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294 Cards in this Set
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Portal vein |
Low velocity continous flow toward liver with mild undulation |
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Portal triad |
Mpv Common hepatic duct Hepatic proper artery |
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Hepatic blood flow |
25% proper hepatic artery 75% portal vein |
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Hepatic o2 |
50% portal vein 50% proper hepatic artery |
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Portal vein diameter |
13 mm |
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Hepatic veins |
Hepatofugal-toward IVC Triphasic -above and below the baseline Above -atrial contraction blood goes back to the liver |
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Hepatic proper artery runs |
Parallell to the main portal vein |
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Proper hepatic artery gives |
Rt and lt hepatic arteries 55% of time |
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Sometimes the rt hepatic artery may come from |
SMA (Seen posterior to mpv and panc head) |
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Sometimes the lt hepatic artery may originate from |
Lt gastric artery |
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Hepatic artery waveform |
Low resistance |
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High resistance hepatic artery means |
Organ rejection |
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Tardus parvus hepatic artery |
Proximal stenosis |
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Ligamentum teres |
Remnant of umbilical vein extending from umbilicus to lt portal vein |
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Falciform ligament |
Peritoneal fold from passage of umbilical vein from umbilicus to lt portal vein |
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Hepatomegaly |
Greater than 15.5 cm |
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If labs are normal |
You do not have hepatomegaly |
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Echogenicity from hyper to hypo |
Renal sinus Pancreas Spleen/liver Renal cortex |
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Sonolucent |
Anechoic |
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Granulomas |
Calcification in spleen/liver |
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Cause of granulomas |
Histoplasmosis Tuberculosis |
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Hepatitis may result in |
Elevated ALT,AST, bilirubin |
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Hep A |
Fecal oral route |
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Hep b and c |
Blood/body fluids |
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Acute hepatitis |
Hypoechoic Enlarged liver Hyperechoic portal vein walls |
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Chronic hepatitis |
Hyperechoic liver Small liver |
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Most comon cause of liver pyogenic abscess |
Biliary tract disease |
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What lobe is affected more from pyogenic abcesses |
Rt lobe |
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Sono findings of pyogenic abcess |
Complex mass Gas Reverb artifact |
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Clinical findings of abscess |
Pain, fever , leukocytosis |
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3 types of liver abcess |
Pyogenic-most common Amebic Fungal |
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Pyogenic vs amebic |
If pt has traveled outside of US Choose amebic |
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Fungal abscess |
Candidiasis Can have different appearances based on time Wheel within a wheel-early most recognizable Bulls eye hypo or hyper with calc |
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Treatment for echinocholal cysts |
Leave it alone and monitor Rupture or aspiration is associated with anaphylaxis shock |
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Echinochocal cysts |
Hydatid disease |
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Echinochocal cysts |
Hydatid disease |
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Schistosomiasis |
Most common parasitic infections in humans |
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Schistosomiasis causes |
Periportal fibrosis resulting in portal hypertension |
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Schistosomiasis us |
Occluded intrahepatic portal veins Thick portal vein walls Signs of portal hypertension |
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Major cause of portal hypertension |
Schistosomiasis |
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Most common cause of cirrhosis in western world |
Hep c |
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Focal sparing |
Happen next to GB-do not measure |
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Focal fatty infiltration |
Happens at porta hepatis-hyperechoic areas |
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Glycogen storage disease |
Accumulation of glycogen in liver |
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GSD is associated with |
Fatty infiltration Adenomas Von gierkes disease |
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Cirrhosis |
Diffuse process of fibrosis and distorted normal liver architecture |
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Causes of cirrhosis |
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Cirrhosis lab values |
Increased AST ALT GGT LDH conjugated bilirubin |
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Cirrhosis US |
Hepatomegaly acute Liver atrophy-chronic Caudate enlargment Surface nodularity Fatty infiltration Portal hypertension risk of HCC |
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If pt has cirrhosis/hep c |
Check liver well for HCC |
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Normal pressure in portal vein |
5-10mmHg-higher than IVC |
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Most common cause of portal hypertension |
Cirrhosis |
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Portal hypertension is |
Asymptomatic |
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Portal hypertension presentation clinically |
GI hemorrage Spit blood or rectal bleeding |
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Secondary us sign of portal hypertension |
Splenomegaly ascites Collaterals |
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Correction of portal hypertension |
TIPS portocaval shunts Linton shunts Warren shunts |
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Linton shunt |
Splenorenal -normal to se hepatofugal |
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Warren shunt |
Distal splenorenal shunt |
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Portal systemic varices |
GE varices Umbilical vein Splenorenal Intestinal Rectal varices |
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Physical signs of collaterals |
Caput medusa Hemorroids Ascites |
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TIPS |
Trans jugular intrahepatic portosystemic shunt |
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TIPS |
Between a hepatic vein and a portal vein usually the rt |
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With TIPS |
RPV and LPV should demonstrate hepatofugal flow MPV hepatopedal? |
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TIPS MALFUNTION |
Low shunt velocity High focal shunt velocity Absent shunt flow Hepatofugal MPV Hepatopedal RPV/LPV |
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Exception to the rule is when there is a recanalized umbilical vein |
Flow in LPV can either be hepatofugal or hepatopedal-rely only in RPV |
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Material used for TIPS |
PTFE -cant evaluate in the first 3-5 days (shadows) |
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Most common indication for adult liver transplant |
Cirrhosis |
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Most common indication for liver transplant in kids |
Biliary atresia |
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Postoperatively the hepatic artery |
Provides the only blood supply to the biliary tree Stenosis will cause biliary tree complications |
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Cavernous transformation |
Worm like venous collaterals that parallel the chronically thrombosed portal vein Typically seen with benign causes of portal vein thrombosis |
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Most common benign cause of portal vein thrombosis |
Cirrhosis/hepatitis |
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Causes of portal vein thrombosis |
Cancer-liver,mets,pancreas Hypercoagulation Splenectomy Pancreatitis Trauma Cirrhosis |
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Portal vein thrombosis us |
Thrombus in pv Dilated pv Cavernous transformation Collaterals |
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Portal vein gas is |
A medical emergency |
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Hemorragic liver cysts |
Ruq pain Decreasing hematocrit |
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Most common benign tumor of the liver |
Cavernous hemangiomas |
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Cavernous hemangiomas |
Usually hyperechoic (hypo if fatty liver) Posterior enhancement Color doppler does not usually show flow May enlarge with estrogen |
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Hemangiomas |
Multiple vessels |
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Focal nodular hyperplasia |
Localized overgrowth of hepatocytes |
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FNH |
Stealth lessions Produces mass effect by displacing intrahepatic vessels |
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Hepatic adenomas associated with |
Pills GSD |
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Hepatic adenomas must be resected |
Due to their risk of malignant transformation |
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Hepatic lipoma show |
Speed artifact |
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Sound speed in tissue |
1540 |
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Sound speed in fat |
1450m/s Objects posterior to a fatty mass will be seen more posterior-slow return time |
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HCC |
Most common primary malignancy of liver |
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HCC |
Single mass or diffuse growth thats hard to see |
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HCC lab values |
Increased AFP AST ALT |
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Hepatoblastoma |
Malignant kids |
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Hepatoblastoma usually |
Before 2 y/old |
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Infantile hemangioendothelioma |
Benign tumor in neonatals May undergo regression |
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Hepatoma |
HCC |
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When is AFP elevated |
HCC/HEPATOMA LIVER METS HEPATOBLASTOMA germ cell tumors-testis and ovaries |
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IRN |
Calculated from PT |
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Normal IRN in absence of blood thinners |
0.8-1.2 |
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PT normal range |
12-13 seconds |
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Gallblader is located at |
Inferior end of main lobar fissure |
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Porta hepatis |
Proper hepatic artery Main portal vein Common hepatic duct |
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Cystic artery comes off from |
Rt hepatic artery |
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Valves of Heister |
Spiral fold in prox cystic duct |
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Hartman pouch |
Diverticulum of the neck |
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Phrygian cap |
Fold between body and fundus |
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Junctional fold |
Between neck and body |
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Cbd passes |
Posterior to first part of duodenum and pancreatic head to join the panc duct at ampulla of vater |
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Most common cause of gb wall thickening |
Cholecystitis |
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We cannot eval cholecystitis in presence of |
Ascites |
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Causes of GB wall thickening |
Cholecystitis Ascites Congestive Heart failure Pancreatitis Hepatitis Hypoalbuminemia
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Causes of jaundice |
Pre hepatic Hepatic Post hepatic |
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Pre heaptic jaundice |
To much hemolysis Excessive RBC break down -to much bilirubin to be processed by liver unconjugated hyperbilirubinemia |
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Hepatic jaundice |
Liver disease that impedes liver to conjugate bilirubin |
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Post hepatic jaundice |
Obstruction of biliary tree Causing conjugated bilirubinemia |
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Conjugated hyperbilirubinemia or biliary obstruction |
Pale stool Dark urine |
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Biliary obstruction |
Choledocholethiasis Mirizzi syndrome Choledocal cysts Caroli disease Biliary atresia Cholangitis Pancreatic cancer GB cancer |
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Sludge |
Echogenic material Nonshadowing Layers Shifts with change in position |
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Sludge is |
Calcium +cholesterol |
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Sludge causes |
Bile stasis TPN or fasting Hemolysis Cholecytitis Cystic duct obstruction |
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Tumefactive sludge |
Thick sludge that may mimic a GB mass |
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Cholelithiasis |
Mobile Shadowing Strongly echogenic |
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Gallstones are composed of |
Cholesterol Calcium |
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Cystic duct obstruction may result in |
Acute cholecystitis Empyema GB perforation Abcess Bile peritonitis |
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GB filled with stones |
WES sign-wall echo shadow |
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Murphy sign |
Acute cholecystitis |
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Acute cholecystitis |
GB inflamation due to a stone in cystic duct |
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Acute cholecystitis clinical signs |
RUQ pain/murphy sign Fever Leukocytosis |
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Acute cholecystitis US |
Gallstones Sludge Wall thickening-diffuse Gb dilatation Pericholecystic fluid |
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Acute cholecystitis |
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Chronic cholecystitis |
Does not look different from acute Clinicak diagnosis if its repetitive |
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Emphysematous cholecystitis |
Acute cholecystitis due to wall ischemia and infection |
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Emphysematous cholecystitis |
Common in diabetic pt-narrow of cystic artery |
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Emphysematous cholecystitis |
High perforation rate-emergency |
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Emphysematous cholecystitis |
Gas in gb wall/lumen/biliary tree Ring down artifact Dirty shadow Champagne sign |
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Emphyema of GB |
Acute cholecystitis (cystic duct obstruction) in presence of bile with bacteria Pus in gb |
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GB perforation |
Rare If u dont see the GB Fluid in fossa |
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Acalculous cholecystitis |
Usually in hospitalized pt after surgery |
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Milk of calcium bile |
Sludge with a high concentration of of calcium |
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Milk of calcium bile |
Limy bile Shadows |
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Porcelain GB |
Calcifications of GB wall associated with chronic cholecystitis |
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Porcelain GB |
Assoc with cancer |
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Hydrops |
Impacted stone in neck/cystic duct |
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GB polyps are cancerous if |
More than 10 mm in diameter |
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Cholesterolosis |
lipids deposit in GB wall |
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Cholesterolosis |
Strawberry GB |
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Cholesterolosis |
Silent Or colicky abd pain |
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GB carcinoma |
Less than 50% are discovered before surgery;most post surgery |
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Adenomyomatosis |
Hyperplastic changes of gb wall Thickening and diverticula |
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Adenomyomatosis |
Diverticula in gb wall accumulate stones/sludge within them giving comet tail artifact |
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Biliary obstruction causes |
Gallstones Pancreatic head cancer |
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Biliary obstruction is considered clinically |
When pt presents with jaunice |
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Lab values for biliary obstruction |
Elevated ALP CONJUGATED BILIRUBIN GGT |
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When distal CBD is obstructed |
Extrahepatic and intrahepatic ducts dilate too |
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CBD commonly measured |
When the rt hepatic artery courses between common hepatic duct and the MPV |
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Dilated CBD |
More or equal to 8mm |
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CBD Upper limit in eldery pt |
10 mm |
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Rate of increase of CBD |
One mm per decade |
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Post cholecystectomy CBD upper limit |
10 mm |
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Shotgun sign/paralel chanel sign |
Dilated intrahepatic ducts |
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Causes of intrahepatic ducts only |
Cholangiocarcinoma Caroli disease Pyogenic cholangitis Intrahepatic choledocholithiasis |
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Cholecystokinin |
Causes GB contraction |
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Administer a fatty meal with +results |
Duct increase in size (they should decrease because they will release the bile) |
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Administer fatty meal -results |
Unchanged or decrease in size -happens normally |
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The part of biliary tree that dilates depend on |
Level of obstruction |
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Distal CBD obstruction |
Every thing dilates including GB |
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Common hepatic duct obstruction |
Common hepatic duct dilated intrahepatic ducts dilated GB will be contracted-no bile |
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Junction of rt and lt hepatic ducts obstruction |
Intrahepatic ducts dilatation GB contracted |
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Choledocholithiasis |
Most common cause of extrahepatic obstructive jaundice |
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Choledocholithiasis |
Jaundice RUQ pain |
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Lab for choledocholithiasis |
Elevated ALP GGT conjugated bilirubin |
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Mirizzi syndrome |
Stone in cystic duct Causes compression of common hepatic duct |
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Mirizzi syndrome US |
Intrahepatic ducts dilated Stone in cystic duct Compressed CHD |
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Cholangiocarcinoma |
Bile duct cancer |
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Precursor of cholangiocarcinoma |
Primary sclerosing cholangitis |
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Most common finding of cholangiocarcinoma |
Intrahepatic ducts dilatation |
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Cholangiocarcinoma |
Originate in extrahepatic bile ducts (CHD/CBD) |
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Klatsin tumor |
Originates at junction of rt and lt hepatic duct Results in intrahepatic ducts dilatation only |
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Cholangitis |
Inflamation of biliary tree |
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Cholangitis |
Bile duct wall thickening |
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Charcot triad of cholangitis |
RUQ pain Fever Jaundice |
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Most common cause of cholangitis |
Choledocholithiasis |
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Other causes of cholangitis |
ERCP obstructive tumors( pancreatic,ampullary,cholangiocarcinoma) |
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Cholangitis may result in |
Cirrhosis Portal hypertension Sepsis |
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Biliary atresia |
Absence of extrahepatic ducts Have GB |
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Extrahepatic ducts |
CHD CBD |
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Biliary atresia is suspected when |
Jaundice (hyperbilirubinema) persists beyond 14 days of age |
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Biliary atresia US |
Triangular cord sign Anterior to portal vein |
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Biliary atresia associated with |
Polysplenia |
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Treatment for biliary atresia |
Kasai portoenterostomy (KPE) liver transplant also considered |
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Pneumobilia |
Air in biliary tree |
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Causes of pneumobilia |
ERCP-most common Emphysematous cholecystitis Surgery |
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Choledocal cyst |
Congenial Cystic dilatation of extrahepatic ducts CBD dilatation is most common |
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Choledochal cyst US |
2 cystic structures-Gb and dilated CBD Intrahepatic duct dilatation |
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Choledochal cyst |
Common in asia Before 10 symptoms |
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Caroli disease |
Similar to choledochal cyst Type 5 choledochal cysts |
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Caroli disease |
Affects intrahepatic bile ducts |
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Caroli disease |
Sludge and stones may accumulate in the dilated parts |
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Most common malignant neoplasm that cause biliary obstruction |
Pancreatic adenocarcinoma |
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Courvoisier GB |
Distended non diseased GB due to mechanical obstruction of CBD |
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Double duct sign |
Dilated CBD and pancreatic duct From adenocarcinoma Ca or stone in ampulla of vater |
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Primary sclerosing cholangitis |
Inflamation and fibrosis of intra and extrahepatic bile ducts
Like cirrosis |
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Primary sclerosing cholangitis assoc |
HCC cholangiocarcinoma Colorectal cancer Inflammatory bowel disease |
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Primary biliary cholangitis |
Same as cirrhosis- autoimmune |
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Hallmark for primary biliary cholangitis |
antimitochondrial antibodies |
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Bilirubin |
End product of hemoglobin break down ( spleen) |
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Bilirubin is conjugated by |
Liver |
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Bilirubin conjugation |
Liver removes albumin from bilirubin making it soluble |
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Conjugated bilirubin is |
Water soluble and can be filtered by kidneys if there is excess
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Bilirubin in urine means |
Conjugated hyperbilirubinemia (Bile flow obstruction) |
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ALP |
Alkaline phosphatase found in bile ducts-bone liver placenta Increases with every bile duct obstruction |
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Panc head is |
Anterior to IVC |
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Panc head is |
Medial to duodenum |
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CBD is |
Postero lateral to head of panc |
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GDA is |
Antero lateral to panc head |
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SMA SMV are |
Posterior to the neck of panc Anterior to uncinate procces |
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Panc tail is |
Ant and medial to splenic hilum |
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Duodenum has 4 portions |
1 and 3 trv 2 and 4 sag |
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Panc duct can be dilated from |
Stone in panc duct from chronic pancreatitis Stone in ampulla of vater |
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3 ducts drain in |
Second portion of duodenum |
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Cystic fibrosis |
Causes thick secretions |
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Cystic fibrosis |
Pancreatic issues meconium ileus-no first stool: too thick |
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Most common cause of hyperechoic pancreas in kids |
Cystic fibrosis |
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Pancreatic true cysts |
Are rare |
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Chronic pancreatitis |
Alcohol Cystic fibrosis Autoimmune Hereditary Trauma |
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Chronic pancreatitis US |
Small echogenic gland Dilated panc duct with calc Dilated bile duct Pseudocysts Portal vein thrombosis |
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Acute pancreatitis US |
Enlarged Hypoechoic gland |
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Acute pancreatitis directions |
Resolve Pseudocyst Chronic |
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Complications of acute pancreatitis |
Pseudocysts Thrombosis Hemorrage Abscess Pseudoaneyrism Panc necrosis |
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When dealing with pancreatitis check |
Vessels for thrombosis |
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Pancreatic phlegmon |
Focal pancreatitis Compl of acute pancreatitis |
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Most common cause of acute pancreatitis |
Gallstones Alcohol |
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Lipase |
Later longer |
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Amylase |
First to rise First to go down |
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Islet cell tumors |
Endocrine tumors |
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Islet cell tumor are associated with |
MEN VHL |
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Islet cell tumors |
Insulinoma Gastrinoma Glucagonoma Vipoma etc |
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Insulinomas |
Most common islet cell tumor |
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Insulinomas |
Usually benign |
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Insulinomas |
Hypogycemia Hyperinsulinemia |
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Gastrinomas |
Usually malignant |
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Gastrinomas |
2nd most common |
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Pancreatic islet cell tumor usually located |
Body/tail Except insulinomas/gastrinomas |
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MEN |
Inhereted endocrine disorder that affects Thyroid Parathyroid Pancreas islet cells Adrenals |
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MEN |
Multiple endocrine neoplasia |
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Pancreatic serous cystadenoma |
Benign Assoc with VHL May be echogenic mass if small cysts |
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Mucinous cystic neoplasms |
Most common cystic mass of pancreas Malignant -in body/tail Elevated CEA and CA 19 -9 |
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Pancreatic divisum results in |
Pancreatitis Smaller santorini duct drainig the pancreas -not enough |
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Most common cause of panc pseudocysts in kids is |
Trauma-check for bruises child abuse |
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Pancreas is located in |
Anterior pararenal space |
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Panc pseudocysts contain |
Amylase lipase trypsin |
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Pseudocyst are more common in |
Lesser sac Tail |
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Pancreatic adenocarcinoma labs |
Lipase Amylase GGT alkaline phosphatase Conjugated bilirubin |
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Adrenal gland is |
Superomedial to kidney |
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Liver is superolateral to |
Rt kidney |
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Spleen is |
Superior to lt kidney |
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Pancreatic tail is anterior to |
Lt kidney upper pole |
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Diaphragm is |
Posterior to kidneys |
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Psoas/quadratus lumborus muscle are |
Posterior to kidneys |
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Order at the hilum of kidney |
Vein-ant Artery Ureter -post |
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Renal cortex |
Normal 1 or more than 1 cm |
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Renal artery |
Main renal artery Segmental Interlobar Arcuate Interlobular |
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Renal artery that runs parallel to renal capsule |
Arcuate artery |
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Horshoe kidneys are found lower in abdomen because |
IMA prevents them from ascending |
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Most common fusion anomaly |
Horseshoe kidney |
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In cross fused kidneys |
One ureter crosses the midline to implant into the right position in bladder |
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Dromedary hump |
Chortical thickening in lt kidney lateral aspect |
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Junctional parenchymal defect |
Upper pole of rt kidney |
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Duplex kidney |
Duplication of collecting system Complete Incomplete |
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Complete duplex kidney |
2 ureters |
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Incomplete duplex kidney |
One ureter |
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Complete duplex kidney results in |
Hydroureter Hydronephrosis of upper pole |
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Abcess vs hemorragic cyst |
Presence of air in abscess Aspiration if no air present |
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ADPKD |
Multiple renal cysts (20-30y/o) |
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ADPKD associated with |
Cysts in other organs Arterial aneurysms-berry |
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ARPKD |
echogenic enlarged kidneys |
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Most common cause of abdominal mass in newborn |
Multicustic dysplastic kindeys |
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MDK |
Usually unilateral The other kidney works harder Multiple cysts |
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Nephrocalcinosis |
Calcium salt depostits in renal parenchyma |
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Most common cause of nephrocalcinosis |
Primary hyperparathyroidism |
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Papillary necrosis |
Necrosis of papilla and renal pyramids |
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Tuberous sclerosis is asocc with |
Renal cysts Angiomyolypoma -bilateral |
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Von hippel lindau disease is assoc with |
Kidneys Adrenal Pancreas tumors/cysts |
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Most common presenting symptom of RCC |
Hematuria |
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RCC |
Adenocarcinoma Hypernephroma |
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Renal oncocytoma |
Usually benign |
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Most common childhood renal tumor |
Wilm (3 years) |
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Is associated with beckwith weidemann syndrome |
Wilms tumor |
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Most common renal tumor in neonates |
Mesoblastic nephroma Can be begnin and malignant |
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Acute pyelonephritis |
Bacterial invasion of renal parenchyma |
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Acute pyelonephritis |
Large hypoechoic kidneys with no sinus echos |
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Focal acute pyelonephritis |
Lobar nephronia Acute focal bacterial nephritis |
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Ephysemateous pyelonephritis |
Bacterial infection that causes renal ischemia-needs surgery to remove the kidney DM Reverb |
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Chronic pyelonephritis |
Small echogenic kidneys |
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Xgpn pyelonephritis |
Type of chronic pyelonephritis usually from staghorn calculi |
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Pyonephrosis |
Pus in dilated renal collecting system |
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Myectoma |
Fungal ball -candidasis |
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Myectoma vs angiomyolipoma |
If they have infection pick myectoma If tuberous sclerosis pick angiomyolipoma |
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