The spermatic cord is composed of the

artery,

artery, and artery; veins

of the ,

, ,

; and connective tissue.

4. The head of the epididymis is located

to the testis and measures

in AP diameter. The head of the

epididymis is best visualized in the

plane. The body and tail of the epididymis are

usually and to

the testis.

5. The primary function of the testes is the production

of , which occurs in the

tubules, and ,

which is produced by the cells of .

6. The is a

peritoneal sac composed of two layers, the

and layers that

cover and surround the testis and epididymis.

The layer covers the testis and

the layer is the inner lining of the

scrotal wall.

7. The is seen

sonographically as an echogenic band within the

testis. It functions as a supporting system for arteries,

veins, lymphatics, and seminiferous tubules.

8. The normal adult testis measures

in length and in transverse and AP

diameters.

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164 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

9. Testicular torsion occurs when the

twists. drainage

is affected fi rst followed by

occlusion. Sonographic visualization of a

is the most

specifi c sign of testicular torsion.

10. Torsion of the

and can cause

acute scrotal pain mimicking testicular torsion.

11. Infl ammation of the epididymis is called

, whereas infl ammation of the testis

is called . On color Doppler affected

or infl amed areas will demonstrate .

12. The most common cause of painless scrotal swelling

is . Acquired hydroceles are

associated with , ,

, or trauma.

13. An acute hydrocele will typically displace the

testis in the direction. Echogenic

infl ammatory deposits that are located on the tunica

vaginalis are called .

14. The most common epididymal lesions are

and

. are

located in the head of the epididymis, whereas

can be located

throughout the epididymis.

15. A varicocele is formed by a dilatation of the veins

of the . Veins

greater than are considered

dilated. The majority of varicoceles occur on the

side. Having the patient perform

the maneuver can aid in the

diagnosis by demonstrating an increase in fl ow.

16. Scrotal hernias typically contain

or that has protruded through a

patent processus .

17. An accumulation of blood located between the

layers of the tunica vaginalis is called a

and is usually the result

of , ,

, or .

18. The majority of intratesticular tumors are malignant.

Benign intratesticular tumors are rare, but do occur

and include cell tumors and

cell tumors.

19. Intratubular testicular calcifi cations are called

and can be diagnosed if more

than echogenic foci are seen per

transducer fi eld. This condition warrants follow-up

sonography because it has been associated with

20. The most common testicular malignancy is the

, which is a cell

tumor. The second most common malignancy is the

cell carcinoma, which is commonly

associated with elevated and

levels.

SHORT ANSWER

1. Discuss the common indications for scrotal sonography.

2. When evaluating a patient with acute scrotal pain, it has been suggested that the sonographer should always evaluate the asymptomatic side fi rst. Why is this true? Why are comparison images important?

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17 — The Scrotum 165

3. Describe the clinical presentation, the most common sonographic appearance, and associated fi ndings in a patient with a seminoma.

4. The diagnosis of an undescended testis is important because this condition can lead to more serious complications later in life. What conditions are associated with cryptorchidism?

5. Describe the sonographic appearance and associated fi ndings seen with epididymo-orchitis.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. A 38-year-old patient presents with a painless, palpable lump in the superior aspect of the scrotum. Describe what is seen in this image. Give two possible diagnoses.

2. A 15-year-old patient presents with acute scrotal pain, nausea, and vomiting. The patient is extremely tender during the examination. This image is taken superior to the epididymis and testis in the region of the spermatic cord. What is seen in this image, indicated by the arrow, and what is this indicative of?

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166 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

3. This patient presents with a palpable lump that corresponds sonographically to an epididymal cyst. This image is taken superior to the testis and epididymis on the left side. What do the arrows represent? What is the normal measurement of these structures? What would you do next to confi rm your diagnosis?

4. Describe the mass seen in this image. Which testicular tumors are more likely to have this appearance?

5. A 30-year-old patient presents with acute scrotal pain, an enlarged scrotum, and fever. Describe everything that is seen in this image. Hypervascularity of the epididymis was also noted. Flow in the testis was normal. What is the diagnosis?

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17 — The Scrotum 167

CASE STUDIES

Review the images and answer the following questions.

1. A 50-year-old man presents with painless scrotal enlargement on the left side. What structure is identifi ed by the small arrows? What does the structure indicated by the large arrows represent? What can cause this? What other pathology is seen? Can this pathology cause any other concerns?

2. These images were taken in a 45-year-old man who presented with a large, fi rm, left testicular lump. Describe what is seen in these two images. What is the likely diagnosis?

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169

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Amphiarthrosis

2. Anisotropy

3. Diarthrosis

4. Endomysium

5. Enthesis

6. Epimysium

7. Fascicle

8. Paratenon

9. Perimysium

10. Retinaculum

a. Small bundle or cluster of fi bers b. Properties vary with direction c. Joint permitting little motion, such as vertebrae d. Connective tissue surrounds an individual muscle

fi ber e. General term for a band or band-like structure

binding organs or tissue to hold them together f. Joint permitting free motion, such as the shoulder g. Site of attachment of a muscle or ligament to bone h. Connective tissue surrounds a bundle of muscle fi ber i. Fatty areolar tissue fi lling the interstices of the facial

compartment in which a tendon is situated j. Connective tissue surrounds entire muscle

18 The Musculoskeletal System

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170 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. What type of structure is identifi ed by the white arrow?

2. What type of structure is identifi ed by the large white arrow?

3. Shoulder anatomy

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18 — The Musculoskeletal System 171

4. Carpal tunnel anatomy

5. Anatomy of the medial knee

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is NOT a benefi t of using sonography to evaluate the musculoskeletal system? a. Sonography is more cost-effective than MRI or CT

b. Sonography does not expose the patient to ionizing radiation

c. Sonography is a dynamic examination

d. All of the above are benefi ts of sonography

2. Which of the following planes are commonly used when imaging the musculoskeletal system? a. Sagittal and transverse

b. Radial and antiradial

c. Long-axis and short-axis

d. Scan planes are not described when imaging the MSK system

3. Bone is attached to muscle by what? a. Fibrocartilage

b. Tendons

c. Nerves

d. Ligaments

4. Which of the following structures is NOT contained in a neurovascular bundle? a. Artery

b. Vein

c. Tendon

d. Nerves

5. Which of the following attaches bone to bone, providing needed stability and strength? a. Fibrocartilage

b. Tendons

c. Nerves

d. Ligaments

6. Which of the following is NOT evaluated in a shoulder examination for rotator cuff injury? a. Biceps tendon

b. Triceps tendon

c. Supraspinatus tendon

d. Infraspinatus tendon

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172 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

7. Which of the following statements regarding the acromioclavicular joint is FALSE? a. Abnormal fl uid collections may form here in

cases of supraspinatus tendon pathology

b. The joint space is wedge-shaped from posterior to anterior

c. The AC joint is a common site for arthritis and osteophytes

d. The AC joint is best evaluated in external rotation

8. Which of the following shares a common insertion point with the supraspinatus tendon on the greater tuberosity of the humerus? a. Infraspinatus tendon

b. Biceps tendon

c. Subscapularis tendon

d. Triceps tendon

9. When evaluating the shoulder with sonography, which of the following is NOT considered a major rotator cuff pathology? a. Cuff atrophy

b. Absence of cuff

c. Abnormal fl uid collection

d. Hyperechoic defect

10. Which of the following structures is NOT found in the anterior elbow? a. Median nerve

b. Ulnar nerve

c. Brachial artery

d. Distal biceps tendon

11. What is the term for tennis elbow? a. Common fl exor osteotendinopathy

b. Biceps osteotendinopathy

c. Common extensor tendinopathy

d. Olecranon bursitis

12. Which of the following is NOT found on the palmar wrist? a. Flexor tendons

b. EPB and APL

c. Median nerve

d. Ulnar and radial nerves

13. Carpal tunnel syndrome results from compression of what? a. Ulnar nerve

b. Radial nerve

c. Palmar nerve

d. Median nerve

14. What is the most common pathology of the knee? A. Rupture of the MCL

B. Baker’s cyst

C. Quadriceps tendon rupture

D. Torn meniscus

15. What is the most frequently injured joint in the body? A. Knee

B. Shoulder

C. Ankle

D. Hip

16. What is the most commonly affected anatomic structure of the posterior ankle? A. Achilles tendon

B. Plantaris tendon

C. Posterior tibialis tendon

D. Flexor digitorum tendon

17. How many tarsal bones make up the foot? A. Three

B. Five

C. Seven

D. Nine

18. Which section of the plantar fascia is most commonly affected in plantar fasciitis? A. Medial

B. Central

C. Lateral

D. Posterior

19. What is the most commonly injured ankle ligament? A. Tibiofi bular ligament

B. Calcaneal fi bular ligament

C. Anterior talofi bular ligament

D. Peroneus longus ligament

20. Which of the following describes the function of the plantar fascia? A. Arch support

B. Gait

C. Distribution of weight

D. All of the above are functions of the plantar fascia

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18 — The Musculoskeletal System 173

FILL-IN-THE-BLANK

1. refers to the change in the

properties of a structure when measured or evaluated

in different directions.

2. A technique called involves

using an abundance of gel to avoid using excessive

pressure when evaluating superfi cial structures.

3. A is a collection of loose

connective tissue between the sheath and tendon

that aids in tendon movement.

4. A is a synovial lined pouch that

produces viscous fl uid that aides in tendon or

muscle slip.

5. When imaged in the short axis, the nerve has a

pattern, with the

nerve fi bers surrounded by the

perineuron or connective tissue.

6. is found in the meniscus and

intervertebral disk spaces and acts as a shock

absorber. or

cartilage lies at the terminal ends of bone in any joint.

7. The biceps tendon is a of the

forearm and of the elbow and

shoulder.

8. The supraspinatus tendon is an of

the humerus and also provides stabilization of the

in the glenohumeral joint.

9. The radial fossa and coronoid fossa can be evaluated

with sonography for joint effusions. Excessive fl uid

in the joint results in the fat pads being displaced

away from the bone.

10. The primary function of the triceps is

of the elbow.

11. Common fl exor osteotendinopathy refers to pathology

of the tendons

and the at

insertion. This is also called

12. The most commonly affected section in

common extensor tendinopathy is the

. The transducer is typically

placed on top of the

in the plane to

start the evaluation.

13. The distal biceps tendon inserts

on the of the

radius. Pathology can include or

thickness tears.

14. On the volar aspect of the wrist are the

tendons and ,

and nerve. The

most commonly evaluated area on the volar wrist is

the .

15. The quadriceps tendon is an important

of the lower extremity. Over 95%

of the fi bers of the quadriceps tendon insert on the

16. The is the primary ligamentous

support structure for the medial knee. The

tears generally occur from the joint

space, whereas the tears can occur

anywhere along the length of the tendon.

17. Evaluation of the posterior knee typically focuses on

the , more commonly known as the

. This typically

presents as a palpable mass in the

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174 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

1. In this image, the white arrows represent the biceps tendon. What does the anechoic space indicated by the white arrowhead represent? What pathology is seen here?

18. The aspect of the ankle is

the most often injured area of the ankle due to

foot injuries.

19. The tendons of the medial ankle are the PTT or

. Directly posterior is the FDL or

, the most posterior is the FHL or

20. The longest and strongest tendon of the body

is the . The

area is the most common site for

rupture. This is proximal to the

insertion on the calcaneus.

SHORT ANSWER

1. Describe the sonographic appearance of a normal tendon.

2. When imaging a tendon, why is it important to be perpendicular to the structure?

3. Describe the normal sonographic appearance of nerves.

4. List the major criteria used to diagnose rotator cuff pathology. What are the minor criteria?

5. What anatomical landmarks are used to evaluate the popliteal fossa for a Baker’s cyst? What diagnostic criteria are used to ensure a Baker’s cyst is the correct diagnosis?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

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18 — The Musculoskeletal System 175

2. In this image of the shoulder, what is represented by the white arrows?

3. Explain what pathology is present in this image of the median nerve at the proximal carpal tunnel.

4. This image was taken over the medial knee. Describe what is seen in this medial collateral ligament.

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176 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY

CASE STUDIES

Review the images and answer the following questions.

1. This 47-year-old man presents with increasing shoulder pain and an inability to lift his arm over his head. Describe the pathology seen in these images. What is the diagnosis?

5. This patient presents with pain in the posterior knee. What pathology is seen here?

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177

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. AFP

2. Biloma

3. Coarctation

4. Hemobilia

5. Hemoperitoneum

6. Hyperalimentation

7. Hyponatremia

8. Ileus

9. Jaundice

a. The administration of nutrients through IV feeding b. A narrowing or constriction c. A tumor marker frequently elevated in cases of

hepatocellular carcinoma, hepatoblastoma, and certain testicular cancers

d. Yellowish pigmentation of the skin and whites of the eyes caused by increased levels of bilirubin

e. A walled-off collection of bile caused by a disruption of the biliary tree

f. Failure of the normal propulsion of the digestive tract g. Blood in the peritoneal cavity h. Hemorrhage or blood in the bile caused by bleeding

into the biliary tree i. An electrolyte imbalance; low sodium levels in the

blood

19 The Pediatric Abdomen

PART 3 • NEONATAL AND PEDIATRIC SONOGRAPHY

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178 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Abdominal vasculature

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following statements regarding hemangioendothelioma is FALSE? a. Infants less than 6 months of age are typically

affected

b. Patients are typically asymptomatic

c. The lesions may be hypoechoic or hyperechoic

d. The lesions may rupture causing hemoperitoneum

2. Which of the following is NOT a benign pediatric liver tumor? a. Mesenchymal hamartoma

b. Cavernous hemangioma

c. Hepatoblastoma

d. Hemangioendothelioma

3. Which type of hepatitis most often affects children and young adults? a. Hepatitis A

b. Hepatitis B

c. Hepatitis C

d. Hepatitis D

4. A pediatric patient presents with a history of fatty infi ltration. Which of the following causes of fatty infi ltration of the liver is irreversible? a. Obesity

b. Diabetes mellitus

c. Hepatitis A

d. Reye’s syndrome

5. In infants and children, which of the following may cause cirrhosis of the liver? a. Biliary atresia

b. Cystic fi brosis

c. Metabolic diseases

d. All of the above may cause cirrhosis

6. Which of the following describes the most common sonographic appearance of a cirrhotic liver? a. Enlarged, hypoechoic liver with echogenic portal

triads

b. Small, hyperechoic liver with a heterogeneous echotexture

c. Small, hypoechoic liver with cystic spaces seen throughout the parenchyma

d. Enlarged, hyperechoic liver with a smooth contour and homogeneous echotexture

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19 — The Pediatric Abdomen 179

7. Which of the following is a rare liver condition that is associated with autosomal recessive polycystic disease? a. Fulminant hepatitis

b. Hemosiderosis

c. Hepatic fi brosis

d. Hemangioendothelioma

8. Primary malignant tumors of the liver include all of the following EXCEPT: a. Hepatoblastoma

b. Hepatoma

c. Hemangioendothelioma

d. Embryonal sarcoma

9. Which of the following laboratory values is usually elevated with a primary pediatric hepatic malignancy? a. PSA

b. Beta-hCG

c. CA-125

d. AFP

10. What is the most common pediatric liver mass? a. Cavernous hemangioma

b. Hepatoblastoma

c. Mesenchymal hamartoma

d. Hepatoma

11. Which disease results in the absence of the intrahepatic and extrahepatic ducts near the porta hepatis and possibly the absence of the gallbladder? a. Choledochal cyst

b. Caroli’s disease

c. Sclerosing cholangitis

d. Biliary atresia

12. An infant presents with a palpable abdominal mass and jaundice. Sonographically, a large cystic mass is seen near the porta hepatis. A normal gallbladder is also visualized separate from the cystic mass. What is the most likely diagnosis? a. Choledochal cyst

b. Caroli’s disease

c. Sclerosing cholangitis

d. Biliary atresia

13. During your abdominal evaluation on a pediatric patient, you notice the gallbladder is small even though the patient has been fasting. Which of the following is NOT a cause of a small or nondistended gallbladder? a. Viral hepatitis

b. Cystic fi brosis

c. Obstruction of the common bile duct

d. Congenital hypoplasia

14. Gallstones are not as commonly seen in the pediatric population; however, certain conditions predispose an infant or child to developing gallstones. Which of the following conditions does NOT predispose a patient to gallstones? a. Sickle cell disease

b. Cystic fi brosis

c. Hemolytic anemia

d. Pancreatitis

15. A 1-month-old boy presents with projectile vomiting and symptoms of dehydration. An olive-shaped mass can be palpated in the epigastric region. What pathology are you looking for as you evaluate the abdomen in this patient? a. Hypertrophic pyloric stenosis

b. Choledochal cyst

c. Biliary atresia

d. Annular pancreas

16. Which of the following statements regarding hypertrophic pyloric stenosis is FALSE? a. The stomach is often fi lled with fl uid, even if the

patient has been fasting

b. Sonographically, a donut sign is seen with a hyperechoic central lumen surrounded by a hypoechoic muscle

c. The stomach wall is also grossly enlarged with hypertrophic pyloric stenosis

d. The pylorus is considered abnormal when the length from the antrum to the distal end exceeds 1.8 cm

17. Duodenal atresia is common in patients with which of the following? a. Trisomy 13

b. Trisomy 15

c. Trisomy 18

d. Trisomy 21

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180 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

18. An infant presents with a history of vomiting. While evaluating the patient, you notice a vessel immediately anterior to the SMA. With further evaluation, this vessel is identifi ed as the SMV. What condition is associated with this fi nding? a. Midgut malrotation

b. Duodenal atresia

c. Rhabdomyosarcoma

d. Intussusception

19. The most common obstructive bowel disorder of early childhood occurs when a segment of bowel prolapses into a more distal segment and is called what? a. Midgut malrotation

b. Duodenal atresia

c. Rhabdomyosarcoma

d. Intussusception

20. An 8-year-old patient presents with right lower quadrant pain, nausea, and fever. An 8-mm, noncompressible structure with a target appearance in the transverse axis is visualized in the right lower quadrant. With color Doppler, hyperemia of the structure is noted. What is the most likely diagnosis? a. Crohn’s disease

b. Appendicitis

c. Midgut malrotation

d. Intussusception

FILL-IN-THE-BLANK

1. Patient preparation for an abdominal sonogram in a

pediatric patient will vary depending on the age of

the patient. Infants are fed every ;

therefore, the examination should be scheduled just

before a feeding. Children 1 to 3 years of age should

fast for and older children should

fast for .

2. The IVC may be interrupted and drain via an

continuation. The hemiazygous

continuation lies more to the aorta.

3. Cavernous hemangiomas are more common in

and usually become evident

around of age. The typical

sonographic appearance is a well-defi ned,

mass.

4. The symptoms of acute viral hepatitis are similar

to those of . One difference is

that the is usually larger in

than in acute viral hepatitis.

5. A liver abscess in infants is usually the result

of an infection from the or

and usually enters the liver

through a contaminated or

vein.

6. Primary liver tumors are common

in children than in adults and of all

pediatric hepatic tumors are malignant.

7. Vessel involvement generally indicates

hepatic disease rather than hepatic

. The most common clinical signs

of hepatoblastoma are and painless

abdominal mass.

8. Differential diagnosis for a hepatoblastoma

include ,

, and

9. Metastatic hepatic lesions are frequently associated

with , ,

, and .

10. Conjugated hyperbilirubinemia in a newborn may

be caused by diseases of the ,

such as , or

abnormalities, such as

11. Biliary atresia presents clinically as persistent

neonatal at

of age. Symptoms are similar to neonatal

and neonatal .

12. Children with and

are predisposed

to the formation of sludge and gallstones.

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19 — The Pediatric Abdomen 181

13. An infl ammatory fi brosis that obliterates the

intra and extrahepatic bile ducts is called

, and the majority

of children with this condition have associated

infl ammatory disease.

14. A solid, malignant tumor that arises in the biliary tract

in children is . It is the second most

common cause of

in older children.

15. Cystic fi brosis affects the glands

in the and

tract. In patients with cystic fi brosis the pancreas

is due to the replacement of

pancreatic tissue by fi brosis and fatty tissue.

16. In patients with pyloric stenosis, the AP diameter of

the pylorus exceeds , the length of

the antrum to the distal end of the channel exceeds

, and the muscle thickness exceeds

17. Duodenal atresia is an cause of a

dilated duodenum and stomach. Extrinsic causes of

an obstruction at this level include ,

cyst, cyst, and

pancreas.

18. With midgut malrotation the relationship of

the following vessels should be evaluated: the

and . If volvulus

is present, the on

gray scale and color Doppler has high sensitivity and

specifi city for the disorder.

19. The most common type of intussusception is

and presents with

stool, and a palpable

. Most occur

between the ages of .

20. Bowel diseases such as Crohn’s disease and

intussusception typically have a or

appearance in the transverse axis

and may have a appearance in the

longitudinal axis.

SHORT ANSWER

1. While scanning a pediatric patient, a hyperechoic solid liver tumor is noted. List the differential diagnoses for a solid, hyperechoic liver tumor in a pediatric patient.

2. List the causes of fatty infi ltration of the liver in the pediatric population.

3. Describe the common sonographic appearance of a primary liver malignancy in the pediatric patient. What other surrounding structures must be evaluated when a liver tumor is diagnosed.

4. Hepatoblastoma is associated with a number of other conditions. List the conditions that increase a child’s risk of developing a hepatoblastoma. At what age does this tumor typically occur?

5. You are asked to perform an abdominal sonogram on a pediatric patient with a history of cystic fi brosis. What abdominal pathology might you expect to fi nd in a patient with this diagnosis?

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182 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. This 3-month-old patient presents with a palpable abdominal mass. Describe the mass seen in this image. List the differential diagnoses for this mass.

2. A 4-month-old patient presents with a palpable right upper quadrant mass and jaundice. This cystic structure is seen within the porta hepatis. The gallbladder is separate from the cystic structure and appears normal. What is the likely diagnosis?

3. A 1-month-old boy presents with a history of projectile vomiting and weight loss. This image was taken in the epigastric region. What is seen in this image? What does the P represent? What measurements will help confi rm the diagnosis?

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19 — The Pediatric Abdomen 183

4. A 1-year-old patient presents with pain and a palpable mass in the right upper quadrant. This image was taken over the palpable mass. What is the most likely diagnosis of a lesion in the bowel that presents with this target sign pattern?

5. This 7-year-old patient presents with severe right lower quadrant pain with fever, nausea, and vomiting. What is seen in this image of the right lower quadrant? What are the arrows pointing to?

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184 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

CASE STUDIES

Review the images and answer the following questions.

1. A 4-year-old patient presents with a palpable abdominal mass. These images are taken from the right lobe of the liver. Describe what is seen. What is the most likely diagnosis? What lab value is typically elevated with this pathology? What other structures should be evaluated for involvement?

2. An 8-year-old patient presents with right upper quadrant pain and jaundice. This image of the porta hepatis demonstrates thickening of the walls of the common bile duct. What pathology could cause this? What associated condition is typically found concurrent with this pathology?

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185

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Diuresis

2. Enuresis

3. Hydronephrosis

4. Refl ux

5. Ureteropelvic junction

6. Ureterovesical junction

a. Occurs when valves at the junction of the ureter and bladder allow urine from the bladder to back up into the ureter and kidney

b. Involuntary discharge of urine during sleep c. Dilatation of the collecting system of the urinary tract d. Area where the ureter enters into the urinary bladder e. Increased secretion or production of urine f. Area where the renal pelvis connects to the ureter

20 The Pediatric Urinary System and Adrenal Glands

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186 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following normal structures may be mistaken for a renal cyst in infants and young children? a. Renal cortex

b. Renal pyramids

c. Column of Bertin

d. Fetal lobulation

2. Which of the following is a normal fi nding in a neonate? a. Bilateral echogenic kidneys with prominent

pyramids

b. Bilateral hypoechoic kidneys with hyperechoic renal sinus

c. Echogenic kidneys with a dilated renal pelvis measuring 2 cm

d. Bilateral kidneys isoechoic to the liver with prominent hyperechoic renal pyramids

3. All of the following may cause increased echogenicity of the renal cortex in children EXCEPT: a. Medullary sponge kidney

b. Leukemia

c. Renal artery stenosis

d. Chronic renal infections

4. What should the normal resistive indices in the interlobar and arcuate arteries of a pediatric patient be? a. Greater than 0.7

b. Less than 0.7

c. Greater than 0.5

d. Less than 0.5

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Normal sonographic anatomy

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20 — The Pediatric Urinary System and Adrenal Glands 187

5. Which of the following statements is FALSE in cases of bilateral renal agenesis? a. Bilateral renal agenesis may be detected during

an obstetric sonogram

b. Bilateral renal agenesis is associated with Potter’s syndrome

c. An overly distended urinary bladder is common in cases of bilateral renal agenesis

d. The adrenal glands may lie in the renal fossa and be mistaken for kidneys in cases of bilateral renal agenesis

6. What is the most frequent site of urinary obstruction in infants? a. The ureterovesical junction

b. The distal urethra

c. The ureteropelvic junction

d. The distal ureter

7. What is the most common cause of urethral obstruction in boys? a. Enlarged prostate

b. Ureterocele

c. Posterior urethral valves

d. Neurogenic bladder

8. Which of the following is NOT seen with posterior urethral valves? a. Bilateral hydronephrosis seen in utero

b. Thinning of the renal cortex

c. Dilated tortuous ureters

d. An enlarged, thin-walled bladder

9. Prune belly syndrome is associated with all of the following EXCEPT: a. Cryptorchidism

b. Dysplastic kidneys

c. Wilm’s tumor

d. Absent abdominal muscles

10. A neonate presents with a history of suspected renal abnormality diagnosed during a prenatal sonogram. On the current sonogram, both kidneys appear symmetrically enlarged and diffusely echogenic. A differentiation between the renal sinus, medulla, and cortex is not seen. What is the most likely diagnosis? a. Prune belly syndrome

b. Bilateral renal hypoplasia

c. Medullary sponge kidney

d. Infantile polycystic kidney disease

11. A male neonate presents with a history of suspected renal abnormality seen on a prenatal sonogram. On examination, the right kidney is normal; however, the left kidney appears to be composed of multiple cysts of varying sizes. No normal renal parenchyma or sinus is visualized. The bladder is also normal. What is the most likely diagnosis? a. Unilateral renal agenesis

b. Multicystic dysplastic kidney

c. Hypoplasia of the left kidney

d. Infantile polycystic kidney disease

12. An infant presents with a palpable mass just inferior to the umbilicus. The area appears red and infl amed. Sonography reveals a cystic area located between the umbilicus and the urinary bladder. What is the most likely diagnosis? a. Bladder diverticulum

b. Urachal cyst

c. Multicystic dysplastic kidney

d. Umbilical hernia

13. What is infantile polycystic kidney disease associated with? a. Medullary sponge kidney

b. Congenital hepatic fi brosis

c. Multicystic dysplastic kidney

d. Tuberous sclerosis

14. What is the most common malignant renal tumor in the pediatric population? a. Wilm’s tumor

b. Neuroblastoma

c. Renal cell carcinoma

d. Mesoblastic nephroma

15. A 3-year-old presents with a palpable right sided fl ank mass. Sonographically, a large, homogeneous, well-circumscribed mass is seen extending from the superior pole of the right kidney. A few cystic spaces are noted within the lesion. What is the most likely diagnosis? a. Mesoblastic nephroma

b. Renal cell carcinoma

c. Wilm’s tumor

d. Angiomyolipoma

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188 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

16. A neonate is born with a palpable left fl ank mass. Sonography reveals a large solid homogeneous mass in the left kidney. Very little normal renal parenchyma is seen. What is the most likely diagnosis in this age group? a. Mesoblastic nephroma

b. Renal cell carcinoma

c. Wilm’s tumor

d. Angiomyolipoma

17. A 2-month-old infant presents with an enlarging, palpable left fl ank mass and mild hypertension. Sonographically, a large, solid, ill-defi ned echogenic mass is seen superior to the left kidney. Calcifi cations with shadowing are present within the mass. The kidney appears to be displaced inferiorly. What is the most likely diagnosis? a. Wilm’s tumor

b. Adrenal hemorrhage

c. Neuroblastoma

d. Adrenal metastasis

18. What is the most common children adrenal tumor? a. Wilm’s tumor

b. Pheochromocytoma

c. Neuroblastoma

d. Nephroblastoma

19. Which of the following statements regarding adrenal hemorrhage is FALSE? a. Adrenal hemorrhage is typically diagnosed when

the infant is 1 month old

b. Infants who are premature or have neonatal sepsis, hypoxia, and birth trauma may develop an adrenal hemorrhage

c. Jaundice may occur, as well as scrotal discoloration in male infants

d. Blunt abdominal trauma or child abuse may cause hemorrhage in older infants

20. Which statement regarding the location of the adrenal glands is TRUE? a. The adrenal glands are located within the anterior

pararenal space

b. The right adrenal gland lies between the right crus of the diaphragm and the liver, posterior to the IVC

c. The left adrenal gland is medial and to the right of the left crus of the diaphragm and anterior to the pancreatic tail

d. With renal agenesis, the adrenal glands are typically harder to locate

FILL-IN-THE-BLANK

1. Renal are seen as an irregular renal

outline and are commonly seen in

but should disappear by about

of age.

2. The cortical echogenicity of the kidneys in neonates

and infants, particularly infants,

is than that in older children.

3. The normal renal artery in a pediatric patient should

demonstrate a sharp peak with

continuous forward fl ow.

4. The resistive indices can help determine if a

dilated urinary system is . The

RI is increased in disease and

disease.

5. Bilateral renal agenesis is associated with

, or a decrease in amniotic fl uid,

syndrome, and

hypoplasia.

6. A dilation of the collecting system, specifi cally the

renal calyces, the renal pelvis, and ureters is called

. The three most common causes

are obstruction,

obstruction, and .

7. With hydronephrosis there should be recognizable

renal surrounding the

dilated collecting system. In cases of bilateral

hydronephrosis, the obstruction is going to be

located in the or

8. In patients with prune belly syndrome, the bladder is

and , whereas in

a patient with posterior urethral valves the bladder is

-walled.

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20 — The Pediatric Urinary System and Adrenal Glands 189

9. A

develops from complete

ureteral obstruction in utero. If the condition is

, it is inconsistent with life.

10. Renal hypoplasia is a but

otherwise normal kidney and most often results

from atrophy secondary to or from

occlusion.

11. Tuberous sclerosis can present with bilateral renal

and .

12. Wilm’s tumor typically presents as a

but may also

present with , ,

, and .

13. The peak age for a Wilm’s tumor is

years. Wilm’s tumor may be

and may invade the vein and

14. A cystic renal mass that appears as multiple

thin-walled cysts or a large cyst with septations

is called

15. The most common sonographic fi nding in cases

of pyelonephritis is of the

kidneys. Areas of or, less often,

echogenicity may also be seen.

16. A solid bladder tumor that can occur in the pediatric

population and may cause hematuria, dysuria,

retention, and UTI is called .

17. A neuroblastoma typically occurs in

and rarely after the age of .

They tend to have -defi ned borders

and are common.

18. A rare functioning adrenal tumor that

originates in the chromaffi n tissue is called

. Common clinical symptoms

include , ,

, and .

19. The adrenal glands are susceptible to hemorrhage

due to their and

high . Adrenal hemorrhage is most

commonly identifi ed between the

of life.

20. Adrenal abscess are the result of neonatal

and are usually .

Clinical symptoms include ,

, and

SHORT ANSWER

1. Describe the differences in the sonographic appearance of the kidneys in infants, children, and adults.

2. Describe how hydronephrosis and multicystic dysplastic kidney can be distinguished sonographically.

3. When evaluating an abdominal mass, the sonographer must determine three important factors to make an accurate diagnosis. Describe the three factors.

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190 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

4. Describe how a Wilm’s tumor would be differentiated from a neuroblastoma sonographically.

5. Describe how a neuroblastoma would be differentiated from an adrenal hemorrhage sonographically.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What pathology is seen in this image of the right kidney? What are the most common causes of this pathology in infants and children?

2. What pathology is seen in this image of the right kidney in a neonate? What liver condition is associated with this renal pathology?

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20 — The Pediatric Urinary System and Adrenal Glands 191

3. A 2-week-old infant presents for a renal sonogram to follow up an abnormality seen on a prenatal sonogram. This image was taken in the right upper quadrant. The left kidney and bladder appear normal. What is the likely diagnosis?

4. A male neonate presents with posterior urethral valves. Bilateral hydronephrosis is seen, with the left kidney worse than the right. A fl uid collection is seen surrounding the right kidney, indicated by the arrows in this image. What does the fl uid most likely represent?

5. An infant presents for a renal sonogram. A duplicated collecting system is seen in the right kidney. The left kidney appears normal. The upper pole collecting system on the right is dilated. This image was taken in the urinary bladder. What are the arrows pointing to?

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192 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

CASE STUDIES

Review the images and answer the following questions.

1. A 3-year-old boy presents with an enlarging palpable mass in the right upper quadrant. A large, solid mass is seen on the right kidney. Very little normal renal tissue is seen in the upper pole. Describe the mass. What is the most likely diagnosis? List the congenital malformations associated with this tumor.

2. A 2-day-old premature newborn has clinical symptoms of anemia and jaundice. An abdominal sonogram is ordered. The only abnormal fi nding is a complex mass superior to the right kidney. What is the most likely diagnosis, given the patient’s age and symptoms? How would you expect this mass to change if a follow-up sonogram is performed in a few weeks?

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193

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Cerebrum

2. Cerebellum

3. Choroid plexus

4. Corpus callosum

5. Falx cerebri

6. Fontanelle

7. Hypoxia

8. Porencephaly

9. Thalamus

a. Lack of oxygen b. Echogenic cluster of cells located within the lateral

ventricles responsible for the production of cerebral spinal fl uid

c. Fold of dura matter that divides the two hemispheres of the brain

d. Largest section of the brain; divided into two hemispheres joined by the corpus callosum

e. Paired ovoid structures in the central brain responsible for relaying nerve impulses and carrying sensory information into the cerebral cortex

f. Posterior portion of the brain composed of two hemispheres

g. Cyst or cavity in the brain, usually the result of a destructive lesion

h. Soft spot between the cranial bones i. Largest white matter structure in the brain; contains

nerve tracts that allow communication between the right and left hemispheres of the brain

21 The Neonatal Brain

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194 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Coronal brain

2. Coronal brain

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21 — The Neonatal Brain 195

3. Coronal brain

4. Sagittal midline brain

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196 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is the primary acoustic window used to image the neonatal brain? a. Mastoid fontanelle

b. Anterior fontanelle

c. Posterior fontanelle

d. Superfi cial fontanelle

2. Excessive pressure on the anterior fontanelle during the examination may cause what? a. Tachycardia

b. Respiratory arrest

c. Bradycardia

d. Image artifacts

3. Which of the following is NOT one of the meninges that cover and protect the brain and spinal cord? a. Pia mater

b. Dura mater

c. Arachnoid

d. Vergae mater

4. Which of the following is NOT one of the four cortical lobes of the brain? a. Frontal

b. Thalamus

c. Parietal

d. Temporal

5. Which of the following is NOT contained in the posterior fossa? a. Third ventricle

b. Fourth ventricle

c. Cerebellum

d. Brainstem

6. Which of the following statements regarding the neonatal brain is FALSE? a. Coronal scanning allows for a comparison of the

echogenicity between the choroid plexus and the periventricular parenchyma

b. The echogenicity of the periventricular white matter should be slightly brighter than the choroid plexus

c. Changes in echogenicity in this area should arouse suspicion for hemorrhage or infarct

d. Evaluating this area through the posterior fontanelle may also be helpful

7. Which of the following statements regarding the premature brain is FALSE? a. In very premature infants, the cavum vergae is

often seen

b. In premature infants, the cisterna magna should still be seen

c. Widely spaced sylvian fi ssures on the coronal view is a marker of extreme prematurity

d. The sulci are easily visible, even in a very premature infant

5. Parasagittal brain

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21 — The Neonatal Brain 197

8. A sonogram of the neonatal brain in a preterm infant demonstrates a thickened and irregular left choroid plexus. Echogenic material is also noted in the left occipital horn of the lateral ventricle. What grade of GM-IVH would be assigned to this patient? a. Grade I

b. Grade II

c. Grade III

d. Grade IV

9. The sonogram on the neonatal brain of a preterm infant demonstrates a focal hyperechoic area anterior to the caudothalamic groove on the parasagittal view bilaterally. The ventricles are not dilated and no other abnormalities are seen. What grade of GM-IVH would be assigned to this patient? a. Grade I

b. Grade II

c. Grade III

d. Grade IV

10. A sonogram is performed on a premature infant 2 days after delivery. An echogenic area is seen in the frontal lobe of the brain. On a follow-up examination, a cystic space is noted in the same area. What grade of GM-IVH would be assigned to this patient? a. Grade I

b. Grade II

c. Grade III

d. Grade IV

11. Which of the following statements regarding Grade I GM-IVH is FALSE? a. The hemorrhage may be unilateral or bilateral

b. Ventricular dilatation does not occur with Grade I GM-IVH

c. Patients with Grade I GM-IVH will experience developmental delays and seizures

d. Over time the clot will evolve and demonstrate a cystic center

12. Which of the following statements regarding Grade II GM-IVH is FALSE? a. The ventricles are dilated in Grade II GM-IVH

b. Grade II GM-IVH occurs when hemorrhage ruptures through the ependymal lining and enters the ventricular cavity

c. Blood typically accumulates and migrates to the most dependent occipital horn

d. Scanning through the posterior fontanelle can aid in visualizing the occipital horn

13. A sonogram of the neonatal head in a preterm infant demonstrates echogenic material fi lling a dilated right lateral ventricle. The lining of the ventricle is thickened and echogenic as well. What grade of GM-IVH would be assigned to this patient? a. Grade I

b. Grade II

c. Grade III

d. Grade IV

14. A fl uid-fi lled space that has replaced normal brain parenchyma due to the result of a destructive process such as an intraparenchymal hemorrhage is called what? a. Anencephaly

b. Meningocele

c. Porencephaly

d. Myelomeningocele

15. A 4-week old premature infant presents for a sonogram of the brain. Small, cystic structures are visualized in the periventricular area of the brain bilaterally. What is the most likely cause of this fi nding? a. Hydrocephalus

b. Grade III GM-IVH

c. Cerebellar hemorrhage

d. Periventricular leukomalacia

16. A dilatation of the ventricular system that results from impairment of cerebral spinal fl uid dynamics or brain parenchymal loss is called: a. Anencephaly

b. Holoprosencephaly

c. Porencephaly

d. Hydrocephalus

17. Which of the following acoustic windows provides the best approach for visualizing cerebellar hemorrhage? a. Mastoid fontanelle

b. Anterior fontanelle

c. Posterior fontanelle

d. Superfi cial fontanelle

18. What is the softening of the white matter of the brain that occurs with ischemia called? a. Holoprosencephaly

b. Leukomalacia

c. Hydrocephalus

d. Intraventricular hemorrhage

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198 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

19. A sonogram of the neonatal brain demonstrates widely separated frontal horns of the lateral ventricles. The third ventricle is displaced upward between the frontal horns. On a midline sagittal image, the medial sulci and gyri are arranged radially in the classic “sunburst sign.” What pathology will cause these fi ndings? a. Holoprosencephaly

b. Dandy-Walker complex

c. Absence of the corpus callosum

d. Hydrocephalus

20. Which of the following is the most severe form of holoprosencephaly? a. Alobar holoprosencephaly

b. Lobar holoprosencephaly

c. Semilobar holoprosencephaly

d. All forms have the same severity

FILL-IN-THE-BLANK

1. Closure of the anterior fontanelle begins at about

of age and is usually complete by

of age.

2. Two alternative acoustic windows are

the fontanelle and the

fontanelle. When evaluating

the neonatal brain, images are obtained in the

and planes.

3. The central nervous system is made up of

the and

. fl uid surrounds

and protects the CNS.

4. Three protective membranes called

cover and protect the brain and spinal cord. The

is the outer layer that attaches to

the inside of the cranial vault. The

surrounds the surface of the cerebral cortex and the

is interposed between the two.

5. The brain is divided into the ,

, and .

6. The ventricular system is comprised of the paired

ventricles and the midline

and ventricles.

7. When evaluating the brain via the anterior fontanelle

in the coronal plane, images are obtained by

angling the transducer from the

lobe to the posterior cortex. The

of the brain is projected on the left

side of the image.

8. In the sagittal plane, the transducer is angled

to through

each cerebral hemisphere. By convention, the

aspect of the brain is placed on the

left side of the image.

9. Nearly all premature infants show an increased

in the parenchymal region

around the peritrigonal area of the ventricles. This

is termed the . Scanning through

the fontanelle places the fi ber

tracts more parallel to the beam and can aid in the

diagnosis.

10. The majority of germinal matrix intraventricular

hemorrhages occur within the

of life. Preterm neonates with a birth weight less

than and a gestational age of less

than have the greatest risk for

developing cerebral events such as ICH.

11. Intracranial hemorrhage is divided into

grades. The area of the

groove is the primary site for

hemorrhage in the preterm infant.

12. Grade III GM-IVH consists of with

. The lining of the ventricles may

become and due

to irritation from the breakdown of blood products.

Posthemorrhagic is often a

complication.

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21 — The Neonatal Brain 199

13. If an obstruction occurs within the ventricular

system, it is referred to as

hydrocephalus, whereas if it occurs outside the

ventricular system, the term

hydrocephalus is used.

14. When scanning through the mastoid fontanelle in

the coronal plane, the transducer notch is pointed

toward the . For an axial view, the

transducer is positioned with the notch toward the

15. is the most

common hypoxic-ischemic brain injury in the

premature infant. It appears as an increased

and is almost always

and .

16. When evaluating for subdural or subarachnoid fl uid

collections, a high-frequency array

transducer should be used. Fluid in the subarachnoid

space displaces cortical vessels away from the

toward the

, whereas fl uid in

the subdural space displaces cortical vessels toward

the and contains

no .

17. Dandy-Walker malformation is characterized by cystic

dilatation of the ,

superior elevation of the , partial or

complete absence of the , and small

hemispheres.

18. Type Chiari malformation is the

most common type seen in infants and neonates and

is nearly always associated with .

It is associated with a small

, downward displacement of

the , , and

into the upper

spinal canal.

19. The most common intracranial vascular

anomaly presenting in the neonatal period is the

. Sonographically, this presents

as a well-circumscribed, anechoic mass in the

posterior to the

. Color Doppler demonstrates

fl ow within the malformation.

20. Holoprosencephaly occurs when the primitive

forebrain fails to divide into two separate

. Midline

anomalies are also associated with

these malformations.

SHORT ANSWER

1. When performing an examination on a preterm infant, what precautions are taken to limit the risk of infection and stress to the infant?

2. When evaluating the brain in a very premature infant, what sonographic features of prematurity should be understood to avoid misdiagnosis of pathology?

3. Why is intracranial hemorrhage common in premature infants but low in infants born after the 36th week of gestation?

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200 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Was this sagittal image of the brain taken in a term or premature infant? How can you tell?

2. What are the arrows pointing to in this sagittal image of the brain in a premature infant? How would you classify this and why?

4. List the clinical signs of hydrocephalus. 5. Describe the technique used to evaluate infants with suspected elevated intracranial pressure using spectral Doppler.

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21 — The Neonatal Brain 201

3. What are the arrows pointing to in this coronal image of the brain in a premature infant? How would you classify this and why?

4. A prenatal sonogram showed abnormalities in the fetal brain. After delivery, a sonogram of the brain was ordered. The third ventricle was displaced upward and the frontal horns of the lateral ventricles were noted to be separated widely. What is seen in this coronal image? Given these fi ndings, what is the most likely diagnosis?

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202 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

5. This infant was born with severe midline facial anomalies. A sonogram of the neonatal brain was ordered. What is seen in this coronal image? What is the likely diagnosis?

CASE STUDIES

Review the images and answer the following questions.

1. An infant presented for a sonogram of the brain following a traumatic delivery. During the sonogram, echogenic areas were noted bilaterally in the periventricular parenchyma. A follow-up sonogram was performed one month after delivery. This sagittal image was taken lateral to the right lateral ventricle. What is seen in this image? What is the likely diagnosis?

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21 — The Neonatal Brain 203

2. A neonate presents after delivery for a sonogram of the brain following an abnormal prenatal sonogram. Describe what is seen in this coronal image of the brain. What is the most likely diagnosis?

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205

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Cauda equina

2. Conus medullaris

3. Dura

4. Dysraphism

5. Epidural space

6. Filum terminale

7. Hydromelia

8. Myelomalacia

9. Syrinx

a. Tapering end of the spinal cord, caudal to the conus medullaris

b. Outermost layer of the covering of the spinal cord c. Collection of nerve roots at the end of the spinal

column; includes lumbar and sacral nerve roots d. Anomalies associated with incomplete fusion of the

neural tube during embryological development e. Fluid-fi lled cavity in the spinal cord f. Space between the outermost layer of the spinal

cord, the dura, and the spinal column g. The most caudal portion of the spinal cord h. Softening of the spinal cord frequently caused by a

lack of blood supply i. Dilatation of the central canal of the spinal cord

22 The Infant Spine

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206 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Sagittal spine

2. Sagittal spine

3. Sagittal spine

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22 — The Infant Spine 207

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Sonography of the spine is limited to infants under what age? a. 1 month

b. 2 months

c. 6 months

d. 12 months

2. The normal spinal cord tapers to a point and terminates with the conus medullaris at which level? a. S1–L5

b. L4–L5

c. L3–L4

d. L1–L2

3. Which of the following statements regarding the sonographic anatomy of the spinal cord is FALSE? a. In the axial plane, the fi lum terminale appears as

a round, echogenic nerve arising from the tip of the conus

b. The nerves of the cauda equina appear as smaller, echogenic dots surrounding the conus and fi lum

c. The cord is surrounded by CSF, which is contained by the echogenic dura surrounding the canal

d. The spinal cord is seen as a hyperechoic structure located within the spinal canal

4. How many vertebrae make up the sacral spine? a. One

b. Three

c. Five

d. Seven

5. How many vertebrae make up the lumbar spine? a. One

b. Three

c. Five

d. Seven

6. How many vertebrae make up the thoracic spine? a. Five

b. Eight

c. Ten

d. Twelve

7. While performing an evaluation of the spine on an infant, a small, cystic structure is seen inferior to the tip of the conus medularis. No other defect is seen. What is the most likely cause of this structure? a. Filar cyst

b. Tethered cord

c. Meningocele

d. Diastomyelia

4. Transverse spine

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208 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

8. What is the most common location for a spinal dysraphism? a. Cervical spine

b. Thoracic spine

c. Lumbosacral spine

d. Dysraphisms occur equally throughout the spine

9. Which of the following closed spinal dysraphisms does NOT present as a subcutaneous mass? a. Lipomyelocele

b. Tethered cord

c. Lipomyelomeningocele

d. Myelocystocele

10. A defect that occurs when there is a failure of the spinal cord to fold into a neural tube, and presents with the skin, musculature, and bony vertebral arches splayed laterally to the defect is called what? a. Terminal myelocystocele

b. Myelomeningocele

c. Dorsal dermal sinus

d. Diastomyelia

11. Which of the following is a condition in which the spinal cord is separated into two hemicords? a. Terminal myelocystocele

b. Myelomeningocele

c. Dorsal dermal sinus

d. Diastomyelia

12. Which of the following statements regarding tethered cord are FALSE? a. A tethered cord is associated with dysraphic

spinal anomalies

b. A tethered cord is low-lying with a thickened fi lum terminale

c. Symptoms may not present until the child grows and the cord is pulled tight

d. The cord and nerve roots will have increased motion

13. The conus is considered abnormally low at or below which level? a. L1

b. L2

c. L3

d. L5

14. In which region of the spine does diastomyelia most commonly occur? a. Cervical

b. Cervicothoracic

c. Thoracolumbar

d. Lumbosacral

15. Which of the following is a condition that represents a very focal disruption in the development or fusion of the spinal canal and presents with a thin tract that travels from the skin to the spinal canal? a. Terminal myelocystocele

b. Myelomeningocele

c. Dorsal dermal sinus

d. Diastomyelia

16. Which of the following are patients with a dorsal dermal sinus at risk for? a. Meningitis

b. Spinal lipoma

c. Paralysis

d. Scoliosis

17. What is the most common indication for a spinal sonogram? a. Palpable mass

b. Sacral dimple or pit

c. Visible defect

d. Neurological defi cits

18. An infant presents for a spinal sonogram with a palpable, skin-covered mass in the lumbar region. During the evaluation, a bony defect is seen and an echogenic fatty mass is seen to be contained within the spinal canal. The mass appears to distort and tether the spinal cord. What is the most likely diagnosis? a. Intradural lipoma

b. Lipoma of the fi lum terminale

c. Lipomyelomeningocele

d. Lipomyelocele

19. What is a dilated central canal called? a. Hydromelia

b. Myelocystocele

c. Diastomyelia

d. Myelomeningocele

20. A patient presents for a spinal sonogram with a sacral dimple. A hypoechoic tract is visualized extending from the skin to a cystic structure. Neither the hypoechoic tract nor the cystic collection appears to be connected to the spine. No other abnormalities are seen. What is the most likely diagnosis? a. Myelocystocele

b. Pilonidal cyst

c. Myelomeningocele

d. Diastomyelia

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22 — The Infant Spine 209

FILL-IN-THE-BLANK

1. The value of sonography of the spine decreases

at and is nearly nondiagnostic

after , due to ossifi cation of the

spinous processes.

2. The infant spine is examined from the

junction to the .

The level of the ,

as well as the position of the

in the spinal canal, is documented.

3. During the examination, and

motion should be detected

and noted.

4. Sonographically, the spinal cord is ,

whereas the arachnoid-dural layer is

and is seen lining the canal both

anteriorly and posteriorly. The cerebrospinal fl uid is

and is seen surrounding the cord.

5. The spine is larger in the and

regions, due to the amount of

in these areas.

6. The conus gives way to the

, which is surrounded by

the echogenic strands of the

7. Spinal refers to a spinal

abnormality caused by inadequate or improper

fusion of the neural tube early in life. They are

characterized as if neural tissue

is exposed without covering or

if the defect is covered by skin.

8. A presents as a fl at plate of neural

tissue fl ush with the skin surface, whereas in the

, the neural plate is elevated above

the skin surface, due to an enlarged, underlying

subarachnoid space.

9. A tethered cord is a low-lying cord with a thickened

. This can cause

decreased ,

, and function.

10. Patients with or

malformations or syndrome have a

high association with tethered cord.

11. The conus is considered abnormally low at or

below the level of . The cord and

nerve roots will have motion. The

may also be

abnormally thick.

12. is the separation of the spinal cord

into two hemicords separated by a

or septum. It is associated

with cord, ,

, anomalies, and

dilatation of the central canal.

13. A dorsal dermal sinus manifests clinically as a

deep that

should not be confused with a

located in the gluteal fold.

14. Spinal lipomas include ,

, and lipomas of the

15. Sonography of the spine may be done to evaluate

for birth trauma especially following a diffi cult

delivery. Cord injury may

manifest sonographically as cord ,

, and outside

the cord.

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210 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

SHORT ANSWER

1. Describe the appropriate transducer selection and patient positioning used for sonographic evaluation of the neonatal spine.

2. List the closed dysraphisms that can present with a cutaneous marker. What types of cutaneous markers are associated with spinal dysraphisms?

3. Describe the most common method of determining the level of the conus medularis and exact localization of any intraspinal abnormalities.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Where does the conus end in this sagittal panoramic image of the neonatal spine?

2. What is the arrow pointing to in this image? Where is this structure located?

3. Where does the conus end in this sagittal panoramic image of the neonatal spine? What is this condition called? When is the conus considered abnormally low?

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22 — The Infant Spine 211

CASE STUDIES

Review the images and answer the following questions.

1. An infant presents for a sonogram of the spine with the clinical fi nding of a deep midline dimple. Describe what is seen in the following images. Is the spinal cord tethered?

4. Describe what is seen in this transverse image taken at the level of the sacrum. What is the likely diagnosis?

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213

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Abduct

2. Adduct

3. Arthrocentesis

4. Erythrocyte sedimentation rate

5. Mesoderm

6. Oligohydramnios

7. Osteomyelitis

8. Torticollis

a. Infection of the bone marrow and bone b. To move away from the midline c. The middle germ cell layer that contributes to the

embryologic development of connective tissue, bone, blood, muscle, vessels, and lymphatics

d. To move toward the midline e. A head that is held sideways due to muscle

contraction f. To remove fl uid from a joint through a needle g. A decreased amount of amniotic fl uid around

the fetus h. Laboratory test that is a nonspecifi c indicator for

infl ammation

23 The Infant Hip Joint

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214 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

A B

1. Anterior hip joint

F E

2. Female bony pelvis

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23 — The Infant Hip Joint 215

3. Sonographic anatomy

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. What are the two most common methods used to evaluate for DDH? a. Clinical assessment and MRI

b. Clinical assessment and sonography

c. Sonography and X-ray

d. Sonography and laparoscopic evaluation

2. Which germ cell layer are the bones, connective tissues, and muscles derived from? a. Ectoderm

b. Endoderm

c. Mesoderm

d. Zygoderm

3. When does DDH occur most commonly? a. At birth

b. At 2 months of age

c. At 4 months of age

d. At 8 months of age

4. Which of the following is NOT a risk factor for developing DDH? a. Babies born in the breech position

b. Positive family history

c. High birth weight

d. Polyhydramnios

5. In which of the following maneuvers does the examiner attempt to push the femoral head out of the socket? a. Ortolani’s maneuver

b. Barlow’s maneuver

c. Murphy’s maneuver

d. Whitlow’s maneuver

6. Which of the following statements regarding the alpha angle is FALSE? a. The alpha angle is defi ned as the bony roof of the

acetabulum

b. The alpha angle is obtained in the transverse plane

c. The alpha angle is the primary measure of hip dysplasia

d. When the alpha angle is greater than 60 degrees, it is considered normal

7. Which of the following statements regarding evaluation of the hips is FALSE? a. The coronal plane can be used to assess how

well the femoral head is contained within the acetabulum

b. A dislocated hip will sit completely out of the acetabulum

c. The lower limit for normal femoral head coverage is 45%

d. Assessing femoral head coverage is the most reproducible method for diagnosing DDH

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216 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

8. A hip that demonstrates posterior, superior, and lateral displacement of the femoral head during fl exion imaging is what? a. Dislocated

b. Subluxed

c. Normal

d. Infl amed

9. Which of the following statements regarding the transverse scan plane is FALSE? a. The transverse scan plan may be obtained in a

neutral or fl exed position

b. The alpha and beta angles are taken in this plane

c. Stress maneuvers are performed in the transverse plane

d. If the hip is dislocated, the normal U confi guration will not be identifi ed

10. A 3-year-old patient presents with a low-grade fever and refusal to bear weight on her left hip. She recently had an upper respiratory infection. What is the MOST likely diagnosis? a. Septic arthritis

b. Hip dislocation

c. DDH

d. Transient synovitis

FILL-IN-THE-BLANK

1. Developmental dysplasia of the hip describes a

range of dysplasia including: ,

, and frank .

2. The frequency of DDH is in

3. The hip bone is composed of the ,

, and .

4. The rounded femoral head sits in the .

5. The femoral head is composed of

at birth. It begins to ossify from the center outward

between months.

6. During fetal development,

contribute to the laxity of fetal

ligaments.

7. An is considered a strong positive

Barlow and Ortolani sign.

8. Imaging is performed with and without

. Imaging planes include the

plane without

and the plane with and without

9. In the coronal scan plan, the femoral head is seen

sitting in the . The

should appear as a straight line.

10. An alpha angle of greater than or equal to

is considered normal.

11. In a coronal/fl exion image of the hip, the hip

has a ball-on-a-spoon appearance. The ball is

the , the

represents the

handle of the spoon, and the scoop of the spoon is

the .

12. In the transverse scan plan, the

and the form a

U or V confi guration around the

13. When a child presents with hip pain, fever, limited

movement, and refusal to bear weight, sonography

can be used to evaluate for the presence of a

14. can be treated

with anti-infl ammatory medication and rest, whereas

is a more serious

bacterial infection that is typically treated with

intravenous antibiotics.

15. When evaluating for a hip effusion, the normal

hip capsule has a appearance,

whereas if an effusion is present the capsule bulges

. An abnormal appearance

is defi ned as a capsular thickness greater than

mm.

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23 — The Infant Hip Joint 217

SHORT ANSWER

1. How does the composition of the femoral head affect the ability to perform a diagnostic sonogram of the infant hip?

2. What risk factors are associated with DDH?

3. What physical characteristics may indicate an infant has DDH?

4. Why is sonography of the infant’s hips typically performed at 4 to 6 weeks of age and not earlier?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. This 3-month-old patient presents with an abnormal physical examination. What is being measured in this image? What is the purpose of this measurement?

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218 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY

2. What is being measured in this image? Is this measurement considered normal?

3. What is being measured in this image? Is this measurement considered normal?

4. A 3-year-old patient presents with fever and pain in the left hip. What is seen in this image of the hip?

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23 — The Infant Hip Joint 219

CASE STUDIES

Review the images and answer the following question.

1. A 10-week-old girl presents with an abnormal physical examination for a sonogram of the hips. Describe what is seen in this image.

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221

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Allograft

2. Heterotopically

3. Histocompatibility

4. Immunosuppressive medication

a. Pharmaceutical agents prescribed to prevent or decrease the immune response

b. Graft transplanted between genetically nonidentical individuals of the same species

c. Occurring in an abnormal place d. State of a donor and recipient sharing a suffi cient

number of histocompatibility antigens so an allograft is accepted and remains functional

PART 4 • SPECIAL STUDY SONOGRAPHY

24 Organ Transplantation

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222 PART 4 — SPECIAL STUDY SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. A patient who has uremia may be a candidate for which type of organ transplant? a. Liver

b. Kidney

c. Pancreas

d. Lung

2. Which of the following is NOT a common cause of liver transplant? a. Diabetes

b. Hepatitis C

c. Cirrhosis

d. Alcoholic liver disease

3. Which of the following is NOT a contraindication to liver transplantation? a. Sepsis

b. Metastatic cancer

c. Active substance abuse

d. All of the above are contraindications to liver transplantation

4. A patient with which of the following conditions is MOST likely to be a candidate for pancreas transplant? a. Alcoholism

b. Uremia

c. Uncontrolled diabetes

d. Cystic fi brosis

5. Which of the following laboratory values are used to evaluate the function of a renal allograft? a. AST and ALT

b. PT and INR

c. Amylase and lipase

d. BUN and creatinine

6. Which of the following is NOT a fl uid collection that can cause compression of the vascular fl ow to a renal allograft? a. Biloma

b. Hematoma

c. Lymphocele

d. Urinoma

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Anatomy of kidney transplant

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24 — Organ Transplantation 223

7. Which of the following is a condition that affects renal function and is more common in cadaveric grafts? a. Acute accelerated rejection

b. Acute tubular necrosis

c. Lymphocele

d. Polymona-BK virus nephropathy

8. Which of the following is typically seen as a result of biopsy trauma in a renal allograft? a. Lymphocele

b. Abscess

c. Arteriovenous malformation

d. Urinoma

9. What is the most signifi cant liver allograft pathology? a. Biliary sludge

b. Biloma

c. Hepatic artery stenosis

d. Biliary strictures

10. What is the gold standard for evaluation of renal allograft rejection? a. Sonography

b. Core biopsy

c. Computed tomography

d. Nuclear medicine

FILL-IN-THE-BLANK

1. Following an organ transplant, patients

are typically on two types of medication:

and

. Levels that are too low can lead

to , whereas higher levels can

cause .

2. The one-year survival rate for a liver transplant is

%, a simultaneous pancreas and

kidney transplant is % successful,

a pancreas transplant following a renal transplant

is % successful, and a pancreas

transplant alone is only %

effective.

3. There are two types of organ donations, either a

donor or one harvested from a

4. A pancreatic allograft is placed either in

the , where it is oriented

, or abdomen,

where it is oriented .

5. The surgery for a liver allograft requires

vascular connections, as well as a

anastomosis.

6. A liver allograft from a live donor involves a right

hepatectomy of segments , along

with the right vein.

7. A renal allograft has an average life span of

years; however, a living donor

organ has a life span of years.

8. A renal allograft must be evaluated sonographically for

its and overall , as

well as thickness of the .

9. Chronic rejection of a renal allograft occurs after

months. The kidney begins to

and interstitial

becomes noticeable sonographically.

10. Spectral Doppler tracings of the

arteries should be obtained from the upper, mid,

and lower poles of the renal allograft. An RI

� and or a pulsatility index

� are considered normal.

11. Two sonographic signs of rejection of a pancreatic

allograft include a echotexture and

an overall in graft size.

12. Fluid collections surrounding a liver allograft

should resolve within days

postoperatively.

13. Renal artery leads to

diminished fl ow to the renal allograft and causes

a in the size of the allograft.

Spectral Doppler will demonstrate a peak systolic

velocity > c/s with distant

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224 PART 4 — SPECIAL STUDY SONOGRAPHY

14. Biliary strictures in a liver allograft present clinically

with and

abnormal

. Biliary stasis can lead to ascending

15. Hepatic thrombosis and stenosis

are major clinical concerns in liver allografts.

Evaluation of the portal vein must demonstrate

fl ow.

SHORT ANSWER

1. Describe the typical location for the placement of a renal allograft. What is a heterotopic renal transplant?

2. Describe the changes that can be seen sonographically in a renal allograft when acute accelerated rejection or acute tubular necrosis is present.

3. Why is it important to cross-match and type the HLA of the donor and recipient prior to organ transplantation?

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What vessel is being interrogated in this image? Does the waveform appear normal? Why is it important to evaluate fl ow in this vessel?

2. What vessel is being interrogated in this image? Does this waveform appear normal? What direction of fl ow is normal in this vessel?

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24 — Organ Transplantation 225

3. What measurements are recorded in this image? What is the normal value for the RI in a renal allograft?

4. What vessels are the arrows (A) and (B) pointing to in this image of a renal allograft?

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227

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Cardiac tamponade

2. Deep vein thrombosis

3. Diagnostic peritoneal lavage

4. Hemoperitoneum

5. Hemothorax

6. Laparotomy

7. Parietal pleura

8. Pericardial effusion

9. Pleural effusion

a. Pleura that lines the inner chest walls and covers the diaphragm

b. The presence of extravasated blood in the peritoneal cavity

c. Mechanical compression of the heart resulting from large amounts of fl uid collecting in the pericardial space, limiting the heart’s normal range of motion

d. Presence of fl uid in the pleural cavity e. A procedure in which an incision is made in

the abdomen to insert a camera to visualize the abdomen and pelvic structures and spaces

f. Presence of fl uid within the pericardium g. Surgical procedure used to insert a catheter through

the abdominal wall and fascia; used to evaluate for bleeding in the abdomen

h. The formation or presence of a thrombus within a vein

i. Accumulation of blood in the pleural cavity

25 Emergency Sonography

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228 PART 4 — SPECIAL STUDY SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. What is the main purpose of the FAST exam? a. Evaluate for gallstones and kidney stones

b. Perform a complete abdominal sonogram in as little time as possible

c. Evaluate for free fl uid or blood in the abdomen following trauma

d. Evaluate for life-threatening conditions such as AAA and appendicitis

2. The primary purpose of the eFAST exam is to extend the search for what? a. Pleural effusion

b. Pericardial effusion

c. Cardiac tamponade

d. Pneumothorax

3. Which of the following does the emergency cardiac examination NOT evaluate for? a. Pericardial fl uid

b. Diagnosis of mitral valve prolapse

c. Detection of cardiac motion in patients with pulseless electrical activity

d. Evaluation of tamponade

4. Which of the following is NOT one of the most common acoustic windows used in emergency echocardiography? a. Suprasternal

b. Parasternal

c. Apical

d. Subxiphoid

5. What is fl uid surrounding the heart and located within the pericardial sac called? a. Ascites

b. Pleural effusion

c. Pericardial effusion

d. Pneumothorax

6. Which of the following statements regarding pericardial effusion is FALSE? a. Blood can collect between the visceral and

parietal layers

b. Rapid hemorrhage can cause hypertension

c. A decrease in right heart fi lling can be noted

d. Decreased left ventricular stroke volume is possible

ANATOMY AND PHYSIOLOGY REVIEW

IMAGE LABELING

Complete the labels in the images that follow.

1. Anatomy of the thorax

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25 — Emergency Sonography 229

7. A 32-year-old patient presents to the emergency room following a serious motor vehicle accident. Fluid is noted around the heart and the intraventricular septum appears to bow into the left ventricle. What is this condition known as? a. Pleural effusion

b. Pneumothorax

c. Cardiac tamponade

d. Pulseless cardiac activity

8. Which of the following is the most sensitive at detecting pneumothorax? a. Sonography

b. Physical examination

c. Patient complaints

d. Chest radiography

9. A patient presents to the emergency room with a history of trauma to the chest. When evaluating the thorax, you visualize the “gliding sign” as the patient breathes in and out. This sign is appreciated bilaterally. What does this represent? a. This sign is not used to evaluate for chest

pathology

b. This sign is normal; no pneumothorax is seen

c. This patient has bilateral pneumothorax and requires immediate intervention

d. The represents a cardiac tamponade and requires immediate intervention

10. A patient with a pneumothorax will present with absent lung sliding on real-time sonography. Which of the following conditions CANNOT cause this fi nding? a. Acute respiratory distress syndrome

b. Mainstem intubation

c. Pleural embolism

d. Pleural adhesions

FILL-IN-THE-BLANK

1. Many life-threatening injuries cause bleeding

in the , ,

, and regions.

2. The primary purpose of the FAST exam is a

methodical search for free or

in the dependent portions of

the , spaces,

spaces, and the .

3. With the transducer oriented transversely in

the subxiphoid region, the

image can be seen. The

of the heart including both atria

should be located on the patient’s right side. The

of the heart is located more to the

patient’s left side.

4. Two layers of pericardium surround the

heart, the pericardium and

the pericardium. Up to

mL of normal serous fl uid can

collect within the pericardial sac.

5. In the subxiphoid window, blood will most often be

noted or posteriorly as it outlines

the free wall of the left atria and ventricle.

6. With cardiac tamponade the outer wall of

the ventricles depress . The

intraventricular septum bows into the

ventricle, which is known

7. In normal patients, a sliding motion can be

seen and is caused by the movement of the

pleura during respiration along the

static pleura. This is seen as an

line that moves with respiration.

8. The normal, back-and-forth movement of the

pleural layers causes a sign

or a sign. Absence of sliding

indicates there is a . The more

location is the common site for

pneumothorax.

9. On M-mode, the normal sliding lung will

demonstrate a sign. In the case of

pneumothorax, the M-mode will reveal a series of

lines called the

or sign.

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230 PART 4 — SPECIAL STUDY SONOGRAPHY

10. The phenomenon of demonstrating absent lung

sliding and normal lung sliding occurring between

the pneumothorax and the normal lung is known as

the . The lung

may sometimes be identifi ed as a

structure superior to the .

11. When or

abdominal trauma occurs, the FAST examination

may be used to locate

12. The examination is performed with the patient in a

position, but placing the patient

in the position shifts areas of

dependency and increases the sensitivity of the FAST

exam in detection of free fl uid in the hepatorenal

space and the perisplenic space.

13. The space located between the liver capsule

and right kidney is called the

14. When the patient is supine, the is

the most dependent portion of the peritoneal cavity.

15. A modifi ed examination of the deep venous system

of the lower extremities focuses on a three-point

evaluation of the

vein at the junction, the

proximal and

vein, and the

vein.

SHORT ANSWER

1. List the benefi ts of the FAST and eFAST examinations.

2. The presence of electrical activity without a palpable pulse being present can occur due to a number of low-fl ow states. List four low-fl ow states that can cause these fi ndings.

3. Describe the two techniques used to evaluate for a pneumothorax with sonography.

4. List the potential spaces evaluated with a FAST examination.

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25 — Emergency Sonography 231

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Name the potential space labeled A and the potential space labeled B.

2. What are the arrows pointing to in this image? What condition may this lead to?

3. Describe what is seen in this M-mode image. Is this normal? How would this change if a pneumothorax was present?

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232 PART 4 — SPECIAL STUDY SONOGRAPHY

4. Describe what is seen in this split screen image of the femoral artery and vein. What technique is used here to evaluate for deep venous thrombosis?

CASE STUDY

Review the images and answer the following question.

1. A patient presents to the emergency room following a severe motor vehicle accident with chest trauma from the steering wheel. This image was taken from the right upper quadrant. Describe what is seen in this image.

Kawamura_WB_CH25.indd 232 12/1/11 4:33 PM

233

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Granuloma

2. Hyperemia

3. In vivo

4. In vitro

5. Occult

6. Radiolucent

7. Radiopaque

a. Something hidden from view b. Occurs or is made to occur within a living organism

or natural setting c. Tissue, contrast, or material that attenuates or blocks

radiation; appears bright on radiograph d. Tumorlike mass formation which usually contains

macrophages and fi broblasts that form as a result of chronic infl ammation and isolation of the infected area

e. Tissue or material that allows the transmission of X-rays and appears dark on a radiograph

f. Made to occur in a laboratory vessel or in a controlled experimental environment but does not occur within a living organism or natural setting

g. Increase in the quantity of blood fl ow to a body part; typically due to an infl ammatory response

26 Foreign Bodies

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234 PART 4 — SPECIAL STUDY SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following materials is radiography most likely to visualize? a. Gravel

b. Wood splinter

c. Cactus spine

d. Plastic sliver

2. Foreign bodies can be more diffi cult to detect with sonography when they are smaller than what size? a. 1 cm

b. 7 mm

c. 5 mm

d. 2.5 mm

3. Which of the following statements regarding foreign bodies is FALSE? a. Metallic foreign bodies can be easily seen with

both sonography and radiography

b. Most glass foreign bodies can be easily seen with both sonography and radiography

c. Organic foreign bodies are the easiest to locate with radiography

d. Inorganic foreign bodies present little challenge for sonography

4. A patient presents with a red, painful area on his or her right hand that presented after working out in the yard. With sonography, you visualize a 1.5-cm echogenic linear structure directly under the area of concern. A hypoechoic halo is seen surrounding the echogenic structure and posterior shadowing is also noted. In what phase would you categorize this foreign body? a. Acute

b. Intermediate

c. Chronic

d. Granulomatous

5. A patient presents with a painful area on the bottom of his or her foot that initially presented more than a week ago. There is a palpable lump present in the area. With sonography, you visualize a very echogenic linear structure with a clean shadow. In what phase would you categorize this foreign body? a. Acute

b. Subacute

c. Intermediate

d. Chronic

6. What is the most common complication of untreated or retained foreign bodies? a. Nerve injury

b. Infection

c. Tendon injury

d. Allergic reaction

7. Which of the following can cause false-positive fi ndings? a. Calcifi cations

b. Scar tissue

c. Air trapped in the soft tissue

d. All of the above may cause a false positive fi nding

8. Which of the following is an organic foreign body? a. Bee stinger

b. Glass shard

c. Graphite

d. Gravel

9. Which of the following does NOT describe the typical sonographic appearance of a foreign body? a. Echogenic with clean shadowing

b. Hypoechoic with an echogenic ring surrounding it

c. Echogenic with a hypoechoic ring surrounding it

d. Echogenic with comet tail artifact

FILL-IN-THE-BLANK

1. Whether or not a foreign body is demonstrated on a

radiograph depends on the of the

object.

2. Radiography detects 98% of radiopaque objects such

as , most , and

3. A high-frequency array transducer

is typically used to evaluate for the presence of

foreign bodies.

4. Artifacts such as and

can be helpful in both identifying

and locating a foreign body.

Kawamura_WB_CH26.indd 234 12/1/11 4:33 PM

26 — Foreign Bodies 235

5. Color Doppler may be used to demonstrate

surrounding the

foreign body.

6. A radiograph can provide information regarding

the , , and

of the foreign body. Radiographs

obtained in two perpendicular projections can be

used to the location.

7. A foreign body will only be radiographically

visualized if its density is than the

surrounding soft tissue.

8. When evaluating a foreign body with sonography,

visualizing the foreign body to the

transducer is important.

9. Foreign bodies are described in one of three

categories , , or

10. In the intermediate phase, the air that is present

in the acute phase is slowly replaced with

; therefore, the

artifact is typically not present. A more pronounced

is seen to surround the foreign

body.

11. In the chronic stage, a dense,

material encapsulates the foreign body. The

infl ammatory response can result in a clean

12. Metallic and glass foreign bodies may present with

artifacts.

13. Using sonographic guidance for foreign body

removal can result in reducing the size of

the with a less traumatic

to fi nd and remove the material.

14. The greatest advantage of CT over conventional

radiography or sonography is its capability of

demonstrating foreign bodies in .

CT can detect , ,

, and in bone and

muscle.

15. MRI should not be used for foreign

bodies.

SHORT ANSWER

1. List three types of foreign bodies radiography is likely to detect and three types of foreign bodies radiography is unlikely to detect.

2. Describe the techniques used to increase visualization of foreign bodies with sonography.

3. Describe the appearance of a foreign body in the acute phase.

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236 PART 4 — SPECIAL STUDY SONOGRAPHY

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. What artifact is seen in this image that helps the sonographer locate the foreign body? What causes this artifact?

2. Describe what is seen in this image. What are the arrows pointing to? What does this represent?

Kawamura_WB_CH26.indd 236 12/1/11 4:33 PM

237

REVIEW OF GLOSSARY TERMS

MATCHING

Match the terms with their defi nitions.

Key Terms Defi nitions

1. Coagulopathy

2. Core biopsy

3. Fine-needle aspiration

4. Fresh frozen plasma

5. International normalized ratio

6. Partial thromboplastin time

7. Pneumothorax

8. Prostate specifi c antigen

9. Prothrombin time

10. Pseudoaneurysm

a. Value used to standardize prothrombin time results between institutions

b. Collection of air or gas in the pleural cavity between the lung and chest wall that creates pressure on the lung

c. Complication that can occur after cardiac catheterization or angioplasty in which a hematoma is formed by a leakage of blood from a small hole in the femoral artery

d. A defect in the body’s mechanism for blood clotting e. Lab value that can indicated the presence of prostate

conditions such as prostate cancer, BPH, and prostatitis

f. PT; lab test used to evaluate for blood clotting abnormalities; the time it takes the blood to clot after thromboplastin and calcium are added to the sample

g. Procedure that uses a hollow core biopsy needle to remove a sample of tissue

h. PTT; laboratory test used to evaluate for blood clotting abnormalities

i. A form of blood plasma that contains all of the clotting factors except platelets that is used to treat patients with a coagulopathy prior to interventional procedures

j. A procedure that uses a small needle attached to a syringe; a vacuum is created and sample cells are aspirated for evaluation

27 Sonography-Guided Interventional Procedures

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238 PART 4 — SPECIAL STUDY SONOGRAPHY

CHAPTER REVIEW

MULTIPLE CHOICE

Complete each question by circling the best answer.

1. Which of the following is NOT a contraindication to needle biopsy? a. Uncooperative patient

b. Lesion deeper than 5 cm

c. Uncorrectable coagulopathy

d. Unsafe biopsy route

2. Which of the following is NOT included in a coagulation study? a. PT

b. INR

c. WBC

d. PTT

3. Which test standardizes the results of the other coagulation studies as it adjusts for variations in processing and is expressed as a number? a. PT

b. INR

c. WBC

d. PTT

4. Which of the following CANNOT cause a coagulopathy? a. Blood thinners

b. Aspirin use

c. Certain antibiotics

d. Vitamin K

5. Which of the following is a procedure that uses a 20- to 27-gauge needle attached to a syringe to obtain a sample of cells for cytologic examination? a. Core biopsy

b. Nephrostomy

c. Fine-needle aspiration

d. Paracentesis

6. Which of the following needle gauges will produce the largest specimen size? a. 14 gauge

b. 16 gauge

c. 22 gauge

d. 27 gauge

7. Which of the following statements regarding needle visualization is FALSE? a. Larger caliber needles are more readily visualized

than smaller caliber needles

b. The needle may appear as a dot or line depending on the imaging plane

c. The needle and transducer should be in the same plane to produce the best visualization

d. The more parallel the needle is to the transducer, the easier it is to visualize

8. What is the purpose of the time-out during a procedure? a. Give the physician and staff a break during long

procedures

b. Verify the correct patient is present and confi rm the procedure and procedure site

c. Verify that all of the materials are in place for the procedure and everyone is ready to begin

d. Verify that the physician and staff are adequately trained in performing the procedure

9. Which of the following is NOT one of the most common complications to occur following a biopsy? a. Infection

b. Pain

c. Vasovagal reaction

d. Hematoma

10. Which of the following procedures is performed to remove an accumulation of serous fl uid in the peritoneal cavity? a. Thoracentesis

b. Abscess drainage

c. Nephrostomy

d. Paracentesis

FILL-IN-THE-BLANK

1. Sonographic guidance allows for real-time visualization

of the as it passes

through tissue planes to the target area.

2. Color Doppler is used to prevent complications

by identifying and helping the clinician to avoid

that may be in

the needle path.

Kawamura_WB_CH27.indd 238 12/1/11 4:34 PM

27 — Sonography-Guided Interventional Procedures 239

3. A biopsy can help distinguish between

or lesions and

disease.

4. Three tests ,

, and

measure the time

it takes for blood to form a clot.

5. Patients with a coagulopathy may be given

or vitamin prior to the procedure

if the need for the procedure outweighs the risk of

bleeding.

6. When planning a biopsy route, major

, , the

, and other

must be avoided.

7. A

is a procedure that involves

removing small samples of tissue using an

automated hollow core needle commonly referred to

as a .

8. The larger samples obtained from a core biopsy

are sent for a more defi nitive

evaluation. This type of procedure is

commonly performed in the ,

, ,

, and

organs.

9. The sonographic appearance of a needle is either a

hyperechoic or ,

depending on which imaging plane is used.

10. The sonographer’s role is to recommend the

and approach to

the lesion.

11. Written must be

obtained from the patient and everyone in the room

must pause for a prior to the start

of the procedure.

12. Measuring the distance from the to

the will help determine the length

of the procedure needle needed.

13. A needle guide that is fi xed to the transducer keeps

the needle of the transducer;

however it also reduces operator freedom in choosing

the .

14. A procedure that is performed without a needle

guide is considered .

15. A paracentesis can be performed for

or reasons.

16. The most common causes of ascites are

and .

17. A procedure performed to remove fl uid from the

pleural space is called a . Patients

are typically positioned , leaning

over a table.

18. Indications for a prostate biopsy include elevated

, abnormal

, or

palpable nodules. The patient is placed in the

position.

19. Percutaneous injection can be used

to treat pseudoaneurysms. Complications include

migration of the thrombin.

20. Fine needle aspiration of thyroid nodules less than

is discouraged because micro-

carcinomas infrequently metastasize.

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240 PART 4 — SPECIAL STUDY SONOGRAPHY

SHORT ANSWER

1. Describe the advantages of sonography-guided procedures over CT-guided procedures or open surgery.

2. Although sonography-guided biopsy can be used for many lesions, certain lesions may not be amenable to sonographic guidance. List three instances in which sonography-guided biopsy would not be used.

3. Discuss the reasons a biopsy of a lesion is performed.

4. List the possible complications of sonography-guided procedures.

IMAGE EVALUATION/PATHOLOGY

Review the images and answer the following questions.

1. Is this needle (N) visualized in plane or out of plane? Is the needle parallel or perpendicular to the ultrasound beam?

2. Is this needle (N) visualized in plane or out of plane? Which is easier to visualize, a needle in plane or out of plane?

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27 — Sonography-Guided Interventional Procedures 241

3. What do the two parallel lines represent in this image? What are the advantages of using this guide? What does the cursor between those lines represent?

4. This image was taken in a patient undergoing a core biopsy of a liver lesion. What are the possible complications from a core liver biopsy?

5. This image was taken in a patient undergoing a core biopsy of the kidney. List the main reasons a biopsy of the kidney is performed. From which part of the kidney is the biopsy sample typically obtained?

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242 PART 4 — SPECIAL STUDY SONOGRAPHY

CASE STUDY

Review the images and answer the following question.

1. A patient presents with a unilateral, loculated fl uid collection in the left pleural space. What are the diagnostic indications for thoracentesis? What are the complications?

Kawamura_WB_CH27.indd 242 12/1/11 4:34 PM

Cover
Half Title Page
Title Page
Copyright
Contents
CHAPTER 1: Introduction

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

PART 1: ABDOMINAL SONOGRAPHY

CHAPTER 2: The Abdominal Wall and Diaphragm

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 3: The Peritoneal Cavity

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 4: Vascular Structure

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 5: The Liver

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 6: The Gallbladder and Biliary System

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 7: The Pancreas

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 8: The Spleen

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 9: The Gastrointestinal Tract

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 10: The Kidneys

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 11: The Lower Urinary System

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 12: The Prostate Gland

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 13: The Adrenal Glands

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 14: The Retroperitoneum

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

PART 2: SUPERFICIAL STRUCTURE SONOGRAPHY

CHAPTER 15: The Thyroid Gland, Parathyroid Glands, and Neck

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 16: The Breast

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 17: The Scrotum

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 18: The Musculoskeletal System

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

PART 3: NEONATAL AND PEDIATRIC SONOGRAPHY

CHAPTER 19: The Pediatric Abdomen

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 20: The Pediatric Urinary System and Adrenal Glands

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 21: The Neonatal Brain

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 22: The Infant Spine

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

CHAPTER 23: The Infant Hip Joint

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDIES

PART 4: SPECIAL STUDY SONOGRAPHY

CHAPTER 24: Organ Transplantation

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY

CHAPTER 25: Emergency Sonography

REVIEW OF GLOSSARY TERMS
ANATOMY AND PHYSIOLOGY REVIEW
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDY

CHAPTER 26: Foreign Bodies

REVIEW OF GLOSSARY TERMS
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY

CHAPTER 27: Sonography-Guided Interventional Procedures

REVIEW OF GLOSSARY TERMS
CHAPTER REVIEW
IMAGE EVALUATION/PATHOLOGY
CASE STUDY