ARDMS Abdomen Review (Based off of URR Review Course)

What does an increased RI mean

increased resistance in vascular bed

What does an increased pulsatility index mean

increased resistance in vascular bed

Normal PI for vessels supplying organs such as kidneys

< 0.75

Hydrostatic pressure:

when supine

at ankle when standing

above heart when standing

0 mmHg

100 mmHg

-30 mmHg

What vessel is the most posterior abdominal vessel

aorta

Paired branches of the aorta (5)

suprarenal arteries (adrenal glands)

renal arteries (kidneys)

gonadal arteries (ovaries/testicles)

lumbar arteries

common iliac arteries

Unpaired branches of the aorta (4)

celiac axis (common hepatic, splenic, left gastric arteries)

SMA

IMA

median sacral artery

What level common iliac arteries bifurcate

L3-4

Decreased hematocrit may indicate what

bleed in body

What happens to the aorta as you follow it distally (2)

gets smaller

becomes more anterior

Aortic Ectasia

lack of tapering of aorta as you move distally (can be precursor to aneurysm)

AAA

What vessel walls are involved

focal dilation of aorta >3cm or >50% diameter between two adjacent segments

all three

Most common cause of AAA

atherosclerotic disease

Risk factors for AAA (4)

1. male

2. family history

3. smoking

4. chronic hypertension

Saccular aneurysm

localized round out pouching, may have small stalk

Fusiform aneurysm

vessel wall stretched in circumferential manner (most common)

Mycotic aneurysm

infected aneurysm, seen with syphilis

Most common location of fusiform aneurysms

infrarenal

At what diameter is surgical intervention done on an AAA

>5.5cm

Complications of AAA (5)

1. rupture

2. decreased blood to lower extremities

3. thrombus accumulation and embolization (blue toe syndrome)

4. affects renal circulation and systemic blood pressure (if suprarenal)

5. compress IVC

Yin Yang Sign

sonographic sign with AAA

swirling of blood in body of aneurysm on color doppler

Splanchnic artery aneurysm most commonly occurs in

What gender is this more common in

splenic artery

women

Aneurysm in the hepatic artery most commonly occurs in what segment

extra hepatic

With endovascular aortic repair, what happens to the native aortic sac over time

What plane should it be measured in

decreased in size

transverse

If aortic sac expands more than _____ between exams, a leak should be suspected

0.6 cm

Type I dissection

Type II dissection

Type III dissection

ascending and descending aorta

ascending aorta, associated with Marfan syndrome

descending aorta

Marfan syndrome

genetic disorder affecting connective tissue of heart, vessels, bones

Aortic rupture symptoms

back pain

hypotension

Leriche syndrome (3)

aortoiliac occlusive disease

occlusion of abdominal aorta just above CIA bif

causes bilateral lower extremity ischemia symptoms

Retroperitoneal fibrosis other name, most common location

Ormond disease

most commonly at aortic bifurcation and inferiorly in pelvis

Retroperitoneal fibrosis sonographically (4)

soft tissue mass surrounding great vessels

hypoechoic

smooth borders

possible hydronephrosis (due to ureteral obstruction)

Abnormal dilation of the abdominal segment of the IVC measures

> 2.5 cm

Normal Doppler flow of the IVC is

triphasic

Most common variation of IVC anatomy

duplicated IVC

infrarenal segment duplicated with left IVC entering left renal vein (suprarenal IVC normal)

Transposed IVC

IVC on left side of abdomen (instead of right)

Interrupted IVC (3)

IVC doesn't go to right atrium

enters azygos/hemiazygos veins to reach SVC

no intrahepatic segment

Causes of IVC dilation (5)

1. right heart failure (most common)

2. congestive heart failure

3. pulmonary hypertension

4. mass effect

5. pregnancy

Greenfield Filter (3)

prevents emboli from reaching lungs

infrarenal

echogenic "umbrella"

Most common malignancy to invade renal vein and IVC

RCC (renal cell carcinoma)

Liver is encapsulated by _____ capsule

glisson

Portal triad includes

portal vein

hepatic artery

bile duct

In pediatric patients, the liver shouldn't extend more than _____ below the costal margin

1cm below

The right hepatic vein (in right intersegmental fissure) divides the right lobe of the liver into what segments

The left hepatic vein (in left intersegmental fissure) divides the left lobe of the liver into what segments

anterior and posterior segments

medial and lateral segments

Triangular ligament attaches the superior liver

to the diaphragm

Falciform ligemant attaches the anterior surface of the liver

to the abdominal wall

Ligamentum teres is what

What is it also called

remnant of umbilical vein

round ligament

Ligamentum venosum is

remnant of ductus venosum from fetal circulation

(umbilical vein-left portal vein-ductus venosus-IVC-right atrium)

Hepatoduodenal ligament contains (3)

MPV

hepatic artery

CBD

Branches of MPV

RPPV

RAPV

LMPV

LLPV

MPV carries _____% of all blood entering liver, hepatic artery carries _____%

80

20

Normal portal vein diameter

<13mm

What is the most common variation in hepatic vein anatomy

accessory right hepatic vein

Caroli disease

congenital defect of bile ducts, numerous cysts in biliary tree

Caroli disease sonographically (3)

1. focal cystic areas

2. connecting to biliary tree

3. resembles polycystic disease

Cyst criteria (5)

1. smooth borders

2. regular walls

3. no internal echoes

4. through transmission

5. posterior enhancement

Hemorrhagic cyst sonographically (5)

1. septations with fluid levels

2. smooth borders

3. regular walls

4. through transmission

5. posterior enhancement

Polycystic Liver disease

What age does it present

autosomal dominant

presents 30-40 years

Polycystic liver disease sonographically (4)

1. focal cystic areas

2. varying sizes

3. thin septations

4. may have cysts in pancreas, kidneys, spleen

Biliary Hamartomas (Von Meyenburg Complexes)

dilated intrahepatic ducts with dense stroma

Biliary Hamartomas (Von Meyenburg Complexes) sonographically (3)

1. small echogenic nodules

2. heterogeneous liver

3. <1cm

Causes of fatty infiltration of liver (5)

diabetes

alcohol abuse

obesity

starvation

cystic fibrosis

Diffuse fatty infiltration sonographically (5)

mild: slight increase in fine echoes, normal visualization of diaphragm and vessel borders

moderate: moderate increase in fine echoes, impaired visualization of diaphragm and vessel borders

severe: marked increase in fine echoes, poor or non-visualization of diaphragm and vessel borders

hepatomegaly

possible narrowing of hepatic veins

Focal fatty infiltration sonographically (5)

focal increased echogenicity

possible irregular borders

usually adjacent to portal structures

similar to hemangioma

no displacement of surrounding structures

Focal fatty sparing sonographically (5)

focal decreased echogenicity (remaining liver tissue increased echogenicity)

possible irregular borders

usually adjacent to gallbladder fossa

similar to malignancy

no displacement of surrounding structures

Amyloid disease (2)

deposit of amyloid protein in vessel walls of various organs

commonly involving liver

Glycogen storage disease, most common type

autosomal recessive

von Gierke disease

Glycogen storage disease with excessive storage of glycogen sonographically (2)

hepatomegaly

increased echogenicity

Glycogen storage disease with reduced storage of glycogen sonographically (3)

hypo echoic parenchyma

prominent portal walls

"starry sky" (similar to hepatitis)

What is hemochromatosis

What is it inherited from

Sonographic appearance

abnormal iron deposition

inherited or due to anemia

sonographically includes features of fibrosis and cirrhosis

Wilson disease (2)

autosomal recessive disease

excessive deposition of copper in liver

Wilson disease symptoms (5)

jaundice

hematemesis

portal hypertension

ascites

rusty/brown-colored ring around iris of eye (Kayser-Fleischer rings)

Wilson disease sonographically (3)

echogenic fatty liver

fibrotic periportal thickening

nodular cirrhotic changes

Cirrhosis symptoms (5)

increased abdominal girth (ascites)

jaundice

liver atrophy

splenomegaly

weight loss

Causes of cirrhosis (9)

hep C

alcohol abuse

chronic liver disease

biliary obstruction

hep B

glycogen storage disease

hemochromatosis

wilson disease

Budd Chiari syndrome

Cirrhosis sonographically (6)

nodular surface

hepatomegaly or right lobe atrophy with compensatory hypertrophy of left lobe

portal hypertension

splenomegaly

thickened gallbladder wall

ascites

Symptoms of hepatitis (6)

jaundice

hepatomegaly

nausea

fever/chills

malaise

dark urine

Acute hepatitis sonographically (4)

"starry sky" appearance (normal liver texture or portal vein borders may be more prominent)

increased echogenicity

hepatosplenomegaly

gallbladder wall thickening

Chronic hepatitis sonographically (4)

coarse echo texture

decreased brightness of portal triads

normal size

increased liver echogenicity (due to fibrosis)

Echinococcal cysts sonographically (3)

large cyst with "daughter cysts" within

honeycomb appearance, water lily sign

most commonly found in right lobe

What is schistosomiasis

parasitic infection (most common in humans)

Schistosomiasis sonographically (4)

thick, echogenic portal vein walls

debris/occlusion in intrahepatic portal venous system

decreased liver size

portal hypertension

Pneumocystis jirovecci (pneumocystis carinii) cause and what patients is it most common in

yeast-like fungus

AIDS patients

Pneumocystis jirovecci (pneumocystis carinii) sonographically (1)

multiple non-shadowing echogenic foci

Granulomatous infections sonographically (1)

multiple echogenic foci (granulomas) in spleen and liver

Three types of hepatic abscess

pyogenic

amoebic

fungal

Hepatic abscess symptoms (6)

fever

nausea

diarrhea

RUQ pain

hepatomegaly

leukocytosis

Pyogenic hepatic abscess sonographically (2)

solitary or multiple complex lesions

fluid collections in: morison's pouch, subdiaphragmatic, subphrenic space

Amebic hepatic abscess sonographically (3)

complex lesion

typically in right lobe

history of travel

Most common benign lesion of the liver

What gender is it more common in

What lobe is it usually found in

Usual symptoms

What can cause it to enlarge

hemangioma

women

right

asymptomatic

pregnancy, estrogen therapy

Hepatic hemangioma sonographically (3)

homogenous

hyper echoic

well-defined

Most common benign vascular tumor in infancy

Most common symptom

When does it spontaneously regress by

infantile hemangioendothelioma

cardiac failure

age 2

Second most common benign liver mass

What gender and age group is it more common in

Most common symptom

focal nodular hyperplasia

women of child bearing years

asymptomatic

Focal nodular hyperplasia sonographically (2)

well-defined lesion

hyper echoic to isoechoic

What gender is liver cell adenoma more common in

What medication is it associated with

What disease is it commonly associated with

women

oral contraceptives

glycogen storage disease

Liver cell adenoma sonographically (3)

well-defined lesion

central hyper echoic area

surrounded by halo

What is the most common primary malignancy of the liver

What is the most common risk factor

What gender is it more common in

hepatocellular carcinoma

cirrhosis

males

Hepatocellular carcinoma symptoms (5)

fever

hepatomegaly

palpable mass

ascites

weight loss

Hepatocellular carcinoma sonographically (4)

solitary massive tumor

multiple nodules throughout liver

diffuse infiltrative masses

variable

Most common pediatric primary liver malignancy

What age does it occur before

What lab value is associated with it

hepatoblastoma

age 2

elevated alpha-fetoprotein

Hepatoblastoma is associated with (2)

Beckwith-wiedemann syndrome

familial adenomatous polyposis