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64 Cards in this Set
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First lymph node involved with right testicular cancer:
a. Right infrarenal, paracaval b. Right inguinal c. Right common iliac d. Right obturator e. Right periaortic |
Answer: Infrarenal, paracaval (Interaortocaval)
Testicular cancer spreads predominantly, initially through lymphatic routes, i.e, on the left, first nodal group is just below the left renal vein; on the right, the first nodal group is pericaval at the level or just below the renal veins. Stepwise spread for right testicular cancer is from the testis to interaortocaval, precaval, preaortic, paracaval, right common iliac, and right external iliac lymph nodes. The most common landing site for a right-sided testicular tumor is the interaortocaval lymph nodes. The testicular lymphatics of the left testis drain stepwise from the testis to the nodes of the paraaortic, preaortic, left common iliac, left external iliac, interaortocaval, precaval, and finally, to the paracaval nodes. The primary landing site for the left testis is the para-aortic area at the level of the left renal hilum. (Source: e-medicine) |
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Most commonly injured with saddle injury:
a. Penile urethra b. Bulbous urethra c. Membranous urethra d. Prostatic urethra |
bulbous urethra
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Patient with hematuria and lesion (filling defect) in collection system measuring 75 HU on CT:
a. Acute blood clot b. Fungus ball c. TCC d. Uric acid stone e. Sloughed papilla |
acute blood clot
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67 year-old with longstanding HTN and adrenal mass that drops out on out of phase imaging. Most likely represents:
a. Nonfunctioning adrenal adenoma with essential HTN b. Functioning adenoma with Conn’s syndrome c. Functioning adenoma with Cushings syndrome |
Nonfunctioning adrenal adenoma with essential HTN
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Nonfunctioning adrenal adenoma with essential HTN
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BPH
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After trauma, patient has pubic rami fractures bilaterally and left SI joint diastasis. Boggy rectum on exam , no blood at urethral meatus. Next step?
a. cystogram b. retrograde urethrogram c. pelvic US d. IVP e. Foley f. CT |
Cystogram (if no blood at meatus); RUG (if blood at meatus or boggy rectum)
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Most common location for extra-adrenal pheochromocytoma:
a. Bladder b. Presacral plexus c. Thoracic sympathetic chain d. Lumbar sympathetic chain e. Thyroid parathyroid f. Mediastinum |
Lumbar sympathetic chain
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50 year old with 3 cm enhancing lesion in the kidney. What would make you leave it alone?
a. -65 HU area within it b. biopsy shows oncocytes c. cystic areas d. stellate central scar |
-65 HU area within it
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Most likely cause of reflux in a single, nonduplicated system (bilateral VUR)?
a. inferior insertion of ureter b. short intramural segment c. anterior insertion of ureter d. posterior insertion of ureter e. medial insertion of ureter |
Short intramural segment
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Most common location for extra-adrenal pheochromocytoma:
a. Bladder b. Presacral plexus c. Thoracic sympathetic chain d. Lumbar sympathetic chain e. Thyroid parathyroid f. Mediastinum |
Answer: Lumbar sympathetic chain
Approximately 10% of pheochromocytomas are extraadrenal. Most are located in the abdomen. The most common site is the sympathetic chain at the organ of Zuckerkandl, which consists of paraganglia found in the retroperitoneal region along the aorta around the inferior mesenteric artery. Approximately 1% are in the thorax, 1% are in the bladder, and 1% are in the neck. Sympathetic ganglia are found predominantly in the paraaxial region of the trunk along the prevertebral and paravertebral sympathetic chains and in the connective tissue in or near the walls of pelvic organs. The organ of Zuckerkandl is the only macroscopic extraadrenal sympathetic paraganglion, located at the origin of inferior mesenteric artery. The most common location of extra-adrenal pheochromocytomas is the superior aortic region (between the diaphragm and the inferior renal poles). |
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Most likely cause of reflux in a single, nonduplicated system (bilateral VUR)?
a. inferior insertion of ureter b. short intramural segment c. anterior insertion of ureter d. posterior insertion of ureter e. medial insertion of ureter |
Answer: Short intramural segment
The most common cause for primary reflux in children is an abnormality in the section of the ureter that enters the bladder (called the intravesical ureter). The intravesical ureter may not be long enough to enable the ureter to close sufficiently to prevent urine reflux, or the ureter may be inserted abnormally into the bladder. This condition often resolves as the child grows and the ureter lengthens. Other causes of primary reflux include abnormalities in detrusor muscle tissue of the bladder, abnormalities in the location of the urethral opening (e.g., hypospadias), and abnormalities in the shape of urethral opening. Secondary reflux: UTI, urinary tract abnormalities (e.g., narrowing, stricture; duplicated ureters; ureterocele); obstructions (e.g., UPJ obstruction, stones). |
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Man w/ hx of nephrotic syndrome has acute right flank pain, macroscopic hematuria. CT: enlarged right kidney and a faint nephrogram. Diagnosis?
a. renal vein thrombosis b. pyelonephritis c. RAS d. obstructing stone |
Answer: Renal vein thrombosis
Chronic MGN presents with hypertension and renal failure. Imaging findings include small, echogenic kidneys bilaterally with possible cortical nephrocalcinosis. The nephropathy most commonly associated with RVT is MGN. Nephrotic syndrome is actually the most common cause of renal vein thrombosis. Membranous glomerulonephropathy is the most common underlying renal disease (as many as 60% of patients with MGN will develop RVT). It is essentially a hypercoagulable state---proteinuria. Causes of RVT: Tumor (especially RCC, others include lymphoma, TCC, adrenal, and gonadal); Membranous glomerulonephritis (MGN); SLE; Amyloid; Extension of gonadal vein thrombus; Hypercoagulable states; Transplant rejection. |
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Patient on a contrast CT shows decreased enhancement with a faint pyelogram in one kidney. Which is most likely?
a. Renal artery stenosis b. Renal vein thrombosis c. Ureteral obstruction |
Answer: Ureteral obstruction
Most common cause of unilateral delayed nephrogram is ureteral obstruction. Dähnert Renal artery stenosis is seen in 4 % of autopsies Renal vein thrombosis is seen in 0.5% of autopsies |
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What is the most common cause of renal vein thrombosis?
a. renal cell carcinoma b. diabetic nephrosclerosis c. glomerulonephritis d. nephritic syndrome |
Answer: Glomerulonephritis
In adults, its membraneous glomerulonephritis (50% with this disease have RV thrombosis). Mnemonic for renal vein thrombosis causes is “TEST MAN”: Thrombophlebitis, Enterocolitis (dehydration), Sickle cell dz & SLE, Trauma, Membraneous glomerulonephritis, Amyloidosis, Neoplasm |
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Ectopic ureter in a young boy is associated with the following:
a. can cause (p/w) epididymitis b. almost always associated with duplicated collecting system c. is not associated with reflux if inserts a bladder neck d. presents with incontinence, dribbling |
Answer: Can cause/present with epididymitis
Epididymitis is common in pre-pubescent adolescent boys. Ectopic ureters are not necessarily associated with duplicated collecting systems, especially in males. In females, ectopic ureters are most often associated with duplex collecting systems (80%) versus in males, mostly single collecting systems. In males, ectopic ureter attaches to seminal vesicle, ejaculatory ducts, posterior urethra, vas deferens. No enuresis in boys as insertion is above external sphincter. In females, ectopic ureter attaches to vagina, urethra, and frequently presents with incontinence. |
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Postmenopausal woman, 3.5 cm cyst in ovary with very fine thin septation. Appropriate next step:
A. Immediate CT scan B. 3 month follow up C. Surgical excision D. Laparoscopy E. Nothing |
Answer: Surgical excision (if sepatations)
The septation makes it a complex cyst and that 18% are malignant when cyst > 3 cm in size with low RI (<0.4) in postmenopausal woman. A simple ovarian cyst is characterized by a wall < 3mm, smooth inner wall, no septations and anechoic. Postmenopausal: < 5.0cm and simple – Follow up in 3 months, then 6 months x 2, then 1 year. If > 5.0cm or complex at any size – laparoscopy and resection. Premenopausal: < 2.5cm and simple – Physiologic follicle. No follow up. > 2.5cm to 10cm (simple or complex) – Follow up in 6 weeks x 2. >10cm – Laparoscopy and resection. |
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35-year-old female has bilateral symmetric echogenic renal cortices (nephrocalcinosis). What is the likely etiology?
a. Chronic glomerulonephritis b. Hyperparathyroidism c. Hyperthryoidism d. Renal tubular acidosis e. Acute tubular necrosis |
Answer: Acute cortical necrosis (first), Chronic glomerulonephritis (second)
Cortical nephrocalcinosis, most common cause in adult is acute cortical necrosis, the second is chronic glomerulonephritis. Acute cortical necrosis can follow placenta abruptio, placenta previa, septic abortion, transfusion reactions, burns, snake bite, severe dehydration, shock, severe heart failure, and abdominal aortic surgery. Thin rim of calcification with tram line appearance, homogeneous increased echogenicity (on US) of renal parenchyma. "COAG": Cortical Necrosis (Pregnancy, Shock, Infection, Toxins), Oxalosis, Alport syndrome/AIDS nephropathy, Glomerulonephritis (chronic) Medullary nephrocalcinosis: most common adult cause is hyperparathyroidism. Common causes include medullary sponge kidney, hypercalcemic states, and RTA. Uncommon causes include papillary necrosis, TB, hyperoxaluria, and chronic furosemide use. |
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All of the following demonstrate echogenic renal cortices on ultrasound EXCEPT:
a. Alport’s syndrome b. Lymphoma c. Acute pyelonephritis d. Chronic pyelonephritis e. HIV nephropathy f. Nephrocalcinosis g. Fetal kidneys |
Answer: Lymphoma, acute pyelonephritis
Renal lymphoma: single/multiple anechoic/hypoechoic masses, may show increased through transmission. Dähnert 5th p. 924. Acute pyelonephritis: in most cases, US appear normal, with sensitivity for detecting inflammation that is lower than CT scan. Chronic pyelonephritis: renal enlargement and compression of the renal sinuses can be detected sonographically in severe cases of pyelonephritis. Ill-defined areas of hypoechogenicity may be seen, due to edema, or areas of hyperechogenicity may be present, due to hemorrhage. These changes may be accompanied by effacement of the corticomedullary boundaries. |
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Which is NOT associated with retroperitoneal fibrosis?
a) lymphoma b) xanthogranulomatous pyelonephritis c) aortic aneurysm d) radiation e) methysergine |
Answer: Xanthogranulomatous pyelonephritis
In 68% of patients with RPF no cause is found. In the remainder, implicated causes include drugs, abdominal aortic aneurysm, ureteric renal injury, infection, retroperitoneal malignancy (NHL, carcinoid, lymphoma, retroperitoneal metastasis), post-radiation therapy, retroperitoneal fluid collection, and chemotherapy. Classic triad: ureterectasis, medial deviation of ureters, and gradual tapering of ureteral caliber. Danert 962. |
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LEAST likely associated with bladder diverticulum:
a. Secondary to schistosomiasis b. Some are congenital c. Bladder outlet obstruction d. Increased risk of malignancy e. Calculi may form |
Answer: Secondary to cystic schistosomiasis (not associated with bladder diverticula)
Schistosomiasis causes bladder wall calcifications and is a risk factor for SCC, but not associated with bladder diverticula. Bladder diverticulum associations: Primary (40%) = congenital/idiopathic - occur in sites of congenital weakness of muscular wall such as ureteral meatus or posterolateral wall (Hutch diverticulum). Secondary associations (60%) listed below: 1: Postoperative. 2: Associated with bladder outlet obstruction (e.g., PUV, urethral stricture, prostatic enlargement, neurogenic). 3: Associated with syndromes (e.g., Prune Belly, Menkes kinky hair syndrome, Williams syndrome, Ehlers-Danlos type 9) |
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Which is associated with Meigs syndrome?
a. Ovarian fibroma b. Peritoneal calcification c. Pseudomyxoma peritonei d. Ovarian virilizing tumor e. Unilateral left pleural effusion |
Answer: Ovarian fibroma
A syndrome characterized by a solid ovarian tumor, usually a fibroma, accompanied by ascites and pleural effusion. Occurs mainly in elderly women. Pseudo-Meig’s syndrome (a term given by Meigs) is the same as true Meig’s syndrome, except that in pseudo-Meig’s syndrome the tumor may be in the ovary, tubes, uterus or round ligament. |
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Prenatal US shows round, hypoechoic mass (cyst) in upper pole of one of the kidneys. Most likely represents:
A. Obstructed upper pole in a duplicated collecting system B. ARPKD C. ADPKD D. Multicytic dysplastic kidney E. Wilms' tumor |
Answer: Obstructed upper pole moeity in a duplicated collecting system
Unilateral lesions in the fetal kidneys - most likely MCDK or UPJ obstruction. Unilateral obstruction may not always involve the entire kidney. A duplicated kidney may have an obstructed upper pole, most likely caused by an ectopic ureter. Dilitation of the lower pole moiety is typically caused by reflux. Even if the obstructing ureterocele is not seen, the disparity between the obstructed upper pole and the normal (or less dilated) lower pole can suggest the diagnosis. Bilateral lesions of the fetal kidneys: ARPKD, bladder outlet obstruction (PUV), ADPKD (but rarely detected in utero). Sonographically, Wilms' tumor is usually evenly echogenic or echogenic with discrete holes corresponding to areas of cystic necrosis. Peak incidence is age 3, with 80% of cases detected between ages 1-5. |
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TRUE about hydrosonography?
a) used to evaluate cause of endometrial thickening b) best done transabdominally c) uses iodinated contrast d) best performed during secretory phase of cycle e) not to be done post menopausal |
Answer: Used to evaluate cause of endometrial thickening
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TRUE in regards to RUG for man with a suspected stricture:
a. Drip contrast in by gravity b. Insert catheter under fluoroscopic guidance c. Obtain oblique spot views d. Overhead views with complete distention of the urethra e. Post gonococcal strictures are always short |
Answer: Obtain oblique spot views
The technical aspects of a retrograde urethrogram involve placing a nonlubricated 8F or 10F urethral catheter into the fossa navicularis and inflating the balloon with 1-3 mL of sterile water until the balloon occludes the urethral lumen. A scout film is obtained. Approximately 10 mL of iodinated contrast media then is injected into the catheter under fluoroscopy, and images of the anterior urethra are taken. Extreme pressure during the injection phase can lead to extravasation and should be avoided. Do not mistake the membranous urethra for a stricture. On a retrograde urethrogram, the membranous urethra lies between the distal end of the verumontanum and the conical tip of the bulbous urethra. Take RPO views of penile and bulbous and posterior urethra and supine views of posterior urethra and bladder base. Exam is not complete until the posterior urethra is filled into bladder base. If external sphincter is in spasm, have patient valsalva or attempt to void against catheter, then relax. |
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Sickle cell (trait) is at risk for which renal malignancy?
a. renal medullary carcinoma b. renal cell carcinoma c. transitional cell carcinoma d. justglomeruular apparatus tumor e. angiomyolipoma |
Answer: Renal medullary carcinoma
Renal medullary carcinoma is an infiltrating renal neoplasm arising from the collecting tubules of the renal medulla. Typical age is < 40 yrs, there is a high association with sickle cell trait and less commonly with Hgb SC disease. It has a poor prognosis. Radiographically, renal medullary carcinoma is indistinguishable from other infiltrating renal neoplasms, centrally located, and demonstrate an infiltrative growth pattern in the renal parenchyma. It often encases or obliterates the renal collecting system. Sickle cell trait is known in almost all of patients with renal medullary carcinoma. Thus, renal medullary carcinoma has been suggested as the seventh sickle cell nephropathy. The other six nephropathies are unilateral hematuria, papillary necrosis, nephrotic syndrome, renal infarction, inability to concentrate urine, and pyelonephritis. |
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Empty right renal fossa on US. 3 cm cystic structure on right side between bladder and prostate gland. What is cyst?
a. Congenital absence of kidney b. Chronic reflux c. Horseshoe kidney d. Seminal vesicle cyst e. Crossed-fused ectopia f. Pelvic kidney |
Answer: Cyst is a seminal vesicle cyst, associated with (ipsilateral) congenital absence of kidney
Congenital renal agenesis is usually unilateral (fatal if bilateral) and characterized by an absent kidney, absent ureter and seminal vesicle (between bladder and the prostate gland). It results from failure of the metanephric bud to form during 5th week of gestation. |
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LEAST likely to be associated with Wilms tumor:
A. Horseshoe kidney B. Nephroblastomatosis C. Hereditary aniridia D.Beckwith-Weidemann syndme E. Hemihypertrophy F. Genital anomalies |
Answer: HEREDITARY aniridia
Most cases of Wilms tumor are not hereditary; however, familial Wilms tumor arises with high frequency in certain families. Genetic syndromes that predispose to and may include Wilms tumor include the following: Beckwith-Wiedemann syndrome (macroglossia, gigantism, and umbilical hernia); Hemihypertrophy; Sporadic aniridia (NOTE: Not HEREDITARY aniridia); Wilms tumor, aniridia, genitourinary malformations, and mental retardation (WAGR syndrome); Denys-Drash syndrome (Wilms tumor, pseudohermaphroditism, and glomerulopathy); Trisomy 18 mutation; Soto's Syndrome (cerebral gigantism). Nephroblastomatosis is persistent rests of nephrogenic cells within the renal parenchyma and is a precursor of Wilms' tumor. |
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To dx nephroblastomatosis, get:
a. Contrast CT b. US c. Renal cortical scintigraphy d. Gallium scan |
Answer: Contrast CT
CECT is preferred study to evaluate renal nephroblastomatosis, as peripheral low-attenuated nodules show less enhancement than renal parenchyma. Nephrogenic rests are foci of metanephric blastema that persist beyond 36 weeks gestation and have potential for malignant transformation into Wilms’. MR: nodules demonstrate low T1 and T2 foci. They are hypoechoic by US. |
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Ideal CT phase for detecting renal mass?
a. Precontrast b. Arterial phase c. Corticomedullary phase d. Nephrographic phase e. Delayed phase |
Answer: Nephrogenic phase
Non contrast phase: baseline for enhancement characteristics (enhancement > 10-12 HU suspicious for malignancy), calcifications. Arterial phase (early corticomedullary phase): optimal imaging of renal arterial anatomy (donor nephrectomy) Corticomedullary phase (CMP) - pitfalls in the diagnosis of < 3cm renal masses, pseudo enhancement of a renal cyst, small central hypodense masses easier to miss, best phase to assess tumor extension into renal vein; optimal phase for evaluation of liver, spleen, pancreas to exclude metastases. Nephrographic phase (NP): Optimal detection, maximum diagnostic confidence for small renal masses. Excretory phase (EP): helpful for central masses or suspected transitional cell carcinoma. |
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MR of adrenal gland in patient with small cell lung cancer, in and out of phase images both show hypointensity. Diagnosis?
a. Metastasis b. Adenoma c. Pheochromocytoma d. Myelolipoma |
Answer: Metastasis
In/opposed phase imaging takes advantage of the chemical shift seen with intracellular lipid. Fat and water protons are in a slightly different chemical environment, and therefore will cycle in and out of phase at a given echo time. When they are in phase their signal will be additive. When they are out of phase their signal will be destructive. What this means is that lesions that contain lipid and water within the same voxel will drop out, ( e.g. BM fat turns dark). Note that bulk fat does not drop out very much, as this technique is most sensitive to the presence of intracellular lipid. In/opposed phase imaging has been shown to have a mean signal loss on the out-of-phase imaging of 36% for adenomas, while the mean signal loss for metastases was only 5%. Lesions which demonstrate drop in signal on the out-of-phase images include adenoma and myelolipoma. |
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Obstructive ureteral stone on noncontrast CT diagnosed by:
a. Soft tissue rim sign b. Comet tail sign c. Perinephric hematoma d. Increased density of the obstructed kidney |
Answer: Soft tissue rim sign
a. In patients with flank pain, the presence of a rim sign is a strong indicator that a calcification along the course of the ureter is a stone. Absence of the rim sign indicates that a calcification remains indeterminate. b. Comet tail sign is one of the criteria necessary for the diagnosis of rounded ateletasis, along with adjacent pleural thickening, volume loss, and a rounded peripheral lesion. |
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Most common risk factor for placenta accreta ( percreta)?
a. Prior Caeserian section b. Prior vaginal delivery c. DES d. Multiple gestations e. Gestational diabetes f. Placenta previa |
Answer: Prior Caeserian section
Placenta accreta is abnormal attachment of the placenta to the uterine wall (decidua) such that the chorionic villi invade abnormally into the myometrium. Three grades are used, based on pathologic assessment of myometrial invasion by the chorionic villi: Placenta Accreta - chorionic villi in contact with myometrium (80% of cases) Placenta Increta - chorionic villi invade into myometrium (15% of cases) Placenta Percreta - chorionic villi invade into serosa (5% of cases) All three forms of are associated with a history of prior cesarean section, history of uterine instrumentation or surgery, or placenta previa, endometritis, Asherman syndrome, adenomyosis. |
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TRUE about ectopic ureterocele:
a. More common in boys than girls b. More common on the left side c. Almost always associated with a duplicated collecting system d. Never associated with reflux when inserted near bladder neck |
Answer: More common on the left side
Ectopic ureteroceles occur when ureteral bud arises in an abnormal cephalad position from the mesonephric duct and moving caudally resulting in a ureteral orifice distal to trigone of bladder. 20% are in single non-duplicated systems (equal M:F). 80% are in duplicated systems, usually upper pole moiety (duplex system ureteroceles are seen 4 to 8 times more frequently in girls, F:M 4-8:1). The left side more frequently than right. All duplex system ureteroceles are ectopic and associated with dysplastic, poorly functioning upper pole moiety. In 1/2 of cases, lower pole ureter is on ipsilateral side to ureterocele reflux. |
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Ectopic ureter insertion in a boy most likely to be seen with:
A. Ectopic kidney B. Duplicated collecting system C. Hydronephrosis D. Polycystic kidneys |
Answer: Duplicated collecting system
The Weigert-Meyer rule applies here. When there is duplication of the collecting system, the upper pole moiety inserts ectopically (usually inferior and medial) and obstructs, while the lower pole moiety inserts orthotopically and refluxes. The remaining choices are less frequently associated with ectopic ureter. |
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2 days post renal transplant, patient develops flank pain, hematuria. US reveals reversal of diastolic flow of segmental renal artery. Dx?
a. Renal artery stenosis b. ATN c. Acute rejection d. Renal vein thrombosis |
Answer: Renal vein thrombosis
d. US findings for RVT include plateau-like reversal of diastolic arterial flow, decreased systolic rise time. Symptoms include hematuria/proteinuria, flank pain/graft tenderness, oliguria. b. US findings for ATN include increased RI values and transient enlargement of the transplant kidney. No constitutional symptoms or hematuria. Frequently presents with oliguria/anuria. a. US findings for RAS include increased velocity > 200cm/s, marked tardus-parvus waveform, and 2:1 ratio between peak stenotic and poststenotic velocities. Usually, RAS occurs proximally close to the anastamosis. c. US findings for acute rejection include enlarged edematous kidneys, decreased cortical echogenicity (edema), can have increased RI and reversal of diastolic flow. However, usually presents several weeks after transplant (mean 3rd-4th week). Symptoms include malaise, fever, weight gain, flank pain, oliguria, hypertension. |
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6 hrs post renal transplant with decreased urine output. US shows reversal of flow in segmental renal artery:
a) Renal Vein Thrombosis b) Hyperacute rejection c) ATN |
Answer: Acute tubular necrosis
ATN 2.9 days Perioperative rejection 6.9 days Renal vein thrombosis 4.8 d Hematoma < 24 hr Reversal of flow is seen in ATN, RVT, and rejection. ATN demonstrates transient enlargement of transplant and transient increase in resistive index. Reversed flow should be considered a sign of renal vein thrombosis if “holodiastolic” – throughout diastole. |
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12 hrs (3 days) post renal transplant with swollen/edematous kidneys and mildly increased RI. Cause?
a. ATN b. renal vein thrombosis c. RAS d. cyclosporine toxicity e. rejection |
Answer: Acute tubular necrosis
The most common immediate post-transplant complication is ATN which manifests as renal edema and mildly increased RI and hyperacute/acute rejection. ATN typically resolves over the first two weeks post transplant. The acutely rejecting kidney may also appear swollen and with elevated RI but the time course is different and this is best diagnosed with serial renal function studies showing decrease in renal function. Few recipients of cadaveric grafts with mild to moderate graft dysfunction within the first 48 hours of transplantation require imaging studies or renal biopsy as most will have ATN. |
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Tardus-parvus waveform can be specific in setting of what?
A. Renal artery stenosis after administration of captopril B. The elderly patient C. A calcified renal artery D. Diabetic Patient |
Answer: Renal artery stenosis after administration of captopril
The tardus–parvus wave form is a sign of a significant arterial stenosis. The normal renal arterial signal shows a very rapid, almost vertical upstroke. A slowed systolic upstroke and a delayed time to peak systolic velocity is the definition of a tardus – parvus waveform. Pharmacologic manipulation with captopril may enhance waveform abnormalities in patients with renal artery stenosis. |
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Would NOT cause increased RIs in a renal transplant?
A. acute rejection B. cyclosporine toxicity C. acute obstruction D. renal artery stenosis E. pyelonephritis F. ATN G. hydronephrosis H. AVF |
Answer: Renal artery stenosis or AVF (do NOT give increased resistive index)
Causes of elevated resistive indices: Parenchymal: acute rejection, acute tubular necrosis, pyelonephritis Vascular: renal vein thrombosis, hypotension Urological: ureteral obstruction Technical: graft compression |
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RI of .9 in a segmental renal artery s/p transplant is most consistent with:
a. Renal vein thrombosis b. Acute rejection c. Cyclosporin toxicity d. Acute tubular necrosis |
Answer: Acute rejection (the answer could be different depending on time frame)
Rejection of renal transplant is the most common cause of parenchymal failure. Doppler US shows initial decrease in resistive index (RI) then increase in RI to >.8. >.9 has 100% positive predictive value and 26% sensitivity. ATN occurs within 72 hours of transplantation. There may be a transient increase in RI. Review: RI = (Flowsystolic – Flowdiastolic) / Flowsystolic .→ when resistance to flow goes up, RI goes up (because there may be little or no diastolic flow). Source: Dähnert 5th ed. p.955, 956. US Req. p. 467. |
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NOT a cause of endometrial thickening postmenopause?
a. Endometrial polyp b. Tamoxifen c. Endometrial cancer d. Adenomyosis |
Answer: Adenomyosis
Adenomyosis thickens the junctional zone, not the endometrium. Adenomyosis is seen most commonly in pre-menopausal women. Endometrial thickness varies in menstruating women from 4 mm in the early proliferative phase to 13 mm in the late secretory phase. The upper limit of normal thickness in asymptomatic postmenopausal women has been suggested at 8 mm, +/- HRT. |
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Specific for adenomyosis on US:
a Heterogenous myometrium b Focal mass c Widened subendometrial halo d Subendometrial cystic regions |
Answer: Subendometrial cystic regions
Identifying subendometrial cystic regions on US is diagnostic of adenomyosis. A focal mass/heterogeneous myometrium is non-specific and could be many things (e.g. myoma). A widened subendometrial halo = widened junctional zone is for the MRI appearance of adenomyosis. |
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TRUE regarding adenomyosis?
a. typical low T1 & foci of high T2 b. local excision c. easy to differentiate from fibroid on US |
Answer: Typically low T1 and foci of high T2
T1: usually low, isointense to myometrium; small foci of high signal may be present, corresponding to areas of hemorrhage. T2: the junctional zone (inner layer of myometrium that normally appears as a dark band surrounding the endometrium on T2 is thickened (>12 mm). The border between junctional zone and myometrium is indistinct. Small T2 bright foci are often present. |
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TRUE regarding adenomyosis?
a. Hysterosalpingography is the diagnostic test of choice b. It appears low signal on T2 c. Local resection best treatment d. Endometrial tissue in the adnexa e. Rarely mistaken for leiomyoma on hysterosalpingography |
Answer: It appears low signal on T2 weighted images
Adenomyosis is focal/diffuse benign invasion of myometrium by endometrium (heterotopic “endometrial islands”). MR is modality of choice, see myometrial mass with indistinct margins of primarily low signal intensity on all sequences. May also see central high-intensity spot on T1 and T2 corresponding to hemorrhagic areas. The treatment is hysterectomy. |
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FALSE regarding adenomyosis?
a. more common in nulliparous women b. can have normal US appearance c. can be mistaken for a fibroid d. a result of invagination of the decidua basalis (ectopic decidua basalis in myometrium) e. can be diffuse or focal |
Answer: More common in nulliparous women (FALSE)
Seen in multiparous women >30 years during mestrual life. Most lesions are microscopic and not seen by US. Can be clinically and sonographically difficult to distinguish from a fibroid. It is an invasion of the myometrium by the endometrium. Dähnert 5th ed p. 1022 & US Requisites p. 403. Answer: More common in nulliparous women (FALSE) Seen in multiparous women >30 years during mestrual life. Most lesions are microscopic and not seen by US. Can be clinically and sonographically difficult to distinguish from a fibroid. It is an invasion of the myometrium by the endometrium. Dähnert 5th ed p. 1022 & US Requisites p. 403. |
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Urethral cancer associated with:
a. ureteritis cystica b. ureteral malacoplakia c. bladder cancer d. ureteral polyp |
Answer: Bladder cancer
Patients with a history of bladder cancer have an increased risk of urethral cancer. Urethral cancer: the most common type of urethral malignancy is squamous-cell cancer. In men, these lesions comprise 78% of the total cases and occur primarily in the bulbomembranous and penile regions. TCC is the second most common urethral malignancy in both sexes. In males, occurs in the prostatic urethra. Some suggest concordance between urethral cancer and STDs. HPV recently was associated with urethral cancer. Ureteritis cystica (UC) or cystic pyeloureteritis is a rare condition, characterized by multiple cysts and filling defects in the ureter and renal pelvis, visualized during IVP and retrograde pyelography. UC is a benign inflammatory pathology; even though it may mimic a malign tumor with radiography findings. It has a benign course with rare complication and progression. Malacoplakia occurs most often in the urogenital system, is rare. Radiographically, malacoplakia appears as single or multiple smooth, rounded, filling defects of the bladder. The appearance is nonspecific and may be similar to that seen with bullous cystitis, cystitis cystica, and other inflammatory bladder lesions. Differentiation of malacoplakia from transitional cell carcinoma and other tumors requires cystoscopy and biopsy, because there are no characteristic radiographic features. Usually displays a benign, self-limiting course and is usually amenable to successful treatment with antibiotics and endoscopic resection and fulguration. |
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Regarding the penile urethra:
a. stricture at penoscrotal junction most commonly due to catheterization (penoscrotal junction is where most catheter induced trauma occurs) b. most common cancer is adenocarcinoma c. anterior urethra defined as the distance to penoscrotal junction d. gonococcal strictures are short segment |
Answer: Stricture at the penoscrotal junction is most commonly due to catheterization; penoscrotal junction is where most catheter induced trauma occurs
Urethral cancers: Squamous cell CA most common - 75%. Transitional Cell CA - 15%. Adenocarcinomas - most common malignancy to occur in a urethral diverticulum. Thought to be related to chronic irritation and inflammation of the urethra. Lymphatic spread before hematogenous spread. 2 major risk factors: chronic urethral inflammation, or sexually transmitted disease with urethral stricture. Squamous cell CA most common - 80% - most originate in the bulbar or membranous urethra. Transitional Cell CA - 15% - most also originate in the prostatic urethra. Association exists between TCC of the prostatic urethra and previous transurethral resection of bladder CA. Catheterization is the most common cause of anterior urethral injury. Occurs at membranous urethra or penoscrotal junction. Other causes of urethral strictures: 1. Urethritis (non-infectious). 2. Urethritis (infectious - typically gonococcus, chlamydia, ureaplasma urealyticum, or less commonly, TB). 3. Gonococcal structures typically are at the proximal bulbar urethra. |
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TRUE about male urethra?
a) female get diverticula at same rate as males b) adenocarcinoma more common than SCC in urethra |
Answer: Adenocarcinoma is more common than SCC in the urethra
More women than men get diverticula. Urethral cancer: the most common type of urethral malignancy is squamous-cell cancer; occur primarily in the bulbomembranous and penile regions. TCC is the second most common; occurs in the prostatic urethra. Some suggest concordance between urethral cancer and STDs. HPV recently was associated with urethral cancer. |
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TRUE about female urethra?
a) diverticula need marsupalization b) diverticula located posteriorly c) develops after long term catheterization d) causes stress incontinence |
Answer: Diverticula located posteriorly
Female urethral diverticulum is a localized outpouching of the urethra into the anterior vaginal wall. Most often present in the posterolatral mid or distal urethra, it results from repeated inection of periurethral glands, obstruction, and enlargement of obstructed periurethral glands. Most common symptoms are irritative (i.e., frequency, urgency and dysuria) lower urinary tract symptoms (LUTS). Dyspareunia 12-24 % and 5-32% will complain of post-void dribbling. Recurrent cystitis or UTI 33%. Other complaints include pain, hematuria, vaginal discharge, urinary retention, incontinence (stress or urge). Occasionally, urethral carcinoma and calculi may be present. Not all require surgical excision. Options include transurethral incision of diverticular neck, marsupialization (creation of permanent opening) of the diverticular sac into vagina [Spence procedure], and surgical excision. |
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FALSE regarding urethral diverticulum in females?
a. They are most often congenital b. Can pres w/ stress incontinence c. Treated by marsupialization d. They are usually located off the posterior wall of the urethra |
Answer: They are most often congenital
Seems to be recalled differently with different answers: If read carefully, this question is definitely correct. Urethral diverticula occur more often in females than males, and are rarely congenital. They occur when periurethral glands become infected and obstructed. Commonly occur in the distal 1/3 of the urethra, and occur POSTERIORLY in the urethra, causing indentation of the ANTERIOR wall of the vagina. Rarely occur in the anterior wall or the proximal 1/3. If nonobstructed, 75% will be seen on postvoid IVP film, 90% on VCUG, the remainder require double-balloon catheter positive pressure urethography. Calculi in 5-10%. Classically present with postvoid dribbling, dysuria and dyspareunia. |
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Which part due congenital urethral diverticulum occurs in?
a. Prostatic urethra (posterior urethral valves cause dilation) b. Membranous c. Bulbous d. Trigone of the bladder |
Answer: Bulbous
Congenital urethral diverticulum occurs only in males and arises from the ventral surface of the anterior urethra due to the failure of closure of urethral folds, or an abortive attempt at urethral duplication. A urethral diverticulum in the adult female is throught to be acquired. |
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Prenatal US, fetus has oligohy-dramnios, bilateral renal cysts. Most likely diagnosis?
a. AR polycystic kidney disease b. AD polycystic kidney disease c. medullary cystic disease d. multicystic dysplastic kidney e. congenital nephrosis |
Answer: Multicystic dysplastic kidney
MCDK result from early (8-10 weeks) severe urinary obstruction causing maldevelopment of renal parenchyma replaced by cysts of variable size. Kidneys are enlarged. If the contralateral kidney is normal, bladder seen, and AFI normal, then good prognosis. Fetuses with severe oligohydramnios, non-visualization of the bladder have a poor prognosis with likely lethal renal disease. ADPKD and medullary cystic disease aren’t routinely seen in the infant. ADPKD occasionally seen with renal enlargement most common finding with echogencitity. ARPKD is seen in the fetus but does not have discernable cysts, rather the kidneys are large and echogenic with through-transmission. May have oligohydramnios depending on renal function. |
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Location of Cowper's glands?
A. (posterior)membranous urethra B. anterior bulbous urethra C. posterior bulbous urethra C. posterior prostatic urethra D. penile urethra |
Answer: Posterior membranous urethra
Cowper glands = bulbouretheral glands, are paired glands homologous to the Bartholin's glands in the female. Located in the urogenital diaphragm (membranous urethra); empty below into the proximal bulbous urethra. Pea-sized Cowper's glands lie laterally and posteriorly between fasciae and sphincter urethrae within urogenital diaphragm. Secrete a clear fluid that functions as a lubricant and a coagulation factor for semen during ejaculation. Abnormalities of these glands and their ducts may result from obstruction and, less frequently, trauma and infection. |
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Most specific for ARPKD on US:
A. Small kidneys B. Hydronephrosis C. Increased echogenicity D. Decreased echoenicity E. Multicystic |
Answer: Increased echogenicity
ARPKD results in bilateral, symmetrically enlarged kidneys that maintain their reniform shape. Beneath the capsule are scattered opalescent cysts from dilated collecting ducts, usually 1-2 mm in diameter, but sometimes larger. Interstitial fibrosis develops but the glomeruli remain normal. Generally, there is a reciprocal relationship between the degree of renal and hepatic involvement. In children as well as in neonates renal sonography may show increased echogenicity in the kidneys, particularly in the pyramids, loss of corticomedullary junction differentiation, mild-to-moderate nephromegaly, and (occasionally) dilated cystic-appearing collecting ducts. Microcalcification in ARPKD is caused by the precipitation of calcium within dilated collecting ducts. |
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NOT associated with ARPKD?
a. Increased risk of RCC compared to rest of population b. Resolution after renal transplant c. Best seen with ultrasound d. Hepatic fibrosis |
Answer: Increased risk of RCC compared to rest of population (NOT associated)
ARPKD is the most common heritable cystic renal disease occurring in infancy and childhood. It is distinct from ADPKD which tends to occur in an older population. ARPKD is characterized by pathologic changes in the kidney and/or liver. In the kidney, epithelial hyperplasia occurs along the collecting duct of nephron. The hyperplastic cells change from being resorptive to becoming secretory. The combination of epithelial hyperplasia and fluid secretion results in significant ductal ectasia. Depending on the number of ducts involved, the kidneys may be massively enlarged. US reveals multiple small subcapsular cystic spaces that correspond histologically with radially oriented, ectatic collecting ducts. Ultrasonography is the primary radiographic modality for the evaluation of ARPKD, especially during the perinatal/neonatal periods. Liver disease is present in every patient with ARPKD. The chief pathologic hallmarks of liver disease are periportal fibrosis and biliary duct ectasia; most common clinical manifestation of congenital hepatic fibrosis is portal hypertension. The less severe the renal findings, the more severe the hepatic findings. |
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NOT associated with (VHL) von Hippel-Lindau syndrome?
a. angiomyolipoma b. renal cysts c. renal cell cancer d. pheochromocytoma |
Answer: Angiomyolipoma (NOT associated)
Angiomyolipoma is associated with tuberous sclerosis. von Hippel-Lindau (VHL) disease is a rare inherited disorder manifested by visceral cysts, benign masses, and potential for malignant transformation in multiple organ systems. Clinical hallmarks of VHL are development of retinal and central nervous system (CNS) hemangioblastomas, pheochromocytomas, multiple cysts of the pancreas and kidneys, and a high potential for malignant transformation of renal cysts into carcinoma. |
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NOT a cause of persistent (delayed) nephrogram?
a. Acute pyelonephritis b. RVT c. ATN d. RAS e. Hypotension f. Contrast induced nephropathy g. Acute ureteral obstruction |
Answer: Acute pyelonephritis
Of the choices given, renal vein thrombosis, acute tubular necrosis and renal artery stenosis are clearly listed by Dahnert as causing a persistent nephrogram. Acute pyelonephritis causes a striated nephrogram. Other causes of persistent nephrogram: systemic hypotensive reaction – a drop in perfusion pressure after contrast reaches kidney leads to increased salt and water reabsorption and slowed tubular transit. Acute venous outflow obstruction in renal vein thrombosis - obstructive nephrogram with progressive increase in opacity of entire kidney. |
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Corpus luteal cyst ruptures at:
a. 1 cm b. 2 cm c. 3 cm |
3 cm
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Ovarian follicle rupture at:
A. 10mm B. 15mm C. 20mm D. 25mm |
Answer: 20 mm
Mean diameter at rupture is 20-23 mm. Sizes up to 30 mm are seen in ovarian hyperstimulation syndrome. US: early antral follicles are 2-4mm; developing follicles are 5-10 mm; dominant follicle reaches 10mm on day 8-9 and reaches final mature size of 18-24 mm on day 14 prior to ovulation. |
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Asherman's syndrome (or synechiae) is best diagnosed by:
a. HSG b. US |
Answer: Hysteroscopy is best (not an answer choice); HSG second best
Asherman’s is thought to be under-diagnosed because it is usually undetectable by straightforward diagnostic procedures such as ultrasound scan. Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG). Asherman's syndrome is an uncommon, acquired, gynecological disorder characterized by changes in the menstrual cycle. Patients experience reduced menstrual flow, increased cramping and abdominal pain, eventual cessation of menstrual cycles (amenorrhea), and, in many instances, infertility. Most often these symptoms are the result of severe inflammation of the lining of the uterus (endometriosis) that is caused by the development of bands of scar tissue that join parts of the walls of the uterus to one another, thus reducing the volume of the uterine cavity (intrauterine adhesions and synechiae). |
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Most common testicular metastasis?
a. Lymphoma b. Renal c. Stomach |
Answer: Lymphoma
Lymphoma, leukemia, and melanoma are the most common malignancies that metastasize to the testicle |
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On BE, endometriosis (melanoma mets) is similar to?
a. Intraperitoneal mets b. GIST tumor c. Metastatic melanoma d. Lipoma |
Answer: Intraperitoneal mets
Endometriosis: rectosigmoid colon is the most common site of gastrointestinal involvement (85%). Rectosigmoid endometriosis usually manifests on double contrast barium enema as extrinsic mass effect flattening, tethering, and/or spiculation of the anterior border of the rectosigmoid colon. Radiographic findings caused by endometriotic implants in the ileum are similar to those caused in the colon. Intraperitoneally seeded metastasis ot the ileum should be the leading consideration in the differential diagnosis. |
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NOT associated with increased echogenicity of infant renal (medullary) pyramids?
a. Fanconi anemia b. Prune belly syndrome c. RTA d. Lasix (Furosemide) e. Hypercalciuria f. Williams' |
Answer: Prune belly syndrome (NOT associated)
The differential diagnosis of echogenic renal pyramids in children includes nephrocalcinosis as the single most frequent cause. Lasix (furosemide) and renal tubular acidosis are also well known causes of medullary nephrocalcinosis. Fanconi anemia is an autosomal recessive disease with severe hypoplastic childhood anemia which is known to cause echogenic pyramids in the absence of nephrocalcinosis. |
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Infant/neonate with echogenic cortex in kidneys, most likely?
a. ATN b. RAS c. Furosemide toxicity d. Hypercalciuria e. RVT |
Answer: Furosemide toxicity
Furosemide therapy – long-time furosemide therapy in premature infants and neonates with CHF results in hypercalciuria. Hypercalciuria is associated with increased echogenicity of the renal pyramids and renal stone formation. Hypercalciuria – increased calcium excretion in the urine. Causes of hypercalciuria include idiopathic and familial, medications (furosemide), immobilization, malignancy, and renal tubular acidosis. In children, ATN is usually caused by drugs (contrast, aminoglycosides, NSAIDs), ischemia, or myoglobin (following seizures). On ultrasound, the medulla demonstrates normal-to-decreased echogenicity with normal-to-increased echogenicity of the renal cortex. Pyramids sharply delineated, RIs are elevated. RVT causes include placental abruption, prematurity, birth trauma, dehydration, glycosuria (infants of diabetic mothers) and sepsis. Renal vein thrombosis occurs more commonly on the left due to the longer left renal vein. |
