Textbook Review Mod 1

Front 1

what is the most cephalad branch of the abdominal? what does it bifercate into? What is the doppler signal like in this artery?

Back 1

Celiac artery/axis.
-bifercates 1-3cm from origin into common hepatic and spenic arteries
-doppler signal is low resistance with continuous flow through diastole.
-the splenic(lt branch) and hepatic(rt branch) arteries also exibit a low resistance flow pattered caused by the low flow resistance within the microcirculation of the liver and spleen.

Front 2

What happens if the celiac artery is occluded?

Back 2

Collateralization occurs through the pacreaticoduodenal arterial arcade(vessels surrounding pancreas and duodenum)
-These vessels enlarge, and feed into the gastroduodenal artery reserving flow for the common hepatic artery.
-The hepatic artery, or splenic artery may appear normal even if the origin of the celiac axis is occluded.

Front 3

Explain the course of the splenic artery, and its doppler signal?

Back 3

-tortuous
-runs along the posteriosuperior pancreatic margin, branching, and terminates in the hilum of the spleen.
-Becaus it is tortuos, it often has turbulent flow.

Front 4

Explain the course of the common hepatic artery until it enters the liver?

Back 4

-runs superior to pancreaic head
-gastroduodenal artery branches off
-common hepatic artery becomes proper hepatic artery which follows the portal vein tothe porta hepatis
(refer to image A on pg. 516 of zwibel)

Front 5

Explain the course of the hepatic arteries in the liver?What is the doppler flow like?

Back 5

At the porta hepatis, it is divided into left and right hepatic arteries which branch off through the liver.
-Flow is low-resistant with large amount of continuous forward flow through diastole.

Front 6

Explain some variations of the hepatic arteries?

Back 6

1)common hepatic artery arising from SMA(4%)
2)RHA arising from SMA(11%)
3)LHA arising from left gastric artery.

Front 7

What is the second branch of the abdominal AO? What does it supply?

Back 7

SMA supplies:
-jejunum
-ileum
-cecum
-ascending colon
-Prox 2/3 of trx colon
-portions of the duodenum and pancreatic head

Front 8

Describe the anatomical location of the SMA?

Back 8

-surrounded by distinct layer of echogenic fat
-panc is ant.
-AO is post.

Front 9

describe the doppler waveform of the SMA?

Back 9

-turbulent near origin, but more uniform distally
-high resistant in fasting patient
-low resistant within 30-90 minutes of eating with broad systolic peaks and continuous diastolic flow.

Front 10

Where does the portal venous system transfer blood from?

Back 10

bowel and spleen to the liver.

Front 11

Explain the course of the portal vein?

Back 11

Begins at junction of splenic and superior messenteric veins.
-courses oblique and to the rt to terminate at the porta hepatis
-branches into rt and lt branches with supply their corrisponding lobes

Front 12

Explain the course of the splenic vein

Back 12

follows the course of the body and tail of the panc.

Front 13

explain the course of the superior messentericvein?

Back 13

extends posteriorly from the portal vein junction and parallels the SMA
-best seen in longitudinal

Front 14

Where can the IMV empty?

Back 14

-Splenic vein(38%)
-Splenic/SMV junction(32%)
-SMV(25%)

Front 15

HOw can the coronary vein be helpful?

Back 15

It may shunt blood from the portal to systemic circulation in cases of portal hypertension

Front 16

What is the normal direction, and doppler of portal vein flow

Back 16

Hepatopedal(toward the liver)
-normal flow demonstrates a windstorm sound
-w/ right heart failure, and fluid overload, RA pulsitations may be transfered through the liver to the portal vein which then exhibits pulsatile doppler flow.

Front 17

What happens to the splenic and superior messenteric arteries with respiration?

Back 17

the are increased in calebre, and do not change with respiration.

Front 18

Where are the hepatic veins in comparisin to the liver?

Back 18

Rt-btw ant and post segments
Middle-btw rt and left segments
Lt-btw med and lat
The caudate lobe has separate drainage from the rest of the liver (directly into the IVC)

Front 19

What are some variations of hepatic vein anatomy?

Back 19

-LHV is duplicated
-accessory hepatic veins
-absent of one of the 3 main HV's

Front 20

Name some dfferences btw hepatic and portal veins

Back 20

1)course-hepatic=longitudinal
portal=trx
2)Convergence-HV-converge @IVC
PV-converge at porta hepatis
3) change is size:
HV-larger toward diaphragm
PV-larger towards hepatis
4)Margins:
HV-naked
PV-surrounded by echogenic sheath

Front 21

What is the doppler signal like in the HV's?

Back 21

chaotic and pulsitile resulting from transmission of RA pulsitations

Front 22

Describe the normal doppler signal of the IVC?

Back 22

-near the heart, it can be somewhat pusitile
-distally, flow is phasic and similar to the pattern seen in extremity veins

Front 23

What are some anomolies that can occur with the IVC?

Back 23

-duplication(0.2%)
-transposition(0.2-0.5%)

Front 24

Describe the course of the right and left renal arteries? What is the doppler flow pattern of them?

Back 24

RIGHT:
-comes of the AO anteriolaterally
-passes post. to IVC
LEFT:
-Comes of the AO laterally, and courses to the renal hilum

Doppler: Low resistance

Front 25

What are some anomolies associated with renal arteries?

Back 25

1/3 of knys are supplied by 2 ore more arteries arising from the AO:
-main renal artery can be duplicated
-extra arteries may arise fro AO, and attach to the hilum, or poles
-accessory arteries may also arise from the ipsilateral iliac artery, AO, or other arteries.
-accessory renal arteries

Front 26

Explain the courses of the LT and RT renal veins? What is the doppler signal?

Back 26

Left:
-receives adenal vein(from above),and left gonadal vein(from below). Passes ant. to AO and pos. to SMA
RT:
-Shorter than LT
-directly to IVC from hilum.

Doppler:
shows same phasic flow variations as IVC

Front 27

What are some variations of renal veins?

Back 27

LT:
-circumaortic w/ separate vein passing ant. and post. to the AO
-retroaortic, w/ single branch passing posterior to the aorta rather than anterior.
Rt:
-Accessory renal veins draining directly into IVC

Front 28

What can the greater saphenous vein and/or lesser saphenous vein be used for?

Back 28

conduit for coronary and peripheral arterial reconstruction

Front 29

Explain the difference btw accute, subaccute, and chronic trombus

Back 29

acute=<14 days
subacute=14days-6 months
chronic->6 mo.

Front 30

What features does blood flow in normal veins have?

Back 30

1)spontaneous
2)phasic
3)ceases w/ valsalva
4)augmented by distal compression
5)unidirectional(towards the heart)

Front 31

What are the causes of renovascular hypertension?

Back 31

-Atherosclerosis(in the prox renal artery)(most common)
-Fibromuscular dysplasia(in mid-dis renal artery)(More frequent in women)
-dissection&/or extension of aortic dissection

Front 32

Why would renal doppler need to be done?

Back 32

-uncontrolled hypertension(esp. in younger patients)
-Decreasing renal fx
-abdominal bruit

Front 33

Segmental and interlobar renal arteries

Back 33

segmental-course through the hilum and are branches of the main renal artery

interlobar-arise from segmentals and lie btw renal medullary pyramids and penetrate parenchma

Front 34

what is the order of renal artery branches

Back 34

main renal artery
segmental arteries
interlobar
interlobular

Front 35

What is the purpose of renal doppler

Back 35

-identify cause of hypertension
-prevent renal failure
-evaluate renal transplants for artery twists, kinks, stenosis, and rejection

Front 36

Differentiate btw direct and indirect renal artery doppler

Back 36

direct-sample renal artery from prox to distal and sample segmental renal arteries bilaterally.

Indirect-only sample segmental and/or interlobar arteries. Quick exam time, but limited in detecting >70% stenosis

Front 37

What transducer should be used for renal artery doppler?

Back 37

2.25-3mhz

Front 38

Explain the technique for doppler of the renal arteries?

Back 38

-Measure doppler of the ao 2-3cm disto=al to xiphoid process
-obtain doppler waveforms from multiple sites from the renal artery origin to the hilum bilaterally. Also, sample segmental arteries

Front 39

RAR

Back 39

renal/aortic peak systolic velocity ratio
highest velocity in renal artery compared to velocity of the aorta 2-3 cm distal to xiphoid process

Front 40

What is the criteria for >60 renal artery stenosis?

Back 40

RAR>3.5
peak systolic velocity >180cm/s
post-stenotic turbulence
low flow in distal renal artery

Front 41

what are the characteristics of renal artery occlusion?

Back 41

no flow in a well visualized renal artery
low amplitude color and spectral doppler signal from the parynchma
small kny size(<9cm)

Front 42

Renal parynchal disease

Back 42

Normal renal artery=low resistance
Parenchymal disease=reduced velocity, high resistance in main renal artery, segmental and interlobar arteries.

Front 43

what are the limitations of direct renal doppler?

Back 43

-high technical failure rate(12-25%)
-accessory renal arteries occur 20% of the time
-poor doppler angles
-long exam time
-requires very skilled tech

Front 44

WHAT is the normal wave form for indirect renal testing?

Back 44

-presence of an ESP
-AT <0.07sec
-diastolic flow

Front 45

What is the criteria for >60% stenosis with indirect testing?

Back 45

-increased AT(>0.07 sec)
-tardus-parvus waveform
-loss of early systolic peak(ESP)
-flattened systolic uplsope
-AT<3m/s
-Low RT(<0.75)
-Reduced color flow unilaterally

Front 46

What is RI used for in the kidneys? What are the normal and abnormal values?

Back 46

Used to evaluate for transplant rejection
NORMAL=<0.73+-0.04
ABNORMAL=>0.8+-0.7

Front 47

what are the limitations of indirect renal sampling?

Back 47

-stenosis in accessory renal arteries is hard to find(doppler in upper, mid, and lower poles of segmental arteries helps reduce false negative)
-not efficient at detecting stenosis <60%
-positive study in segmental arteries cannot differentiate stenosis from occlusion in the main renal artery
-parynchmal disease with main renal artery stenosis may cause segmental waveform to become more resistive leading to a false negative

Front 48

What is the purpose of messenteric doppler?

Back 48

To diagnose messenteric ishemia

Front 49

mesenteric ishemia

Back 49

-uncommon due to colalteral
-usually due to athero occlusive disease
-The celiac, SMA, and IMA have to all be involved for bowel ishemia to occur.
-can be chronic or acute(due to embolization)

Front 50

What are the symptoms of mesenteric ischemia?

Back 50

-abdominal cramps and pain after eating
-diarrhea, change in bowel habits
-weight loss
-"fear of food" syndrome

Front 51

Pancreaticoduodenal artery

Back 51

-branch of the gastroduodenal artery
-allows communication btw the celiac axis, and the SMA

Front 52

Explain the technique for mesenteric doppler?

Back 52

-patient supine
-3 mhz trans.
-identify Ao and obtain doppler
-obtain spectra from all measenteric vessels and measure peak systolic and diastollic velocities.

Front 53

What is the mesenteric criteria for >70% stenosis?

Back 53

Celiac artery-PSV>200cm/s w/ post stenotic turbulence
SMA-PSV>275cm/s w/ post stenotic turbulence

Front 54

what are some other applications for mesenteric doppler?

Back 54

celiac compression syndroem
SMA compresion syndrome

Front 55

what is normal portal vein flow?

Back 55

-low velocity(20-40 cm/s)
-no filling defects
-hapatopedal direction
-no varices
-normal flow direction in potential collaterals

Front 56

What is portal hypertension? What can it be caused by?

Back 56

-elevated preassure in the portal venous system due to increased impedence of flow through the liver. Due to:
Prehepatic obstrucion
intrahepatic
Post hepatic

Front 57

Explain prehepatic, intrahepatic, and post hepatic obstruction?

Back 57

prehepatic:
Thrombosis of portal vein or splenic vein
extrinsic compression of portal v

Intrahepatic:
-cirrhosis(most common)
-hepatic fibrosis
-lymphoma

Post hepatic:
-IVC obstruction
-Hepatic vein obstruction

Front 58

What can portal hypertension lead to?

Back 58

-Ascites
-splenomegaly
-GI-esophageal bleeding
-jaundice
-signs of hepatic failure

Front 59

what is the technique for portal doppler?

Back 59

-Measure portal vein diameter
-Measure velocity and direction
-Measure vein and branches for patency, and flow direction
-measure spleen
-R/O extrinsic compression by mass
-evaluate IVC for obstruction

Front 60

what are some common porto-systemic shunts?

Back 60

-Lt gastric vein(coronary vein):
regrograde in 80-90% of PHT
increased pressure in this vessel may cause esophageal varices

-Gastric varices:
near stomach
under left lobe of liver
near spleen

Front 61

other porto-systemic shunts

Back 61

-recanalized paraumbilical vein with hepatofugal flow
-spleno-renal shunt(spleniv vein to left of renal vein)

Front 62

TIPS shunts

Back 62

Transjugular intrahepatic portosystemic shunts:
-stent in the liver btw the portal vein and hepatic vein
-purpose is decompression of the portal venous system
-doesn't address cause of portal hypertension

Front 63

Budd-chiari syndrome

Back 63

-Stenosis or obstruction of the hepatic veins. May be caused by:
Hepatomegaly
splenomegaly
ascites

Front 64

what does normal hepatic flow look like?

Back 64

-respiratory variation
-pulsitile

Front 65

When are patients chosen for a liver transplant?

Back 65

When their life expectancy without transplantation is lower than there life expectancy with a transplant

Front 66

What are the most common diseases requiring liver transplant?

Back 66

1) hep c
2)alcoholic liver disease
3)cryptogenic cirrhosis

Front 67

Why were hep b patients considered poor transplant candidates? has that changed?

Back 67

because of the high recurrence rate of infection resulting in rapid progression to cirrhosis
-this has changed due to the use of hyperimmunoglobulins and nucleoside analogs

Front 68

What is the standard for liver transplants of patients with HCC?

Back 68

no lesion >5cm or no more than 3 lesions >3cm

Front 69

What will be seen on U/S with a normal liver transplant patien?

Back 69

normal, or slighly heterogenous liver echotexture
-may bee intraperitoneal fluid, or small serosas, or hamatomas(resolve by 10dys)
-normal appearance of the billiary tree. biliary anastamosis should be inspected for changes in caliber
-normal to have pneumobilia
-assess vascular patency(of hepatic artery, portal veins, hepatic veins, IVC, esp. anastamosis areas)

Front 70

Billiary stricture

Back 70

may be difficult to diagnose early because due to poor nerve supply, patients do not typically experience colic.
Symptoms:
-assymptomatic
-painless obstructive jaundice
-Abnormal LFT's

Classified into anastamotic, and intrahepatic

Front 71

Anastomotic strictures

Back 71

-most common cause of biliary obstruction after transplantation
-Scarring results in retraction of duct wall , and narrowing of luminal diameter

Front 72

Intrahepatic strictures

Back 72

-proximal to anastamosis
-either unifocal, or multiocal
-the hepatic artery is the only lood supply to the CBD and intrahepatic bile ducts, so most intrahepatic duct strictures are due to ischemia caused by hepatic artery occlusion/

Front 73

what may echogenic intraluminal material within the billiary tree represent.

Back 73

ominous sign
-sometimes caused by severe billiary ischmia resulting in sloughing billiary epithelium.

Front 74

recurrent sclerosis cholangitits

Back 74

-happens 20% for those transplanting for sclerosis cholagitis
-diffuse mural thickening of intrahepatic and/or CBD
-Diverticulum-like outpouchings of the CBD
-occasionally, patients with ascending cholagitis may present with an identical ultrasound appearance

Front 75

biliary sludge

Back 75

10-29% of liver transplant pts.
-once sludge is present, it has the potential to produce biliary ostruction and lif-thretening ascending cholagitis
-should evaluate the CBD to exclude leision or leaks
-should evaluate hepatic artery to ensure optimal arterial supply

Front 76

Dysfunction of the schincter of oddi

Back 76

hepatic dysfuction due to diffuse dialation of bile ducts in the absense of biliary stenosis
-devascularization or denervation of the ampulla of vater resulting in dysfunction of the sphincter of oddi

Front 77

Arterial complications with liver transplant

Back 77

results in transplanted hepatic artery becoming the only arterial blood supply to intrahepatic biliary epithelium. Early detection before biliary necrosis is paramount in managing liver trx patiets.

Front 78

Hepatic artery thrombosis

Back 78

can present clinically with delayed biliary leak, fulminant hepatic failure, or intermittent episodes of sepsis
-Doppler shows absense of flow in the hepatic artery, or tardus parvus arterial waveform
-

Front 79

what are the risk factors for hepatic artery thrombosis with liver transplatation

Back 79

-complex vascular reconstruction
-rejection
-severestenosis
-increased cold ischemic to of donor liver
-ABO blood type incompatability

Front 80

False positive for hepatic artery thrombosis

Back 80

severe hepatic edema
systemic hypotension
high grade hepatic arterty stenosis

if unsure, confirm on CT because it is very NB

Front 81

Hepatic artery stenosis

Back 81

-most common at anastamosis
-clinically:biliary ischemia, or abnormal LFT's
-doppler provides either diect evidence(identifying and localizing narrowed segment), or indirect evidence(tardus parvus waveform anywhere in the hepatic artery) of hepatic artery stenosis

Front 82

Hepatic artery pseudoaneurysm

Back 82

shows as a cystic periportal structure with intense swirling flow on color doppler and a disorganized spectral waveform

Front 83

celiac artery stenosis

Back 83

-may be due to atheromatous disease or impingement of the celiac axis by the medial arcuate ligament
-patients often are asymptomatic prior to trasplantation, but post transplant, they become symptomatic, presenting with evidence of biliary ischemia and abnormalities in serum LFT's

Front 84

Portal vein stenosis or thrombosis

Back 84

clinical=hepatic failure / signs of portal hypertension

Front 85

Stenosis of IVC

Back 85

May occur at either the suprahepatic or infraheptaic anastamosis
-IVC shows obvious narrowing at the site of anastamosis, associated with focal region of aliasing on color dopppler
-hepatic veins may show reversal of flow

Front 86

Extrahepatic fluid collections

Back 86

common in the areas of bascular arnastamosis
-bare area of the liver

Front 87

Adrenal hemorrhage

Back 87

-right sided adrenal hemorrhage from venous engorgement or coagulaopathy caused by patient's preexisting liver disease

Front 88

inctrahepatic fluid collections

Back 88

-along the falciform ligament and ligamentum venosum
-bilomas may present as hypoechoic and round or complex
-intraparenchymal hematoas may occur

Front 89

ABSCESS VS INFARCT

Back 89

Infarcts-hypoechoic areas reflecting liquifaction and necrosis. Doppler evidence of hepatic arterial compromise

Abscess-a complex cystic structure with thick, irregular walls

Front 90

Recurrent HCC

Back 90

-most common site=lungs
-2nd most common=within allograft