LIVER QUESTIONS

NORNAL LIVER
Which techniques are important to use during ultrasound evaluation of the
liver for optimal technique?

A. Subcostal scans

B. Intercostal scans

C. Breath-holding during scanning

D. Fasting condition

E. All of the above

What is the significance of a Reidel’s lobe?

A. It is an anatomic variant of no clinical significance.

B. A transverse liver may be mistaken for splenomegaly.

C. A false diagnosis of hepatomegaly results if it is measured as the length of the

liver.

D. A and B

E. B and C

How can normal variants of liver shape be mistaken for abnormalities?

A. Diaphragmatic grooves can be mistaken for infarcts.

B. Measurement of Reidel’s lobe can be mistaken for hepatomegaly.

C. A transverse liver may lead to a false diagnosis of splenomegaly.

D. A and B

E. B and C

1
Concerning comparison of abdominal organ parenchymal echogenicities,
which statement(s) is (are) true?

A. Liver echogenicity is less than renal cortical echogenicity.

B. Renal sinus echogenicity is less than renal cortical echogenicity.

C. Liver echogenicity is less than splenic echogenicity.

D. Pancreatic echogenicity is less than liver echogenicity.

E. Splenic echogenicity is greater than renal sinus echogenicity.

The umbilical vein remnant (remains)lies within the

A. Falciform ligament

B. Ligamentum teres

C. Ligamentum venosum

D. A and B

E. B and C

On a transverse scan through the superior portion of the liver, fluid extending
medially as far as the spine is considered to be

A. Pleural

B. Ascites

C. Iatrogenic

D. Infected

E. None of the above

2
According to the traditional method of liver division using external surface
landmarks, the falciform ligament divides

A. the liver into right and left lobes with the right lobe being six times larger than
the left.

B. the liver into equal sized right and left lobes

C. the left lobe into medial and lateral segments

D. the caudate lobe from the left lobe

E. None of the above

In daily ultrasound practice what is the practical usefulness of knowing where

to find the main lobar fissure?

A. It helps to locate the gallbladder fossa, when a gallbladder is not seen

B. It marks the undersurface of the liver

C. It is a sign of gallstones

D. A and B

E. B and C ANSWER: A

The fissure for ligamentum venosum contains the fetal remnant of the

A. Umbilical vein

B. Umbilical artery

C. Ductus venosus

D. Portal sinus

E. Fossa ovalis ANSWER: C

3
True or false?

Recanalization of the ductus venosus occurs in response to portal hypertension.

ANSWER: False. The ductus venosus does not recanalize like the umbilical vein.

The caudate lobe of the liver is located:

A. Anterior to the inferior vena cava

B. Posterior to ligamentum venosum

C. Posterior to the left lobe of the liver

D. All of the above

E. None of the above ANSWER: D

Because of its unique venous drainage into the inferior vena cava, the caudate
lobe

A. Appears to be spared from diseases affecting the remainder of the liver

B. Remains normal in size, while the rest of the liver shrinks(reduce in size)

C. Hypertrophies in response to increased venous flow

D. A and B

E. A and C ANSWER:D

Which vessels bring the most blood into the liver?

A. Hepatic veins

B. Portal veins

C. Hepatic arteries

D. A and B

E. B and C ANSWER: B

4
True or false?

The structures in the portal triad are the portal vein, bile duct and hepatic vein.

ANSWER: False, the portal triad includes the portal vein, bile duct and hepatic
artery.

True or false?

On color Doppler the color of the hepatic artery should be red, while the color of
the portal vein should be blue, because one is an artery and the other is a vein.

ANSWER: False. Both should be the same color (red or blue, depending on how
the color map was set), because both have the same direction of flow, that is
hepatopetal.

Concerning the spectral Doppler waveform of the portal vein, it

A. has antegrade and retrograde flow reflecting strong cardiac pulsations

B. is continuous throughout the cardiac cycle

C. reflects respiratory motion

D. A and B

E. B and C

ANSWER: E

Spectral Doppler waveforms of the hepatic veins are:

A. Pulsatile

B. similar to other large central veins in the body

C. triphasic

D. A and B

E. All of the above ANSWER:E

5
Which tubular structures are normally visible within the substance of the
liver on routine sonograms?

A. Hepatic arteries and bile ducts

B. Portal veins and bile ducts

C. Portal veins and hepatic veins

D. Hepatic veins and hepatic arteries

E. Hepatic veins and bile ducts

ANSWER: C

Why do portal veins have bright walls on sonograms?

A. The walls of portal veins are generally thicker and easier to see.

B. Portal triad structures add to beam reflectivity.

C. Glisson’s capsule provides added echogenicity.

D. A and B

E. B and C

ANSWER:: E

Write the letter P for portal veins or H for hepatic veins on the line next to the
characteristic feature for that liver vessel.

P____ 1. Veins assume a more horizontal orientation.

P____ 2. These veins have bright or hyperechoic margins.

H____ 3. These veins enlarge toward the superior part of the liver.

H____ 4. These veins are found at the peripheral parts of the lobes or segments.

H____ 5. These veins have imperceptible walls.

P____ 6. Lobes and segments are named after these veins.

6
P____ 7. Blood flow in these veins is hepatopetal.

H____ 8. The blood in these veins is more deoxygenated as compared with the
other veins.

ANSWERS: 1P; 2P; 3H; 4H; 5H; 6P; 7P; 8H

Scans of the liver showing the large portal veins mark which part of the liver:

A. Upper

B. Middle

C. Lower

D. Anterior

E. Posterior ANSWER: B

LIVER SEGMENTATION
According to the traditional method of liver division using external surface
landmarks, the falciform ligament divides

A. the liver into right and left lobes with the right lobe being six times larger than
the left.

B. the liver into equal sized right and left lobes

C. the left lobe into medial and lateral segments

D. the caudate lobe from the left lobe

E. None of the above ANSWER: A

7
The more traditional method of liver division is based on:

A. Intactness of vascular inflow

B. Intactness of vascular outflow

C. Biliary drainage

D. All of the above

E. None of the above ANSWER: E

True or false ?

Hepatic veins are used as dividers between lobes and segments, while portal veins
are central within the lobes and segments.

ANSWER: True

Which of the following statements is/are true?

A. The middle hepatic vein divides the liver into right and left lobes.

B. The left hepatic vein divides the left lobe into medial and lateral segments high
in the liver.

C. The right hepatic vein divides the right lobe into superior and inferior segments.

D. A and B

E. All of the above ANSWER: D

8
Anatomic dividers of the liver into two equal lobes include:

A. thefalciform ligament

B. the plane defined by the middle hepatic vein and IVC

C. the plane through the IVC and gallbladder fossa

D. A and B

E. B and C

ANSWER: E

Write the letter of the location of the anatomic divider of the left lobe of the
liver in the blank space in front of the statement, which matches with the
location.

A. High sections of left liver lobe

B. Middle sections of left liver lobe

C. Lowest sections of left liver lobe

____1. The left hepatic vein divides the left lobe into medial and lateral segments.

____2. The falciform ligament divides the left lobe into medial and lateral
segments.

____3. The umbilical segment of the left portal vein divides the left lobe into
medial and lateral segments.

ANSWER: 1 A, 2 C, 3 B

9
A plane through the liver intersecting the bifurcation of the main portal vein
subdivides the liver into:

A. Superior and inferior segments

B. Anterior and posterior segments

C. Medial and lateral segments

D. A and B

E. B and C ANSWER: D

The caudate lobe of the liver is located:

A. Anterior to the inferior vena cava

B. Posterior to ligamentum venosum

C. Posterior to the left lobe of the liver

D. All of the above

E. None of the above ANSWER: D

Although there are a variety of classification systems of the liver, they all
contain which of the following divisions?

A. The caudate lobe

B. Anterior and posterior segments of the right lobe

C. Medial and lateral segments of the left lobe.

D. A and B

E. All of the above ANSWER: E

10
DIFFUSELYABNORMAL LIVER
1 .Ultrasound is a non-invasive technique used to evaluate for diffuse and focal
liver disease. This section deals with diffuse abnormalities of the liver.

2. WHAT AERE SONOGRAPHIC LIVER PATTERNS:

• NORMAL

• CENTRILOBULAR

• FATTY-FIBROTIC

3. Sonography has the limitation that mild diseases of the liver may show no
sonographic changes and the liver may appear normal.

4. What are two contrasting diffuse sonographic patterns of liver parenchyma

other than normal.

They are: centrilobular & fatty-fibrotic.

5. A normal liver can be made to look echogenic by increasing: Gain or power

settings

6.How do you know if the technique chosen for a liver sonogram is

overgained or not?

A. The power is set as low as possible.

B. The liver parenchyma is set to maximal echogenicity, but the lumens of blood
vessels in the liver are free of artifactual echoes.

C. The gain curve is set to peak in the mid-zone of the liver.

D. A and B

E. B and C ANSWER: B

11
7. What are the characteristic of LIVER CENTRI-LOBULAR PATTERN.

• Decreased echogenicity of liver parenchyma

• Increased visualization of PV walls BY :

– increased brightness

– increased apparent number

8 .What are the characteristic of LIVER FATTY - FIBROTIC PATTERN

– Increased echogenicity of liver parenchyma

– Decreased definition of PV walls

– Echotexture :

a )homogeneous (fine)

b )heterogeneous (coarse)

– Posterior sound attenuation

9.What are the characteristic of DIFFUSE FATTY INFILTRATION

• Increased echogenicity parenchyma

• Decreased definition PV walls

• Posterior sound attenuation

• Enlarged liver

• Tends to have fine homogeneous echotexture

10.Write the letter F for fatty fibrotic, C for centrilobular or N for none on the line
next to the characteristic feature for that liver pattern.

– __C __ 1. Decreased echogenicity of liver parenchyma.

– __ F __ 2. Posterior sound attenuation of the liver.

– __F__ 3. Decreased definition of portal vein walls.

12
 – __C__ 4. Increased apparent number of portal veins in the liver.

– __C__ 5. Increased echogenicity of portal vein walls.

– __N__ 6. Increased vascularity of the liver.

– ___N_ 7. Increased sound enhancement of the liver.

– ANSWERS: 1C; 2F; 3F; 4C; 5C; 6N; 7N

11 With the fatty-fibrotic liver pattern, portal vein walls lose their brightness,
because

– A. the portal vein walls become very thin and difficult to image.

– B. sound attenuation occurs in the liver.

– C. there is loss of contrast between the echogenicity of the

parenchyma, portal vein walls and periportal connective tissue.

– D. All of the above

– E. None of the above ANSWER: C

12. The centrilobular pattern of liver parenchymal disorders is also called the
acute pattern, since most of the cases are due to acute hepatitis

13. The sonographic fatty-fibrotic liver pattern may be caused by:

Fatty infiltration

Fibrosis

Chronic hepatitis

Cirrhosis

acute alcoholic hepatitis.

13
14. CENTRI-LOBULAR PATTERN CAN BE :

• Acute hepatitis

• Leukemia

• Lymphoma

• Toxic shock syndrome

• Acute right CHF

• Normal: 2%

15. What are etiologies of fatty infiltration of the liver include:

• Obesity

• Drugs / Toxins

Alcohol

Corticosteroids

Cytotoxic agents (chemotherapy)

• Metabolic disorders

Glycogen storage diseases

Diabetes mellitus

Hyperlipidemias

• Nutritional factors

Hyperalimentation

Starvation

Intestinal bypass surgery

• Idiopathic

14
 16. Which of the following are true concerning the differences between
focal fatty infiltration and focal fatty sparing?

A. Focal fatty infiltrated areas are hypoechoic, while focal fatty spared areas
are hyperechoic.

B. Focal fatty spared areas are found in specific sites in the liver, while fatty

infiltration occurs more randomly (accidentally)

C. Both fatty infiltrated and fatty spared areas exert no mass effect.

D. In fatty infiltrated areas blood vessels are narrowed, while there is no

effect on blood vessels in fatty spared areas.

E .Geographic area distribution is a term more associated with focal fatty

infiltration than with focal fatty sparing.

TRUE ANSWERS: B, C and D

18 What are the characteristic of FOCAL FATTY INFILTRATION

• Geographic pattern

• Interdigitation of normal parenchyma

• No mass effect on vessels

• Solitary or multiple

19 What are the characteristic of FOCAL FATTY SPARING

• Hyperechoic fatty liver background

• Focal hypoechoic regions (normal)

• Common sites

– anterior to portahepatis

– near gallbladder

15
 – adjacent to left PV

– adjacent to fissures

– subcapsular

20.How do focal fatty infiltration and focal fatty sparing differ

sonographically?

A. One is hyperechoic and the other hypoechoic relative to the surrounding

tissue.

B. One is focal and the other is geographic.

C. One is wedge-shaped and the other is rectangular.

D. One is homogeneous and the other is heterogeneous.

E. One exerts mass effect and the other does not.

ANSWER: A

18. Which sonographic feature distinguishes fatty infiltration in the liver

from chronic hepatitis?

A. Liver size

B. Liver shape

C. Liver echogenicity

D. Posterior enhancement

E. Definition of portal vein walls

ANSWER: A.

16
20 What are the characteristic of CHRONIC HEPATITIS

• Increased echogenicity parenchyma

• Decreased definition PV walls

• Almost no posterior attenuation

• Normal size

• Tends to have coarse echotexture

(mildly heterogeneous

21 TheCauses of cirrhosis include:

• Alcohol

• Viral hepatitis (B and C)

• Metabolic

Hemochromatosis

Wilson’s disease

• Cholestasis

Biliary cirrhosis

• Budd-Chiari syndrome

• Cryptogenic

22Budd-Chiarisyndrome presents with the classical triad of abdominal

pain,ascites and hepatomegaly.

17
23 WHAT ARESONOGRAPHIC FEATURES OF CIRRHOSIS

• Fatty-fibrotic pattern
– heterogeneous echotexture
(coarse “motheaten”)
– almost no posterior attenuation
• Shrunken liver(reduction in size)
• Nodular surface
• Elevated caudate:right lobe ratio

24There are a number of sonographic signs of portal hypertension. They

include:

• ascites
• dilatation of the main portal, splenic and superior mesenteric veins
• presence of collateral vessels
• splenomegaly
• various Doppler findings

25 Which sonographic feature distinguishes cirrhosis from chronic hepatitis?

A. Liver size

B. Nodularity

C. Echogenicity

D. Posterior attenuation

E. Definition of portal vein walls

ANSWER: B.

18
26 QUESTION: True or false?

The caudate lobe hypertrophies in response to cirrhosis, while the rest of the liver
shrinks.

ANSWER: False. The caudate lobe does not actually hypertrophy. It appears
enlarged, because the rest of the liver shrinks.

27 ENLARGED CAUDATE LOBE

CAUDATE: RIGHT LOBE RATIO

• Highly specific for cirrhosis

Ratio >0.65 96% specificity

Ratio >0.73 99% specificity

• Poor sensitivity

28 Sonographic signs of portal hypertension include:

• A. Dilated portal veins

• B. Evidence of collateral vessels

• C. Dilated inferior vena cava

• D. A and B

• E. All of the above

• ANSWER: D

19
29 The main collateral vessels visualized by sonography are the following
veins:

• Coronary

• Gastroesophageal

• Umbilical

• Gastrosplenic

• Splenorenal

• Retroperitoneal - paravertebral

30 Collateral vessels recognized sonographically include:

• A. Coronary vein

• B. Splenorenal shunt

• C. Gastroesophageal veins

• D. Umbilical vein

• E. All of the above

• ANSWER: E

31 WHAT ARE DOPPLERFINDINGS INLIVER CIRRHOSIS

• Hepatofugal (reversed) portal vein flow

• Reduced respiratory variation of the portal vein

• Decreased velocity in the main portal vein

• Loss of normal flow reversal in the hepatic veins

• Enlarged hepatic arteries

20
32 Normally with color Doppler the color of the hepatic artery and portal vein
are the same.

• ANSWER: True, because the direction of blood flow is the same, i.e. toward
the liver.

DIFFUSELY HETEROGENEOUS LIVER CAN BE :

A ) BENIGN

Cirrhosis

Hepatic fibrosis

Fatty infiltration

B ) MALIGNANT

Metastases

HCC (hepatocellular carcinoma ).

Lymphoma

Leukemia

21
II .SONOGRAPHY OF CYSTIC LIVER MASSES
34.What are sonographically of Simple cyst criteria?

– anechoic

– smooth, thin walls

– well-defined sharp back-wall

– acoustic enhancement

35 .What type of vascular lesion in the liver may simulate(imitate) a cyst?

– A. Aneurysm

– B. Arterial to portal vein fistula

– C. Portal vein to hepatic vein fistula

– D. Pseudoaneurysm

– E. All of the above ANSWER: E

36 What can account (description)for echoes in a liver cyst?

A. Blood

B. Pus

C. Crystals

D. Debris

E. All of the above

ANSWER: E

22
36 Multiple hepatic cysts are associated with which of the following:

A. Tuberous sclerosis

B. Von HippelLindau syndrome

C. Autosomal dominant polycystic kidney disease

D. A and B

E. B and C

ANSWER: E

37 True or False?

Most cysts in the liver are acquired (obtain)cysts, usually on the basis of trauma or
infection.

ANSWER: True

38 What sonographic feature(s) distinguish a hematoma from an abscess?

A. Increased sound transmission

B. Temporal changes in echogenicity

C. Shadowing from gas

D. A and B

E. B and C

ANSWER: E

23
SONOGRAPHY OF SOLID LIVER MASSES
Name some subtle (delicate)signs of liver masses.

ANSWERS:

• Slight change in echogenicity

.Mild(Gentle)architectural disruption

.Displacement, compression, draping or bowing (distort)

of a vessel

• Critical edge shadows emanating from the rounded border of a

mass

• Rounding of the inferior edge of the liver

• A contour deformity

• Deformity of adjacent organ

The most common benign solid liver lesions include:

• Hemangioma

• Adenoma

• Focal nodular hyperplasia

• Regenerating nodule

• Focal fatty infiltration

• n

• Focal fatty sparing

• Microabscesses

24
Which feature(s) of hemangioma make(s) them difficult to differentiate from
a malignant lesion?

A. Irregular outline

B. Multiplicity of lesions

C. Enlargement of lesion

D. A and B

E. All of the above ANSWER: E

Hepatic adenomas have

A. Kupfer cells

B. High risk of spontaneous hemorrhage

C. Malignant degeneration

D. A and B

E. B and C ANSWER:D

Focal nodular hyperplasia has close association with which of the following:

A. Glycogen storage diseases

B. Birth control pills

C. Anabolic steroids

D. All of the above

E. None of the above

ANSWER: E

25
 Malignant solid masses include:

Metastases

Hepatocellular carcinoma

Leukemia / Lymphoma

Cholangiocarcinoma

Mesenchymal tumors (rare)

The sonographic appearance of a target lesion is specific for which pathologic

entity in the liver?

A. Abscess

B. Bladder carcinoma metastasis

C. Hematoma

D. All of the above

E. None of the above

ANSWER: E

CALCIFIED LIVER METASTASES PRIMARY TUMOR

• Colon

• Ovary

• Breast

• Stomach

• Pancreas

• Melanoma

• Leiomyosarcoma

26
 • Osteosarcoma

CYSTIC LIVER METASTASES INCLUDE:

CYSTICPRIMARY TUMOR

• Ovary

• Colon

• Pancreas

NECROSIS/HEMORRHAGE

• Sarcoma

• Squamous cell

• Testicular

• Melanoma

If you found multiple solid masses in the liver located predominantly in the
right lobe of the liver, what would be a reasonable suggestion?

A. Technical factors causing poor visualization of the left lobe of the

liver

B. Amebic abscesses and possibility of travel to endemic area

C. Liver metastases, probably right colon carcinoma

D. A and B

E. B and C ANSWER: C

27
The differential diagnosis of small focal lesions in the liver includes:

metastases

microabscesses

regenerating nodules

multifocalhepatoma

leukemia / lymphoma

infarcts.

Microabscesses in the liver are

A. mostly due to bacterial infection.

B. typically small target-like lesions.

C. most likely to affect an immune compromised patient.

D. A and B

E. B and C ANSWER: E

Complications of liver metastases include:

A. Biliary ductal obstruction

B. Vascular invasion

C. Necrosis

D. Infection

E. All of the above

ANSWER: E

28
HEPATOCELLULAR CARCINOMAAssociated with chronic liver disease
INCLUDE :

• Hepatitis B,C

• Cirrhosis

– Alcoholic

– Wilson’s disease

– Hemochromatosis

• Aflatoxin

How does fibrolamellar hepatocellular carcinoma differ from the usual

hepatocellular carcinoma?

A. It has a better prognosis.

B. It occurs in younger patients.

C. It is more likely to have a central scar.

D. A and B

E. All of the above

Answer: E

HEPATOCELLULAR CARCINOMA COMPLICATIONS INCLUDE :

High propensity (susceptibility) for vascular invasion

– PV, HV, IVC

– Arterial-portal shunts

– tumor thrombus with arterial signals

• Necrosis, hemorrhage, infection

29
Which of the following statement(s) is/are true concerning hepatocellular
carcinoma?

A. It is associated with underlying chronic liver disease.

B. It affects approximately 12% of patients with cirrhosis.

C. The lesions tend to be hypervascular.

D. Hepatomas have propensity for vascular invasion.

E. All of the above ANSWER: E

Which statement(s) is/are true concerning Doppler evaluation of thrombus in

a liver vessel?

A. Absence of Doppler signals in an area of thrombus in a liver

vessel are diagnostic of tumor thrombus.

B. Arterial signals in a thrombus in a liver vessel are diagnostic of

tumor thrombus.

C. Absence of Doppler signals in a thrombus in a liver vessel are

diagnostic of bland (blood) thrombus.

D. A and B

E. B and C ANSWER: B

30
Which statement(s) about lymphomas in the liver are true?

A. Diffuse involvement is a more common presentation of lymphoma

in the liver than focal involvement.

B. Patterns of echogenicity of focal liver lymphoma cannot be

differentiated from metastases.

C. Hodgkin’s is more common than non-Hodgkin’s lymphoma in

AIDS patients.

D. A and B

E. All of the above ANSWER: D

LIVER PATHOLOGY IN AIDS INCLUDE:

• Non-Hodgkin’s Lymphoma

– 25% have focal lesions

• Kaposi’s sarcoma

– Small hyperechoic nodules

– Periportal thickening

• Opportunistic infections

– Pneumocystis carinii

– MAI, CMV

– Microabscesses

31
HEPATIC TARGET LESIONS INCLUD

BENIGN

Microabscesses

Hemangioma

Adenoma

FNH

MALIGNANT

Metastases

HCC

Lymphoma

HYPERECHOIC LIVER MASSES INCLUDE :

BENIGN

Hemangioma

Abscess

Adenoma

FNH

Focal fatty infiltration

Hemorrhagic cyst

MALIGNANT

Metastases

HCC

Lymphoma
32
CALCIFIED HEPATIC MASSES INCLUDE :

BENIGN

Microabscesses

Hemangioma

Abscess

Adenoma

FNH

Focal fatty sparing

MALIGNANT

Metastases

HCC

Lymphoma

33
GALLBLADDER QUESTIONS
Which of the following are essential for sonographic scanning of the
gallbladder?

A. Fasting state

B. 5 MHz or higher transducer

C. At least two different patient positions for scanning

D. Water administration into the stomach

ANSWERS: A,B,C

Explain how the gallbladder can be used as a sonographic “standard of

reference” in the right upper quadrant.

A Cysts in the liver and right kidney can be compared to the gallbladder, as long as
they are at similar depths. If the echogenicity of their contents is the same as that
of the gallbladder, then they are simple cysts. If their contents is more echogenic,
then the cysts contain true echoes and are not simple cysts

What are structures that can mimic (imitate)the gallbladder?

These include omental cysts, enteric duplication cysts, choledochal cysts,

aneurysms, abscesses.

Why should the gallbladder be scanned in a fasting state?

ANSWER:

A collapsed postprandial gallbladder cannot be differentiated from a diseased

gallbladder that has wall thickening. In a distended gallbladder, bile outlines
calculi and the exam becomes more accurate.

34
The cystic duct contains numerous folds called :valves of Heister.

What is the difference between the common hepatic and the common bile
duct?

ANSWER:

The common hepatic duct is the most proximal part of the bile duct after it exits
the liver. The common bile duct begins after the cystic duct joins it.

What is the significance of gallbladder septations?

A. Recurring bouts of unexplained abdominal pain

B. Early obstruction

C. No known clinical significance

D. Stasis and stone formation

ANSWER: C

WHAT IS THE ANATOMIC VARIANT OF GALLBLADDER: THE

PHRYGIAN CAP

Question: True or false?

Demonstration of the cystic duct should be part of a routine gallbladder ultrasound

examination.

Answer:

False. The cystic duct is rarely seen, unless it is distended with bile.

Name the three sonographic criteria, which must be met for the diagnosis of
gallstones.

ANSWER:

Echogenic focus, acoustical shadow, mobility.

35
WHAT IS Faceted stones

As gallstones rub against each other, over time they may acquire flat surfaces.
These are called faceted stones, because they are like the cut surfaces on
gemstones

EXPLAIN HOW FALSE GALLSTONE IS FORMED

A pocket of gas in a loop of bowel immediately adjacent to the gallbladder may

create the false appearance of a gallstone.

HOW YOU CAN DIFFERENTIATE SHADOW FROM air or gaz to stons

The shadowing from air or gas is described as “dirty”, because it contains

reverberation artifacts and scattered echoes. In contradistinction, shadows from
stones are “clean and sharp”, lacking such extra echoes.

What can you do to prove that an echogenic focus in the gallbladder is a false
gallstone?

Answer:

Image it in two perpendicular planes

Change position of the patient (a stone should roll, gas would shift and dissipate)

Look at the type of shadow (“clean” versus “dirty”)

What technical factors improve visualization of an acoustic shadow behind a

gallstone?

ANSWER:

• Higher frequency, low power, low gain settings, stone within focal zone and
within center of beam.

36
ARE ALL SHADOWS NEAR GALLBLADDER CAUSED BY STONES?

NO THEYMAY BE CAUSED BY:

• Reflection/refraction artifacts

• Bowel gas

• Surgical clips

• Liver calcifications

• Bile duct air

Explain how the cystic duct can cause false positive diagnoses of
cholelithiasis.

Reflection and refraction artifacts from curved edges of structs may result from
the tortuous neck of the gallbladder, These shadows disappear when the angle of
incidence is changed

Shadows from the curved edges of structures may be explained by:

A. Reflection artifact

B. Refraction artifact

C. Critical angle shadow

D. All of the above ANSWER: D.

Name some pathologic causes for non-visualization of the gallbladder.

• Cholecystectomy

• Chronic cholecystitis ± stones

• Gallbladder carcinoma

• Obstruction of biliary tree proximal to cystic duct

• Congenital absence of GB

37
WHAT TO DO IF NON-VISUALIZATION OF GB

• Use main lobar fissure

• WES (wall-echo-shadow) sign

• Double arc shadow sign

• Examine type of shadow: clean vs dirty

• Change patient position to shift gas

• Administer water into duodenum to displace gas

What is the other name of double arc shadow sign : the WES sign(wall-echo-
shadow).

List several causes of echogenic structures in the gallbladder that do not

produce (show) acoustical shadows

tiny calculi pus

polyps fungus balls

sludge balls parasites

cholesterol crystals carcinoma

blood clots metastasis

What is the other name of V-shaped reverberation artifacts seen

inCHOLESTEROL POLYPS :comet-tail artifacts

What is the criteria of CHOLESTEROL POLYPS :V-shaped reverberation

artifacts or comet-tail artifacts

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What sonographic features of a polyp-like structure in the gallbladder raise
concern for possibility of malignancy?

• has irregular borders,

• is larger than 8-10 mm,

• has a broad-based connection to the wall.

Explain the composition of sludge.

Sludge is thick echogenic bile composed of calcium bilirubinate granules and

cholesterol crystals

What if the clinical significance of sludge?

ANSWER:

Poor emptying of the gallbladder.

What is hepatization of the gall bladder?

When sludge fills the lumen and is isoechoic with liver parenchyma, the entity is
called “hepatization” of the gallbladder.

How can you differentiate a tumefactive sludge from mass?

BY Doppler :If blood flow, then not sludge , consider tumor mass

What is the normal wall thickness of the gallbladder: 1-2mm

WHAT ARE THE CAUSES OF DIFFUSE GB WALL THICKENING ?(FOR

cholecystitis).

• Non-fasting

• Cholecystitis : acute or chronic

• Ascites : edema, hypoalbuminemia, artifact

• Liver disease : hepatitis, cirrhosis

• Renal disease :failure, uremia

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List several causes of gallbladder wall thickening other than cholecystitis.

• Pancreatitis

• CHF

• Tumor infiltration

• Adenomyomatosis

• AIDS cholangiopathy

• Sepsis

List the most common sonographic signs of acute cholecystitis.

• gallstones

• positive Murphy’s sign (present in up to 92% of patients)

• thickened wall seen in 50-75% of patients with acute, and in 25% of

patients with chronic cholecystitis

• enlarged gallbladder

• increased flow pattern on color Doppler (non-specific).

List the complications of acute cholecystitis :

• gangrenous cholecystitis

• hemorrhagic cholecystitis

• perforation/abscess

• emphysematouscholecystitis.

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List the Sonographic findings in gangrenous cholecystitis :

• striated wall thickening

• intraluminal membranes

• mass-like protrusions into the lumen

• pericholecystic collections

• internal echoes due to pus

What type of patient is likely to get emphysematous cholecystitis?males (70%).

Both an emphysematous gallbladder and a porcelain gallbladder have a

hyperechoic wall. How can you differentiate between the two
sonographically?

ANSWER:

By the type of shadowing. A porcelain gallbladder has clean, sharp shadowing,

while emphysematous cholecystitis has a dirty shadow, full of reverberations.

In what clinical settings does acalculouscholecystitis occur?

– major surgery -parenteral nutrition

– severe trauma -underlying illness

– severe burns -sepsis

What is the presumed etiology of acalculouscholecystitis?

– ischemia -chemical toxicity

– infection -obstructed duct

What is the underlying(primary)pathology of adenomyomatosis?

Adenomyomatosis results from proliferation of the mucosa into the muscular wall

What is Rokitansky-Aschoffsinuses

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It is the condition in which thre is a proliferation of the mucosa into the muscular
wall and causes outpouchings of mucosa within the wall and formation . There is
stasis of bile within these sinuses and subsequent precipitation of crystals and
stone formation

The V-shaped ring-down artifacts, also called “comet-tail” artifacts

What causes the “comet-tail” artifacts in adenomyomatosis?

The ring-down is due to vibration or “ringing” of the sound from vibrations caused
by the cholesterol crystals deposited within the Rokitansky-Aschoff sinuses.

What is the distribution of gallbladder wall thickening in adenomyomatosis?

The distribution of the thickening of the gallbladder wall may be diffuse,

segmental or foca

SonographicallyWhat is the difference between carcinoma and tumefactive

Carcinoma has arterial Doppler signals, while tumefactive sludge does not

Which tumors most commonly metastasize to the gallbladder?

melanoma, breast and colon carcinoma

BILE DUCTS

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What is the typical anatomic relationship of the porta vein, hepatic artery and
bile duct in the portahepatis?

The bile duct lies anterolateral to the portal vein,The hepatic artery is usually
located anteromedial to the main portal vein,

What are the anatomic parts of the extrahepatic bile duct

common hepatic duct,the cystic duct,the common duct,the common bile duct

Explain how the anatomic relationship between the extrahepatic bile duct
and the main portal vein changes between the points where the bile duct exits
the liver and enters the duodenum

Proximal CD LIES Anterior to MPV in Porta

Mid CD LIES Posterior to duodenum

Distal CD LIES Posterior to pancreatic head

What are anatomic pitfalls(errors) that may occur between arteries and bile
ducts?.

a)The proper hepatic artery is often mistaken for the common hepatic duct

b)the GDA (gastroduodenal artery) is mistaken for the commonblie duct

What is the normal relationship of structures in the portal triad?

A. The portal vein is the most posterior of the three structures.

B. The bile duct lies along the anteromedial surface of the vein.

C. The artery lies along the anterolateral surface of the vein.

D. All of the above

E. None of the above. ANSWER: A

How to differenciate of the common duct from the hepatic artery

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 a) use Doppler, A bile duct demonstrates no flow on Doppler evaluation.
b) scanning in a plane transverse, or actually transaxial, to the portahepatis
where you have “teddy bear ears” or “Mickey Mouse ears” :The largest
circle posteriorly is the main portal vein (PV). The right ear is the bile duct
(BD), while the left ear is the hepatic artery (HA).
c) Another method to differentiate between hepatic artery and bile duct is to
follow the tubular structure distally. If the “tubular structure” turns toward
the celiac artery or if it continues distally and ends up anterior to the head of
the pancreas as the gastroduodenal artery, then it is the hepatic artery (HA).
If the distal part of the tubular structure continues posteriorly into the head
of the pancreas , then it is the bile duct (CBD).

How can we be sure that the fluid-filled tubular structure anterior to the
main portal vein is the bile duct and not an artery?

d) ANSWER:

e) Use Doppler. Follow the tubular structure toward its origin. Do transverse
views through the portal hepatis to see if the tube is anterolateral to the
portal vein, in which case it should be the bile duct.

What is the difference in the normal diameters of the common hepatic and
common bile ducts?: less or equal than 2mm

Which part of the biliary tree dilates first--the intrahepatic or the

extrahepatic ducts? Why?

The common duct dilates before intrahepatic ducts dilate,

This is explained by the Law of Laplace, which states that, as pressure increases,
an object with a larger diameter (extrahepatic duct) dilates before an object with a
smaller diameter (intrahepatic duct), as seen in biliary obstruction.

List several situations in which the bile duct is dilated, but not obstructed.

44
 • Elderly

• Recently relieved obstruction

• Post-cholecystectomy

• Previous long standing obstruction

– damaged duct walls

– loss of elasticity

List several situations in which the bile duct is obstructed, but not dilated.

• Acute, early obstruction

• Diseased duct that cannot dilate

– Sclerosing cholangitis

• Infiltrative or fibrotic liver disease

• Obstruction proximal to CD

– Klatskin tumor

One sign of dilatation of the intrahepatic portion of the biliary tree is the so-
called ”too many tubes sign”.

What are sonographic signs of intrahepatic biliary ductal dilatation?

ANSWER:

“Too many tubes sign”, “double channel sign”, “parallel channel sign”, “double
barrel shotgun sign”, “railroad track sign”.

Most common cause of false positive diagnosis is dilated hepatic arteries are:

– cirrhosis

– portal hypertension

The main causes of biliary obstruction are

45
 • neoplasms 90%
• pancreatitis83%
• choledocholithiasis 79%

Choledocholithiasis is one of the most common causes of biliary ductal

obstruction

Why is it difficult to demonstrate choledocholithiasis?

ANSWER: Very little bile for contrast.

Why is it so difficult to diagnose stones in the cystic duct?

ANSWER:

Very little bile for contrast. Convoluted course of the cystic duct and presence of
valves of Heister.

List some mimickers that can cause a false positive diagnosis of

choledocholithiasis.

• Air in adjacent bowel

.Hepatic artery indentation( dance ) or calcification

• Surgical clips

• Folds in duct

• Insertion site of cystic duct into CBD

• Bile duct air

• Liver calcification

• Pancreatic calcification

What are the most common causes of biliary ductal dilatation?

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The accuracy in diagnosing neoplasm as the cause of biliary obstruction is 90%.

Cholangiocarcinoma has several different forms of presentation. What are

they?

ANSWER:

Focal wall thickening, ductal stricture, polypoid mass, and a diffuse sclerosing
pattern.

What percentage of cholangiocarcinomas are multicentric?5% of cases

What is a KLATSKIN TUMOR

aKlatskin tumor is a type of cholangiocarcinoma, which occurs at the confluence

of right and left intrahepatic ducts

What are PERIPORTAL LYMPHADENOPATHYEtiology

Infectious (usually viral)

Inflammatory (sarcoidosis)

Malignant (leukemia, lymphoma, metastases

Name conditions that can cause thickening of the bile duct walls?

sclerosing cholangitis

ascending cholangitis

choledocholithiasis

AIDS cholangiopathy

pancreatitis

orientalcholangiohepatitis

Sclerosing cholangitis is associated with which of the following?

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A. Pseudomembanous colitis

B. Ulcerative colitis

C. Necrotizing enterocolitis

D. All of the above

ANSWER: B

List several causes of segmental intrahepatic biliary obstruction.

• hepatic tumor: primary or metastatic

• cholangiocarcinoma

• portal nodes

• calculi

• sclerosing cholangitis

• strictures

Name the complications of the dilated bile ducts associated with some of the
types of choledochal cysts

biliary stasis

ductal stones

biliary obstruction

cholangitis

liver abscess

cholangiocarcinoma.

What other organ system may be affected in patients with choledochal cysts?

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ANSWER: Renal

What are the worst complications of type 4 choledochal cyst?

ANSWER: Cholangiocarcinoma and renal failure

PANCEAS
What types of hepatic pathology may cause the pancreas to appear to be
abnormally hypoechoic?fatty infiltration

What are the classical sonographic findings in acute pancreatitis?

diffuse pancreatic enlargement an

decreased echogenicity.

Dilatation of the pancreatic duct .more than 2 mm

What is the most common location of a pancreatic pseudocyst?peripancreatic

region or within the lesser sac

Pancreatic duct dilatation may be caused by _biliary tract disease__ and

ALCOHOL ABUSE.

The most common functional endocrine neoplasms of the pancreas are

insulinomas and gastrinomas.

These tend to be hypoechoic and well defined but may be quite small. Insulinomas
are usually solitary (70%) whilegastrinomas tend to be multiple (75%).

What are common indications for pancreatic ultrasonography?

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Pancreatic size and texture,

solid and cystic masses,

duct dilatation, and fluid collections may be identified along with pathology in
adjacent organs.

How much fluid is usually required to distend the stomach adequately for
improving ultrasound imaging of the pancreas? 250 to 500 cc

List three techniques which may be used to improve visualization of the

pancreas.

drink 250 to 500 cc of water or juice

The semi-erect position may also help displace gas from the area of the pancreas.

Supine position

What are the main vascular landmarks related to the body and tail of the
pancreas?

SMV,SMA,SA,SV

What are the key components which contribute to the echogenicity of the
pancreas?fatty and fibrous

SPLEEN
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Regarding comparison of parenchymal organ echogenicities, which statements are
true?

A. The spleen is less echogenic than the liver.

B. Renal cortex is less echogenic than splenic parenchyma.

C. The spleen is more echogenic than the renal sinus.

D. Renal cortex is less echogenic than the renal sinus.

E. Liver echogenicity is greater than renal cortex.

ANSWERS: B, D,E

Sonographically, which organ has more vessels visible within its parenchyma:
the liver or the spleen?

ANSWER: Liver

Why is it more difficult to obtain scans of the spleen than of the liver?

ANSWER:

It is more difficult to obtain scans of the spleen than the liver because of
interference with surrounding ribs and air-filled structures (lung, stomach, splenic
flexure of colon, small bowel). Also, the spleen is smaller than the liver and does
not fill out as much of the corresponding quadrant.

Which statements regarding accessory spleens are true?

A. Accessory spleens are found in as high as 10% of the population.

B. They are smoothly, marginated, small round solid masses near the spleen.

C. They are isoechoic with splenic parenchyma.

D. They are more common with splenomegaly.

E all of the above

Perisplenic collaterals are usually a sign of:

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A. Ischemia

B. Portal hypertension

C. Heart failure

D. Splenic infection

ANSWER: B

True or false?

A cyst in the spleen is usually the result of old trauma.

ANSWER: True.

What is the distinguishing feature of a hematoma?

ANSWER: Temporal change in echogenicity

Which conditions are associated with splenic abscesses?

A. Bacterial endocarditis

B. Septicemia

C. Immune deficiency

D. A and B

E. All of the above ANSWER: E

What may cause a thick-walled, irregularly outlined, complex cystic mass in

the spleen?

A. Abscess

B. Hematoma

C. Metastasis

D. Primary tumor

E. All of the above

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ANSWER:E

Name reasons why a splenic metastasis may have a cystic center.

ANSWER:

Necrosis, hemorrhage, infection, cystic degeneration, cystic primary.

What is the usual etiology of splenic granulomas?

ANSWER:

Histoplasmosisortuberculosis.

What is the typical sonographic appearance of an infarct?

ANSWER:

A triangular or wedge-shaped hypoechoic defect with its base toward the periphery
of the spleen.

What are the sonographic appearances of lymphoma in the spleen?

ANSWER:

Focal mass or masses, diffuse infiltration (change in echogenicity or echotexture),

no apparent changes.

Name three primary tumors of the spleen.

ANSWER: Angiosarcoma, lymphangioma, hemangioma

True or false?

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A parasitic cyst in the spleen is most often due to echinococcal disease.

ANSWER: True

Regarding hemangiomas in the spleen,which statements are true?

A. Hemangiomas in the spleen are similar to those in the liver.

B. Hemangiomas in the spleen are rare.

C. Sonographic features of hemangiomas in the spleen are non-specific.

D. Hemangiomas in the liver are associated with hemangiomas in the spleen.

ANSWERS: A, B, C

What are the most common primary tumors that metastasize to the spleen?

A. Stomach, colon, pancreas and liver

B. Melanoma, breast, lung, colon

C. Breast, ovary, uterus, pituitary

D. Colon, kidney, adrenal, breast

ANSWER: B

Name three primary tumors of the spleen.

ANSWER: Angiosarcoma, lymphangioma, hemangioma.

ADRENAL SONOGRAPHY
54
The right adrenal gland is located :

A. Posterior to the inferior vena cava

B. Lateral to the inferior vena cava

C. Lateral to the right crus of the diaphragm

D. All of the above

E. None of the above ANSWER: D

The adrenal gland and the kidney share similar anatomic features in that:

A. Both are located within the perirenal space.

B. Both have a hypoechoic outer rim and a hyperechoic center.

C. Both are easily imaged from the flanks.

D. A and B

E. B and C ANSWER: D

Adrenal masses may cause:

A. Displacement of the inferior vena cava anteriorly

B. Deformity of the renal contour

C. Displacement of the kidney

D. All of the above

E. B and C

ANSWER: D.

What do adrenal cysts and liver cysts have in common?

A. They have similar embryologic origin

55
B. They often result from a previous hemorrhage

C. They are usually calcified

D. A and B

E. B and C ANSWER: B

Name several predisposing factors for adrenal hemorrhage.

ANSWER:Neonatal hemoconcentration, dehydration, hypoxia, birth trauma,

stress; renal vein thrombosis; anticoagulant therapy in adults.

Benign adrenal cortical adenomas are usually:

A. incidental findings

B. hormonally active

C. bilateral

D. A and B

E. B and C ANSWER:A

What do adrenal myelolipomas and renal angiomyolipomas have in common?

A. Both are hyperechoic

B. Both contain fat

C. Both contain myeloid elements

D. A and B

E. All of the above ANSWER: D

What is true of pheochromocytomas?

A. They originate within the adrenal medulla

56
B. They are benign, not malignant tumors.

C. They are incidental and asymptomatic

D. A and B

E. All of the above ANSWER: A

Adrenal carcinoma:

A. is usually hormonally inactive and asymptomatic

B. often grows to a large size before detection

C. is calcified in 30% of cases

D. A and B

E. B and C ANSWER: E

Neuroblastoma

A. is the second most common abdominal mass in the pediatric age group.

B. contains calcifications more often than nephroblastomas (Wilms tumors)

C. rarely metastasizes to the liver

D. All of the above

E. A and B ANSWER: D

Which primary tumor accounts (explanation)for most of the metastases to the

adrenal?

A. Colon B. Lung C. Melanoma D.Thyroid E. Breast

ANSWER: B

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