3/17/2015

Purpose of the Lecture

• Recount rational facts about various organs and systems so that the information may be easily recalled in an assessment Abdominal Sonography situation. Registry Review • Utilize the information from this lecture to appropriately respond to clinical situations.

Steven M. Penny, M.A., RT(R), RDMS • Recognize important sonographic terminology and definitions. Johnston Community College NCUS 2015 Annual Symposium • Help prepare for national certification.

Importance of clinical correlation… Importance of clinical correlation….

• In order to do perform well in clinical and on • Sonographic findings: examinations, the sonographer must be capable – Enlarged hypoechoic of correlating clinical history with sonographic – Peripancreatic fluid collection findings. • Diagnosis: • For example: – Acute – Clinical history includes: • 28 year old female • Sudden onset of back pain • Elevated amylase and lipase • Nausea and vomiting

Liver Review

1 3/17/2015

Fatty Fatty Liver

• Definition: a reversible disease characterized by • Causes: deposits of fat with in the liver cells. – Obesity • AKA – hepatic steatosis – Alcohol abuse • Clinical findings: – Chemotherapy – May be clinically silent – Diabetes – Can produce elevation in LFTs • Sonographic findings: – Diffusely echogenic liver – Difficult to penetrate – Difficult to visualize hepatic architecture, vasculature, and diaphragm. http://realfoodfamily.com/wp-content/uploads/2013/02/fatty-liver.gif

Focal Fatty Sparing Focal Fatty Infiltration

• Common Locations • Common locations: – Adjacent to the gallbladder – Same as focal fatty sparing – Adjacent to the porta hepatis – Can resemble a hyperchoic mass – Caudate lobe may be spared – Can resemble a hypoechoic mass

Cirrhosis Which of the following is typically not a potential cause of ? • Definition: hepatocyte death, fibrosis and necrosis of the liver, with the subsequent development of 1. Chronic regenerating nodules. 2. Alcoholism • Clinical findings: – 3. Cholangitis – Elevated LFTs 4. von Hippel-Lindau – disease – Fatigue – Weight loss – Initial (chronic stages produced shrunken right lobe / the caudate may be enlarged)

2 3/17/2015

Cirrhosis Which of the following is not a common sequela of cirrhosis? • Most common cause is alcoholism. 1. Hepatic candidiasis 2. Portal vein thombosis 3. Portal 4.

Sonographic Findings of Cirrhosis

• Shrunken right lobe (enlarged caudate) • Definition: elevation of blood pressure within the • Nodular surface irregularity portal venous system • Coarse echotexture • The most common cause is cirrhosis, though it • Splenomegaly can be caused by portal vein thrombosis or tumor compression of the portal vein. • Ascites • Normal flow toward the liver = hepatopedal or • Monophasic flow in the hepatic veins hepatopetal flow. • Hepatofugal flow in the portal veins • Reversed flow away from the liver in the portal vein = hepatofugal flow. • Portal hypertension can produce hepatofugal flow.

Portal Hypertension What structure should you investigate to demonstrate this finding? • As the liver becomes more r is resistant to flow, 1. Right hepatic vein there is a reopening or recanalization of the paraumbilical vein seen here…. 2. Main portal vein 3. Middle hepatic vein 4. Left portal vein

3 3/17/2015

Portal Hypertension The portal vein should not exceed:

• Leads to the development of abdominal varices: 1. 10 mm – Examples include esophageal varices and splenorenal varices. 2. 5 mm – Be sure to analyze the splenic 3. 13 mm hilum and GE junction. 4. 6.5 mm

Focal Solid Liver Lesions Cavernous Hemangioma • Key points: – Many of these can appear sonographically similarly, • Most common liver mass so you need to know specific keywords and clinical • Mostly asymptomatic findings to help differentiate the following tumor: • More common in women • Cavernous hemangioma • More common in right lobe • Hepatic adenoma • Focal nodular hyperplasia • Mostly hyperechoic • Abscesses – Hydatid – Pyogenic – Amebic – Candidiasis

Hemangiomas may result from the use Focal Nodular Hyperplasia of birth control pills. 1. True • Second most common liver tumor. • Mostly asymptomatic. 2. False • Called the stealth lesion. • Contains a central scar noted (possibly) on sonography, but typically better seen on CT or MRI.

4 3/17/2015

FNH may result from the use of birth Hepatic Adenoma control pills. 1. True • Typically asymptomatic. • Typically hypoechoic (but can vary). 2. False

Hepatic adenomas may result from the Summary…. use of birth control pills. • The hepatic adenoma does have a causal link 1. True with oral contraceptive use. 2. False • While the hemangioma and FNH are not caused by birth control pills, they may enlarge secondary to estrogen stimulation.

Liver Abscesses or Parasitic Hydatid Liver

• May present clinically similar: • Echinococcus granulosus – the parasite that – Elevated LFTs and WBC causes the cyst – Nausea & vomiting • Found most often in sheep and cattle-raising – countries: – Middle East • Here are some key words/information for each of – Australia these. – Mediterranean

• Hold on…………….

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5 3/17/2015

Hydatid Liver Cyst Pyogenic Abscess

• Sonographic findings: • Bacterial infection that spreads to the liver. – Water lily sign (cyst floating in a larger cyst) • Typically from predisposing bacterial conditions – Mother cyst containing a daughter cyst like cholecystitis, appendicitis, diverticulitis, or – Hydatid sand even endocarditis. • Complex appearing.

Amebic Abscess Hepatic Candidiasis

• Caused by a parasite. • Fungal infection (Candida albicans) • Typically found in contaminated water. • Immunocompromised: • Causes dysentery (bloody diarrhea, abdominal – Cancer patient pain, fever). – AIDS patient • Recent travel to another country: – Transplant patient – Mexico – Central or South America – India – Africa

Which of the following would most likely be seen (key points) in a patient following appendicitis? 1. Pyogenic abscess • Most common liver cancer is metastasis from: – Colon – tend to be target or bulls-eye lesions 2. Amebic abscess – Breast - hypoechoic 3. Hydatid cyst – - hypoechoic – Pancreas – hyperechoic 4. Candidiasis • Can also have cystic appearning mets

6 3/17/2015

Liver Cancer (key points) Which of the following can be used as a tumor marker for HCC? • Most common primary: 1. Lactate – Hepatocellular carcinoma dehydrogenase • Most commonly caused by cirrhosis • Mostly appears solid and hypoechoic 2. Serum • Patients have a history of weight loss 3. hCG • Patients will have elevated LFTs 4. Alpha-fetoprotein

One more important connection… Urinary Tract Review

• Hepatoblastomas – Pediatric liver carcinoma • Elevated AFP • Increased risk for kids who have Beckwith- Weidemann syndrome (growth disorder consisting of and enlargement of several organs)

What is the most common cause of Renal Fungal Disease fungal urinary tract infections? 1. Echinococcus • Typically found in immunocompromised patients: garnerosis – Also diabetics – Ill infants 2. Staphylococcus – Patients with long-standing indwelling catheters 3. Candida albicans • You may see fungal balls too! 4. Streptococcus

7 3/17/2015

What is the accumulation of calcium Nephrocalcinosis within the renal parenchyma? 1. Calcemic • Two types: renunculitis – Medullary nephrocalcinosis • Most commonly caused by medullary sponge 2. Nephrocalcinosis kidneys • Can be caused by hyperparathyroidism (which 3. Urolithiasis produces hypercalcemia) 4. ARPKD – Cortical nephrocalcinosis

Which renal mass is most likely Oncocytoma associated with a stellate central scar? 1. Hypernephroma • Benign renal tumor • Often found in men in their 60s 2. Renal adenoma • Difficult to differentiate sonographically from RCC 3. Angiomyolipoma 4. Oncocytoma

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Which of the following has a link with Angiomyolipomas ? 1. Angiomyolipomas • Tuberous sclerosis – Neurocutaneous lesion disorder that leads to the 2. Renal cell development of tumors in various organ systems carcinomas including the kidneys, skin, and brain • AMLs appear as echogenic tumors on the 3. Renal kidneys hemangiomas 4. Renal adenomas

8 3/17/2015

ADPKD

Renal Cystic Disease • ADPKD – autosomal dominant polycystic disease (Think adults are dominant!) – Characterize sonographically by multiple cysts of varying sizes on both kidneys. – In fact, to be diagnosed with ADPKD, the patient should have at least one cyst on both kidneys or two cysts on one kidney. – Associated with cysts in other organs, especially the liver and pancreas – May not manifest until the 4th decade of life. – Clinical symptoms include hypertension, palpable , and possibly impaired renal function

ARPKD MCDK

• ARKD – autosomal recessive polycystic kidney • MCDK – multicystic dysplastic kidney disease disease (infantile) – Caused by an early embryonic urinary tract – Dilation of the renal collecting tubules obstruction – Cyst may be too small to be differentiated with – No function renal tissue sonography – Sonographically appears as multiple cysts of varying – Kidneys appear ENLARGED and ECHOGENIC! sizes in the renal fossa (not consistent with life if bilateral)

Which of the following is associated Gallbladder and Biliary Review with comet tail artifact emanating from the gallbladder wall?

1. GB carcinoma 2. Adenomyomatosis 3. Chronic cholecystitis 4. Gallbladder polyps

9 3/17/2015

Which of the following would be Adenomyomatosis associated with the development of air within the gallbladder wall? • Adenomyomatosis – the accumulation of cholesterol crystals within the gallbladder wall – The crystals are located within pockets referred to as 1. Pyogenic Rokitansky-Aschoff sinuses. cholecystitis – These crystals produce comet tail artifact. 2. Gallbladder

carcinoma 3. Chronic cholecystitis 4. Emphysematous cholecystitis

Emphysematous Cholecystitis Emphysematous Cholecystitis

• Caused by bacterial invasion within the • Most commonly encountered in diabetic patients. gallbladder wall. • Patient may be asymptomatic. • The bacteria produce gas. • The gas produces ring down artifact.

Gallbladder enlargement is present Courvoisier Gallbladder when the gallbladder diameter exceeds: • Courvoisier gallbladder – an enlarged (hydropic) gallbladder caused by a mass in the head of the 1. 3mm pancreas 2. 5cm – The gallbladder is palpable on physical examination. – It is not tender to the touch nor will it illicit Murphy’s 3. 30mm sign. 4. 2.7cm

10 3/17/2015

What is an uncommon cause of jaundice, pain, What is the most likely diagnosis? and fever secondary to choledocholithiasis? 1. WES sign 1. Klatskin syndrome 2. Surgical clip 2. 3. Porcelain gallbladder 3. Mirizzi syndrome 4. Cholecystitis 4. Krukenburg tumor

Mirizzi Syndrome What is the location of a ? • Jaundice, pain, and fever secondary to stone 1. Between the RHD lodged in the cystic duct. and LHD • Difficult to diagnose sonographically. 2. Distal CBD near the pancreas 3. Proximal CBD 4. Cystic duct

One more thing….a few pediatric Klatskin Tumor pathologies to remember….

• Klatskin tumor is located at the junction the RHD • Caroli disease is characterized by segmental and LHD. dilation of the intrahepatic ducts • It is the most common form of . • – narrowing or complete • Patients present with jaundice, unexplained obliteration of the biliary ducts – leads to cirrhosis weight loss, , and pruritus. and portal hypertension • Pruritus is severe itchiness of the secondary to hepatic disease. • – cystic dilation of the common duct (most common) - there are several forms of choledochal cysts

11 3/17/2015

Pancreas Review Pancreatic Carcinoma

• Pancreatic adenocarcinoma – Most common form of pancreatic cancer. – Most common found in the head of the pancreas. – Most common appearance is solid and hypoechoic. – Can present with Courvoisier gallbladder. • Pancreatic cystadenocarcinoma – Most commonly located in the body and tail of the pancreas. – These patients present later because of the location of the mass. – Large, complex mass with cystic components.

What is the most common type of islet Adenocarcinoma vs. Cystadenocarcinoma cell tumor?

C 1. Gastrinoma 2. Granuloma 3. Insulinoma A 4. Adenomyoma

Adenocarcinoma comes before Cystadenocarcinoma.

One more thing….. Islet Cell Tumors Von Hippel-Lindau Disease

• Insulinoma • Characterized by the development of cysts within – Small, hypoechoic mass the pancreas and other organs. – Produces excess insulin (leads to hypoglycemia) • Patients are at • Gastrinoma increased risk for – Small, hypoechoic mass (may contain calcifications) developing RCC. – Zollinger-Ellison syndrome – the production of excessive gastric juices that leads to the development of a peptic ulcer

12 3/17/2015

What adrenal tumor is associated with Adrenal Review uncontrolled hypertension?

1. Adrenal hematoma 2. Pheochromocytoma 3. Neuroblastoma 4. Adrenal adenoma

Pheochromocytoma Cushing syndrome

• Benign adrenal tumor • Results from high levels of cortisol secretion by • Also associated with tachycardia, headaches, the adrenal cortex. tremors, anxiety, and excessive sweating. • Can be caused by an adrenal adenoma. • Tends to be a hyperechoic mass. • Clinical symptoms: – Obesity – Thinning arms and legs – Buffalo hump – Hyperglycemia – Fatigue

Conn syndrome What lab is used as a tumor marker for a yolk sac tumor in the testicle? • Results from high levels of aldosterone produces by the adrenal cortex. 1. LDH • Can be caused by an adrenal adenoma. 2. Alkaline • Clinical findings: phosphatase – Excessive thirst – Excessive urination 3. hCG – Hypernatremia (elevated sodium) 4. AFP – Hypokalemia (low potassium)

13 3/17/2015

Which of the following is the most Torsion vs. Epididymitis/Orchitis specific finding of an abnormal lymph node? • Two vastly different abnormalities can present clinically similar: 1. Size 2. Shape 3. Echogenic hilum 4. Color flow

What is the most common location of prostatic cancer?

Thanks for listening! 1. Verumontanum

2. Fibromuscular I hope you enjoy the rest of the symposium. stroma 3. Central zone

4. Peripheral zone Some images © 2010 Wolters Kluwer Health/ Lippincott Williams and Wilkins

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