for this week, this is the assignment,
Workbook Chapter 5 The liver pages 37 through 48
This is the book:
Title: Diagnostic Medical Sonography Abdomen and Superficial Structures
Author: Diane M. Kawamura and Bridgette M. Lunsford
Publisher: Wolters Kluwer/Lippincott Williams &Wilkins, Third Edition
Code: ISBN-13: 978-1-60547-995-B
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
A GUIDE TO CLINICAL
PRACTICE, ABDOMEN
AND SUPERFICIAL
STRUCTURES
Kawamura_WB_FM.indd iKawamura_WB_FM.indd i 12/2/11 12:54 AM12/2/11 12:54 AM
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
Kawamura_WB_FM.indd iiiKawamura_WB_FM.indd iii 12/2/11 12:54 AM12/2/11 12:54 AM
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.
Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business
351 West Camden Street Two Commerce Square
Baltimore, MD 21201 2001 Market Street
Philadelphia, PA 19103
Third Edition
All rights reserved. This book is protected by copyright. No part of it may be reproduced in any form by any
means, including photocopying, or utilized by any information storage and retrieval system without written
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Materials appearing in the book prepared by individuals as part of their offi cial duties as U.S. government
employees are not covered by the above-mentioned copyright.
Printed in China.
Library of Congress Cataloging-in-Publication Data
Cataloging-in-Publication Data available upon request.
Care has been taken to confi rm the accuracy of the information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, express or implied, with
respect to the contents of the publication. Application of the information in a particular situation remains the
professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with current recommendations and practice at the time of publication. How-
ever, in view of ongoing research, changes in government regulations, and the constant fl ow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for
any change in indications and dosage and for added warnings and precautions. This is particularly important
when the recommended agent is a new or infrequently employed drug.
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http://www.lww.com
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
v
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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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1
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.
A.
D.
C.
B.
1. Patient Positioning – What position is the patient in?
B.
C.
A. C.
2. Longitudinal Plane
B.
D.
A. C.
3. Coronal Plane
B.
D.
A. C.
4. Transverse Plane
Kawamura_WB_CH01.indd 2 12/1/11 3:35 PM
1 — Introduction 3
Sagittal Coronal
A. C.
D.
B.
H.
F.
G.E.
5. Endovaginal Planes
Sagittal Coronal or Transverse
D.
B.
H.
F.
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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9
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.
D.
(Boundary indefinite
and overlapping)
Posterior
Left
lateral
(flank)
Antero-lateral
Anterolateral
B.
C.
1. Transverse section of the abdominal wall
A.
G.
B.
C.
D.
E.
F.
2. Subcutaneous layers of the abdominal wall
Kawamura_WB_CH02.indd 10 12/2/11 1:10 AM
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 .
Kawamura_WB_CH02.indd 12 12/2/11 1:10 AM
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?
Kawamura_WB_CH02.indd 14 12/2/11 1:10 AM
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?
Kawamura_WB_CH02.indd 15 12/2/11 1:10 AM
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?
Kawamura_WB_CH02.indd 16 12/2/11 1:10 AM
17
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.
B.
C.
D.
E.
F.
G.
Midclavicular lines
A.
Transpyloric plane
Subcostal plane
I.
Intertubercular plane
H.
1. Addison’s lines – Label the nine abdominopelvic regions.
B.
C.
Median plane
A.
Ubmilicus
Transumbilical
plane
D.
2. Quadrants of the abdominopelvic cavity – Label the four quadrants.
Kawamura_WB_CH03.indd 18 12/1/11 3:56 PM
3 — The Peritoneal Cavity 19
Transverse
mesocolon
Left colic
flexure
Transverse
colon
Right colic
flexure
A.
Ascending
colon
Tenia coli
Descending
colon
Root of
mesentery of
small intestine
B.C.E. D.
Phrenicocolic
ligament
F.
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
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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.
Kawamura_WB_CH03.indd 21 12/1/11 3:56 PM
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?
Kawamura_WB_CH03.indd 22 12/1/11 3:56 PM
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?
Kawamura_WB_CH03.indd 23 12/1/11 3:56 PM
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?
Kawamura_WB_CH03.indd 24 12/1/11 3:56 PM
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
27
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
Kawamura_WB_CH04.indd 27 12/1/11 3:56 PM
28 PART 1 — ABDOMINAL SONOGRAPHY
ANATOMY AND PHYSIOLOGY REVIEW
IMAGE LABELING
Complete the labels in the images that follow.
A.
D.
E.
F.
K.
G.
H.
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
Kawamura_WB_CH04.indd 29 12/1/11 3:56 PM
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
Kawamura_WB_CH04.indd 30 12/1/11 3:56 PM
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.
Kawamura_WB_CH04.indd 31 12/1/11 3:56 PM
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.
Kawamura_WB_CH04.indd 32 12/1/11 3:56 PM
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?
Kawamura_WB_CH04.indd 33 12/1/11 3:56 PM
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?
Kawamura_WB_CH04.indd 35 12/1/11 3:56 PM
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
37
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
Kawamura_WB_CH05.indd 37 12/1/11 4:01 PM
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
B.
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
Kawamura_WB_CH05.indd 38 12/1/11 4:01 PM
5 — The Liver 39
2. Liver anatomy
3. Liver anatomy
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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, B
12
, 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
Kawamura_WB_CH05.indd 42 12/1/11 4:01 PM
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
.
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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 .
Kawamura_WB_CH05.indd 44 12/1/11 4:01 PM
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?
Kawamura_WB_CH05.indd 46 12/1/11 4:01 PM
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
49
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.
A
B
C
D
E
I
H
G
F
1. Biliary system
2. Anatomy
Kawamura_WB_CH06.indd 50 12/1/11 4:02 PM
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.
Kawamura_WB_CH06.indd 54 12/1/11 4:02 PM
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?
Kawamura_WB_CH06.indd 55 12/1/11 4:02 PM
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
59
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.
A
D
B
C
1. Pancreatic anatomy
E
A
B
D
C
2. Surrounding anatomy
Kawamura_WB_CH07.indd 60 12/1/11 4:03 PM
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
Kawamura_WB_CH07.indd 62 12/1/11 4:03 PM
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 .
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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
A.
CB
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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69
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.
A
B
C
D
E
F
G
HI
J
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?
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79
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.
D
C
I
H
G
F
A
B
J
E
K
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
D
E
Lumen
Peritoneum
C
B
A
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
.
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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?
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89
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
D
EFG
A
J
I
H
1. Retroperitoneal anatomy
C
A
B
D
E
F
G
L5
2. Urinary systsem
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10 — The Kidneys 91
B
E
F
G
H
AK
L
M
J
I
C
D
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.
F
H
D
E
G
C
A
B
1. Female pelvis
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11 — The Lower Urinary System 103
E
G
H
A
B
C
F
D
2. Male pelvis
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104 PART 1 — ABDOMINAL SONOGRAPHY
A
B
C
D
E
F
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.
Kawamura_WB_CH11.indd 106 12/1/11 4:07 PM
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.
H
I
F GD
CAB
K
J
E
1. Male pelvis
B
C
D
E
A
G
F
2. Sagittal view of the male pelvis
Kawamura_WB_CH12.indd 112 12/1/11 4:07 PM
12 — The Prostate Gland 113
F
A
B
E
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?
Kawamura_WB_CH12.indd 118 12/1/11 4:07 PM
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.
A
B
C
E
D
1. Adrenal anatomy
H
F
G
B
C
D
E
A
2. Retroperitoneal anatomy
Kawamura_WB_CH13.indd 120 12/1/11 4:08 PM
13 — The Adrenal Glands 121
LEFT
RIGHT
P
O
S
TE
R
IO
R
E B
C
A
D
A
N
TE
R
IO
R
3. Right scan plane
LEFT
RIGHT
C
G
A
F
E
D
B
P
O
S
TE
R
IO
R
A
N
TE
R
IO
R
4. Left scan plane
Kawamura_WB_CH13.indd 121 12/1/11 4:08 PM
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.
Kawamura_WB_CH13.indd 123 12/1/11 4:08 PM
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.
P
K
K
RF
IVC A
A
B
C
D
1. Retroperitoneal compartments
BA
F
E
C
D
G
H
I
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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15 — The Thyroid Gland, Parathyroid Glands, and Neck 139
ANATOMY AND PHYSIOLOGY REVIEW
IMAGE LABELING
Complete the labels in the images that follow.
CF
A
E
D
B
G
1. Anterior view of the neck
A
B
D
C
2. Anterosuperior view of the neck
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140 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
J
I
H
G
F
E
A
B
C
D
3. Arterial vasculature of the neck
A
B
C
D
E
F
G
H
I
J
4. Musculature of the neck
5. Sonographic anatomy
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15 — The Thyroid Gland, Parathyroid Glands, and Neck 141
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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142 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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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15 — The Thyroid Gland, Parathyroid Glands, and Neck 143
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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144 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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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15 — The Thyroid Gland, Parathyroid Glands, and Neck 145
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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146 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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?
Kawamura_WB_CH15.indd 146 12/1/11 4:22 PM
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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148 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
ANATOMY AND PHYSIOLOGY REVIEW
IMAGE LABELING
Complete the labels in the images that follow.
N
A
M
B
C
D
E
F
G
H
I
K
J
L
1. Breast anatomy
G
F
E
D
B
C
A
2. Functional unit of the breast
Kawamura_WB_CH16.indd 148 12/1/11 4:22 PM
16 — The Breast 149
3. Zonal anatomy of the breast
RT
A
D C
B
LT
A B
4. Transducer scan planes
RT
H
F
B
D
P
C K
E
OG
A
M
I
N
J
L
LT
5. Quadrant and clock face annotation
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150 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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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16 — The Breast 151
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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152 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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 — The Breast 153
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
is
.
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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154 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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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156 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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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16 — The Breast 157
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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160 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
ANATOMY AND PHYSIOLOGY REVIEW
IMAGE LABELING
Complete the labels in the images that follow.
F
G
H
I
K
B
E
D
C
A
J
1. Scrotal anatomy
2. Scrotal anatomy
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17 — The Scrotum 161
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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162 PART 2 — SUPERFICIAL STRUCTURE SONOGRAPHY
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?
Kawamura_WB_CH18.indd 176 12/1/11 4:27 PM
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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Kawamura_WB_CH21.indd 204 12/1/11 4:30 PM
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
C
D
1. Anterior hip joint
B
C
D
A
H
G
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.
D
C
B
E
F
G
A
K
I
H
J
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
as
.
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
or
.
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.
Kawamura_WB_CH26.indd 235 12/1/11 4:33 PM
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
Kawamura_WB_CH27.indd 237 12/1/11 4:34 PM
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.
Kawamura_WB_CH27.indd 239 12/1/11 4:34 PM
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?
Kawamura_WB_CH27.indd 240 12/1/11 4:34 PM
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?
Kawamura_WB_CH27.indd 241 12/1/11 4:34 PM
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
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