Liver Disease Imaging Quiz
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Questions and Answers

What is the most common cause of acute liver failure in the United States?

  • Acetaminophen overdose (correct)
  • Alcohol abuse
  • Metabolic syndrome
  • Viral hepatitis

    • What condition is characterized by the accumulation of triglycerides within hepatocytes?

  • Hepatomegaly
  • Hepatitis
  • Steatosis (correct)
  • Cirrhosis

    • What imaging characteristic is often observed in cases of fatty infiltration in the liver?

  • Uniform echo density
  • Increased acoustic penetration
  • Decreased echogenicity
  • Increased attenuation (correct)

    • Where are focal regions of normal liver commonly seen in a fatty infiltrated liver?

    <p>Anterior to the gallbladder</p> Signup and view all the answers

    What is often noted as a characteristic of focal fatty sparing regions?

    <p>Decreased echogenicity</p> Signup and view all the answers

    What does a marked difference in echogenicity between the liver and kidney indicate?

    <p>Severe liver disease</p> Signup and view all the answers

    During sonography, what does decreased sound penetration in the liver suggest?

    <p>Increased triglyceride storage</p> Signup and view all the answers

    What is a common sonographic finding in patients with hepatomegaly and fatty infiltration?

    <p>Lack of visualization of internal vessels</p> Signup and view all the answers

    What is the most common cause of portal hypertension?

    <p>Cirrhosis and destruction of liver cells</p> Signup and view all the answers

    What is the normal pressure range of the portal vein?

    <p>5-10 mmHg</p> Signup and view all the answers

    Which procedure is used to create a bypass for portal hypertension?

    <p>Portacaval shunt</p> Signup and view all the answers

    What is the primary symptom that indicates the presence of esophageal varices due to portal hypertension?

    <p>Hematemesis</p> Signup and view all the answers

    Which of the following conditions is NOT a known complication associated with Budd-Chiari syndrome?

    <p>Volume overload in the heart</p> Signup and view all the answers

    Which characteristic is NOT typically associated with a hepatic cyst on sonographic imaging?

    <p>Thick walls</p> Signup and view all the answers

    What type of blood flow is indicated by reversed flow in the main portal vein?

    <p>Hepatofugal flow</p> Signup and view all the answers

    Which of the following is a common distinguishing feature of echinococcal cysts during sonographic examination?

    <p>Mural or shell-like calcification</p> Signup and view all the answers

    In which situation would one observe splenomegaly?

    <p>Bud-Chiari syndrome</p> Signup and view all the answers

    What does the presence of Caput medusa indicate?

    <p>Portal hypertension</p> Signup and view all the answers

    Which condition may lead to hepatomegaly and ascites due to obstruction in hepatic veins?

    <p>Budd-Chiari syndrome</p> Signup and view all the answers

    What is the typical appearance of a simple hepatic cyst on ultrasound?

    <p>Anechoic with acoustic enhancement</p> Signup and view all the answers

    Which of the following vascular changes is often observed with portal hypertension?

    <p>Increased portal vein diameter</p> Signup and view all the answers

    What is the primary cause of glycogen storage disease type 1?

    <p>Deficiency of glucose-6-phosphatase enzyme</p> Signup and view all the answers

    Which statement is NOT true regarding Hepatitis B?

    <p>It is the most common cause of chronic liver disease</p> Signup and view all the answers

    Which of the following is a common sonographic finding in acute hepatitis?

    <p>Hypoechoic liver with 'starry night' appearance</p> Signup and view all the answers

    What condition is primarily characterized by diffuse liver damage and changes in lobular architecture?

    <p>Cirrhosis</p> Signup and view all the answers

    Which enzyme is typically elevated in patients with cirrhosis?

    <p>AST (SGOT)</p> Signup and view all the answers

    What is a well-known association of Hepatitis C?

    <p>Chronic liver disease and liver transplantation</p> Signup and view all the answers

    What does 'periportal cuffing' indicate in sonography?

    <p>Acute liver inflammation</p> Signup and view all the answers

    Which of the following is NOT typically associated with cirrhosis?

    <p>Iron deposits in the liver</p> Signup and view all the answers

    Which type of glycogen storage disease is characterized by a deficiency in the enzyme glucose-6-phosphatase?

    <p>GSD type 1</p> Signup and view all the answers

    What finding is commonly observed in patients with chronic hepatitis?

    <p>Hyperechoic liver</p> Signup and view all the answers

    Which disease is primarily characterized by liver inflammation due to autoimmune mechanisms?

    <p>Autoimmune hepatitis</p> Signup and view all the answers

    What is one of the consequences of long-term cirrhosis?

    <p>Formation of regenerative nodules</p> Signup and view all the answers

    Which hepatitis type is primarily transmitted through the fecal-oral route?

    <p>Hepatitis A</p> Signup and view all the answers

    What might indicate the presence of portal hypertension on an ultrasound examination?

    <p>Enlarged spleen</p> Signup and view all the answers

    What symptom is commonly associated with a pyogenic liver abscess?

    <p>RUQ pain</p> Signup and view all the answers

    Which organism is the most common cause of pyogenic liver abscess?

    <p>Escherichia coli</p> Signup and view all the answers

    Which type of liver abscess occurs due to amoebic dysentery?

    <p>Amebic liver abscess</p> Signup and view all the answers

    What imaging characteristic is associated with a schistosomiasis liver abscess?

    <p>Turtle back sign</p> Signup and view all the answers

    What is the most common opportunistic infection in HIV-infected persons?

    <p>Pneumocystis jiroveci pneumonia</p> Signup and view all the answers

    What sign is indicative of chronic Hepatitis B infection with hepatic lesions?

    <p>Starry sky pattern</p> Signup and view all the answers

    Which symptom is a key indicator of an amebic liver abscess?

    <p>Diarrhea</p> Signup and view all the answers

    What type of collection is often characterized by the 'water-lily sign'?

    <p>Echinococcal cyst</p> Signup and view all the answers

    Which imaging result is most indicative of Pneumocystis pneumonia in an HIV patient?

    <p>Multiple tiny focal calcifications</p> Signup and view all the answers

    What surgical or diagnostic procedure is essential to confirm a bacterial liver abscess?

    <p>Aspiration</p> Signup and view all the answers

    What appearance does a fungal infection of the liver typically take on during the disease progression?

    <p>Wheels within wheels</p> Signup and view all the answers

    Which result often signifies portal hypertension due to schistosomiasis?

    <p>Splenomegaly</p> Signup and view all the answers

    What is the standard source of a pyogenic liver abscess?

    <p>Biliary tract</p> Signup and view all the answers

    What is a common clinical feature of liver abscess caused by Schistosomiasis?

    <p>Fever and RUQ pain</p> Signup and view all the answers

    What is the primary role of the gallbladder?

    <p>To store and transport bile from the liver to the GI system</p> Signup and view all the answers

    What is the normal measurement for the intrahepatic duct?

    <p>2 mm or no more than 40% of portal vein</p> Signup and view all the answers

    What type of cholecystitis occurs without the presence of gallstones?

    <p>Acalculous Cholecystitis</p> Signup and view all the answers

    Which structure does the common bile duct join with to form the Ampulla of Vater?

    <p>Main pancreatic duct</p> Signup and view all the answers

    What is one potential complication of acute cholecystitis?

    <p>Gallbladder Perforation</p> Signup and view all the answers

    What sonographic finding is most indicative of empyema of the gallbladder?

    <p>Atypical bile echoes</p> Signup and view all the answers

    In which part of the gallbladder is perforation most likely to occur due to blood supply issues?

    <p>Fundus of the gallbladder</p> Signup and view all the answers

    What are common symptoms associated with acute cholecystitis?

    <p>RUQ pain, N/V, and fever</p> Signup and view all the answers

    What is a common sonographic finding in gangrenous cholecystitis?

    <p>Hypoechoic areas with gas</p> Signup and view all the answers

    What does a positive Murphy’s sign indicate in the context of gallbladder disease?

    <p>Inflammation such as cholecystitis</p> Signup and view all the answers

    Which condition is characterized by pus in the gallbladder?

    <p>Empyema of Gallbladder</p> Signup and view all the answers

    What symptom may not be present in some patients with gangrenous cholecystitis due to nerve damage?

    <p>Positive Murphy's sign</p> Signup and view all the answers

    Which imaging finding is common in cases of gallbladder perforation?

    <p>Fluid collection in GB fossa</p> Signup and view all the answers

    Which condition is characterized by gas-forming bacteria invading the gallbladder wall?

    <p>Emphysematous cholecystitis</p> Signup and view all the answers

    What is a typical sonographic finding in emphysematous cholecystitis?

    <p>Echogenic foci in GB wall or lumen</p> Signup and view all the answers

    Which group of patients is more likely to develop emphysematous cholecystitis?

    <p>Men</p> Signup and view all the answers

    What finding is indicative of chronic cholecystitis?

    <p>Gallbladder wall thickening</p> Signup and view all the answers

    How can gas bubbles behave in the gallbladder when a patient changes positions?

    <p>They can swirl within the lumen</p> Signup and view all the answers

    What is the relationship between gallbladder polyps and malignancy?

    <p>Size is the most important indicator of malignancy.</p> Signup and view all the answers

    What finding suggests porcelain gallbladder on sonography?

    <p>Single echogenic line representing calcified wall</p> Signup and view all the answers

    Which condition often leads to the accumulation of cholesterol in the gallbladder wall?

    <p>Adenomyomatosis</p> Signup and view all the answers

    Which symptom is commonly associated with chronic cholecystitis?

    <p>Intermittent nausea and vomiting</p> Signup and view all the answers

    What is a notable risk associated with emphysematous cholecystitis?

    <p>High rate of gangrene and perforation</p> Signup and view all the answers

    Which type of gallbladder polyp generally does not require treatment?

    <p>Lesions less than 10mm</p> Signup and view all the answers

    What abnormal finding would increase suspicion of gallbladder carcinoma?

    <p>Wall thickening greater than 1cm</p> Signup and view all the answers

    Which feature is commonly seen with cholesterolosis in the gallbladder?

    <p>Multiple, small, no shadowing foci</p> Signup and view all the answers

    Which benign liver tumor is typically found incidentally and is most common in the general population?

    <p>Cavernous Hemangioma</p> Signup and view all the answers

    What characteristic is NOT associated with Hepatic Adenoma?

    <p>Presence of central fibrous scar</p> Signup and view all the answers

    What is a primary advantage of color Doppler imaging in evaluating liver masses?

    <p>Assessing the internal vascularity</p> Signup and view all the answers

    Total hepatic resection is generally recommended for which of the following conditions?

    <p>Hepatocellular Carcinoma</p> Signup and view all the answers

    Which statement about Focal Nodular Hyperplasia (FNH) is false?

    <p>It is more common in men than women.</p> Signup and view all the answers

    What echogenic characteristic is typical for Hepatocellular Carcinoma?

    <p>Hypoechoic with chaotic internal vasculature</p> Signup and view all the answers

    In the context of liver metastases, which type is most commonly associated with the lungs?

    <p>Bulls eye or Target metastases</p> Signup and view all the answers

    What is the most significant laboratory finding associated with Hepatocellular Carcinoma?

    <p>Elevated AFP</p> Signup and view all the answers

    What characteristic distinguishes hepatic lipoma from other liver masses?

    <p>Propagation speed artifact due to fat</p> Signup and view all the answers

    What is a common clinical presentation in patients with Hepatoblastoma?

    <p>Hepatomegaly in infants</p> Signup and view all the answers

    In which age group is Hepatocellular Carcinoma most commonly found?

    <p>Between ages 40 to 60</p> Signup and view all the answers

    Which liver mass type is strongly associated with the intake of estrogen-based medications?

    <p>Hepatic Adenoma</p> Signup and view all the answers

    What common complication is associated with metastatic liver disease?

    <p>Normal laboratory values</p> Signup and view all the answers

    Which of the following is a typical sonographic appearance of the hepatic masses?

    <p>Hyperechoic with posterior enhancement</p> Signup and view all the answers

    Which benign liver tumor is most frequently associated with hemangiomas?

    <p>Focal Nodular Hyperplasia</p> Signup and view all the answers

    What syndrome results from an impacted stone at the cystic duct causing compression of the common hepatic duct?

    <p>Mirizzi syndrome</p> Signup and view all the answers

    What is a classic symptom of cholangiocarcinoma?

    <p>Weight loss</p> Signup and view all the answers

    What laboratory finding is typically increased in patients with cholangitis?

    <p>Increased serum bilirubin</p> Signup and view all the answers

    Which of the following should be a consideration when diagnosing primary sclerosing cholangitis?

    <p>Intrahepatic duct dilatation</p> Signup and view all the answers

    What is the most common cause of pneumobilia?

    <p>ERCP procedure</p> Signup and view all the answers

    In which situation is the presence of air in the biliary tract most likely observed?

    <p>Post-ERCP</p> Signup and view all the answers

    What does Charcot's triad consist of in the context of cholangitis?

    <p>RUQ pain, fever, jaundice</p> Signup and view all the answers

    What condition is associated with biliary obstruction caused by the parasitic roundworm Ascaris lumbricoides?

    <p>Biliary ascariasis</p> Signup and view all the answers

    What finding is characteristic of a Klatskin tumor?

    <p>Intrahepatic but not extrahepatic biliary dilation</p> Signup and view all the answers

    What imaging characteristic is observed in pneumobilia?

    <p>Bright echogenic foci</p> Signup and view all the answers

    What is the most common finding associated with primary sclerosing cholangitis?

    <p>Intrahepatic duct dilation</p> Signup and view all the answers

    What is the primary complication resulting from choledocholithiasis?

    <p>Acute pancreatitis</p> Signup and view all the answers

    Which age group is most commonly affected by cholangiocarcinoma?

    <p>Adults aged 50-70</p> Signup and view all the answers

    What is associated with the presence of multiple shadowing stones within the common bile duct?

    <p>Cholecodocholithiasis</p> Signup and view all the answers

    What anatomical position describes the iliac veins in relation to the inferior vena cava?

    <p>Inferior</p> Signup and view all the answers

    What is the most common symptom that leads to the suspicion of biliary atresia in infants?

    <p>Persistent jaundice beyond 14 days of age</p> Signup and view all the answers

    Which position accurately describes a patient lying on their right side?

    <p>Right lateral decubitus</p> Signup and view all the answers

    Which condition is associated with the 'Triangular Cord Sign' in imaging?

    <p>Biliary atresia</p> Signup and view all the answers

    What is the term used to describe an anatomical image obtained from returning echoes?

    <p>Sonogram</p> Signup and view all the answers

    Which procedure is considered the most successful treatment for biliary atresia if performed early?

    <p>Kasai portoenterostomy</p> Signup and view all the answers

    Which scanning plane was used to obtain the sonogram of the left kidney?

    <p>Longitudinal</p> Signup and view all the answers

    What term describes an organ or tissue that produces echoes by reflecting the acoustic beam?

    <p>Hyperechoic</p> Signup and view all the answers

    Which type of choledochal cyst is most common?

    <p>Type I</p> Signup and view all the answers

    What imaging characteristic would you expect from an anechoic structure?

    <p>It is echo-free</p> Signup and view all the answers

    Which of the following is NOT commonly associated with choledochal cysts?

    <p>Gallbladder carcinoma</p> Signup and view all the answers

    What does hypoechoic refer to in terms of tissue appearance?

    <p>Less bright than surrounding tissues</p> Signup and view all the answers

    What imaging finding is characteristic of Caroli disease?

    <p>Multifocal segmental dilatation of intrahepatic bile ducts</p> Signup and view all the answers

    What is a significant complication associated with choledocholithiasis?

    <p>Acute pancreatitis</p> Signup and view all the answers

    Which term identifies a structure that is less echogenic than its surroundings?

    <p>Hypoechoic</p> Signup and view all the answers

    What kind of artifact occurs due to low reflectivity in ultrasound imaging?

    <p>Acoustic shadowing</p> Signup and view all the answers

    Which condition is characterized by an overdistended gallbladder filled with thick bile or pus?

    <p>Hydropic gallbladder</p> Signup and view all the answers

    In the case of post cholecystectomy, what happens to the diameter of the common bile duct as patients age?

    <p>It increases by approximately 1mm per decade</p> Signup and view all the answers

    What does acoustic enhancement signify in ultrasound imaging?

    <p>Increased signal amplitude returning from structures</p> Signup and view all the answers

    How is a homogeneous echo texture characterized?

    <p>Equal intensity of echoes</p> Signup and view all the answers

    What lab values are typically elevated in cases of biliary obstruction?

    <p>Alkaline phosphatase and direct bilirubin</p> Signup and view all the answers

    Which of the following is a significant indicator of a dilated intrahepatic bile duct?

    <p>Intrahepatic ducts &gt;2mm</p> Signup and view all the answers

    What would describe a structure with several different echo characteristics?

    <p>Heterogeneous</p> Signup and view all the answers

    What happens to the gallbladder when there is a distal common bile duct obstruction?

    <p>It distends</p> Signup and view all the answers

    What characteristic does hyperechoic tissue exhibit?

    <p>It is brighter than surrounding tissues</p> Signup and view all the answers

    Which of the following is a classic sign associated with biliary obstruction?

    <p>Fever and RUQ pain</p> Signup and view all the answers

    What could cause shadowing in ultrasound imaging?

    <p>Air bubbles</p> Signup and view all the answers

    What might be an indication for administering a fatty meal during evaluation?

    <p>High levels of conjugated bilirubin</p> Signup and view all the answers

    What term describes reduced echo amplitude due to attenuation?

    <p>Shadowing</p> Signup and view all the answers

    Which term describes an image that exhibits equal intensity throughout?

    <p>Homogeneous</p> Signup and view all the answers

    What characteristic is indicative of a cystic mass?

    <p>Anechoic center</p> Signup and view all the answers

    Which muscle is NOT part of the posterior abdominal wall?

    <p>Rectus abdominis</p> Signup and view all the answers

    Which part of the diaphragm is located centrally and does NOT have bony attachments?

    <p>Central tendon</p> Signup and view all the answers

    What characteristic describes the wall of a solid mass?

    <p>Irregular and poorly defined</p> Signup and view all the answers

    Which term best describes a complex mass?

    <p>Exhibits both anechoic and echogenic areas</p> Signup and view all the answers

    What is the primary function of the diaphragm?

    <p>To aid in respiration</p> Signup and view all the answers

    What should be evaluated when assessing the amplitude of echoes distal to a mass?

    <p>Attenuation properties</p> Signup and view all the answers

    Which structure is referred to as the double-domed musculotendinous partition?

    <p>Diaphragm</p> Signup and view all the answers

    Which part of the diaphragm arises from the bodies of the lumbar vertebrae?

    <p>Diaphragmatic crura</p> Signup and view all the answers

    What is a characteristic feature of 'transonic' structures?

    <p>Little attenuation of the acoustic beam</p> Signup and view all the answers

    What does acoustic enhancement artifact indicate in sonographic imaging?

    <p>Increased echo amplitude from surrounding tissue</p> Signup and view all the answers

    What imaging technique is commonly used to evaluate the abdominal wall structures?

    <p>Sonography</p> Signup and view all the answers

    Which factor can affect the appearance of edge shadowing artifacts?

    <p>Cystic wall thickness</p> Signup and view all the answers

    What is the key purpose of using stand-off pads in abdominal imaging?

    <p>To assist in visualizing near-field structures</p> Signup and view all the answers

    Which characteristic is associated with echopenic structures?

    <p>Very low internal echoes</p> Signup and view all the answers

    Which layer of muscle is categorized as intermediate extrinsic back muscles?

    <p>Latissimus dorsi</p> Signup and view all the answers

    What documentation is crucial to include on a sonographer's preliminary report?

    <p>Facility, date, and time of examination</p> Signup and view all the answers

    What anatomical structure forms the roof of the abdominal cavity?

    <p>Diaphragm</p> Signup and view all the answers

    Which of the following is TRUE regarding the central tendon of the diaphragm?

    <p>It resembles three leaves of a clover</p> Signup and view all the answers

    Who is legally responsible for providing a diagnosis based on sonographic findings?

    <p>Physician</p> Signup and view all the answers

    What does a low amplitude echo posterior to a solid mass typically indicate?

    <p>Increased acoustic attenuation</p> Signup and view all the answers

    What is essential for the sonographer in clinical practice during patient preparation?

    <p>Collecting comprehensive clinical information</p> Signup and view all the answers

    What describes the ability of a sonography examination to accurately identify disease that is present?

    <p>Sensitivity</p> Signup and view all the answers

    Which statistical parameter increases when the number of false-positive examinations decreases?

    <p>Specificity</p> Signup and view all the answers

    What is the formula to calculate positive predictive value?

    <p>true-positive ÷ (true-positives + false-positives) × 100</p> Signup and view all the answers

    What structure is located halfway from the umbilicus to the pubic symphysis?

    <p>Arcuate line</p> Signup and view all the answers

    What is the primary function of the aponeurosis in the abdominal wall?

    <p>Attach muscles to fixed points</p> Signup and view all the answers

    Which of the following abdominal wall muscles is located on the anterior wall?

    <p>Pyramidalis</p> Signup and view all the answers

    What is indicated by a positive predictive value of 90%?

    <p>9 out of 10 patients with a positive test truly have the disease</p> Signup and view all the answers

    Which two tissues compose the superficial fascia of the abdominal wall?

    <p>Connective tissue and fat</p> Signup and view all the answers

    What separates the bilateral rectus sheaths in the abdominal wall?

    <p>Linea alba</p> Signup and view all the answers

    What type of abdomen wall hernia occurs due to weaknesses in the inguinal canal?

    <p>Inguinal hernia</p> Signup and view all the answers

    Which component provides a strong compartment for the rectus abdominis muscles?

    <p>Rectus sheath</p> Signup and view all the answers

    What anatomical feature forms where the fetal umbilical vessels passed during development?

    <p>Umbilicus</p> Signup and view all the answers

    Which blood vessel relation is correct concerning the abdominal wall structure?

    <p>Superficial fascia has limited blood vessels</p> Signup and view all the answers

    What defines the inguinal canal in adults?

    <p>Oblique passageway approximately 4cm long</p> Signup and view all the answers

    What is the primary imaging characteristic of peritoneal implants associated with peritoneal metastasis?

    <p>Small polypoid masses projecting from the peritoneum</p> Signup and view all the answers

    Which condition is most commonly associated with omental caking?

    <p>Primary ovarian cancer</p> Signup and view all the answers

    What is the most significant factor that distinguishes transudative effusions from exudative effusions?

    <p>Protein content</p> Signup and view all the answers

    What is a key indication for performing a paracentesis?

    <p>To relieve abdominal pressure</p> Signup and view all the answers

    Which diagnostic procedure is used to aspirate fluid from the pleural space?

    <p>Thoracentesis</p> Signup and view all the answers

    What complication is often monitored during a thoracentesis procedure?

    <p>Pneumothorax</p> Signup and view all the answers

    What is the primary purpose of a percutaneous abscess drainage (PAD) procedure?

    <p>To aspirate and analyze abscess contents</p> Signup and view all the answers

    Which of the following best describes a transudative pleural effusion?

    <p>It is associated with conditions like liver cirrhosis.</p> Signup and view all the answers

    What technique is essential during a paracentesis to avoid damaging vessels?

    <p>Ultrasound guidance</p> Signup and view all the answers

    What is a common symptom experienced by patients after a thoracentesis procedure?

    <p>Coughing when lungs re-expand</p> Signup and view all the answers

    What separates the rectus sheath from the parietal peritoneum inferior to the umbilicus?

    <p>Transversalis fascia</p> Signup and view all the answers

    Which of the following is NOT a type of abdominal wall pathology?

    <p>Hemangioma</p> Signup and view all the answers

    What shape is typically associated with a rectus sheath hematoma?

    <p>Lenticular</p> Signup and view all the answers

    What is a common cause for rectus sheath hematomas?

    <p>External trauma</p> Signup and view all the answers

    Where do most abdominal wall hernias typically occur?

    <p>Anterior wall</p> Signup and view all the answers

    What is a key characteristic of periumbilical abscesses on ultrasound?

    <p>Complex mixed echo appearance</p> Signup and view all the answers

    Which of the following factors does NOT contribute to hernia formation?

    <p>Frequent aerobic exercise</p> Signup and view all the answers

    What is often the most reliable finding in a patient with an abscess?

    <p>Presence of fever</p> Signup and view all the answers

    What is the main location for accumulation in cases of ascites?

    <p>Most dependent areas of the body</p> Signup and view all the answers

    In which type of hernia is the sac located medial to the inferior epigastric vessels?

    <p>Direct inguinal hernia</p> Signup and view all the answers

    What condition is characterized by a fluid-filled collection near surgical or painful areas?

    <p>Abscess</p> Signup and view all the answers

    Which of the following is NOT a complication associated with anticoagulation therapy?

    <p>Inguinal hernia</p> Signup and view all the answers

    What is a common sonographic appearance of long-standing hematomas?

    <p>Hypoechoic with thick contours</p> Signup and view all the answers

    What effect does an external compression from a rectus sheath hematoma have on nearby structures?

    <p>Compression and irritation of the urinary bladder</p> Signup and view all the answers

    What is the primary cause for the accumulation of transudative ascites?

    <p>Low serum osmotic pressure</p> Signup and view all the answers

    Which structure is commonly referred to as the Pouch of Douglas?

    <p>Rectouterine Space</p> Signup and view all the answers

    What is a characteristic feature of exudative ascites on ultrasound?

    <p>High level of protein and cellular material</p> Signup and view all the answers

    What are the common sites for ascites accumulation?

    <p>Pouch of Douglas, paracolic gutters</p> Signup and view all the answers

    What condition is associated with the presence of pseudomyxoma peritonei?

    <p>Malignancy of the appendix</p> Signup and view all the answers

    Which type of collection is associated with a hematoma?

    <p>Coagulated blood</p> Signup and view all the answers

    What describes the sonographic appearance of a biloma?

    <p>Cystic mass with debris</p> Signup and view all the answers

    Which condition is a common cause of urinoma?

    <p>Renal trauma</p> Signup and view all the answers

    What is the approximate location of mesenteric adenopathy enlargement?

    <p>Along the bowel in the mesentery</p> Signup and view all the answers

    What is a distinguishing feature of peritoneal mesothelioma?

    <p>Solid mass associated with asbestos exposure</p> Signup and view all the answers

    What commonly results in the formation of a lymphocele?

    <p>Surgical disruption of lymphatic channels</p> Signup and view all the answers

    What is a likely appearance of a peritoneal abscess on ultrasound?

    <p>Well-defined fluid collection without blood flow</p> Signup and view all the answers

    What characterizes the development of ascites in patients with cirrhosis?

    <p>Portal hypertension</p> Signup and view all the answers

    What is often the first imaging technique used in trauma cases to assess for free fluid?

    <p>Focused assessment with sonography</p> Signup and view all the answers

    Which hernia type is located directly lateral to the inferior epigastric vessels?

    <p>Indirect inguinal hernia</p> Signup and view all the answers

    What causes an umbilical hernia?

    <p>Weakness of the abdominal wall from the umbilical cord</p> Signup and view all the answers

    Where is a direct inguinal hernia located in relation to the inferior epigastric vessels?

    <p>Medial</p> Signup and view all the answers

    What condition is associated with hernias that cannot easily be moved back into place?

    <p>Incarcerated hernia</p> Signup and view all the answers

    Which hernia occurs adjacent to the femoral vein just below the groin crease?

    <p>Femoral hernia</p> Signup and view all the answers

    What type of hernia is described as very difficult to diagnose due to lack of visible bulging?

    <p>Obturator hernia</p> Signup and view all the answers

    What is not a scanning protocol specifically used to document hernia information?

    <p>Identifying liver lesions</p> Signup and view all the answers

    Which characteristic can sonography NOT help evaluate in hernia assessment?

    <p>Liquefaction of the liver</p> Signup and view all the answers

    What is the primary reason for the increased risk of strangulation in certain hernias?

    <p>Non-reducibility of the hernia</p> Signup and view all the answers

    What type of hernia occurs along the edge of the rectus abdominus muscle?

    <p>Spigelian hernia</p> Signup and view all the answers

    Which imaging strategy is specifically highlighted for its real-time capability in hernia assessment?

    <p>Sonography</p> Signup and view all the answers

    Which abdominal wall tumor is characterized by the accumulation of fat?

    <p>Lipoma</p> Signup and view all the answers

    What is NOT a symptom associated with diaphragmatic eventration?

    <p>Complete paralysis of the diaphragm</p> Signup and view all the answers

    What imaging finding is most indicative of a pleural effusion?

    <p>Loculated fluid collections</p> Signup and view all the answers

    What structure connects the lesser curvature of the stomach to the liver?

    <p>Gastrohepatic ligament</p> Signup and view all the answers

    Which ligament is a remnant of the fetal umbilical vein?

    <p>Ligamentum teres</p> Signup and view all the answers

    What is the primary gravity-dependent potential space in the abdominal cavity?

    <p>Morrison pouch</p> Signup and view all the answers

    Which space is formed by the peritoneum reflecting over the rectum and posterior bladder wall?

    <p>Vesicorectal space</p> Signup and view all the answers

    Which ligament connects the stomach to the spleen?

    <p>Gastrosplenic ligament</p> Signup and view all the answers

    What is the role of ligaments in the peritoneal cavity?

    <p>Divide portions of the peritoneal cavity</p> Signup and view all the answers

    What potential space is located between the diaphragm and anterior superior liver, leftward of the falciform ligament?

    <p>Left anterior subphrenic space</p> Signup and view all the answers

    Which ligament connects the splenic hilum to the posterior abdominal wall?

    <p>Splenorenal ligament</p> Signup and view all the answers

    What is the significance of the epiploic foramen?

    <p>It connects the greater sac to the lesser sac.</p> Signup and view all the answers

    Which potential space collects fluid from the supracolic area and lesser sac?

    <p>Hepatorenal space</p> Signup and view all the answers

    What is a potential result of disease presence in the peritoneal spaces?

    <p>Fluid or other materials may collect</p> Signup and view all the answers

    Which ligament forms the left extremity of the bare area of the liver?

    <p>Left triangular ligament</p> Signup and view all the answers

    What are the right and left paracolic gutters important for?

    <p>Communication between supracolic and infracolic compartments</p> Signup and view all the answers

    What does the term 'bare area of liver' refer to?

    <p>The region not covered by peritoneum</p> Signup and view all the answers

    Study Notes

    Fungal Infection/ Abscess Candidiasis

    • A blood infection causing small abscesses in the liver
    • "Wheel within a wheel" - a lesion with a peripheral hypoechoic zone, an inner echogenic wheel and a hypoechoic center- most recognizable early stage of fungal infection
    • "Bulls eye" - lesion appears like this when the hypoechoic center calcifies
    • "Uniformly hypoechoic focus" - most common presentation of the lesion; may resemble metastases
    • "Echogenic focus" - calcification is the scar formation, seen in the late process of the disease

    Cavernous Hemangiomas

    • Most common benign liver tumor, occurring in up to 4% of the population
    • Usually an incidental finding and often asymptomatic.
    • Hyperechoic appearance due to multiple vascular channels lined with endothelium.
    • Posterior enhancement is usually present.
    • May enlarge with pregnancy and estrogen intake
    • May appear hypoechoic in fatty livers.
    • Usually no color flow within the tumor
    • Contrasted enhanced imaging demonstrates centripetal flow.

    Focal Nodular Hyperplasia (FNH)

    • 2nd most common benign liver mass
    • Lacks normal hepatic architecture.
    • Arterial supply is from the hepatic artery and venous drainage into the hepatic veins.
    • No portal venous branch.
    • More common in women of reproductive age.
    • Composed of hepatocytes, Kupffer's cells, and bile ductules; organized, well-defined and without a true capsule.
    • Associated with hemangiomas.
    • Solid mass with varying echogenicity.
    • Solitary lesion in 80-95% of cases.
    • Central fibrous scar, Spoke wheel appearance on color Doppler.
    • Often located in the right lobe or left lateral segment.
    • "Stealth lesion" - isoechoic lesions that displace intrahepatic blood vessels.

    Hepatic Adenoma (LCA) - Liver Cell Adenoma

    • Mostly occur in women of childbearing age.
    • Strongly associated with oral contraceptive and estrogen use.
    • Clinical symptoms vary; can be asymptomatic.
    • Rare, benign epithelial neoplasm composed of normal or atypical hepatocytes.
    • Can be associated with glycogen storage disease.
    • Surgical resection is recommended due to risk of malignant transformation.
    • Encapsulated, well-circumscribed, hyperechoic mass with a hypoechoic halo; may also appear hypoechoic or isoechoic relative to normal liver parenchyma.
    • Increased vasculature with flow in the center and periphery of the lesion on color Doppler.

    Hepatic Lipoma

    • Extremely rare fatty tumors.
    • Associated with Tuberous sclerosis.
    • Hyperechoic mass with propagation speed artifact.
    • Decreased speed of sound in fat (1450 m/s) results in a prolonged sound return time.
    • Broken diaphragm artifact.
    • CT can confirm the fatty nature of the mass.

    Hyperechoic Liver Masses:

    • Hepatic lipoma
    • Hemangioma
    • Echogenic metastasis
    • Focal fatty infiltration

    Hepatocellular Carcinoma (HCC)

    • Also known as Hepatoma.
    • Most common primary liver malignancy.
    • Occurs predominantly in patients with underlying chronic liver disease and cirrhosis.
    • 5th most common cancer worldwide.
    • Commonly invade venous structures (portal veins, hepatic veins, and IVC).
    • Uncommon before age 40; most common in the 6th decade of life.
    • Increase in AFP, AST (SGOT) and ALT (SGPT)
    • Variable appearance on ultrasound.
    • Most are hypoechoic.
    • Chaotic internal vasculature on Color Doppler.
    • Clinical Symptoms: Weight loss, Nausea & Vomiting, RUQ pain, Pruritus, Splenomegaly, Palpable mass, Hepatomegaly, Jaundice, Ascites.
    • Treatments: Hepatic resection, Transcatheter arterial chemoembolization, Percutaneous ethanol injection, Radiofrequency ablation, Cryoablation, Liver transplant.

    Hepatoblastoma

    • Rare tumor mainly in infants.
    • Most often occur prior to the age of 2.
    • Hepatomegaly, Calcifications may be present.
    • Elevated AFP levels.
    • Associated with Beckwith-Wiedemann syndrome and Familial adenomatous polyposis.
    • Associated with lung metastases and portal vein invasion.

    Metastatic Disease

    • Liver is the most common site for metastases after lymph nodes.
    • Incidence is 18 to 20 times more common than HCC.
    • Most common primary cancers: gallbladder, colon, stomach, pancreas, kidney, ovaries, breast, and lung.
    • The liver is vulnerable to metastasis due to its large blood volume and large reserve of lymphatic drainage.
    • **Approximately 40% of patients with cancer have liver metastases. **
    • LFT values can be normal.
    • AST and ALT may be elevated.
    • ALP and bilirubin elevated with biliary obstruction.
    • AFP is typically not elevated in liver metastatic disease.
    • Sonographic Findings:
      • Hyperechoic: Gastrointestinal tract
      • Hypoechoic: Lymphoma
      • "Bulls eye" or "Target": Lung
      • Calcified: Mucinous adenocarcinoma of the colon
      • Cystic: Leiomyosarcoma (uterus)
    • Ultrasound-guided biopsy is needed to confirm primary tissue diagnosis due to the nonspecific sonographic appearance of metastases.

    Gallbladder Part 1

    • The function is to store and transport bile from the liver to the GI system.
    • The biliary system comprises the gallbladder and the hepatic ducts.
    • The hepatic ducts are divided into intrahepatic and extrahepatic ducts.
    • The right and left hepatic ducts (intrahepatic) converge at the porta hepatis to form the common hepatic duct.
    • The CHD is joined by the cystic duct to form the common bile duct (CBD).
    • The common bile duct and main pancreatic duct (Duct of Wirsung) join to form the Ampulla of Vater.
    • CBD passes posterior to the first part of the duodenum and the pancreatic head.
    • The ampulla of Vater empties through the duodenal papilla, controlled by the Sphincter of Oddi.
    • The Porta hepatis - The Portal triad consists of the Main Portal vein, Common Hepatic Duct, and Proper Hepatic artery.
    • Also known as the "Mickey Mouse Sign".

    Measurements of Biliary Ducts

    • The duct is measured from the inner wall to the inner wall.
    • Normal intraluminal measurement for the intrahepatic duct is 2 mm or no more than 40% of the portal vein.
    • Measurement controversy exists for CBD and CHD.
    • CHD typically does not measure greater than 4 mm.
    • CBD typically should measure 3 mm.

    Acalculous Cholecystitis

    • Acute cholecystitis without the presence of gallstones.
    • Usually a secondary event in critically ill hospitalized patients.
    • Causes: - Bile stasis (viscous bile) - Decreased gallbladder contraction - Infection (secondary event)
    • Sonographic Findings: Wall thickening, positive Murphy's sign, pericholecystic fluid.
    • Symptoms: RUQ pain, Nausea, Vomiting.
    • Associated with:
      • Infection from or post surgery
      • Viral infection
      • TPN > 3 months
      • Severe trauma
      • Severe burns
      • Sepsis
      • HIV/AIDS
      • Blood transfusion reaction
      • High dosage opioid analgesics

    Complicated Cholecystitis

    • Patients with acute cholecystitis are at risk for:
      • Empyema
      • Gallbladder perforation
      • Gangrenous cholecystitis
      • Emphysematous cholecystitis

    Empyema of the Gallbladder

    • Pus in the gallbladder.
    • Also known as Suppurative Cholecystitis.
    • Often initiated with obstruction of the cystic duct.
    • Sonographic Findings: Suspect if atypical bile echoes are present.
    • **Symptoms: ** Same as Acute Cholecystitis, Fever, chills, RUQ pain.
    • Sepsis is possible.

    Gallbladder Perforation

    • A rare, life-threatening complication of acute cholecystitis.
    • The GB Fundus - most distal part with regard to blood supply - is the most common perforation site.
    • Localized fluid collection in the GB fossa is common.
    • Higher morbidity and mortality rates are often encountered due to delayed treatment because of diagnostic difficulties.
    • Labs often show an increase in WBC and abnormal LFTs.
    • Complications include: Peritonitis, Pericholecystic Abscess, Biliary fistula.
    • Sonographic Findings: Complex fluid collection (abscess), Irregular GB wall, Gallstones, Inflammatory changes in the GB fossa, Focal defect in the GB wall.
    • Symptoms: RUQ pain, N/V, Fever, chills,

    Gangrenous Cholecystitis

    • Due to absent blood supply or infection.
    • GB wall becomes ischemic - eventually necrotic.
    • Lab values usually show an increase in WBCs.
    • Sonographic Findings:
      • Often non-specific
      • Thickened, irregular wall with both hyperechoic and hypoechoic striations.
      • Gas within the GB wall or lumen.
      • Absent GB wall.
      • Abscesses may be present.
    • Symptoms: Acutely ill patient, Positive Murphy's sign in ⅓ of patients.
    • Nerve damage may lead to a negative Murphy's sign, resulting in diffuse pain.

    Emphysematous Cholecystitis

    • Acute cholecystitis due to gallbladder wall ischemia and infection.
    • Gas-forming bacteria invade the GB wall, lumen, or biliary tree.
    • More common in men.
    • Occurs more commonly in diabetic patients.
    • Higher rate of gangrene and perforation.
    • Fatal in about 15% of cases.
    • Sonographic findings:
      • Comet-tail or ring-down artifacts are seen due to the presence of gas.
      • Gas bubbles produced by bacteria may rise to the non-dependent wall of the GB.
      • Change position with patient position.
      • Air appears as echogenic foci within the GB wall or lumen.

    Causes of gas in the biliary system:

    • ERCP surgery.
    • Sphincter of Oddi papillotomy.
    • Choledochojejunostomy (anastomosis of CBD to jejunum).
    • GB (biliary) fistula.
    • Emphysematous cholecystitis.

    Chronic Cholecystitis

    • Clinically defined as recurring symptoms of biliary colic due to previous episodes of acute cholecystitis.
    • Usually associated with gallstones.
    • Affects women more than men.
    • Occurs more often in the elderly.
    • Intolerance to fatty or fried foods associated with intermittent N/V
    • FINDINGS: Thick GB wall, Contracted GB, Sludge and obstructed cystic duct may be present.

    Gallbladder Wall Thickening

    • GB wall thickness greater than 3mm is abnormal.
    • Most common cause is Cholecystitis.
    • Nonfasting patients will have a thicker GB wall.
    • Other causes:
      • Hypoalbuminemia
      • Ascites
      • Hepatitis
      • Congestive Heart Failure
      • Pancreatitis

    Porcelain Gallbladder

    • Calcification of the GB wall associated with chronic cholecystitis.
    • More common in men.
    • Associated with GB carcinoma.
    • Sonographic findings: Single echogenic line representing the calcified wall.
    • All or part of the wall may be calcified.
    • If the wall is a strong reflector, a posterior shadow may be seen and obstruct the visualization of the GB.

    Gallbladder Polyps

    • Masses extending from the GB mucosa.
    • If less than 10mm unlikely to be cancerous and generally do not require treatment.
    • Often asymptomatic.
    • No association with age, gender, or obesity.
    • Majority composed of cholesterol and benign.
    • SIZE - is the most important indicator of malignancy.
    • Lesions greater than 10mm have a higher malignancy rate.
    • Sonographic Findings: Fixed, non-mobile hyperechoic mass attached to the wall, no posterior shadowing.
    • Can be single or multiple.
    • Polyps greater than 1 cm should be surgically removed.

    Hyperplastic Cholecystoses

    • A group of benign, non-inflammatory conditions that are both degenerative and proliferative.
      • Adenomyomas
      • Cholesterosis
      • Neuromatosis
      • Fibromatosis
      • Lipomatosis

    Adenomyomatosis

    • Hyperplastic changes involving the gallbladder wall causing overgrowth of the mucosa, thickening of the wall, and formation of diverticula.
    • More common in women.
    • Diverticula within the gallbladder wall (Rokitansky-Aschoff sinuses) accumulate stones or sludge within them.
    • Patients may present with RUQ pain.
    • Sonographic Findings:
      • Focal or diffuse wall thickening.
      • Small, round, anechoic spaces in the GB wall represent Rokitansky-Aschoff sinuses.
      • Echogenic foci spaced in the GB wall show acoustic shadowing, comet-tail reverberation artifact, or "Twinkle artifact" with Color Doppler.
      • Gallstones are common.

    Cholesterolosis

    • Lipids (triglycerides and cholesterol) are deposited in the GB wall.
    • More frequent in women.
    • Can be diffuse and not impair the GB.
    • Appear as polyps, vary in size and can be as large as 1cm.
    • Also known as "Strawberry Gallbladder" due to golden yellow lipid deposits against the red gallbladder mucosa (diffuse form).
    • Usually, no clinical symptoms but can experience colicky abdominal pain.

    Gallbladder Carcinoma

    • Signs and symptoms are usually nonspecific and mimic cholecystitis.
    • Can metastasize to the liver, lymph nodes, CHD, and surrounding organs.
    • Less than 50% of GB cancers are diagnosed preoperatively.
    • Many are diagnosed incidentally post-cholecystectomy.
    • Late stage: patient presents with jaundice, malaise, and weight loss.
    • 5-year survival rate is less than 5%.
    • Sonographic Findings:
      • Typically advanced stage by the time of ultrasound.
      • Heterogenous, irregular-shaped mass.
      • Replaces the GB.
      • Tumefactive sludge or sludge ball can mimic a GB mass.
      • A GB mass > 1 cm, wall thickening > 1 cm, or disruption of the GB wall increases suspicion of malignancy.
      • Color Doppler can help show internal vascularity if malignancy is present.

    Gallbladder Part 2

    Biliary Atresia

    • Most common obstructive biliary disease in infants and young children.
    • Absence or destruction of extrahepatic bile ducts (CHD and CBD).
    • Twice as common in males.
    • Suspected when jaundice (hyperbilirubinemia) persists beyond 14 days of age.
    • Up to 38% of children can survive with their own liver for 30 years after a Kasai portoenterostomy (KPE) procedure.
    • Associated with "Triangular Cord Sign" = echogenic, triangular structure anterior to the portal vein.
    • KPE - most successful treatment if performed before 90 days of life.
    • Liver transplantation is also an option.

    Associated with:

    • Polysplenia
    • Absent IVC
    • Situs Inversus
    • Situs ambiguous
    • Cardiac anomalies (ASD, VSD)

    Choledochal Cysts

    • Congenital bile duct anomaly - cystic dilation of extrahepatic bile ducts.
    • Most common (Type I) involves the dilation of the CBD.
    • More prevalent in Asia.
    • More than 33% of the reported cases are from Japan.
    • Symptoms usually occur before the age of 10.
    • Sonographic Findings Type I:
      • Two cystic structures in the RUQ (Gallbladder and dilated CBD).
      • Intrahepatic bile duct dilatation.

    Associated With:

    • Pancreatitis
    • Cholangitis
    • Cirrhosis
    • Portal hypertension
    • Cholangiocarcinoma

    Caroli Disease/Caroli Syndrome

    • Congenital anomaly of biliary tract
    • Multifocal segmental dilatation of Intrahepatic bile ducts
    • Generally inherited
    • Associated with congenital hepatic fibrosis, autosomal recessive polycystic kidney disease, and portal hypertension

    Sonographic Findings of Caroli Disease

    • Multiple cystic structures converge toward porta hepatis
    • Structures communicate with bile ducts
    • Sludge and calculi may accumulate in these ectatic ducts
    • Sludge and calculi result in poor acoustic shadowing

    Courvoisier Gallbladder

    • Dilation begins with gallbladder
    • Followed by common duct
    • Finally intrahepatic tree
    • After removal of the mass obstructing the gallbladder, it decompresses actively
    • Ducts passively return to normal to reverse order

    Hydropic Gallbladder

    • Overdistended gallbladder filled with mucoid, thick bile, or pus
    • Most common cause is stone obstructing GB neck or cystic duct
    • Usually non-inflammatory
    • Can be asymptomatic
    • Can cause RUQ pain, N/V
    • Can be associated with Kawasaki disease
    • Sonographic findings:
      • Grossly distended
      • Thin-walled
      • Measures >5 cm TRV (width)
      • Measures > 4cm AP
      • May have stones

    Causes of a Not Visualized Gallbladder

    • Patient is nonfasting
    • Postcholecystectomy
    • Contracted gallbladder with stones (chronic cholecystitis)
    • Congenitally absent gallbladder
    • Porcelain gallbladder
    • Hepatization of gallbladder
    • Mirizzi syndrome or gallstone ileus
    • GB neoplasms completely filling lumen
    • Ectopic GB
    • Emphysematous GB
    • Overlying bowel
    • Residual barium in nearby bowel

    Post Cholecystectomy

    • The diameter of the common duct increases with age
    • 1 mm per decade rule is acceptable rate of size increase
    • Common duct may measure up to 10 mm

    Fatty Meal

    • Biliary dynamics, gallbladder contractility or obstruction can be assessed by administering a fatty meal
    • Cholecystokinin is a hormone that is released by the ingestion of fatty foods and causes gallbladder contraction
    • Equivocal bile duct dilation or abnormal lab values (conjugated bilirubin, ALP-alkaline phosphatase) would be reasons to administer a fatty meal
    • Negative results = unchanged or decreased size
    • Positive results = DUCT increase in size

    Biliary Obstruction

    • Obstruction causes direct interference with bile flow
    • From intrinsic or extrinsic (stones, tumors, or strictures)
    • Intrahepatic or extrahepatic
    • Majority are due to pathology in the DISTAL CBD
    • Gallstones & Carcinoma of the HEAD of the PANCREAS 2 most common lesions
    • Elevated labs:
      • ALP
      • Direct Bilirubin
      • GGT
    • Clinically:
      • Jaundice
      • RUQ pain
      • Fever
      • Palpable RUQ mass
    • Causes of Biliary Obstruction Include:
      • Choledocholithiasis
      • Mirizzi syndrome
      • Cholangitis
      • Biliary atresia
      • Choledochal cyst
      • Carol’s disease
      • Pancreatic adenocarcinoma
      • Gallbladder carcinoma

    Dilated Intrahepatic Ducts

    • Criteria to differentiate intrahepatic bile ducts from portal veins:
      • “Parallel channel sign”
      • “Double Barreled Shot-Gun Sign”
      • Dilated hepatic duct anterior to portal vein
    • Causes of intrahepatic bile duct dilatation ONLY:
      • Cholangiocarcinoma (Klatskin tumor)
      • Intrahepatic choledocholithiasis
      • Recurrent ptogenic cholangitis
      • Caroli disease
      • Intrahepatic ducts >2mm or more than 40% of portal vein = dilated

    Level of Obstruction

    • Part of the biliary tree that dilates as a result of obstruction depends on the level of obstruction.
    • Obstruction at the junction of the right and left hepatic ducts
      • Only the common hepatic duct and intrahepatic ducts will dilate. The gallbladder will be contracted
    • Distal common bile duct obstruction
      • This is the most common location for an obstructing stone. The entire system distends including the gallbladder
    • Common hepatic obstruction
      • Only intrahepatic ducts dilate. The gallbladder will be contracted

    Choledocholithiasis

    • Most common pathology in the biliary tract
    • Stones within the bile duct
    • Most common cause of extrahepatic obstructive jaundice
    • Complications:
      • Biliary cirrhosis
      • Cholangitis
      • Pancreatitis
    • Symptoms:
      • RUQ pain/ biliary colic
      • Jaundice
    • LABS:
      • Increased alkaline phosphatase
      • Increased conjugated bilirubin
      • Increased transaminase

    Mirizzi Syndrome

    • Extrahepatic biliary obstruction due to an impacted stone at the cystic duct causing extrinsic mechanical compression of the common hepatic duct
    • Associated findings:
      • Intrahepatic duct dilatation
      • Cystic duct stone
      • Curved segmental stenosis of CHD
      • Cholecystocholedochal fistula

    Cholangiocarcinoma (bile duct carcinoma)

    • Bile duct adenocarcinoma – typically originate within extrahepatic bile ducts (CHD or CBD)
    • Klatskin tumor - is a cholangiocarcinoma located at the hepatic hilum (junction of right and left hepatic duct) resulting in intrahepatic but not extrahepatic biliary dilation
    • Occurs equally in men & women between age 50-70
    • Most common predisposing condition is PRIMARY SCLEROSING CHOLANGITIS
    • Most common finding:
      • Intrahepatic duct dilatation
    • Symptoms:
      • Jaundice
      • Weight loss
      • Abdominal pain
    • LABS:
      • Increased serum bilirubin
      • Increased ALP

    Cholangitis

    • Inflammation of the biliary tree
    • May result in cirrhosis, portal hypertension, and sepsis
    • Sonographic: bile duct wall thickening
    • LABS INCREASED:
      • Conjugated bilirubin
      • ALP
      • GGT
      • Amylase & Lipase
      • Leukocytosis
    • Classic Triad: “CHARCOT TRIAD”
      • RUQ Pain
      • Fever
      • Jaundice
    • Causes:
      • Most common - choledocholithiasis
      • ERCP
      • Obstructive tumors
        • pancreatic cancer
        • Cholangiocarcinoma
        • Ampullary cancer

    Primary Sclerosing Cholangitis

    • Common bile duct walls are thickened
    • Thickened walls cause dilatation (stellate pattern) of intrahepatic ducts
    • Dilated common bile and common hepatic ducts are seen in patient with cholangitis

    Pneumobilia

    • Air in the biliary tract
    • Commonly associated with ERCP (endoscopic retrograde cholangiopancreatogram)
    • Ultrasound Findings:
      • Variable length echogenic foci in the intrahepatic ducts
      • Air produces a dirty shadow
      • Important to determine if in duct or portal vein

    Causes of Pneumobilia

    • ERCP
    • Sphincter of Oddi papillotomy
    • Choledochojejunostomy
    • Gallbladder fistula
    • Emphysematous cholecystitis

    Biliary Ascariasis (Roundworm)

    • Disease caused by parasitic roundworm Ascaris lumbricoides
    • Intestinal and biliary tract obstruction represent most common complication
    • Worm may block the ampulla of Vater or the main pancreatic duct resulting in acute pancreatitis
    • Ascariasis is commonly encountered in South-East Asian countries
    • SONOGRAPHIC FINDINGS:
      • Worms appear as long, thin, echogenic, linear structures within bile ducts or GB
      • Worms are 20 to 30 cm in length and up to 6 mm thick)
      • Movement may also be seen

    Chapter One: Introduction

    Directional Terms

    • Superior/cranial: toward the head, closer to the head, the upper portion of the body, the upper part of a structure or a structure higher than another structure.
    • Inferior/caudal: Toward the feet, away from the head, the lower portion of the body, toward the lower part of a structure, or a structure lower than another structure.
    • Anterior/ventral: Toward the front or at the front of the body or a structure in front of another structure.
    • Posterior/dorsal: Toward the back or the back of the body or a structure behind another structure.
    • Medial: Toward the middle or midline of the body or the middle of a structure.
    • Lateral: Away from the middle or the midline of the body or pertaining to the side.
    • Ipsilateral: Located on the same side of the body or affecting the same side of the body.
    • Contralateral: Located on the opposite side of the body or affecting the opposite side of the body.
    • Distal: Farther from the attachment of an extremity to the trunk or the origin of a body part.
    • Superficial: Toward or on the body surface or external.
    • Deep: Away from the body surface or internal.

    Patient Positions

    • Oblique: named for the body side closest to the scanning table
    • Right posterior oblique (RPO): lying on the right posterior surface, the left posterior surface is elevated
    • Left posterior oblique (LPO): Lying on the left posterior surface, the right posterior surface is elevated
    • Right anterior oblique (RAO): Lying on the right anterior surface, the left anterior surface is elevated
    • Left anterior oblique (LAO): Lying on the left anterior surface, the right anterior surface is elevated
    • Right lateral decubitus: Right side down
    • Left lateral decubitus: Left side down

    Image Quality Definitions

    Echogenic

    • Describes an organ or tissue that is capable of producing echoes by reflecting the acoustic beam.
    • Describes relative tissue texture (e.g., more or less echogenic than another tissue).
    • Aberration from normal echogenicity may signify pathology or poor scanning.

    Anechoic

    • Describes the portion of an image that appears echo-free.
    • Examples: Urine-filled bladder, bile-filled gallbladder, blood-filled ventricle
    • Sonolucent or transonic are misnomers and should not be substituted for anechoic.
    • Anechoic is correct to describe the appearance of the echo.
    • Cyst or cyst-like is correct to describe the histopathologic nature of an anechoic structure.

    Hyperechoic, Hypoechoic, Echopenic, Isoechoic

    • Brightness changes occur if scattering amplitude changes from one tissue.
    • Terminology to describe normal and abnormal appearances include:
      • Hyperechoic
      • Hypoechoic
      • Echogenic
      • Isoechoic
    • Hyperechoic echoes are brighter than surrounding tissues or brighter than normal for a tissue or organ.
    • Results from an increased amount of sound scatter relative to the surrounding tissue.
    • Hypoechoic portions of an image are not as bright as surrounding tissues or less bright than normal.
    • Results from reduced sound scatter relative to the surrounding tissue.
    • Echopenic—a structure less echogenic than others or has few internal echoes.
    • Isoechoic—a structure of equal echo density.

    Homogeneous, Heterogeneous

    • Homogeneous - refers to imaged echoes of equal intensity.
    • A homogeneous portion of the image may be anechoic, hypoechoic, hyperechoic, or echopenic.
    • Heterogeneous - describes tissue or organ structures that have several different echo characteristics.
    • A normal liver, spleen, or testicle has a homogeneous echo texture, whereas a normal kidney is heterogeneous, with several different echo textures.

    Enhancement, Shadowing

    • Acoustic enhancement and acoustic shadowing are opposite, and both are artifacts.
    • Enhancement - increased acoustic signal amplitude returning from regions lying beyond an object that causes little or no attenuation of the sound beam such as fluid-filled structures.
    • Shadowing - reduced echo amplitude from sound not transmitting due to attenuation or low reflectivity.
    • Echogenic calculi attenuate sound. Sound does not pass through results in sharp, distinctive shadow.
    • Air bubbles (bowel gas) do not allow sound transmission, and sound is reflected. Shadowing caused by air is often referred to as soft or dirty shadowing.

    Enhancement

    • Enhancement of echoes compared with surrounding tissue
    • Usually occurs distal to fluid-filled structures with decreased attenuation, which allows increased signal amplitude

    Shadowing

    • Transverse gallbladder with cholecystitis (thickened wall) and cholelithiasis creating an acoustic shadow due to attenuation

    Sonographic Characteristics

    Cyst

    • A cyst diagnosis is based on sonographic characteristic criteria:
      • Cysts retain an anechoic center even at high instrument gain settings.
      • The mass has sharply defined posterior wall indicative of a strong interface between cyst fluid and tissue or parenchyma.
      • There is an increased echo amplitude in the tissue beginning at the far wall proceeding distally compared with surrounding tissue / Acoustic Enhancement Artifact
      • Reverberation artifacts can be identified at the near wall if the cyst is located close to the transducer.
      • Edge shadowing artifacts may appear, depending on the incident angle (refraction) and the thickness of the cystic wall at the periphery of the structure.

    Solid

    • A solid structure may have a hyperechoic, hypoechoic, echopenic, or anechoic homogeneous echo texture, or it may be heterogeneous because it contains many different types of interfaces.
    • Usually exhibit the following characteristics:
      • Internal echoes that increase with an increase in instrument gain settings.
      • Irregular, often poorly defined walls and margins.
      • Low-amplitude echoes or shadowing posterior to the mass due to increased acoustic attenuation by soft tissue or calculi

    Complex

    • A complex structure usually exhibits both anechoic and echogenic areas on the image, originating from both fluid and soft tissue components within the mass.
    • Relative echogenicity complex soft tissue mass is related to a variety of constituents, including:
      • Collagen content
      • Interstitial components
      • Vascularity
      • Degree and type of tissue degeneration

    Transonic or Sonolucent

    • Refers to messes, organs, or tissues attenuating little of the acoustic beam--images result with distal high-intensity echoes.
    • Example: Cystic structure with associated acoustic enhancement artifact
    • Masses attenuating large amounts of sound results in marked decrease in the amplitude of distal echoes.### Cystic Mass Surface
    • Retains an anechoic center

    Evaluating Echo Amplitude distal to a Mass

    • Attenuation properties

    Sonographer Examination Prep

    • Gather patient information
      • Indications for the study
      • Clinical information
      • Clinical assessment
      • Level of patient apprehension

    Preliminary Report (Technical Impression)

    • Minimum image documentation
      • Facility, date, time
      • Instrument and transducer information
      • Intensity, MI, TI
      • Patient identification, age, gender
      • Operator identification
      • Icons: Body position, transducer orientation, image orientation if appropriate

    Preliminary Report (Technical Impression)

    • Minimum information to include
      • Patient's name and other identifying information
      • Date of the examination
      • Relevant clinical information
      • Specific examination requested
      • Name of the patient's health care provider and contact information

    Report Terminology and Interpretation

    • Echogenicity
      • Anechoic, hypoechoic, hyperechoic, isoechoic, cystic, solid, complex
    • Texture
      • Homogeneous, heterogeneous
    • Distribution
      • Focal or diffused
    • Artifacts
      • Enhancement, shadowing
    • Measurements (location)
      • Vessels, ducts, organs, wall thickness, masses
    • Abnormal amounts of fluid collections

    Who Provides Diagnosis?

    • Physician

    Statistical Parameters:

    • True-positive result: Sonography findings are positive, and the patient has the disease.
    • True-negative result: Sonography findings are negative, and the patient does not have the disease.
    • False-positive result: Sonography findings are positive, but the patient does not have the disease.
    • False-negative result: Sonography findings are negative, but the patient has the disease.

    Sensitivity

    • Measures how well sonography documents existing disease or pathology.
    • Formula: [true-positive ÷ (true-positive + false-negative) × 100]
    • Increases with fewer false-negative examinations.

    Specificity

    • Measures how well sonography documents normal findings or excludes patients without disease.
    • Formula: [true-negative ÷ (true-negative + false-positive) × 100]
    • Increases with fewer false-positive examinations.

    Accuracy

    • Measures sonography's ability to find disease when present and not find it when absent.
    • Formula: [true-positive + true-negative ÷ (all patients receiving the sonographic examination) × 100]

    Positive Predictive Value

    • Probability that subjects with a positive test truly have the disease.
    • Formula: [true-positive ÷ (true-positives + false-positives) × 100]

    Negative Predictive Value

    • Probability that patients with a negative test are free of disease.
    • Formula: [true-negatives ÷ (true-negatives + false-negatives) × 100]

    What Increases if the Number of False-Positive Examinations Decreases?

    • Specificity

    Abdominal Wall Fascia

    • Thin fibrous tissue covering muscles anteriorly and posteriorly.
    • Located between the skin and underlying structures.
    • Rich in blood vessels and nerves.
    • No internal strength.

    Superficial Fascia

    • Attached to the skin.
    • Composed of connective tissue and varying amounts of fat.

    Deep Fascia

    • Underlies the superficial layers.
    • Loosely joined by fibrous strands.
    • Covers muscles and partitions them into groups.
    • Thin and densely packed, stronger than superficial fascia.

    Aponeurosis

    • Layers of flat, tendinous fibrous sheets fused with strong connective tissue.
    • Serves as tendons and primarily attaches muscles to fixed points.
    • Minimal blood vessels and nerves.
    • Located more in ventral abdominal regions.

    Abdominal Wall Layers

    • Skin
    • Subcutaneous tissue (superficial fascia)
    • Muscles and their aponeuroses
    • Deep fascia
    • Extraperitoneal fat
    • Parietal peritoneum

    Abdominal Wall Muscles

    • Rectus abdominis muscles (paired, vertical)
    • Pyramidalis muscle (small, triangular)
    • External oblique muscle (paired, flat)
    • Internal oblique muscle (paired, flat)
    • Transverse abdominal muscle (paired, flat)

    Rectus Sheath

    • Strong, fibrous compartment for rectus abdominis and pyramidalis muscles.
    • Anterior and posterior layers formed from intercrossing and interweaving aponeuroses.
    • Contains arteries, veins, lymphatic vessels, and nerves.

    Arcuate Line

    • Located halfway between the umbilicus and pubic symphysis.
    • Transition where the posterior rectus sheath terminates.
    • Superior to the arcuate line: posterior sheath covers the proximal superior ¾ of rectus abdominis muscles.
    • Distal to the arcuate line: posterior sheath is absent, only transverse fascia separates rectus abdominis from peritoneum.

    Linea Alba

    • Formed by interlacing fibers of anterior and posterior sheath layers in the anterior median line.
    • Runs vertically along the entire length of the abdomen.
    • Separates bilateral rectus sheaths.
    • Wider superiorly, narrows inferiorly.
    • A groove in the skin may be visible in thin/muscular people.

    Umbilicus

    • All layers of the anterolateral abdominal wall fuse.
    • Umbilical ring is a defect in linea alba located under the umbilicus.
    • Represents passageway for fetal umbilical vessels to and from the cord and placenta.
    • After birth, fat accumulation in subcutaneous tissue raises the umbilical ring and depresses the umbilicus.

    Inguinal Ligament

    • Inferior border of the external oblique muscle.
    • Extends between the ASIS and the pubic tubercle.

    Inguinal Canal

    • Located superior and medial to the inguinal ligament.
    • Formed during fetal development.
    • Structures enter and exit the abdominal cavity.
    • Potential sites for hernias.

    Inguinal Canal Openings

    • Deep (internal) inguinal ring: entrance
    • Superficial (external) inguinal ring: exit for spermatic cord or round ligament
    • Contains: blood vessels, lymphatic vessels, and iliohypogastric nerves.

    Posterior Abdominal Wall

    • Layers:
      • Fascia: covered by continuous endoabdominal fascia, continuous with transversalis fascia.
      • Lumbar vertebra
      • Posterior abdominal wall muscles
      • Diaphragm
      • Fat
      • Nerves
      • Blood vessels
      • Lymphatic vessels

    Posterior Abdominal Wall Muscles

    • Psoas major (paired, long, thick, fusiform)
    • Iliacus (paired, triangular)
    • Quadratus lumborum (paired, thick sheet)
    • Psoas minor (paired, long, slender, anterior to psoas major)
    • Iliopsoas (formed by psoas and iliacus muscles)
    • Latissimus dorsi (paired, broadest back muscle)
    • Erector spinae (group of three columns on each side of vertebral column)
    • Transversospinal (oblique group of three muscles deep to erector spinae)

    Diaphragm

    • Double-domed, musculotendinous partition separating the thoracic and abdominal cavities.
    • Superior surface: convex, forms the floor of the thoracic cavity.
    • Inferior surface: concave, forms the roof of the abdominal cavity.
    • Muscular part located peripherally, fibers converge radially on the central tendon.
    • Central tendon has no bony attachments and appears incompletely divided into three leaves.

    Diaphragmatic Crura

    • Musculotendinous bands arising from anterior surfaces of superior three lumbar vertebrae.
    • Right crus: larger and longer than the left crus, located anterior to the aorta.
    • Left crus: arises from the first two lumbar vertebrae.

    Diaphragm Scanning

    • Use high-frequency, short focus transducers (7.56 MHz or higher linear array).
    • Evaluate for:
      • Inflammatory lesions
      • Hemorrhage
      • Hernia
      • Masses

    Abdominal Wall Pathologies

    • Three major categories:
      • Abdominal wall
      • Peritoneum
      • Abdominal spaces
    • Affected by inflammatory, traumatic, and neoplastic changes.

    Abscess

    • Space-occupying lesions with fluid content, assuming various shapes.
    • Sonographic appearance:
      • Lenticular or shape of the space.
      • Anechoic, may have internal echoes, septations, or fluid-fluid level.
      • Gas-containing abscesses are echogenic and may shadow.
      • Good acoustic transmission.

    Hematoma

    • Near wound or surgical site.
    • Sonographic appearance:
      • Lenticular or shape of the space.
      • Appearance changes with resolution: fresh blood or clotted blood is hypoechoic, clot fragmentation creates internal echoes, long-standing hematomas have thick contours.
      • Acoustic transmission coincides with the stage and age, good to slow or decreased.

    Ascites

    • Fluid accumulation in the abdominopelvic cavity.
    • Sonographic appearance:
      • Anechoic if benign, internal echoes if malignant.
      • Increased acoustic transmission.

    Urinoma

    • Fluid collection adjacent to the kidneys.
    • Sonographic appearance:
      • Usually anechoic, unless infected.
      • Increased acoustic transmission.

    Lymphocele

    • Fluid collection adjacent to a renal transplant.
    • Sonographic appearance:
      • Usually anechoic, may have septations.
      • Increased acoustic transmission.

    Periumbilical Abscess

    • Sonographic appearance:
      • Mixed echo appearance with good acoustic transmission.

    Rectus Sheath Hematoma

    • Bleeding from superior or inferior epigastric vessels or tear in rectus muscle.
    • Superior to the arcuate line: hematomas are superficially located, confined between anterior and posterior sheaths.
    • Inferior to the arcuate line: hematomas are more extensive, extend into the Space of Retzius, causing compression and irritation of the bladder.

    Causes of Rectus Sheath Hematoma

    • External trauma
    • Trauma from surgery
    • Vigorous muscle contraction
    • Valsalva with severe coughing/vomiting
    • Pregnancy
    • Anticoagulation therapy

    Rectus Sheath Hematoma Sonographic Appearance

    • Variable depending on age of the bleed.
    • Acoustic transmission: good to slow or decreased.
    • Appearance: hypoechoic, echogenic (as they organize), or anechoic (as they liquefy).

    Hernia

    • Protrusion of an organ or tissue through a weakened area in the abdominal wall.

    Two Main Categories of Hernias

    • Ventral: anterior or anterolateral abdominal wall (75% of cases)
    • Groin: indirect inguinal, direct inguinal, and femoral

    Three Major Factors Causing Hernias

    • Abnormal collagen metabolism
    • Pressure overload (obesity, heavy lifting, coughing, smoking)
    • Natural weak areas where vessels penetrate the abdominal wall

    Direct Hernia

    • Located medial to the inferior epigastric vessels.

    Indirect Hernia

    • Located lateral to the inferior epigastric vessels.

    Epigastric Hernia

    • Weakness on the midline of the upper abdominal wall, between the breastbone and umbilicus.

    Inguinal Hernia

    • Most common abdominal wall hernia, more frequent in men than women.

    Incisional Hernia

    • Post-operative weakening of the abdominal wall.

    Indirect Inguinal Hernia

    • Follows the inguinal canal, descending from the abdomen into the scrotum.
    • Located lateral to the inferior epigastric vessels.

    Umbilical Hernia

    • Weakness near the umbilicus, from the umbilical cord.

    Direct Inguinal Hernia

    • Occurs slightly inside the site of an indirect hernia, in a naturally thinner area of the abdominal wall.

    Hernia Types

    • Direct inguinal hernia is medial to inferior epigastric vessels
    • Femoral hernia occurs in the femoral canal, adjacent to femoral vein near the groin crease, often associated with pregnancy
    • Spigelian hernia occurs along the edge of the rectus abdominus through the spigleian fascia, lateral to the abdomen's middle
    • Obturator hernia protrudes from the pelvic cavity through the obturator foramen, difficult to diagnose due to lack of visible bulging
    • Incarcerated hernia occurs when herniated tissue becomes trapped and cannot be moved back into place, can lead to bowel obstruction or strangulation
    • Strangulated hernia is a type of incarcerated hernia where blood flow to the trapped tissue is cut off

    Sonographic Evaluation of Hernia

    • Ultrasound can determine hernia’s location, size, and contents
    • Ultrasound can also evaluate the presence of a peritoneal line interruption, indicating a hernia
    • Ultrasound differentiates the hernia sac based on contents: fluid, peristaltic bowel, motion, gas shadowing, mesenteric fat, and highly reflective tissues lacking peristalsis and shadowing
    • Dynamic maneuvers, like Valsalva and compression, can be used to exaggerate lesions and assess reducibility

    Abdominal Wall Neoplasms

    • Primary abdominal wall tumors may include: lipomas, calcified surgical scars, desmoid tumors, soft-tissue sarcomas, metastatic carcinoma, and melanomas
    • Sonography, CT, MR, and fine-needle biopsy are used to differentiate between lipomas, hematomas, abscesses, hernias, and neoplasms

    Diaphragmatic Pathology

    • Ultrasound can assess: pain, paralysis, herniation, eventration, peridiaphragmatic abnormalities, pleural effusion, and ascites
    • Diaphragmatic paralysis can be detected by comparing movement of the diaphragm on each side during inspiration
    • Eventration is an abnormal elevation of the diaphragm due to incomplete muscle fiber development during gestation, leading to a potential weakness allowing abdominal organs to protrude into the chest (diaphragmatic hernia)

    Peritoneal Cavity

    Abdominal Cavity

    • Peritoneum, a serous membrane lining the abdominal cavity, consists of a parietal layer (lining the abdominal wall) and a visceral layer (covering abdominal organs)
    • Peritoneal cavity is divided into a greater sac, a lesser sac, and a diverticulum from the greater sac, the epiploic foramen
    • The epiploic foramen is posterior to the stomach, connecting the greater and lesser sacs

    Greater Omentum

    • Apron-like structure between the small intestine and the anterior abdominal wall
    • Extends from the greater curvature of the stomach and transverse colon

    Lesser Omentum

    • Lies between the lesser curvature of the stomach and the liver

    Ligaments of Peritoneal Cavity

    • Ligaments divide the peritoneal cavity, guiding the search for fluids and pathology
    • Gastrohepatic ligament aka lesser omentum, connects the lesser curvature of the stomach to the left sagittal fissure of the liver
    • Hepatoduodenal ligament connects the liver to the duodenum, containing the portal triad
    • Falciform ligament ascends from the umbilicus to the liver, containing the ligamentum teres, and forms the upper layers of the coronary and left triangular ligaments
    • Coronary ligament suspends the liver from the diaphragm, forming the borders of the bare area of the liver
    • Left triangular ligament, formed by the left branch of the falciform ligament, forms the left extremity of the bare area of the liver
    • Splenorenal ligament connects the splenic hilum to the posterior abdominal wall, containing the splenic vein and artery
    • Gastrosplenic ligament connects the stomach to the spleen and inferior diaphragm
    • Broad ligament forms the suspensory ligament extending from the lateral uterine sidewalls, dividing the pelvis into anterior and posterior compartments
    • Ligamentum teres, a remnant of the fetal umbilical vein within the falciform ligament, passes into a fissure on the visceral liver surface to join the left branch of the portal vein
    • Ligamentum venosum, a fibrous band (remnant of ductus venosus), ascends in a fissure on the visceral liver surface to attach above the inferior vena cava

    Spaces of Peritoneum

    • These are potential spaces created by the peritoneal layers, reflecting between organs or an organ and the peritoneal wall.
    • Fluid or other materials may collect in these spaces in the presence of disease.

    Potential Spaces of Peritoneum

    • Left Anterior Subphrenic Space, AKA Suprahepatic Space: Extension of the greater sac between the diaphragm and anterior superior liver, leftward of the falciform ligament
    • Left Posterior Suprahepatic Space, AKA Superior recess of Lesser Sac: Extension of the lesser sac between the diaphragm and posterior superior liver
    • Right Subphrenic Space, AKA Suprahepatic Space: Extension of the greater sac between the right hemidiaphragm and anterior superior liver, rightward of the falciform ligament
    • Hepatorenal Space, AKA Morrison Pouch: Created by reflection of the peritoneum from the liver over the right kidney and right posterior peritoneal wall. Most gravity-dependent region in the supine position.
    • Lesser Sac/Omental Bursa: Sandwiched between the posterior stomach and parietal peritoneum covering the anterior pancreas, and splenorenal and gastrosplenic ligaments and epiploic foramen
    • Right Anterior Subphrenic Space and Hepatorenal Space: Located in the right upper quadrant, susceptible to fluid collection.
    • Right & Left Paracolic Gutters: Grooves along the ascending and descending colon conducting fluids between the abdominal compartments
    • Vesicorectal Space, AKA Cul-de-sac in male: Created by peritoneal reflection over the rectum and posterior bladder wall. Most gravity-dependent potential space of the pelvic cavity in the supine position.
    • Rectouterine Space, AKA Rectovaginal Pouch, Pouch of Douglas, Posterior Cul-de-sac in female: Most gravity-dependent potential space of the pelvic cavity in the supine position.
    • Space of Retzius, AKA Prevesicle space or Retropubic Space: Located between the anterior wall of the urinary bladder and the pubic symphysis
    • Uterovesical Space, AKA Uterovesical Pouch, Anterior Cul-de-sac in female: Created by the peritoneal reflection over the uterine fundus, anterior uterus, broad ligament, and the posterior urinary bladder.

    Peritoneal Cavity Pathologies

    Ascites

    • Excessive accumulation of serous fluid in the peritoneal cavity
    • Caused by:
      • Low serum osmotic pressure (protein loss)
      • High portal venous pressure
    • Common causes:
      • Cirrhosis/Portal Hypertension: Due to liver dysfunction
      • Renal failure
      • Congestive heart failure
      • Cancer (malignant ascites)
      • Inflammation
    • Common locations for ascites:
      • Morison’s pouch
      • Inferior aspect of the right lobe of liver
      • Pelvic cul-de-sac
      • Paracolic gutters

    Pseudomyxoma Peritonei

    • Malignant condition with progressive accumulation of mucus-secreting tumor cells in the peritoneum
    • Most often associated with cancer of the appendix
    • Ultrasound appearance: bowel loops matted to the posterior abdominal wall, gallbladder wall thickening with ascites

    Two Types of Ascites

    • Transudative Ascites: Caused by pressure infiltration, lacking protein and cellular materials in the fluid
      • Sonographic appearance: usually simple
      • Common causes:
        • Congestive cardiac disease
        • Portal Hypertension /Liver failure(cirrhosis)
    • Exudative Ascites: Caused by inflammation, seeping from blood vessels & containing large amounts of protein and cellular material
      • Sonographic appearance: usually more complex and echogenic
      • Common causes:
        • Renal failure
        • Inflammatory / peritonitis
        • Ischemic bowel disease
        • Malignancy

    Peritoneal Abscess

    • May occur within a potential space or adjacent to an inflamed or perforated organ
    • Most common location: right subphrenic space due to the high frequency of appendicitis and duodenal ulcers
    • Sonographic appearance: Variable, no blood flow within, Possible hyperemia around thick wall. Air may be present within the abscess, creating a ‘dirty shadow’.

    Hematoma

    • Blood clot or focal area of coagulated blood
    • Caused by: postsurgical complication, trauma, spontaneous in hemophilia patients or other coagulation diseases, anticoagulant medications use.
    • Large hematomas can cause a drop in hematocrit
    • Sonographic appearance depends on age

    Lymphocele

    • Caused by leakage of lymph from a renal allograft or surgical disruption of lymphatic channels
    • Complications of: Renal transplantation, GYN surgery, Vascular surgery, Urological surgery
    • Differential diagnosis include: Any fluid collection such as loculated ascites, urinoma, hematoma, or abscess.

    Biloma

    • Extrahepatic collections of extravasated bile
    • Commonly associated with: Abdominal trauma, Gallbladder disease, Biliary surgery
    • Predominately cystic masses with good through transmission and may contain debris.
    • Located in the RUQ or mid abdomen.

    Urinoma

    • Collection of urine located outside the kidney or bladder
    • Caused by: Renal trauma, Renal surgery, Or from an obstructing lesion
    • Most associated with: Renal transplantation, Posterior urethral valve obstruction
    • May accumulate directly after a renal transplant due to anastomotic leak of the ureter
    • Sonographically similar to lymphocele.

    Mesenteric Adenopathy (Lymphadenopathy)

    • Enlargement of lymph nodes along the mesentery or on the bowel
    • Can be associated with: Inflammatory diseases like colitis and appendicitis, Viral infections, Primary malignancy - lymphoma and colon cancer

    Peritoneal Mesothelioma

    • Rare primary malignant tumor of the peritoneum associated with asbestos exposure
    • Often occurs along the pleura and peritoneum, metastasizing by direct invasion to adjacent organs.
    • Sonographic appearance: solid mass of the peritoneum at the anterior aspect of the liver.

    Peritoneal Implants

    • Associated with peritoneal metastasis
    • Sonographic appearance: Small polypoid masses projecting from the peritoneum
    • Complex ascites and omental caking are common.
    • Commonly associated with: Ovarian, stomach and colon cancers

    Omental Caking

    • Thickening of the greater omentum due to malignant infiltration
    • Commonly associated with: Primary ovarian, stomach and colon cancer

    Pleural Effusions

    • Accumulations of fluid within the pleural space
    • Can cause dyspnea and pleuritic chest pain
    • Classified based on Light’s criteria, comparing pleural fluid and blood chemistries (protein, LDH)
    • Transudative effusions: Pressure infiltration caused by increased hydrostatic pressure and decreased plasma oncotic pressure - Common causes: Heart failure (most common), Liver failure (cirrhosis), Renal failure (nephrotic syndrome)
    • Exudative effusions: Inflammation caused by increased capillary permeability - Common causes: Pneumonia, Cancer, Pulmonary embolism

    Pneumothorax

    • Identified by the absence of gliding between the parietal and visceral pleura and the presence of a comet tail artifact between these layers
    • With patient supine, air can be located on the anterior medial location of the thorax

    Procedures

    Paracentesis

    • Removal of ascites from the peritoneal cavity
    • Diagnostic uses: Perform laboratory testing on the fluid
    • Therapeutic uses: Relieve abdominal pressure causing respiratory difficulties or pain
    • Ultrasound guidance is used to localize an area of abdominal fluid, usually midline or lateral, avoiding the epigastric vessels.

    Percutaneous Abscess Drainage (PAD)

    • Uses sonographic guidance to insert a small flexible catheter into the abscess pocket
    • Abscess contents are aspirated into a syringe and sent to the laboratory for analysis
    • A drainage catheter may be left in place for gravitational drainage and antibiotic instillation.

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    Test your knowledge on the causes, imaging characteristics, and sonographic findings associated with liver conditions, particularly fatty liver disease. This quiz covers key concepts related to acute liver failure and diagnostic imaging. See how well you understand these important topics!

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