The Biliary Tree

Front 1

You are having difficulty locating the gallbladder in a patient with right upper quadrant pain. What anatomic landmark will help you identify the gallbladder fossa?

Back 1

- interlobar hepatic fissure

Front 2

In what anatomic variant is the fundus of the gallbladder folded over the body?

Back 2

- Phrygian cap

Front 3

A patient is referred from the emergency room to rule out acute cholecystitis. You think the gallbladder wall may be thickened. What is the normal diameter of the gallbladder wall?

Back 3

- < 3mm

Front 4

You are scanning the gallbladder and notice some smudgy echoes within it. You suspect the echoes are due to artifact. What is a common cause of artifactual echoes within the gallbladder?

Back 4

- reverberation

- side lobes

- slice thickness artifact

- all of the above

Front 5

You have a patient scheduled for gallbladder sonogram. What preparation is required?

Back 5

- the patient should be fasting for 8-12 hours prior to the study

Front 6

You have been requested to perform a gallbladder u/s to rule out cholelithiasis. What is cholilethiasis?

Back 6

- Gallstones

Front 7

You are scanning the gallbladder and notice that the wall abnormally thick. Which of the following is NOT a cause of gallbladder wall thickening?

Back 7

- Malignant ascites

Front 8

A referring physician has asked you about the accuracy of the gallbladder sonography. The diagnostic accuracy of the gallbladder sonography is:

Back 8

- > 90 %

Front 9

During gallbladder sonography, you notice echogenic foci whithin the gallbladder but do not detect distal acoustic shadowing. What changes below will improve the detectability of stone shadowing?

Back 9

- Increase transducer frequency, increase transducer focusing

Front 10

You are scanning a patient with a porcelain GB. What does this term mean?

Back 10

- The GB wall contains varying amounts of calcification

Front 11

Which of the following best describes the location of the distal CBD?

Back 11

- Posterior and slightly lateral to the panc head

Front 12

The patient you are scanning has eating breakfast prior to your study. What is the appearance of the GB in the postprandial state?

Back 12

- Contraction of the GB w/ difuse wall thickening

Front 13

A patient presents to the u/s department for a sonogram to rule out biliary obstruction. Which lab test would best indicate the presence of bile duct obstruction?

Back 13

- Serum direct bilirubin

Front 14

What is the most common cause of acute cholecystitis?

Back 14

- Calculous obstruction of GB nk or cystic duct

Front 15

Tenderness over the GB with probe pressure is termed:

Back 15

- Murphy's sign

Front 16

You are performing an abdominal u/s study and detect a dilated, nontender GB. What should you look for?

Back 16

- Mass in the head of the pancreas

Front 17

Which of the following is a symptom associated with acute cholecystitis?

Back 17

- Nausea

- Vomiting

- Epigastric pain

- Rt upper quadrant pain

-All of the above

Front 18

you are performing an u/s examination on a patient with acute cholecystitis. Complications of acute cholecystitis that you should look for include all of the following EXCEPT:

Back 18

- Pancreatic carcinoma

Front 19

You have been asked to rule out the presence of choledocholithiasis. What are you looking for?

Back 19

- Stones withing the CBD

Front 20

Identification of what anatomic structure would most help a sonographer locate a contracted GB?

Back 20

- Main lobar fissure

Front 21

The transverse diameter measurement of the Gb in a fasting patient measure 5.3 cm. This measurement is:

Back 21

- Consistent w/ a hydropic GB

Front 22

You are scanning a patient in ICU and notice low-level echoes w/in the GB consistent with sludge. The GB wall is thickened. Which statement below is true?

Back 22

- The patient has sludge most likely due to bile stasis.

Front 23

U/s images obtained on a 48-yr-old male show a comet-tailor V-shaped reverberation artifact originating form the anterior wall of the GB. This artifact most likely results from:

Back 23

- Adenomyomatosis

Front 24

You are performing an u/s study to rule out the presence of cholelithiasis. A small echogenic foci is seen in the posterior aspect of the GB fundus. How can you determine if this foci represents a polyp or a stone?

Back 24

- Shadowing is not present with polyps but is present with stones.

Front 25

What is the sonographic appearance of the lumen effective sludge w/in the GB?

Back 25

- An avscular mass with low-level echoes

Front 26

You are scanning a 34-yr-old multiparous women with symptoms of severe Rt. Upper quadrant pain, nausea, and vomiting. The GB is thick-walked w/ stones and an adjacent complex fluid collection is seen. This findings most likely represent:

Back 26

-Acute cholecystitis complicated by GB perforation

Front 27

You are scanning a 44-yr-old man with diabetes. He complains of severe epigastric pain radiating to the back, vomiting, chills and fever. U/s findings include a large GB w/ non dependent hyperechoic foci associated w/ ringdown artifacts. These findings are most consistent with:

Back 27

- Emphysematous cholecystitis

Front 28

Hypervascularity associated w/ acute cholecystitis is best evaluated w/ Doppler interrogation of what artery below?

Back 28

- Cystic artery

Front 29

Which of the following is NOT a sign of acalculous cholecystitis?

Back 29

- cholelithiasis

Front 30

You are scanning a GB and notice posterior acoustic shadowing. You are unsure if the shadowing is due to bowel gas or gallstones. Which of the following would be helpful in making this distinction?

Back 30

- Roll the patient into a left lateral decubitus position

Front 31

You are imaging the GB in a TRV orientation and notice a long shadow at both edges. What is the etiology of this shadow?

Back 31

- Refraction artifact

Front 32

An u/s image obtained from the GB shows an irregular mass within the lumen which demonstrates hypervascularity by color Doppler imaging. Multiple stones are also seen within the GB lumen. These findings are most consistent with:

Back 32

- GB carcinoma

Front 33

Rokitansky-Aschoff sinuses are associated with which of the following conditions?

Back 33

- Adenomyomatosis

Front 34

The best way to identify the intrahepatic biliary system is to image which structures below?

Back 34

- The intrahepatic biliary system cannot be detected sonographically

Front 35

A patient is referred for a follow-up abdominal sonogram. The previous u/s report indicates that pneumobilia was present. What is pneumobilia?

Back 35

- Air in the bile ducts

Front 36

You suspect intrahepatic bile duct dilatation in a patient with right upper quadrant pain and tenderness. How can you differentiate the dilated ducts from intrahepatic veins?

Back 36

- Dilated bile ducts demonstrate irregular, tortuous walls

- Bile ducts will not demonstrate flow with color Doppler

-A and C only

Front 37

What forms the common bile duct?

Back 37

- Junction of the cystic duct and common hepatic duct

Front 38

During u/s evaluation of the GB system, you notice thickening of the bile duct walls. This finding may be related to which of the following?

Back 38

- Sclerosing cholangitis

- Pancreatitis

- Choledocholithiasis

- Cholangiocarcinoma

-All of the above

Front 39

In this image of the GB, the arrows are pointing to:

Back 39

- Junctional folds

Front 40

You have been asked to perform an u/s to evaluate for biliary obstruction in a patient with a history of weight loss and midepigastric pain. You find both intrahepatic and extrahepatic biliary dilation. The GB is hydropic. Which of the following conditions causing ductal dilation should you look for?

Back 40

- Choledocholithiasis

- Pancreatic carcinoma

- Chronic pancreatitis with stricture formation

- All of the above

Front 41

Cystic dilation of the common bile duct is:

Back 41

- Choledochal cyst

Front 42

A 51-yr-old male is referred for abdominal u/s with abdominal liver function tests and jaundice. Which lab work would aid in differentiation of an intrahepatic versus extra hepatic cause of jaundice?

Back 42

- Serum bilirubin

Front 43

You are scanning at the area of the port hepatic in a patient with alcoholic liver cirrhosis. Two large tubular structures are identified. How can you identify which structure is the duct and which is the hepatic artery?

Back 43

- Doppler signals can be elicited from the artery but not the bile duct.

Front 44

A patient presents for abdominal u/s with a history of jaundice, weight loss, and nausea. You detect dilation of the CBD at the level of the port hepatis but are unable to see the distal CBD due to overlying bowel gas. Which of the following would be most helpful in improving visualization of the CBD?

Back 44

- Roll the patient into a right posterior oblique position

Front 45

The most common anatomic variant of the GB is:

Back 45

- GB folds

Front 46

What is the most accurate test for acute cholecystitis?

Back 46

- Cholescintigraphy

Front 47

You are scanning a patient with a Porcelain GB. You must carefully evaluate the GB b/c these patients are at increase risk for:

Back 47

- GB carcinoma

Front 48

A patient is referred for GB u/s with a history of Rt. upper quadrant pain and nausea. You suspect the presence of a stone in the region of the GB nk, but are not sure. Which of the following would be helpful in confirming the presence of a stone?

Back 48

- Roll the patient into a Lt.: lateral decubitus pposition

Front 49

You have been asked to administer cholecystokinin to a patient. Which of the following do you expect to occur if the study is normal?

Back 49

- The GB will contract

Front 50

You are attempting to locate the common hepatic duct at the port hepatis. What is the most common anatomic relationship of the portal triad at the location?

Back 50

- The common duct is anterior to the hepatic artery and portal vein

Front 51

A patient is referred for u/s with jaundice, pain, nausea and vomiting and a history of cholecystectomy. Which of the following findings is most likely?

Back 51

- Choledocholithiasis

Front 52

You have detected a stone impacted in the distal CBD in a patient with jaundice and abdominal pain. You will tailor your exam to evaluate what complication of this condition?

Back 52

- Pancreatitis

Front 53

You are requested to perform an u.s evaluation of the GB and biliary tree on an elderly female with a small frame. Which of the following transducers is most suited to this task?

Back 53

- 5.0 MHz phased array

Front 54

A patientis referred for a abdominal u/s. You notice a yellow discoloration of the eyes and skin. This condition is called:

Back 54

- Jaundice

Front 55

You are asked to perform an u/s study on a patient with suspected cholangiocarcinoma. What associated findings should you look for?

Back 55

- Dilatation of the biliary tree

Front 56

What is the etiology of the low-level echoes seen in the near field of this GB?

Back 56

-Reverberation artifact

Front 57

What is the etiology of the layered echoes seen in the posterior aspect of this GB?

Back 57

- Biliary sludge

Front 58

You are scanning a patient in the ER with severe nausea and abdominal pain. When you press with the transducer over the GB, the patient has increased pain. What did you do?

Back 58

- Elicited Homan's sign

Front 59

You are scanning a patient with sickle cell anemia and note the presence of gallstones and GB wall thickening. What else should you do to determine if acute cholecystitis is present?

Back 59

- Press with the u/s probe over the GB to determine if it is painful.

- Look carefully to see if a gallstone is lodge in the GB nk.

- Check for presence of pericholecystic fluid.

- All of the above

Front 60

What is the purpose of obtaining images in the Lt. lateral decubitus position during ultrasonography of the GB?

Back 60

- Evaluate mobility of gallstones

Front 61

You are scanning a patient with symptoms of cholelithiasis. Although you cannot clearly identify a GB, you detect a bright band echoes with posterior shadowing in the Rt. upper quadrant. How can you determine if this represents a contracted GB filled with stones?

Back 61

- Connection of the shadowing echoes to the interlobar fissure confirms identification of the Gb

- The wall-echo-shadow (WES) sign confirms identification of the GB

- "Dirty" shadowing from bowel gas can be differentiated from "clear" shadowing from stones by the presence of ringdown artifact in the bowel gas shadow

- All of the above

Front 62

A tumor that may be located in an intrahepatic or extrahepatic bile duct is known as:

Back 62

- Cholangiocarcinoma

Front 63

U/s images you obtained on an 81-yr-old man with acute Rt. upper quadrant pain show gallstones and bright echoes in the GB wall with ringdown artifacts. Which of the following inmost likely?

Back 63

- Emphysematous Cholecystitis

Front 64

You are scanning a 44-yr-old man with diabetes. He complains of severe epigastric pain radiating to the back, vomiting, chills and fever. U/s findings include a large GB w/ non dependent hyperechoic foci associated w/ ringdown artifacts. These findings are most consistent with:

Back 64

- Emphysematous cholecystitis

Front 65

Hypervascularity associated w/ acute cholecystitis is best evaluated w/ Doppler interrogation of what artery below?

Back 65

- Cystic artery

Front 66

Which of the following is NOT a sign of acalculous cholecystitis?

Back 66

- cholelithiasis

Front 67

You are scanning a GB and notice posterior acoustic shadowing. You are unsure if the shadowing is due to bowel gas or gallstones. Which of the following would be helpful in making this distinction?

Back 67

- Roll the patient into a left lateral decubitus position

Front 68

You are imaging the GB in a TRV orientation and notice a long shadow at both edges. What is the etiology of this shadow?

Back 68

- Refraction artifact