My Ultrasound Tutor Study Guide

What are the intraperitoneal organs?

Gallbladder
Liver
Ovaries
Stomach
Spleen
Some Bowel

What is the difference between the visceral and parietal peritoneum?

Visceral is the organs “skin”
Parietal is the outer sac

Exudate vs Transudate ascites?

Exudate = malignant
Transudate = benign

What does a FAST scan mean?

Focused Assessment with Sonography for Trauma

Subphrenic abdomen space?

Inferior to diaphragm (between diaphragm and liver/spleen)

Subhepatic abdomen space?

Inferior to liver (AKA Morison’s pouch)

Lesser sac abdomen space?

Between pancreas and stomach

Paracolic gutters abdomen space?

Lateral sides of abdomen, next to colon

Retropubic Pelvis space?

Behind pelvic bone and anterior to bladder (AKA space of Retzius)

Anterior CDS pelvis space?

Between bladder and uterus in females (Not in males)

Posterior CDS pelvic space?

Between uterus and rectum OR bladder and rectum

Perirenal space vs Pararenal space?

PERIrenal space: Inside with kidneys

PARArenal space: Adjacent to the kidneys

What is the exception to the rule that cysts/tumors don’t affect organ function?

Functional endocrine tumors will show symptoms of too much of that hormone

What symptoms are seen with acute -itis or abscess?

Fever, leukocytosis, pain

With a blockage where will the tubes be dilated?

Proximal to the blockage

What is the covering of the liver called?

Glisson Capsule

What are the 3 main lobes of the liver?

Right, Left, Caudate

What is the liver’s job?

Metabolizes the good stuff, get rid of the bad, makes bile

What are the components of the portal triad?

Portal vein, hepatic artery, bile duct

Intersegmental vs Intrasegmental?

INTER = between segments (Fissures, hepatic veins, ligaments)
INTRA = inside segments (Portal vein, bile duct, hepatic artery)

What separates the RT anterior and RT posterior liver lobe?

Right Hepatic vein
Right intersegmental fissure

What separates the RT anterior and LT medial liver lobe?

Middle hepatic vein
Main lobar fissure
GB

What separates the LT Medial and LT lateral liver lobes?

Left hepatic vein
Left intersegmental fissure
Falciform ligament
Ligamentum teres

Couinaud classification?

1. Caudate Lobe

2. LT Lat Sup

3. LT Lat Inf

4. LT Med

5. RT Ant Inf

6. RT Post Inf

7. RT Post Sup

8. RT Ant Sup

What are the borders of the Caudate Lobe?

Separated from left lobe by ligamentum venosum and bordered posteriorly by IVC

What does the ductus venosus become?

Ligamentum venosum

What does the umbilical vein become?

Ligamentum teres/ Round ligament

What percentage of blood is supplied to the liver by the MPV?

70%

Where do the MPV and proper hepatic artery enter the liver?

Porta hepatis

What are the doppler characteristics of the PV and HA?

BOTH are hepatopetal and intrasegmental

PV minimally phasic
HA low resistance

What are the doppler characteristics of the hepatic veins?

Hepatofugal, pulsatile, intersegmental

What vessels come together to become the MPV?

SMV and splenic vein

What is a Reidel’s lobe?

Extension of rt lobe over rt kidney

What is a papillary process?

Inferior extension of the caudate lobe

What is the normal length of the liver?

Up to 15cm

What is considered a normal MPV diameter?

<13mm

What are the three liver enzymes?

ALT = Alanine Transaminase
ALP = Alkaline Phosphatase
AST = Aspartate Transaminase

Elevated levels of what causes jaundice?

Bilirubin

Indirect vs Direct Bilirubin?

Indirect (Unconjugated) = Pre-liver
Direct (Conjugated) = Liver and after

What causes Indirect/ Unconjugated bilirubin?

RBC hemolysis

What causes Direct/ Conjugated bilirubin?

Acute liver disease, hepatitis, biliary obstruction

What is another name for fatty liver infiltration?

Hepatic Steatosis

What is the most common diffuse liver disease?

Fatty Liver Infiltration

What is the most likely reason for elevated LFTs?

Fatty Liver Infiltration

What is the most common location of focal fatty sparing?

Next to GB/porta hepatis

What is the most common cause of cirrhosis?

Alcoholism

What are the clinical symptoms associated with cirrhosis?

Elevated LFTs, jaundice, fatigue, weight loss, diarrhea

Sonographic appearance of cirrhosis?

Heterogenous/ coarse, small right lobe, enlarged caudate lobe, nodular surface, ascites

If micronodular surface is seen with cirrhosis what is it caused by?

Alcoholism

If Macronodular (>1cm) surface is seen with cirrhosis what is it caused by?

Hepatitis

What is the most common cause of portal hypertension?

Cirrhosis

Where does the blood back up with portal hypertension? (AKA what veins normally drain into the PV)

Splenic vein and coronary (lt gastric) vein

What are the clinical signs of portal hypertension?

Same as cirrhosis (elevated LFTs, jaundice, fatigue + may have caput madusa

What are caput madusa?

Superficial varicose veins in the abdomen

What is a normal MPV?

<13 mm

What are sonographic findings associated with portal hypertension?

Recanalized paraumbilical vein, hepatofugal PV flow, abdominal varices, splenomegaly

What is a TIPSS procedure?

Transjugular Intrahepatic PortoSystemic Shunt

What are the connections used in a TIPSS procedure?

Rt portal vein (prox) to Rt hepatic vein (distal)

Obstruction of the PV is most commonly caused by?

Tumors or lymphadenopathy

What are the clinical signs of Portal vein compression/ thrombosis?

Pain, elevated LFTs, hypovolemia, nausea

What are the sonographic findings of portal vein compression/ thrombosis?

Cavernous transformation and thrombosis of PV

If intrahepatic collaterals (cavernous transformation) are seen what is its association?

PV thrombosis

If extrahepatic collaterals are seen what is its association?

Portal HTN

What is Budd-Chiari Syndrome?

Occlusion of hepatic veins and possibly IVC

What are the clinical and sonographic findings of Budd-Chiari Syndrome?

Elevated LFTs, Hepatomegaly, Enlarged Caudate, absent hepatic vein flow

What is the difference between hepatitis and abscess in the liver?

Hepatitis is a diffuse infection - LFTs abnormal
Abscess is Focal - LFTs may be normal

What is the most common Hepatitis?

Hep A and Hep B

What is the most likely cause of needing liver transplantation?

Hepatitis C

What is the most common acute hepatitis?

Hepatitis A

What are the sono signs of acute hepatitis?

Hepatomegaly, Hypoechoic, starry sky sign

What is the starry sky sign?

Periportal cuffing, increased echogenicity of portal triads associated with acute hepatitis

What is the most common chronic Hepatitis?

Hepatitis C

What are the clinical signs of an abscess?

Infection symptoms, fever, pain, leukocytosis

What are the sonographic signs of an abscess in the liver?

Focal, complex cyst

Hydatid Abscess?

Echinococcal Parasite
Water-lily sign/ Daughter cysts/ Membranes

Amebic Abscess?

Parasite from water
GI first = diarrhea

Pyogenic Abscess?

Pus/Bacteria
From other infection = Hx of -itis/ surgery/ Bx

Candida/ Fungal Abscess?

Immunocompromised pt
Target or halo multiples

What are cysts in the liver associated with?

Polycystic kidney disease

What is the most common benign liver tumor?

Cavernous hemangioma

What is hepatocellular adenoma associated with?

Oral contraceptives

What is considered the stealth lesion in the liver?

Focal Nodular Hyperplasia

What benign liver tumor should you look for the “mass effect”? Central scar with vascularity

Focal Nodularity Hyperplasia

What is in intraparenchymal hematoma?

Bleed from within the organ/liver. More focal appearing

What is the most common primary liver cancer?

Hepatocellular Carcinoma

What are the tumor markers and sonographic appearance of hepatocellular carcinoma (HCC/ Hepatoma)?

Elevated AFP
Solitary, hypoechoic mass, ascites

What is the most common cancer found in the liver?

Metastasis

What are the most common sources of liver mets?

Lung, colon(most common primary), breast

What type of metastasis will have a “target” sign in the liver?

Lung or colon

What is the pediatric version of HCC, pediatric malignancy?

Hepatoblastoma

Hepatoblastoma has an increased risk in those with?

Beckwith-Wiedemann syndrome

What is the most common reason for a liver transplant?

Hepatitis C (because it is chronic)

What is a big indicator for liver transplant rejection?

Abnormal doppler patterns, decreased diastolic flow

What is the most common vascular complication after a liver transplant?

Hepatic artery thrombosis

Where will the dilation be in the biliary tree in relation to the obstruction?

Everything proximal to obstruction will dilate

What is the order of the flow of bile in the biliary tree?

Liver > Biliary radicles > R/L HD > CHD > cystic > GB > cystic > CBD > Ampulla of Vater

What is the vascular supply of the Gallbladder?

Cystic artery (branch of right hepatic artery)

What are the wall layers of the Gallbladder (inner to outer)

Mucosa > Fibromuscular > Serosa

What is the most common variant of the GB?

Phrygian cap (fold of fundus over body)

What is a junctional fold of the GB?

Fold at neck