Lange Review Ultrasonography Examination, 4th Edition

Answers and Explanations

At the end of each explained answer, there is a number combination in parentheses. The first number identifies the reference source; the second number or set of numbers indicates the page or pages on which the relevant information can be found.

1. (B) The three structures that make up the portal triad are the hepatic artery, portal vein, and bile duct. (1:82)

2. (D) Wilms’ tumor, also known as nephroblastoma, is the most common type of renal cancer in children between the ages of 2 and 4 years. The most common symptoms for Wilms’ tumor are hematuria and hypertension. (1:1926)

3. (C) Courvoisier’s sign. Courvoisier law is enlargement of the gallbladder caused by an obstruction of the common bile duct from outside the biliary system. The obstruction usually results from carcinoma of the head of the pancreas and not from a stone in the common duct. The latter produces little or no dilatation of the gallbladder because the gallbladder is usually scarred from infection. Classically, patients present with painless jaundice and a nontender and distended gallbladder. (1:213)

4. (B) Hydropic gallbladder. Complete obstruction of the neck of the gallbladder or the cystic duct leads to hydrops or mucocele of the gallbladder. In this condition, the bile within the gallbladder is absorbed and replaced by a mucoid secretion from the lining of the gallbladder. (6:130)

5. (D) Renal vein thrombosis in the acute stage is associated with enlarged kidneys with dilation of the renal vein proximal to the obstruction. There will be either a decreased or no blood flow on Doppler. Bilateral small kidneys are associated with end-stage renal disease. The normal adult kidneys range from 9 to 12 cm in length. The renal parenchyma is normally less echogenic when compared to the liver parenchyma. In cases of end-stage renal disease, the kidneys become more echogenic. End-stage renal disease may be caused by chronic glomerulonephritis, pyelonephritis, and renal vascular disease. (2:98, 99)

6. (C) A staghorn calculus is a large stone located within the renal pelvis of the kidney. (7:375)

7. (D) Cholecystokinin, a hormone released by the intestinal mucosa, stimulates the release of bile from the gallbladder and pancreatic enzymes from the pancreas. (2:164)

8. (D) The liver is an intraperitoneal structure. The portion of the liver that is not covered by peritoneum is termed the bare area. The bare area is located between the right and left triangular ligaments. (2:144–146)

9. (E) The normal thickness of the gallbladder wall is 3 mm. Thicker walls suggest a pathologic condition that may be biliary in nature. (2:175)

10. (C) The pancreatic head lies caudad to the portal vein and anterior to the inferior vena cava. (2:208)

11. (C) Hydronephrosis is a fluid-filled pelvocaliceal collecting system. Sonographically, hydronephrosis has varied appearances from a mildly distended pelvocaliceal collecting system to moderately distended fluid-filled pelvocaliceal collecting system, and in the most severe form, the kidneys appear cystic with very little renal cortical tissue. (2:284, 285)

12. (B) On a sonographic examination dilatation of the interhepatic ducts, common bile duct, and gallbladder (the gallbladder enlarges before the biliary tree because it has the greatest surface area) is imaged, one should expect the obstruction to be at the distal common bile duct. (2:189)

13. (A) The most common location of a pancreatic pseudo-cyst is in the lesser sac, which is located anterior to the pancreas and posterior to the stomach. (2:216)

14. (B) The extrahepatic portion of the falciform ligament can be visualized when there is massive ascites. The falciform ligament contains the ligamentum of teres and will appear sonographically as an echogenic linear band attaching the bare area of the liver to the anterior abdominal wall. (2:114)

15. (C) Anterior and parallel to the aorta. (7:55)

16. (A) The division by using Couinaud’s sections into right and left lobes of the liver is by the imaginary plane, the main lobar fissure. (6:94)

17. (C) A prominent uncinate process of the pancreas lies posterior to the superior mesenteric artery and vein. (2:208; 7:55)

18. (E) The splenic vein courses transversely across the body along the posterior portion of the body and tail of the pancreas. (6:151)

19. (B) The gastroesophageal junction can sonographically be visualized anterior to the aorta and posterior to the left lobe of the liver. (2:231)

20. (D) Adenomyomatosis is a benign proliferation and thickening of the muscle layer and glandular layer of the gallbladder with formation of intramural diverticula called Rokitansky–Aschoff sinuses (RAS). There are three forms: diffuse, segmental, and localized. It is more common in women, with increasing incidence after the age 40 years. (6:134, 135)

21. (B) The most common cause for acute pyelonephritis is Escherichia coli a Gram-negative rod-shaped bacterium, which invades the renal tissue. It is more common in women than men. (10:142)

22. (A) Angiomyolipoma is an uncommon benign renal mass, which is composed of blood vessels, fat, and muscle. They appear on ultrasound as an echogenic well-defined mass located in the renal cortex. When the mass is small, the patient is usually asymptomatic. Symptoms usually do not appear until the mass enlarges and bleeds, which causes severe flank pain and hematuria. (10:152)

23. (C) The gastroduodenal artery is a branch of the common hepatic artery. It is a landmark for the anterior lateral aspect of the head of the pancreas. (7:241)

24. (E) The left renal vein courses transversely across the body to enter into the inferior vena cava. It may be identified sonographically as a tubular anechoic structure between the aorta and superior mesenteric artery. (9:183)

25. (A) Glisson’s capsule is a dense fibroelastic membrane that completely surrounds the liver and encloses the portal vein, hepatic artery, and bile ducts within the liver. (4:117)

26. (C) Left adrenal hyperplasia may cause anterior displacement of the splenic vein and posterior or inferior displacement of the left kidney. (7:489)

27. (A) The celiac axis has three branches, the common hepatic artery, left gastric artery, and splenic artery. Sonographically, only a short section of the splenic artery can be seen because of its tortuous course. (6:72, 73)

28. (D) Accessory spleens are the most common congenital anomaly of the spleen. They are difficult to image sonographically, but when imaged, they are most often seen at the hilum of the spleen. (2:312)

29. (D) A congenital fold between the body and fundus of the gallbladder is called a Phrygian cap. (6:126)

30. (B) The inferior vein cava forms at the confluence of the right and left common iliac veins, and it empties into the right atrium of the heart. (6:75)

31. (E) Diffuse thickening of the gallbladder wall is a nonspecific finding frequently seen when there is no primary gallbladder disease. It can be seen with acute and chronic cholecystitis but may also be secondary to right-sided heart failure, hepatitis, and benign ascites. In a patient not being NPO, physiologic contraction of the gallbladder has occurred and is one of the most common causes of diffuse thickening of the gallbladder wall. (7:217)

32. (D) If on a sonographic examination, one finds dilated intrahepatic ducts and a small gallbladder, the obstruction will usually be at the level of the common hepatic duct above the entry of the cystic duct. Bile will not be able to pass through the level of obstruction to fill the gallbladder. (7:220)

33. (E) The maximum inner diameter of the main pancreatic duct in a young adult patient measures 2 mm. (6:152)

34. (A) The endocrine function of the pancreas is to produce insulin, glucagon, and somatostatin. The exocrine function of the pancreas is to produce lipase, amylase, trypsin, and chymotrypsinogen. (6:149–159)

35. (A) Creatinine and blood urea nitrogen (BUN) are commonly used to measure renal function. Creatinine is normally filtered out of the blood by the kidneys and removed from the body via the urine. (2:296)

36. (C) Adult polycystic renal disease is an autosomal dominate disease, which usually does not produce symptoms until the third or fourth decade of life. It is also associated with cysts in the liver, pancreas, spleen, and testes. Sonographically, the kidneys are enlarged with multiple cysts of varied size. The kidneys lose their reniform shape as the cysts enlarge. (2:264)

37. (B) The spleen is the best sonographic window to use to image the left hemidiaphragm. (6:225)

38. (D) Patients in the sickle cell crisis (early stages of the disease) will have an enlarged spleen. In the later stages, the spleen becomes fibrotic and atrophies. When the spleen is not imaged, it is referred to as autosplenectomy. (6:233)

39. (A) Urinoma. Bilateral hydronephrosis occurs because of obstruction in the lower urinary system, i.e., enlargement of the prostate from benign or malignant cause, uterine fibroids, late pregnancy, and posterior urethral valve syndrome. Urinoma is a collection of urine usually outside of the kidney due to a tear in the ureter or renal pelvis. (6:186)

40. (D) Normal. The amount of liver damage in patients with acute hepatitis varies from mild to severe. The liver parenchyma may appear normal in a patient with acute hepatitis. (2:138, 139)

41. (C) Renal variant. A hypertrophied column of Bertin is a normal variant of the kidney where there is an indentation of cortical tissue into the renal sinus. (2:257)

42. (B) The ureterovesical junction is the junction between the distal ureter and the base of the bladder. (6:172)

43. (D) Posterolateral to the thyroid is the common carotid artery, internal jugular vein, and the vagus nerve. (2:397)

44. (E) Jaundice. Signs of renal failure included: oliguria, palpable flank mass, generalized edema, pain, fever, hypertension, and muscle weakness are some of the clinical signs of acute renal failure. (7:392, 393)

45. (C) Testicular torsion. A hydrocele is a common cause of scrotal pain. It can be either congenital or caused by trauma, mass, infarction, inflammation, or trauma. (2:418)

46. (B) Adrenal neuroblastoma is the most common malignancy of the adrenal gland found in children. (2:343)

47. (A) When a mass is visualized in the area of the head of the pancreas, one should check the liver for metastasis and dilatation of the intrahepatic ducts. The common bile duct and main pancreatic duct may be dilated secondary to obstruction caused by enlargement of the mass. (3:218, 219)

48. (C) Adenocarcinoma is the most common primary carcinoma of the pancreas. It is most frequently found in the head of the pancreas. The clinical symptoms are weight loss, painless jaundice, nausea, and pain radiating to the back. (2:218)

49. (C) The ligamentum of venosum separates the anterior portion of the caudate lobe from the left lobe of the liver, and the ligament of teres (round ligament) is a cord-like ligament that is located in the free margin of the falciform ligament. The falciform ligament divides the left lobe of the liver into medial and lateral segments. The main lobar fissure divides the liver into right and left lobes. (6:95)

50. (A) The most common benign neoplasm of the liver is a hemangioma, which is also called a cavernous hemangioma. It can be either single or multiple and is more commonly found in women and in the right lobe of the liver. (6:103, 104)

51. (D) Blood from the hepatic veins drain into the inferior vena cava, which delivers deoxygenated blood to the right atrium of the heart. Right-side heart failure will produce venous congestion of the liver, which will lead to marked dilation of the intrahepatic veins. (7:155)

52. (B) The main lobar fissure separates the right and left lobes of the liver. The ligamentum of venosum separates the anterior portion of the caudate lobe from the left lobe of the liver, and the ligament of teres (round ligament) is a cord-like ligament that is located in the free margin of the falciform ligament. The falciform ligament divides the left lobe of the liver into medial and lateral segment. (4:121)

53. (D) The spleen is an intraperitoneal structure. Retroperitoneal structures include the kidney, pancreas, great vessels, adrenal glands, psoas muscles, and duodenum. (7:507)

54. (C) The splenic vein and superior mesenteric vein join together to form the portal vein. The junction of the splenic vein and superior mesenteric vein occurs posterior to the neck of the pancreas. (6:78)

55. (B) The common bile duct unites with the main pancreatic duct just before entering the second portion of the duodenum. (2:197)

56. (A) Empyema of the gallbladder is a complication of acute cholecystitis. The patient presents with high spiking fever, chills, and leukocytosis. The walls of the gallbladder are thickened, and the lumen is filled with pus and debris. There may be a “dirty” shadow caused by the gas, which is formed by the bacteria. (7:216)

57. (B) A cause of an increase in alpha-fetoprotein in a non-pregnant patient is a hepatoma of the liver. (2:148)

58. (C) If the prostate is found enlarged, one should check the kidneys for hydronephrosis. An enlarged prostate gland is a common cause of bladder neck obstruction in older men. (7:419)

59. (A) The anterior wall of the body of the pancreas is the posterior wall of the antrum of the stomach. (2:196)

60. (A) On a transverse scan, the portal vein is seen as a circular structure anterior to the inferior vena cava and superior to the head of the pancreas. (2:87)

61. (B) The most common cause of hyperthyroidism is Graves’ disease that is an autoimmune disease where by the immune system attacks the thyroid and causes diffuse enlargement of the thyroid gland. (6:277)

62. (D) A prominent uncinate process is anterior to the inferior vena cava and posterior to the superior mesenteric vein. (2:196)

63. (C) A dissecting aortic aneurysm is when there is a tear through the intima layer and a blood-filled channel forms within the aortic wall. Patients are usually hypertensive males and have a known aneurysm. (2:91, 92)

64. (B) The adrenal glands can be divided into the cortex and medulla. The cortex has three zones, and each zone secretes a different type of steroid hormone, while the medulla secretes epinephrine and norepinephrine. (2:336)

65. (C) The ligament of teres is formed embryologically from the portal sinus branch of the umbilical vein. This canal closes after birth. Recanalization of the umbilical vein is associated with end-stage cirrhosis and portal hypertension. (6:97, 111)

66. (D) The parallel channel sign, irregular borders, and echo enhancement posterior to the dilated ducts are all characteristic of dilated intrahepatic bile ducts. It is common bile duct near the porta hepatis that is the first to dilate and is greatest in size. (7:227–229)

67. (A) The rectus abdominis muscle arises from the pelvis lines, but it lines the anterior abdominal wall; therefore, it is not located in the retroperitoneal cavity. (7:19)

68. (D) A Klatskin tumor originates at the junction of the right and left hepatic ducts. Cholangiocarcinoma is a primary adenocarcinoma located in the intrahepatic ducts. A Klatskin tumor, cholangiocarcinoma, and enlarged portal lymph nodes will only cause intrahepatic obstruction. Pancreatic carcinoma will initially obstruct the common bile duct before intrahepatic dilatation occurs. (2:189)

69. (B) Direct or conjugated bilirubin elevated levels are seen in cases of obstructive jaundice. The laboratory results suggest obstructive jaundice, and one must check for the causes of the obstruction. (7:199)

70. (C) Prolonged fasting and diabetes, especially in one who is insulin dependent, are causes of enlarged gallbladder. Ascites is a nonbiliary cause of diffuse thickening of the gallbladder wall. Chronic cholecystitis is a cause of a small gallbladder. (7:217, 220)

71. (D) The celiac axis originates within the first 2 cm of the abdominal aorta; therefore, it is located superior to the pancreas. All of the vessels listed are used as landmarks for locating and imaging the pancreas. (6:150, 151)

72. (A) Retroperitoneal masses tend to cause anterior and cranial displacement of surrounding organs. The direction of the displacement is one way to distinguish between a retroperitoneal versus a peritoneal mass. (2:343)

73. (D) Enlarged paraspinal lymph nodes may displace the aorta anteriorly, causing the aorta to appear to be “floating.” (2:339)

74. (D) Sonographically, enlarged nodes appear as hypoechoic masses with no demonstration of through transmission, because of its composition. (2:340, 341)

75. (A) Hepatofugal (portafugal) blood flow is the reversal of blood flow, that is, blood flow away from the liver. This may be caused by portal hypertension or liver disease. (4:10, 11)

76. (B) Anatomical landmarks helpful in locating the left adrenal gland are the aorta, spleen, left kidney, and left crus of the diaphragm. (2:331)

77. (A) Gallbladder polyps can be distinguished from calculi by the absence of shadowing and mobility. (1:207–208)

78. (E) Hydrops is dilatation of the gallbladder, which may be caused by an obstruction in the cystic duct. The gallbladder is palpable, and the patient may be asymptomatic or may present with pain, nausea, and vomiting. The intrahepatic and extrahepatic ducts are not dilated. (5:130)

79. (C) The most common cause of jaundice in the pediatrie patient is biliary atresia, a narrowing and obstruction of the intrahepatic bile duct. (7:204)

80. (C) Examples of primary retroperitoneal tumors imaged sonographically are leiomyosarcomas, neurogenic tumors, fibrosarcomas, rhabdomyosarcomas, and teratomatous tumors. (2:344)

81. (D) A series of relative echogenicity has been established. Going from least echogenic to most: renal parenchyma < liver < spleen < pancreas < renal sinus. (6:153; 7:328)

82. (D) The pancreas in children will be relatively less echogenic and larger in size relative to the body size. The echogenicity of the pancreas increases with age because there is an increase in body fat deposition, which increases the amount of body fat within the parenchyma of the pancreas. (2:248–249)

83. (B) The kidneys are covered by three layers: the true capsule is the most internal layer that covers only the kidney; the perinephric fat is the middle layer, which is between the kidney and adrenal gland; and Gerota’s fascia surrounds the kidneys, perinephric fat, and the adrenal glands. (2:292)

84. (B) The middle, right, and left hepatic veins originate in the liver and drain directly into the inferior vena cava at the level of the diaphragm. They are the largest major visceral branches of the inferior vena cava. (6:76)

85. (B) The spleen is variable in size but it is considered to be convex superiorly and concave inferiorly. (2:258–359)

86. (C) Hypernephroma is a malignant solid renal tumor, which is also called renal cell carcinoma or adenocar-cinoma of the kidney. Transitional cell carcinoma is the most common tumor to the collecting system. Oncocy-toma is a rare benign renal tumor. (1:350–352; 2:322–327)

87. (C) The left kidney lies inferior and medial to the spleen. The diaphragm is superolateral, and posterior to the spleen, and the stomach, tail of the pancreas; splenic flexure is medial to the spleen. (1:322–323; 2:92)

88. (B) A hematocele is a condition in which blood fills the scrotal sac. Sonographically, an acute hematocele appears with thickened scrotal walls and fluid within the scrotal sac without increased through transmission. It is usually a result of trauma or surgery. (7:752, 753)

89. (A) A cavernous hemangioma is the most common benign hepatic neoplasm, and the most common sonographic appearance is an echogenic round or oval with well-defined borders. (2:147)

90. (C) The normal thyroid gland measures 1–2 cm in anteroposterior dimension and 4–6 cm in length. (2:396)

91. (E) Ascites in most cases is secondary to a primary disease process. Some of the causes of ascites include congestive heart failure, nephritic syndromes, and infections, e.g., tuberculosis, trauma, and malignancy. Adenomyomatosis is a benign gallbladder condition, where there proliferation of the mucosal lining of the gallbladder into the muscle layer. Diverticulum of the muscle layer occurs and bile may collect there and cause ring-down artifacts. (6:134, 135; 7:46)

92. (B) Sonographically, the best way to diagnosis a dissecting aneurysm is to document the intimal flap moving with the pulsations of blood through the aorta. (7:70, 71)

93. (A) A mass in the head of the pancreas with a dilated common bile duct is suggestive of obstructive jaundice. (2:189)

94. (B) A subhepatic abscess would be located inferior to the liver and anterior to the right kidney. This space is also referred to as Morrison’s pouch. Other common sites for abscesses are the subphrenic, perinephric, intrarenal, intrahepatic, pelvic, and around lesions at the site of surgery. (6:255)

95. (D) The ligamentum venosum is a remnant of the fetal ductus venosus; the ligament of teres and the falciform ligament are remnants of the fetal umbilical vein. The coronary ligaments define the bare area of the liver. (2:114; 5:95)

96. (A) The gastroduodenal artery is a major branch of the common hepatic artery. (6:73)

97. (D) Patients with Courvoisier gallbladder present with painless jaundice and a palpable right-upper-quadrant mass. The obstruction of the common bile duct is usually caused by enlargement of the head of the pancreas. Patients with acute hepatitis and cirrhosis do have painless jaundice. The jaundice is not caused by obstruction of the biliary system. It is caused by destruction of the liver parenchyma. Porcelain gallbladder is calcification of the gallbladder wall. (6:109–111, 137)

98. (E) A dromedary hump is a cortical bulge of the lateral border of the left kidney. A junctional parenchymal defect is a distinct division between the upper and lower pole of the kidney. A column of Bertin is prominent indentations of the renal sinus. All of these variants have a mass effect on ultrasound. A Phrygian cap is a fold between the fundus and body of the gallbladder. (2:256, 257)

99. (C) Ascites, small liver, portal hypertension, and nodular liver borders may all be present with end-stage liver disease. The bile ducts will not be dilated because of the fibrotic liver parenchyma. (2:139)

100. (A) The head of the pancreas is located anterior to the inferior vena cava. (2:196)

101. (B) The lesser sacs are located between the stomach and pancreas. (2:216)

102. (B) The renal pyramids are located in the medulla of the kidney. (2:248)

103. (C) In chronic renal disease, both kidneys are small and echogenic. (2:268)

104. (B) A long history of alcoholism is a major cause of cirrhosis and ascites often is seen secondarily to cirrhosis. (7:149, 152)

105. (C) Chronic active hepatitis may progress to cirrhosis. The etiology of chronic active hepatitis is usually idiopathic but may be viral or immunological. (2:148)

106. (A) Choledochal cyst is a rare focal cystic dilatation of the common bile duct caused by an anomalous junction of the common bile duct with the main pancreatic duct. The reflux of the pancreatic enzymes causes a weakness of the common bile duct wall and an outpouching of the wall. Choledochal cysts may be associated with gallstones, cirrhosis, and pancreatitis. Clinically, the patient presents with pain, fever, abdominal mass, or jaundice. (2:177)

107. (E) Hashimoto’s thyroiditis is chronic inflammation of the thyroid. It is a common cause of hypothyroidism in regions where there is a lack of iodine. The entire thyroid gland is involved, and sonographically, the thyroid is enlarged with irregular borders with decreased heterogeneous echoes. People with Graves’ disease present with hyperthyroidism, bulging eyes, and skin thickening. The thyroid is enlarged with increased vascularity. Malignant tumors of the thyroid are rare and have varied appearance on ultrasound, from a single small solid nodule to hypoechoic to being isoechoic with the thyroid tissue. In 50% of cases, there will be calcification. (2:402)

108. (D) Calcification of part or the entire wall of the gallbladder is called a porcelain gallbladder. It is associated with chronic cholecystitis and gallstones. These patients have a higher risk of carcinoma of the gallbladder. (2:185)

109. (A) Patients typically are diagnosed with an aortic aneurysm by a pulsatile mass noted on physical examination. They usually have a history of smoking and vascular disease, such as hypertension. On ultrasound, it is important to measure the diameter of the lumen and the location of the aneurysm in reference to the renal arteries. (2:90, 91)

110. (B) The right renal artery courses posterior to the inferior vena cava and may be imaged as a round anechoic structure posterior to the inferior vena cava on a longitudinal scan. (2:84)

111. (A) The retroperitoneal space is the area between the posterior portion of the parietal peritoneum and the posterior abdominal wall muscle. (2:238)

112. (A) When there is extrinsic pressure and obstruction of the common bile duct (i.e., a mass in the head of the pancreas), the gallbladder and biliary tree will be enlarged. (6:159–162)

113. (C) The serum amylase and lipase both elevate upon the onset of pancreatitis, but amylase reaches its maximum value within 24 hours. Lipase remains elevated for a longer period of time. (7:249)

114. (B) Hypertrophic pyloric stenosis (HPS) is more commonly seen in males between the ages of 1 week and 6 months. The pylorus is the channel between the stomach and duodenum. When the muscle of the pylorus is thickened, it prevents food from entering the stomach. The child typically presents with projectile vomiting, dehydration, and a palpable olive-size mass in the epigastric region. The diagnosis of HPS is made if the length of the pylorus is greater than 18 mm, the anterior to posterior diameter is greater than 15 mm, or the muscle thickness is greater than 4 mm. (7:587, 588)

115. (B) Neuroblastoma is a malignant tumor of the adrenal medulla that is found in children. (7:503)

116. (B) Chronic pancreatitis. Enlarged lymph nodes are hypoechoic with no increase in through transmission. Aortic aneurysm, crus of the diaphragm, and bowel may all appear sonographically as hypoechoic. Chronic pancreatitis is imaged as echogenic. (7:512)

117. (D) Budd–Chiari syndrome is caused by thrombus in the hepatic veins or in the inferior vena cava causing obstruction of blood flow to the heart. The obstruction may be congenital or acquired. Budd–Chiari is associated with renal cell carcinoma, primary carcinoma of the liver, or prolonged usage of oral contraceptives. It is characterized by abdominal pain, massive ascites, and hepatomegaly. Sonographically, the right lobe of the liver may be small with normal or enlarged caudate lobe. There will either be absence of blood flow in the hepatic veins and inferior vena cava or abnormal blood flow pattern on Doppler. (7:160, 161)

118. (E) In response to the increased pressure in the portal vein, which is associated with portal hypertension, there may be recanalization of the umbilical vein, which is located within the ligamentum of teres. (2:154, 155)

119. (B) A pelvic kidney is a kidney that has failed to ascend to the renal fossa. It is located in the pelvis but has the same sonographic appearance as a kidney located in the renal fossa. (6:173)

120. (A) The ureteropelvic junction is where the renal pelvis narrows and joins the proximal portion of the ureter. (6:172)

121. (E) According to Platt et al. an RI of the renal artery greater than 0.70 is 90% accurate in diagnosing renal obstruction. (6:211)

122. (C) Cushing’s syndrome is an adrenal disease where there is oversecretion of glucocorticoids. (2:343)

123. (D) Body and tail. Islet cell tumors of the pancreas are well-circumscribed solid masses with low-level echoes and are frequently found in the body and tail of the pancreas and rarely in the head of the pancreas. (2:219, 223)

124. (C) The celiac artery has three branches: the common hepatic artery, left gastric artery, and the splenic artery. (6:72)

125. (A) The most common benign mass of the spleen is a cavernous hemangioma. The most common malignant tumor of the spleen is an angiosarcoma. Congenital cysts of the spleen are rare, and lymphomas are not benign masses. (6:234)

126. (B) The parietal peritoneum lines the abdominal cavity. Organs are intraperitoneal if they are surrounded by peritoneum or retroperitoneal if only their anterior surface is covered. (7:35–37)

127. (C) A normally functioning transplanted kidney will have the same sonographic appearance as a normal kidney located in the renal fossa. (7:400)

128. (D) When food containing fat enters the small intestines, cholecystokinin is released into the bloodstream, which activates the contraction of the gallbladder and the relaxing of the sphincter of Oddi. (7:198)

129. (B) A transplanted kidney is usually placed in the pelvis along the iliopsoas margin and anterior to the psoas muscle. The ureter of the donor kidney is anastomosed to the bladder. The donor renal artery is anastomosed to the external iliac artery, while the renal vein is connected to the internal iliac vein. (7:399)

130. (A) Klatskin tumors arise at the junction of the right and left hepatic ducts and causes dilation of the intrahepatic ducts with no dilatation of the extrahepatic ducts. (6:141, 142)

131. (D) Pancreas. The liver, spleen, hepatic veins, and gallbladder are located in the peritoneal cavity. The great vessels, pancreas, adrenal glands, and kidneys are not surrounded by peritoneum; therefore, they are located in the retroperitoneal cavity. (2:328)

132. (C) The splenic artery originates from the celiac axis and courses along the superior aspect of the pancreas body and tail. (6:72)

133. (C) Artifacts result from a variety of sources including thickness and side-lobe artifacts, reverberation artifacts, electronic noise, and range in ambiguity effects. Edge effects cause acoustic shadowing owing to reflection and refraction of sound. (6:12, 13)

134. (B) When ascites is present, it acts as an acoustic window. Therefore, the liver will appear more echogenic. There is always posterior acoustic enhancement when the sound travels through fluid. (6:11)

135. (A) All ultrasound equipment is calibrated at 1,540 m/s, the speed of sound in soft tissue. When the ultrasound beam goes through a fatty tumor with a lower propagation speed, the tumor will appear farther away than its actual distance. (6:13)

136. (D) A fluid collection located between the diaphragm and the spleen may represent a subphrenic abscess. (2:348)

137. (B) If a mass is solid, displacement of adjacent organs will aid in helping to evaluate the origin of the mass. In a retroperitoneal sarcoma, the kidney, spleen, and pancreas would be displaced anteriorly. (2:348, 349)

138. (C) Splenomegaly may be caused by congestion, i.e., portal thrombosis, trauma, infection, Hodgkin’s disease, lymphoma, neoplasms, storage diseases, and polycythemia vera. (2:318, 319)

139. (A) Adenomyomatosis is a benign infiltrative disease that causes a diffuse thickening of the gallbladder wall. It does not cause enlargement of the gallbladder. (6:134, 135)

140. (D) Posterior to the kidneys are the quadratus lumborum muscles, diaphragm, psoas muscle, and twelfth rib. (6:248)

141. (D) Patients with chronic cirrhosis will have a small nodular fibrotic liver, which impedes blood flow through the liver causing collateral vessel development and portal hypertension. Ascites, peripheral edema, and splenomegaly are usually secondary to the increase in pressure in the portal vein. Liver failure causes jaundice and an increase in the clotting time. Sonographically, the liver is small and echogenic. (7:151)

142. (C) Ureteral jets are not present if there is an obstructive hydronephrosis. A bladder tumor or posterior urethra valves may obstruct urine from exiting the body. In cases of severe obstruction, the increased pressure in the urinary bladder may cause the ureters and renal collecting system to dilate. A parapelvic cyst usually does not cause hydronephrosis. (2:285)

143. (B) An extrarenal pelvis extends from the renal pelvis to outside the renal capsule. One way to differentiate an extrarenal pelvis from hydronephrosis is to place the patient prone. The pressure will collapse the extrarenal pelvis. (6:285, 284)

144. (E) The long narrow arrow points to the heart. The aorta and the inferior vena cava enter the thoracic cavity to the heart. (2:104)

145. (E) The short wide arrow is pointing to the aorta, which enters the thoracic cavity to the heart. The aorta lies posterior to the left lobe of the liver. (2:104)

146. (A) The arrow is pointing to a round anechoic structure anterior and slightly to the left of the spine, which is the aorta. (2:108)

147. (E) Simple cysts are present in 50% of all adults older than 50 years. They are usually of no clinical significance and may be located anywhere in the kidney. Fig. 4–11 of the left kidney documents a small upper pole cyst with a larger cyst of the lower pole. (2:263)

148. (A) The most common causes of a fatty liver are alcohol abuse and obesity. Diabetes, chemotherapy, cystic fibrosis, and tuberculosis are other causes of fatty liver infiltration. The liver varies in appearance depending on the severity of the fatty changes. The liver parenchyma will have an increase in echogenicity with a decrease in acoustic penetration. In cases of severe fatty infiltration, there will be a decrease in the echogenicity of the portal vessel walls caused by the increase in the echogenicity of the liver parenchyma. There may be difficulty in visualization of the diaphragm because of the increase of the liver parenchyma. (7:145)

149. (B) Superior mesenteric artery (SMA) arises from the abdominal aorta. It is seen posterior to the pancreas (1:216)

150. (A) Acute cholecystitis is usually associated with gallstones. Sometimes there may be cholecystitis without gallstones, which is referred to as acalculous cholecystitis. The sonographic appearance will be the same except for the presence of echogenic foci with posterior shadowing within the gallbladder lumen. (6:213)

151. (C) Cystic artery. The sonographic characteristics of acute cholecystitis include an enlarged gallbladder with a transverse diameter >5 cm, gallbladder wall >5 mm, pericholecystic fluid, a positive Murphy’s sign, and an enlarged cystic artery. Not all of the sonographic criteria will be present in every case of cholecystitis. (6:213, 216)

152. (A) The pleural sac surrounds the lungs. The internal pleura (visceral pleura) line the lungs, while the external pleura (parietal pleura) line the inner surface of the chest wall. A pleural effusion is fluid superior to the diaphragm in the pleural sac. The diaphragm must be identified to differentiate fluid in the pleural space verses fluid in the abdominal cavity (ascites). (2:552)

153. (C) The liver is a common site for metastatic involvement. The most common primary sites include the colon, breast, and lungs. Metastatic lesions to the liver have varied sonographic appearances. They may be hypoechoic, echogenic, and well-defined or cause a diffuse echogenic hepatic pattern. (2:152, 153)

154. (B) The arrow is pointing to a normal hepatic vein, which drains into the inferior vena cava. (6:76)

155. (B) The arrow is pointing to the right renal artery, which lies posterior to the inferior vena cava. (6:74)

156. (B) The quadratus lumborum muscle is posterior to the kidney and courses lateral to the psoas muscle. It protects the posterior and lateral abdominal wall. (7:19, 324)

157. (C) The falciform ligament extends from the umbilicus to the diaphragm and can only be imaged sonographically when massive ascites is present. (2:114)

158. (C) A multicystic (dysplastic) kidney is a common cause of a palpable neonatal mass. It is usually unilateral. Bilateral multicystic pathology is not compatible with life. (2:270)

159. (D) The main lobar fissure is a landmark used to document the gallbladder fossa when there is nonvisualization of the gallbladder. It appears sonographically as an echogenic linear structure that extends from the portal vein to the neck of the gallbladder. (2:114)

160. (A) The most common primary neoplasm of the pancreas is an adenocarcinoma. (2:218)

161. (E) The arrowhead is pointing to an enlarged pancreatic duct. The normal measurement of the pancreatic duct is <2 mm. (7:244)

162. (A) Sonographically, acute pancreatitis may appear normal or diffusely enlarged with a decrease in echogenicity. The pancreatic duct may be enlarged. Hemorrhagic pancreatitis appearance depends upon the age of the hemorrhage. Usually there will be a well-defined mass in the head of the pancreas. Phlegmonous pancreatitis typically has an ill-defined hypoechoic mass on ultrasound. Chronic pancreatitis on a sonogram is usually atrophied and is very echogenic. There may be dilatation of the main pancreatic duct secondary to a stone in the duct.

163. (C) Aortic aneurysm with a small thrombus in the proximal aorta and partial occlusion documented by color Doppler on both a transverse and a longitudinal view. (7:66)

164. (B) The superior mesenteric artery is a ventral branch of the aorta. It courses parallel and anterior to the abdominal aorta. (9:44)

165. (A) The sonographic appearance of acute pancreatitis varies depending on the severity of the inflammation. The echogenicity is hypoechoic and usually less than the liver. The pancreas may be enlarged with a dilated pancreatic duct. (10:88–89)

166. (A) The arrow is pointing to a medullary pyramid. (2:255)

167. (C) Gallstones (calculi) sonographically appear as mobile echogenic foci with posterior shadowing. (10:59)

168. (D) Acoustic shadowing. (10:59)

169. (E) The common bile duct is a sonolucent tubular structure that is imaged anterior to the portal vein. (10:53)

170. (C) The upper limits of the normal common bile duct (CBD) is 8 mm. The CBD diameter increases in size after the age of 50 years by approximately 1 mm/decade. (10:53)

171. (B) Pneumobilia is air in the biliary tract. Air in the biliary tract may be caused from chronic cholecystitis, biliary-enteric fistula, or a surgical complication. Sonographically, pneumobilia appears as echogenic foci usually found in the region of the porta hepatis. There may be motion and weak posterior acoustic shadowing of the foci. (10:80)

172. (E) Liver metastatic disease has various sonographic appearances. It may present as multiple echogenic masses of varying sizes. Malignant masses tend to have irregular borders and invade the surrounding tissue. Metastasis of the liver may present as a well-defined mass, hypoechoic mass, or a cystic lesion. Primary sites include the colon and breast. (10:34)

173. (D) The spleen appears normal. (9:139)

174. (C) The common bile duct is formed from the confluence of the common hepatic duct and the cystic duct. (9:92)

175. (B) Atherosclerosis is the most common cause of an aneurysm. (2:90)

176. (C) The arrow is pointing to the common bile duct, which is located anterior to the portal vein. The main portal vein, common bile duct, and hepatic artery form the porta hepatis. (9:82)

177. (D) A duplex collecting system is a common renal variant. The echogenic renal sinus is separated by renal parenchyma. A duplex collecting system can mimic a mass occupying part of the renal sinus. (2:257)

178. (A) An echogenic foci with posterior acoustic shadowing is the sonographic appearance of a calculi. A calculi in the common bile duct may cause dilatation of the duct. (2:86)

179. (C) Gallstones. Hydronephrosis may be unilateral or bilateral. An enlarged prostate, posterior urethra valve, pelvic mass, or a mass in the urinary bladder may cause bilateral renal obstruction. A stone in the ureter may cause unilateral hydronephrosis. Gallstones do not cause compression on the urinary system and have no effect on the urinary system. (7:368, 369)

180. (B) Sitting upright. The correct positioning for the patient undergoing needle thoracentesis is significant for successful procedure. (12:118)

181. (A) Graves’ disease is an autoimmune disease that affects the thyroid gland, eyes, and the skin. The name derives from Robert Graves, MD, and Irish physician who was the first to describe this type of hyperthyroidism. The biochemical abnormality is decreased thyroid-stimulating hormone and increased T3 and T4. (2:520; 7:665, 666)

182. (B) Multiple hypoechoic micronodules. Hashimoto’s thy-roiditis is a chronic lymphocytic thyroiditis. The disease is autoimmune and most frequently caused by hypothyroidism. The typical sonographic appearance is enlargement of the thyroid glands with multiple hypoechoic micronodules. (1:762)

183. (D) CEA stands for carcinoembryonic antigen, a type of protein molecule found in tumor cells and the developing fetus. Both benign and malignant conditions can increase CEA. Types of cancer that can cause an increase in CEA are pancreas, liver, stomach, breast, and lungs. An increase in CEA-125 is associated with ovarian cancer. Increased levels are also seen in non-cancer conditions, such as inflammation, peptic ulcers, and ulcerative colitis. Smokers can have higher CEA values than nonsmok-ers. A consistent increase in CEA after surgical removal of a cancerous tumor is suggestive of relapse. (13:490)

184. (D) Fine needle biopsies are typically performed with local anesthesia. (1:2072; 2:436–442)

185. (D) Pneumobilia (air within the biliary tree) is commonly seen after previous biliary intervention: common bile duct stents, choledochoduodenal fistula, emphyse-matous cholecystitis, and gallstone ileus with endoscopic retrograde cholangiopancreatography (ERCP) are the most common. (1:180; 4:30, 31)

186. (E) The right artery arises from the anterolateral aorta and courses posterior to the inferior vena cava (IVC) to the right renal hilum. The pancreas, duodenum, hepatic veins, caudate lobe, and main lobar fissure are located anterior to the IVC. (2:111; 4:193)

187. (B) Hashimoto’s disease is an autoimmune disease that affects the thyroid. It is also known as Hashimoto thyroiditis and is the most common cause for hypothyroidism. (2:522; 4:297)

188. (D) The most common cause for acute pancreatitis in the United States are gallstones (cholelithiasis) and alcohol abuse; other less common causes include abdominal trauma, peptic ulcer, pancreatic carcinoma, and use of certain medications. (2:255; 4:90)

189. (D) Pelvic Kidnet. Kidneys normally migrate to the renal fossa during the embryonic period. Any kidney not located in the renal fossa is an ectopic kidney. A pelvic kidney may mimic an adnexal mass and is associated with other abnormalities, vesicoureteral reflux, and genital. (2:258)

190. (C) Pancreatic pseudocysts are fluid-filled structures that may be a complication of acute pancreatitis. They are usually filled with pancreatic enzymes, but they may also consist of blood or pus. Pseudocysts have various sonographic appearances. They may appear cystic with or without debris, or they may appear solid. They are most often found in the region around the pancreas, lesser sac, or by the tail. (7:251)

191. (B) The retroperitoneum has three potential spaces where fluid collections and space-occupying lesions (abscesses and hematomas) can be found: the anterior pararenal space, the posterior pararenal space, and the perirenal space. The perirenal space is located within Gerota’s fascia. The kidneys, adrenal glands, lymph nodes, blood vessels, and perirenal fat are located within Gerota’s fascia. (2:40)

192. (E) In most cases with acute cholecystitis, there will also be gallstones. Symmetrical gallbladder wall thickening >3 mm is a nonspecific sign of acute cholecystitis. Gallbladder wall thickening is also seen in patients with ascites, hepatitis, hypoproteinemia, hypoalbuminemia, heart failure, renal disease, and systemic venous hypertension, as well as in patients who have eaten prior to imaging. (2:175)

193. (A) Ring-down artifact is also called comet-tail artifact. A ring-down artifact is a series of reverberations that appear as linear lines posterior to a strong interface. In Fig. 4–39, the gas in the bowel caused the reverberations. (7:226)

194. (C) Renal cysts are commonly seen in more than 50% of people older than 50 years. Cysts are anechoic, round, or oval in shape with increased through transmission. They can be either singular or multiple and located anywhere in the kidney. (2:263)

195. (D) Renal cysts usually affect renal function, and patients are typically asymptomatic unless the cyst is very large or compresses the collecting system causing hydronephrosis. (2:263)

196. (B) Lymph nodes are only visualized on a sonographic examination if they are enlarged >1 cm. Common sites to image for enlarged lymph nodes include around the great vessels (para-aortic and paracaval), peripancreatic, renal hilum, and mesenteric region. Sonographically, lymph nodes are seen round, echo poor, homogeneous masses with no increase in the posterior through transmission. (2:332, 338, 339)

197. (C) A rise in lipase level indicates acute pancreatitis or pancreatic carcinoma. Amylase levels will also rise with acute pancreatitis but do not stay as elevated as or as specific as lipase levels. (2:204, 205)

198. (E) Fatty infiltration of the liver usually causes a diffuse hyperechoic pattern, not a focal pattern. (7:145)

199. (A) Courvoisier’s law states that obstruction of the common bile duct due to pressure from outside the biliary system will lead to an enlarged gallbladder with dilatation of the biliary radicles. (2:218)

200. (D) Chronic pancreatitis occurs after repeated bouts of acute pancreatitis, which is usually caused by biliary disease or alcoholism. The pancreatic tissue becomes fibrotic from chronic inflammation. The fibrotic and fatty changes cause the pancreas to appear more echogenic on a sonogram than normal. The borders may be irregular and dilatation of the pancreatic duct may be secondary to stone formation, causing dilatation of the pancreatic duct. As people get older, the pancreas becomes more echogenic; it is a normal part of the aging process. (2:214)

201. (B) Renal cell carcinoma is the most common renal tumor. It is more common in males, and there is an increased incidence of renal cell carcinoma in patients who are on long-term renal dialysis or have von Hippel–Lindau disease. The sonographic appearance varies depending on the stage of the mass. In stage one, the mass has not metastasized outside the true capsule of the kidney. Angiolipoma, adenoma, and oncocytoma are benign tumors of the kidney. (2:266, 272)

202. (A) Acute tubular necrosis is the most common medical cause of renal disease. Renal infarction is occlusion of a vessel caused by thrombus; it usually occurs in the periphery of the kidney. Patients with diabetes may have small echogenic kidneys, which is the sonographic appearance of chronic renal disease. Nephrocalcinosis disease sonographically appears as echogenic renal pyramids with or without shadowing. (2:289)

203. (A) Adult polycystic kidney disease is an inherited autosomal-dominant disease that most often manifests in the fourth decade. It manifests by cystic dilatation of the proximal convoluted tubules, Bowman’s capsule, and the collecting tubules. It is mostly a bilateral process, with associated cysts in the liver, pancreas, lungs, spleen, thyroid, bladder, ovaries, and testes. The kidneys are enlarged with cysts in the renal cortex and the kidney may lose its reniform shape. (7:349, 350)

204. (E) A bladder diverticula is an outpouching of the bladder mucosa through the muscular layer. A diverticula may be congenital or acquired. An increase in the pressure within the bladder may be caused by a bladder outlet obstruction or a neurogenic bladder, which may lead to a weakening of the bladder wall leading to an outpouching of the wall. A small connection between the bladder and diverticula may be seen on ultrasound, even after the patient has emptied his or her bladder. A ureterocele is a saccular outpouching of the distal ureter into the urinary bladder. (2:352)

205. (D) A calculi in the proximal ureter. (2:301)

206. (B) A fusiform aneurysm is a uniform dilatation of a vessel. The majority of aneurysms occur below the level of the renal arteries. (7:65, 66)

207. (C) Sonographic Murphy’s sign is pain over the gallbladder region upon palpation on physical examination. Kehr’s sign is pain in the left upper quadrant radiating to the left shoulder. It is associated with a ruptured spleen. (6:127)

208. (E) This is an example of biliary duct obstruction of both the intrahepatic and extrahepatic ducts. A mass at the head of the pancreas may cause dilatation of both the intrahepatic and extrahepatic ducts in addition to an enlarged fluid filled gallbladder (Courvoisier’s law). (10:94)

209. (B) Periaortic nodes will displace the superior mesenteric artery anteriorly, not posteriorly. (2:338, 339)

210. (A) Diabetes. Portal vein thrombus many be associated with various pathologies and conditions: hepatitis, chronic pancreatitis, trauma, malignancy, septicemia, pregnancy, portal caval shunts, and splenectomy. The development of collaterals is called cavernous transformation of the portal vein. (1:105)

211. (E) The image is of normal blood flow in the hepatic and portal veins. The color-flow map on the left of the image is used to decipher the direction of blood flow. According to the color-flow map, red is blood flow toward the transducer, and blue is blood flow away from the transducer. (1:28)

212. (D) The image is of calculi in the common bile duct causing dilatation of the duct. (1:186)

213. (B) The dilated common bile duct is located anterior to the portal vein. (1:186)

214. (C) Choledocholithiasis. Stones are usually produced in the gallbladder and the gallbladder should be evaluated for stones. Any obstruction of the common bile duct causes obstruction and dilatation of the duct. (2:181)

215. (E) An adenoma is a benign thyroid mass that compresses the surrounding tissue. Sonographically, it has varied appearances, from anechoic to echogenic. Commonly, a halo can be seen surrounding the adenoma. When there is hyperfunction, an increase of blood flow may be demonstrated around the mass. Graves’ disease is associated with hyperthyroidism with a diffuse homogeneous appearance on ultrasound. Papillary carcinoma has a hypoechoic appearance with microcalcification on ultrasound. (2:303)

216. (B) Afebrile. When inflammation of the gallbladder occurs without gallstones, it is referred to as acalculous cholecystitis. The clinical symptoms include right-upper-quadrant pain, Murphy’s sign, fever, nausea, and vomiting. Laboratory findings include leukocytosis and elevation of serum total bilirubin (7:212, 213)

217. (B) The arrows point to hypoechoic lesions within the left lobe. Focal nodular hyperplasia can be either hypoechoic or hyperechoic focal masses. (7:168)

218. (C) Hypoechoic lesions may be the result of infectious foci. It is very unusual to have metastases with hypoechoic echogenicity. Occasionally, lymphomas may appear as hypoechoic liver metastases. Hemangiomas are echogenic. (7:168)

219. (B) The arrow is pointing to the ligamentum of Teres. The ligamentum of Teres is best visualized on a transverse scan of the liver. It divides the left lobe into medial and lateral segments. (2:111)

220. (A) Alpha-fetoprotein level is elevated in cases of hepa-tocellular carcinoma and in pregnant women. In cases of biliary obstruction, the patient may be jaundiced, have elevated direct bilirubin, alkaline phosphatase, and pruritus. (2:139, 148)

221. (D) This sonogram demonstrate multiple cystic masses of various size within the liver parenchyma, hepatic cyst or hepatic hydadid cyst could give such appearance (1:92–94)

222. (E) Choledocholithiasis appears as echogenic foci in the common bile duct with dilatation of the duct. Cholecystitis, right-sided heart failure, and hypoproteinemia are some causes of a thickened gallbladder wall. (3:38)

223. (C) Metastases are neoplastic involvement in the liver, causing liver enlargement with multiple nodules of varying sonographic patterns. Metastases have been described as hypoechoic, echogenic, bull’s eye, anechoic, and diffusely inhomogeneous. The patient typically presents with weight loss, decreased appetite, abnormal liver function test results, and hepatomegaly. (2:152, 153)

224. (B) Increased levels of creatinine and blood urea nitrogen are seen in renal failure. (2:251)

225. (E) The head of the pancreas is to the right of the portal splenic confluence, anterior to the inferior vena cava, and medial to the c-loop of the duodenum. (2:196)

226. (C) Crohn’s disease is chronic inflammation of the bowel. It usually affects the ileum but may affect both the small and the large intestines. It is most often seen in young adults. (7:296)

227. (B) An early sign of obstructive hydronephrosis is the intrarenal vessels having an RI >0.70. The RI returns to normal after 72 hours. (2:285)

228. (A) A parapelvic cyst is located in the renal hilum. A hematoma, lymphoma, abscess, and urinoma are perirenal fluid collections that can readily be identified on ultrasound. (2:269, 292)

229. (A) Increased blood flow within the dilated vessels can be seen with a Valsalva maneuver. Varicoceles are more common on the left side. (4:750)

230. (D) Mass in the head of the pancreas. (10:94)

231. (E) Enlarged prostate may be seen during a transabdominal pelvic examination indenting the base of the urinary bladder. An evaluation of the prostate gland can also be performed by transrectal sonography. (1:424)

232. (A) Ascites is free-fluid and appears anechoic on sono-grams. (2:38, 352)

233. (C) In cases of moderate to severe fatty infiltration, the echogenicity of the liver will be increased. The diaphragm and intrahepatic vessel borders may be difficult to see because of the increased attenuation of the liver parenchyma. (2:134, 135)

234. (D) This is an echogenic focus within the liver most consistent with a hemangioma. Hemangiomas are the most common benign neoplasms of the liver. (6:103)

235. (D) The spleen is a common site of blunt abdominal trauma. The hematoma will be contained in the spleen if there is no rupture of the splenic capsule. A decrease in hematocrit is an indication that there is blood loss from the cardiovascular system. (2:321)

236. (E) A hemangioma has the same sonographic appearance as a live cell adenoma, focal nodular hyperplasia, hepa-tocellular carcinoma, and metastases to the liver. All of these are benign neoplasms that may appear echogenic on ultrasound. Other diagnostic tests can be used to make a definitive diagnosis. (2:148)

237. (D) Chronic renal disease is imaged as small echogenic kidneys. It may be unilateral or bilateral. Chronic renal disease has many causes such as parenchymal disease, hypertension, and renal artery stenosis. (2:289)

238. (B) This sonogram is a classic image of adenomyomatosis of the gallbladder. Sonographically, one should look for diffuse segmental thickening of the gallbladder wall with intramural diverticula protruding into the lumen. (7:224)

239. (B) In hemolytic disease associated with abrupt breakdown of large amounts of red blood cells, the reticulo-endothelial cells receive more bilirubin than they can detoxify. Therefore, one would present with an elevated indirect or unconjugated bilirubin. (2:154–155)

240. (B) Bowman’s capsule and the glomerulus together are termed the renal corpuscle. Extending from Bowman’s capsule is a renal tubule. Each tubule has three sections: a proximal tubule, a distal convoluted tubule, and a loop of Henle. Together the Bowman’s capsule, glomerulus, and renal tubules constitute a nephron. (7:333–335)

241. (B) The great vessel being imaged is the inferior vena cava. No vessel is imaged sonographically posterior to the aorta. (9:171)

242. (D) The right renal artery is the only vessel located posterior to the inferior vena cava. (9:169)

243. (B) Urinary bladder calculi. (2:352–354)

244. (C) A focal thickening of the bladder wall may be due to cystitis. There are many causes of inflammation of the bladder wall including catheterization, bladder stone, bladder mass, renal disease, poor hygiene, and any disease state that causes stasis of urine in the bladder. (7:432)

245. (D) The subhepatic space is located between the right lobe of the liver and the right kidney. (7:39)

246. (A) The arrow is pointing to the heart.

247. (E) The liver in the sonographic image is normal. The normal liver is homogeneous with midlevel echogenicity. (9:85)

248. (D) Riedel’s lobe is a normal variant of the right lobe of the liver. There is a tongue-like inferior projection of the right lobe. It extends below the lower pole of the right kidney during normal respiration. (9:86)

249. (A) A patient with an acute appendicitis presents with right-lower-quadrant pain and rebound tenderness over McBurney’s point, elevated white blood cell count, fever, nausea, and vomiting. Sonographically, the appendix wall will be thickened more than 2 mm, and the outer diameter will be >6 mm. The appendix will be noncompressible. (2:237–240)

250. (D) This sonogram documents an enlarged (hydropic) gallbladder. (10:69)

251. (A) Hydrops of the gallbladder may be related to obstruction at the level of the cystic or distal common bile duct. (10:69)

252. (A) Sludge in the gallbladder does not cause hydrops of the gallbladder. Same causes of hydrops include muco-cutaneous lymph node syndrome (Kawasaki’s disease), prolonged biliary status, hyperalimentation, and hepatitis. (10:69)

253. (D) Gallbladder carcinoma is rare. Patients who have had a history of gallbladder disease are at an increased risk of getting primary gallbladder carcinoma. Patients do not always have symptoms, and if they do, they are the same as those of other gallbladder diseases. Primary carcinoma of the gallbladder usually does not get diagnosed in the early stages; therefore, there is a high mortality rate. Gallbladder carcinomas have a number of different appearances on sonogram and are nonspecific. Gallstones with an interluminal mass are highly suggestive of gallbladder carcinoma. The sonographic appearance for adenomyosis, acute or chronic cholecystitis, blood clot, cholesterolosis, and papillary adenoma may have the same sonographic appearance as gallbladder carcinoma. (10:71, 72)

254. (A) Foley catheter. The Foley catheter balloon has an anechoic appearance with an echogenic ring. Ureterocele is a submucosal cystic dilatation of the terminal segment of the ureter. (7:423)

255. (B) Subcapsular collections are located inferior to the diaphragm, and they conform to the shape of the organ. (2:34)

256. (B) Hematomas may be a complication from surgery. Most hematomas will resolve, but some will become infected and progress into an abscess. Patients may present with a decreased hematocrit and fever. One way to distinguish between a space-occupying lesion (hematoma, abscess) and ascites is to place the patient into a different position. A space-occupying lesion will not change its appearance, whereas free fluid will shift to the most dependent portion of the body. (2:445)

257. (E) The pancreas is echogenic with calcifications. (10:90)

258. (A) Patients with chronic pancreatitis may present with chronic epigastric pain or with right-upper-quadrant pain, which radiates to the back. The pain may be preceded by a large meal or alcohol consumption. Serum lipase, serum amylase, and bilirubin will be normal unless there is also acute inflammation of the pancreatic tissue. The sonographic appearance varies from a normal appearance to a heterogeneous echogenic pattern with areas of calcification. The main pancreatic duct may be dilated, and in some cases, there will be dilatation of the extrahepatic biliary ducts. (10:90, 91)

259. (B) Normal left adrenal gland. (2:337)

260. (C) Aorta. This sonogram demonstrates a normal left adrenal gland. The sonographic landmarks for imaging the left adrenal gland are the aorta and left kidney. (2:337)

261. (E) All of the above are conditions that may affect the adrenal gland. The primary malignancy that metastasize to the adrenal gland can be from the lungs, breast, liver, bones, lymphoma, melanoma, and the gastrointestinal tract. A decrease in oxygen during delivery may cause hemorrhage to the adrenal glands during the neonatal period. (7:489–491)

262. (B) A cystic mass appears to displace the bowel. (2:357)

263. (A) The image is most consistent with a mesenteric cyst. The mesenteric cyst displaces the bowel and mesentery posteriorly. An ovarian cyst and free fluid do not displace bowel posteriorly. (2:357)

264. (C) The longitudinal and transverse scan demonstrates marked thickening and lengthening of the antral muscle (pyloric canal and muscle). (2:462)

265. (B) This is consistent with hypertrophic pyloric stenosis. The criteria for this diagnosis include wall thickness >3.5 mm and pyloric length >16 mm. (2:463)

266. (E) The image is consistent with a normal pancreas. The main pancreatic duct may be visualized in a normal pancreas. The normal pancreatic duct measures <2 mm. (2:197)

267. (B) The main portal vein is formed posterior to the neck of the pancreas. (2:201)

268. (D) The most common functioning islet cell tumor is an insulinoma. Islet cell tumors can either be functional or nonfunctional, benign or malignant. (2:219)

269. (A) Distal acoustical shadow from the ribs. (7:144)

270. (A) The main lobar fissure is seen on a longitudinal scan as a linear echo coursing from the right portal vein to the neck of the gallbladder. It is also used as a landmark dividing the liver into right and left lobes. (4:121)

271. (D) In obstructive jaundice, alkaline phosphatase, and direct bilirubin will be very high, with aspartate ami-notransferase (AST) also being increased. Patients with hepatitis will also have an increase in alanine amino-transferase (ALT). Alpha-fetoprotein is elevated in non-pregnant adults when there is carcinoma of the liver. Pigment gallstones are common in sickle cell disease. (4:9)

272. (C) The sonogram demonstrates dilated biliary radicles. Color Doppler may be used especially in the left lobe of the liver to distinguish the difference between dilated biliary radicles and portal veins. (7:29)

273. (B) This sonogram shows dilated hepatic veins and a dilated inferior vena cava. Congestive heart failure and hypertension are two of the most common causes of general dilatation of the inferior vena cava. (6:85)

274. (B) The ligament venosum is imaged on the sonogram. The fissure for the ligament venosum also contains the hepato-gastric ligament, which is used as a landmark. It separates the caudate lobe from the left lobe of the liver. (6:95)

275. (A) This sonogram demonstrates a large amount of locu-lated fluid above the left hemidiaphragm. Pleural fluid is excess fluid that accumulates between the two pleural layers (visceral and parietal). (2:348)

276. (D) The sonogram demonstrates that the fluid density contains multiple septi causing loculations of the fluid, consistent with empyema. Empyema is a fluid collection filled with pus. (1:608)

277. (D) The clinical signs of acute cholecystitis are leukocy-tosis, fever, nausea, vomiting, and right-upper-quadrant pain that may be referred to the right shoulder if the inflammation irritates the diaphragm. Sonographically, the gallbladder is enlarged with a thickened wall >5 cm. There may be pericholecystic fluid, which is secondary to the inflammation. (7:212)

278. (A) In chronic cholecystitis, the gallbladder is usually contracted with thickened walls and cholelithiasis. The wall-echo-shadow (WES) sign, anterior wall of the gallbladder, echogenic foci, and shadowing caused by the stone are consistent findings in patients with chronic cholecystitis. In cases of acute cholecystitis, the gallbladder is usually enlarged with thickened walls and cholelithiasis. (7:217, 220)

279. (A) The liver is enlarged and heterogeneous consistent with metastatic disease. Metastatic patterns within the liver have various sonographic appearances anechoic, hypoechoic, echogenic, complex, or a bull’s-eye appearance. (77:176)

280. (E) Hemangioma is a common benign neoplasm of the liver. They are usually incidental findings on a sonogram. Sonographically, they are usually echogenic and may be either singular or multiple in the liver. Clinically, the patients do not have any symptoms unless the hemangioma becomes very large and hemorrhages. (7:168)

281. (B) The hemangioma is located between the right and middle hepatic veins; therefore, it is in the anterior segment of the right lobe. The right hepatic vein separates the right lobe into anterior and posterior segments; the middle hepatic vein divides the liver into right and left lobes. (7:121, 125)

282. (A) A Phrygian cap is a normal variant of the gallbladder. It consists of a fold in the fundal end of the gallbladder. There are no associated problems with a Phrygian cap. (2:126)

283. (D) The patient is in a left lateral decubitus position (right side up) with the transducer placed along the longitudinal axis of the abdomen. The liver is used as a window to visualize the inferior vena cava anterior to the aorta. Sometimes the renal arteries may be visualized arising from the aorta. This view is used to rule out lymphadenopathy surrounding the great vessels. (2:339)

284. (A) The portal vein is the largest at the region of the porta hepatis, and the main portal vein branches into the right and left portal veins. The left portal vein follows a superior anterior course and supplies blood to the left lobe. The right portal vein is larger and follows a caudal posterior course supplying blood to the right lobe of the liver. The walls of the portal veins appear more echogenic than the walls of the hepatic veins. The hepatic veins course dorsomedial toward the inferior vena cava. The most accurate method to differentiate the portal veins from the hepatic veins is to follow the course of the vessels into the liver. (2:117)

285. (B) Lymphadenopathy. Horseshoe kidneys occur during fetal development with fusion usually of the lower poles of the kidneys. The fused poles and the isthmus drape over the spine and may be confused with lymphadenopathy. (7:348)

286. (D) Cirrhosis is a chronic progressive disease leading to liver cell failure, portal hypertension, hepatoma, and ascites. The thickened gallbladder wall is most likely related to hypoproteinemia and to the adjacent ascites that will make the gallbladder appear thickened. (7:152)

287. (D) The crura of the diaphragm are extensions (tendinous fibers) of the diaphragm that attach to the vertebral process of L3 on the right and L1 on the left. The right crus appears as a hypoechoic linear structure and can be visualized as it courses from posterior to the inferior vena cave to anterior to the aorta. (2:331)

288. (A) The left crus of the diaphragm is medial to the left adrenal gland. (2:331)

289. (D) The right crus of the diaphragm. The right crus is posteromedial to the inferior vena cava and anteromedial to the right adrenal gland. (2:332)

290. (B) The right renal artery courses posterior to the inferior cava and anterior to the right crus of the diaphragm. (2:332)

291. (D) Portal vein. (7:132)

292. (E) Common duct is located anterior and parallel to the portal vein. (10:42)

293. (C) The echogenic foci posterior to the diaphragm (arrow) is a mirror-image artifact. A mirror-image artifact is a duplication artifact secondary to the sound beam reflecting off a strong reflector in its path, i.e., the diaphragm. This strong reflector acts as a mirror, and the image will present as two reflected objects rather than one. The image farther from the transducer will be the artifact. (6:13, 49)

294. (B) The sonogram demonstrates periportal lymphadenopathy, which is characterized by enlarged lymph nodes that are secondarily involved in almost all infections and neoplastic disorders. Lymph nodes consist of lymphocytes and reticulum cells, their functions being filtration and production of lymphocytes. All lymph passes through these nodes that act as filters, not only for bacteria but also for cancer cells. Sonographically, we can evaluate lymph nodes in the pelvis, retroperitoneum, portal hepatis, and perirenal and prevertebral vasculature. The sonographic appearance of lymphomatous nodes varies from hypoechoic to anechoic with very good sound transmission. (7:508)

295. (C) There is no definite correlation between kidney size and echogenicity and the degree of renal function. As a general rule, if the renal parenchyma (cortex) is more echogenic than a normal liver, chronic renal insufficiency should be considered. (7:388)

296. (A) The sonogram demonstrates celiac nodes surrounding the celiac artery and its winglike configuration. Note the increased distance between the celiac artery and the aorta caused by these masses. (7:508, 512)

297. (A) This sonogram depicts a fusiform aneurysm. The fusiform aneurysm typically dilates and tapers at the ends. A saccular aneurysm is a discrete round structure, and the ectatic aneurysm is a dilatation longitudinally producing lengthening of the expanded vessel in a uniform diameter. The aorta is considered aneurismal if it exceeds 3 cm. Surgery is not required until the aorta becomes greater than 6 cm because the chance of rupturing is low. (6:80)

298. (D) The left renal vein courses between the aorta and the superior mesenteric artery. (6:77)

299. (C) The caudate lobe is anterior to the inferior vena cava and posterior to the caudate lobe. (6:95)

300. (A) The celiac artery is the first branch of the abdominal aorta. It arises off the anterior aspect of the aorta at the level thoracic vertebra. (6:72)

301. (B) The superior mesenteric artery is the second branch of the abdominal aorta. (6:74)

302. (A) The splenic vein is posterior to the body of the pancreas. (6:78)

303. (A) Stomach. The stomach is located anterior to the pancreas. (2:251)

304. (E) Normal tail, which lies anterior to the splenic vein. (2:248, 249)

305. (B) Common bile duct, which defines the posterolateral margin of the pancreas. (6:150)

306. (E) The gastroduodenal artery defines the anterolateral margin of the pancreas. (6:150)

307. (D) The renal medulla pyramids are hypoechoic. They are located between the echogenic renal sinus and the less echogenic renal cortex. (1:255)

308. (D) This sonogram demonstrate color Doppler flow with urine entering the urinary bladder, which is known as ureteric jet effect. (2:334–335)

309. (A) Color Doppler can be used to document ureteral jets. Obstruction of the ureter causes absence or decreased flow in the ureteral jet on the same side as the pathology. (2:336)

310. (B) The only time that ureteral jet is not present is when there is obstructive hydronephrosis or when the bladder is full. (2:285)

311. (C) The clinical symptoms of a patient with a liver abscess include pain, fever, right-upper-quadrant pain, and leukocytosis. Abscesses may appear sonographically as round, hypoechoic, with increased posterior acoustic enhancement, or they may be complex and irregular in shape. In pyogenic abscess, there may be gas present; and gas appears as hyperechoic with a dirty shadow. (2:144, 145)

312. (E) Polycystic renal disease is associated in 60% of patients with polycystic liver disease. (2:144)

313. (D) The blood flow in the superior mesenteric artery in a fasting patient has a high-resistive index. Post-prandially, the blood flow changes to a low resistive index with an increase in the diastolic flow. (2:100)

314. (B) The perinephric space is surrounded by Gerota’s fascia. (2:329)

315. (E) The arrow is pointing to a normal ureteral jet. One reason for not documenting ureteral jets is obstructive hydronephrosis. (2:285)

316. (B) The head of the pancreas lies anterior to the inferior vena cava. (6:150)

317. (A) Chronic pancreatitis is associated with a normal or small pancreas, irregular borders, and increased echogenicity caused by fibrotic changes, and calcification. There may be ductal dilatation with or without a stone in the duct. The laboratory values for chronic pancreatitis are usually normal. (2:259)

318. (C) A pancreatic pseudocyst is a fluid collection that arises as a complication of acute pancreatitis. The obstructed pancreatic duct increases in size until it ruptures, which causes the pancreatic enzymes to escape outside of the pancreas. The fluid localizes and becomes walled-off forming a pseudocyst. The most common location is in the lesser sac, but a pseudocyst may also be found in the pararenal space or extending into the pelvis or superiorly into the mediastinum. (2:216)

319. (E) The most common complication of a pancreatic pseudocyst is spontaneous rupture, which occurs in 5% of the patients. The fluid will drain one-half of the time into the peritoneal cavity and one-half of the time into the gastrointestinal tract. The former has a 50% mortality rate. (2:216)

320. (D) 5 MHz linear transducer. The rectus abdominis muscle courses from the anterior aspect of the symphysis pubis and pubis crest to the 5th, 6th, and 7th costal cartilages and xiphoid process. It protects and covers the anterior abdominal wall; therefore, a high-frequency linear transducer is the best option because one does not need to penetrate deep to image the rectus abdominis muscle, and the linear array has a wide field of view. (2:31; 5:15)

321. (B) Morison’s pouch is located anterior to the right kidney and posterior to the inferior right lobe of the liver. The lesser sac is anterior to the pancreas and posterior to the stomach. The pouch of Douglas is posterior to the uterus and anterior to the rectum. The greater sac extends from the diaphragm to the pelvis and contains most of the abdominal organs. Morison’s pouch or hepatorenal ress was named after a British surgeon James Rutherford Morison. (2:36, 51)

322. (C) Pyelocaliectasis is dilatation of the collecting system. The collecting system may be dilated because of overhydration, and it is a common finding in post-renal transplant patients. (2:301; 4:405)

323. (C) Ascites. The perirenal fluid collection may be associated with lymphocele, a collection of lymph fluid caused by injury to the lymphatic channels during transplantation; hematoma, a collection of blood; and abscess, which are all associated with renal transplantation. It is difficult to differentiate one from the other. Urinoma is a collection of urine because of a urinary leak of a ureteropelvic or ureteroureter anastomosis. Abscess is a collection of pus caused by an inflammatory response. Ascites is not associated with a renal transplant. (7:403, 404)

324. (A) Perinephric fluid collections are common in postoperative renal transplant patients. Fever, flank pain, and leukocytosis best correlate with an abscess. Because many fluid collections have the same sonographic appearance, the patient’s clinical symptoms will help differentiate between them. Abscesses and hematomas tend to be more complex in appearance than urinomas and lymphoceles. Hematomas, abscesses, and urinoma usually develop earlier than lymphoceles. Lymphoceles typically do not develop until 4–8 weeks postop. A renal cyst is not associated with a renal transplant. (7:403, 404)

325. (B) Several sonographic criteria are used to describe biliary dilatation. In this sonogram, we can recognize (1) tubular lucencies within the liver demonstrating posterior acoustic enhancement. Bile opposed to blood increases transmission; (2) the tubules are irregular with jagged walls as opposed to veins and arteries that are straight—normal ducts are not visualized within the liver. (7:229)

326. (C) The arrow is pointing to an example of chronic pancreatitis. With chronic pancreatitis, the pancreas generally is diffusely smaller and more fibrotic than usual with areas of calcification and ductal dilatation. In acute pancreatitis, the pancreas is generally diffusely larger and less echogenic than normal. In adenocarcinoma and islet cell tumors, the pancreas is generally focally enlarged in the pancreatic head with the former and the tail in the latter. (2:211)

327. (C) There is irregular diffuse thickening of the bladder wall of unknown origin. The prostate is not enlarged, and there is no evidence of a bladder outlet obstruction, which most commonly is secondary to benign prostatic hypertrophy or carcinoma. Enlarged endometrial tissue may be found penetrating the bladder wall and extending in the lumen in severe cases of endometriosis in premenopausal women. (2:303)

328. (E) Both kidneys in patients with chronic renal failure appear small and echogenic. It is a nonspecific finding and may result from hypertension, chronic inflammation, or chronic ischemia. (2:289)

329. (D) Serum creatinine and blood urea nitrogen are elevated in kidney disease. (2:250)

330. (D) Attenuation is the decrease in amplitude and intensity as a wave travels through a medium. One of the criteria for a cyst is the posterior acoustic enhancement. A characteristic of fluid is that it does not absorb (attenuate) sound waves. (11:288)

331. (D) Adult polycystic kidney disease is cystic dilatation of the proximal convoluted tubules, Bowman’s capsule, and the collecting tubules. As the cysts grow, they compress the nephrons causing renal insufficiency, which usually manifests in the fourth decade of life. Cysts may also occur in the liver, spleen, pancreas, lungs, ovaries, or testes. Infantile polycystic disease in its most severe form is not compatible with life. In less severe forms, the kidney will appear enlarged and echogenic because of the small cystic interfaces that occur in the kidney. Parapelvic cysts are found around the renal pelvic region. They usually do not interfere with the renal function. The ureteropelvic junction is one of the most common congenital causes of hydronephrosis. Sonographically, it is seen as dilatation of the collecting system and proximal portion of the ureter. (2:270)

332. (A) Multicystic dysplastic kidney disease is the most common cause of an abdominal mass in the newborn. It is usually unilateral, occurring more often in the left kidney. The contralateral kidney is at an increased risk for such abnormalities as ureteropelvic junction obstruction. Sonographically, the cysts appear in varying sizes, with the largest cysts in the periphery, absence of the connections between the cysts, absence of an identifiable renal sinus, and absence of renal parenchyma surrounding the cysts. (2:270)

333. (A) This sonogram of the kidney is not normal. There is dilatation of the renal calyces. There are numerous causes for hydronephrosis; any pathology in the lower urinary system may cause bilateral hydronephrosis, while upper urinary pathology may cause unilateral hydronephrosis. Some of the causes of hydronephrosis include congenital anomalies, as in posterior urethral valves, bladder neck obstruction; acquired causes, such as calculi, prostate enlargement, inflammation, bladder tumor; intrinsic causes, such as calculi, pyelonephritis, stricture, inflammation; and extrinsic causes, such as neoplasm and retroperitoneal adenopathy. (2:279)

334. (B) Acute tuberous necrosis is the most common medical cause for renal failure. It is a reversible renal disease. Sonographically, the kidneys will appear enlarged with echogenic renal pyramids. Tuberous sclerosis involves numerous body systems. Sonographically, multiple cysts or angiomyolipomas are seen. (2:289)

335. (C) The celiac axis is the first major branch of the aorta. It arises off the anterior aspect of the aorta before it trifurcates into the proper hepatic artery, splenic artery, and left gastric artery. (6:72)

336. (A) The sonogram demonstrates a normal right adrenal gland. In utero and in the neonate, the adrenal glands are prominent, being one-third the size of the kidney. (7:622)

337. (B) This decubitus coronal sonogram documents a severe dilatation of the renal collecting system extending into the renal pelvis, with marked thinning of the renal parenchyma. The low-level internal echoes are caused by artifact. Pyonephrosis is a collection of pus within the dilated collecting system. The pus is caused by long-standing stasis of urine. Sonographically, the dilated calyces will have internal echoes without increased posterior acoustic enhancement. (2:284, 289)

338. (B) The arcuate arteries are arc-shaped vessels that separate the cortex from the medulla. They are imaged sonographically as a small echogenic line above the renal pyramids. (2:247)

339. (C) The open arrowhead is pointing to the renal medullary pyramids. (2:254)

340. (A) Renal column of Bertin is composed of cortical tissue that extends into the medullary area between the pyramids. (2:257)

341. (E) Cirrhosis. The sonogram documents dilated biliary radicles that are caused by obstructed biliary radicles. Dilatation of biliary radicle may be secondary to a stone, mass lesions in the area of the head of the pancreas, a neoplasm, or metastatic lesions within the liver. Cirrhosis is related to medical jaundice, and there will be no evidence of biliary dilatation. (2:189)

342. (E) A neuroblastoma is an adrenal mass found in children. It will not cause splenomegaly. (1:1407)

343. (C) The patient was asymptomatic; it is most likely a simple benign hepatic cyst. Symptoms usually do not develop unless the cyst is large. Patients who have lymphoma, metastases, hydatid cysts, or polycystic liver disease will present with symptoms and elevated laboratory results. (2:142)

344. (E) Adenocarcinoma is found most often in males, especially in black males. There is an increased incidence of adenocarcinoma in patients with a history of smoking, a high-fat diet, chronic pancreatitis, diabetes, or cirrhosis. Adenocarcinoma usually presents as a hypoechoic mass in the head of the pancreas (Fig. 4–131A) demonstrate a hypochoic mass in the head of the pancreas, (Fig. 4–131B), intrahepatic biliary dilatations (Fig. 131C), enlaged gallbladder (Courvoisier’s gallbladder) (7:255)

345. (D) The sonogram documents a small echogenic kidney with a loss of distinction between cortex, medulla, and renal sinus. Chronic glomerulonephritis is the most common cause of chronic renal failure. (2:289)

346. (E) When the transducer is placed transversely in a upward sharp angle, the heart will be come visible on an abdominal scan. (7:144)

347. (B) There are different types of thyroiditis, and chronic thyroiditis is Hashimoto’s disease. It is the most common cause of hypothyroidism. It usually occurs in young females. Sonographically, the thyroid is enlarged with either a heterogeneous or a hypoechoic echo pattern. (6:279)

348. (E) Neuroblastoma is a rare malignant mass found in children usually younger than 8 years. Adenoma, cyst, myelolipoma, and pheochromocytoma are benign adrenal masses. Infrequently, pheochromocytomas may be malignant. (6:246)

349. (A) The right adrenal gland is located posterior to the inferior vena cava. When the right adrenal gland enlarges, it may displace the inferior vena cava anteriorly. (5:240)

350. (E) Dilated Intrahepatic ducts. (6:177)

351. (D) Air within the biliary tree is known as pneumobilia. Pneumobilia is caused by; emphysematous cholecystitis, cholecysto-enteric fistula, choledochojejunostomy and prolonged acute choleystitis. Pancreatic carcinoma is not a known cause. (1:180)

352. (D) Hemangioma. Hepatic hemangiomas are the most common benign hepatic tumors and most are asymptomatic. (7:375)

353. (D) A linear transducer has a rectangular format, which allows a larger field of view. The large footprint of a linear transducer makes it difficult to scan intercostally because of the rib artifacts and does not increase resolution. The instrument settings of an ultrasound machine to produce the highest resolution are necessary to document posterior shadowing of small calculi. Factors that the sonog-rapher can control to increase resolution include use of a high-frequency transducer, decreasing gain (decreases scattering), place the focal zone at the area of interest, and the use of tissue harmonics. (5:15, 185)

354. (E) Normal sonographic appearance of liver and right kidney. (2:278)

355. (B) This sonogram demonstrates a marked increased echogenicity of the liver as compared with the kidney. The echogenicity of the liver should be compared with the kidney. (2:253)

356. (C) In the adult, glycogen storage disease, fatty metamorphosis, chronic hepatitis, cirrhosis, and hemochro-matosis all present with an echogenic liver and decrease through penetration. In a child, this is frequently a complication of glycogen storage disease. (2:172)

357. (E) The sonographer has no control over the speed of sound. To optimize a sonographic image, the sonographer is able to adjust and choose the overall gain, time-gain compensation, transducer type and frequency, and the depth and focus control. (2:126)

358. (A) A resistive index (RI) of less than 0.70 is considered normal. (2:284)

359. (C) Splenomegaly is diagnosed when the spleen measures greater than 13 cm in the long axis. Sonographically, the left kidney will be compressed and displaced posteriorly. (2:314)

360. (A) This image is of a gallbladder filled with stones. (2:180)

361. (D) This sonogram demonstrates calculus cholecystitis. When the gallbladder is filled with calculi, all that may be imaged on sonogram is the wall echo shadowing (WES) sign. (2:180)

362. (E) The laboratory findings in patients with cholelithiasis are consistent with an increase in alkaline phosphatase. Other liver function test results may be abnormal (AST, ALT). Serum amylase may be elevated in patients with pancreatitis; increased creatinine is consistent with renal insufficiency; serum indirect bilirubin is elevated in patients with hepatocellular disease. (1:176)

363. (B) Renal parenchymal disease. The sonographic hallmark of this disease is a bilateral increase in echogenicity throughout the renal parenchyma (7:388)

364. (B) Posterior urethral valves is the most common cause of urethral obstruction in boys. The valves are located in the posterior urethra and obstruct the urethra. Dilatation of the urethra, hydrouretera, and hydronephrosis may occur secondary to the obstruction. (7:606)

365. (D) The valves of Heister are tiny valves located in the proximal portion of the cystic duct. They prevent the duct from kinking. (1:194; 2:204)

366. (E) Patients with a history of cirrhosis have an increased incidence of developing hepatomas in the liver. (2:139)

367. (C) A choledochal cyst is usually diagnosed in childhood and is more common in Asians. The most common sonographic appearance of a choledochal cyst is a cyst communicating with the common bile. If choledochal cysts are not diagnosed and treated early, the patient is at an increased risk of developing gallbladder carcinoma and cholangiocarcinoma. (6:137)

368. (D) Primary gallbladder carcinoma is more commonly found in women, and there is an increased incidence in people working in the textile, rubber, and automotive industries. Gallstones are present in the majority of cases, and a percentage of cases will present with a porcelain gallbladder. Sonographically, the gallbladder may also have a thickened wall, and a mass may be seen within the gallbladder lumen. (6:222)

369. (E) A Baker’s cyst is located in the bursa posterior to the distal femur. (7:777)

370. (C) A Riedel’s lobe is an anatomic variation of the liver, where the right lobe of the liver has a tongue-like extension. It is more common in women, and on physical examination, the liver will give the impression of hepatomegaly. (7:126)