ARDMS Abdomen Sonography Examination AB-Abdomen Exam Questions

Answer : C

Patients with liver disease often have coagulopathy due to impaired synthesis of clotting factors. This places them at greater risk for bleeding or hematoma formation after biopsy. While hypertension may increase bleeding risk slightly, liver disease presents a significantly higher risk due to impaired coagulation.

According to the Society of Interventional Radiology (SIR) guidelines:

''Liver dysfunction is a significant risk factor for post-biopsy hemorrhage due to associated coagulopathy.''

SIR Consensus Guidelines for Coagulation Parameters in Image-Guided Procedures, 2019.

American Association for the Study of Liver Diseases (AASLD), Practice Guidance, 2021.

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Answer : C

The ultrasound image demonstrates a dilated common bile duct (CBD), measuring approximately 7.7 mm in diameter. A normal CBD should generally measure less than 6 mm in a patient under 60 years old and may increase approximately 1 mm per decade thereafter or after cholecystectomy.

In the absence of gallstones within the CBD, one of the most concerning causes of CBD dilation is distal obstruction due to an extrinsic compressive lesion. The most common and clinically significant cause of distal CBD obstruction is a mass at the head of the pancreas.

A pancreatic head mass (e.g., adenocarcinoma) may compress the distal CBD and pancreatic duct simultaneously, resulting in the ''double duct sign'' --- dilation of both the CBD and pancreatic duct. This is a classic finding in pancreatic cancer.

Comparison of answer choices:

Liver mass --- unlikely to cause isolated CBD dilation unless invading the porta hepatis.

Cystic duct stone --- may cause gallbladder hydrops but typically not CBD dilation unless Mirizzi syndrome is present.

Pancreatic head mass --- Correct. This is the most likely cause of painless progressive CBD dilation without visible intraductal stones.

Gallbladder stones --- These may be associated with biliary colic or cholecystitis but typically do not cause CBD dilation unless the stone has migrated and obstructed the distal duct.

Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound, 5th ed. Elsevier; 2017.

Lee JK, Sagel SS, Stanley RJ. Computed Body Tomography with MRI Correlation, 4th ed. Lippincott Williams & Wilkins; 2006.

ACR Appropriateness Criteria Right Upper Quadrant Pain (2021).

Answer : C

Courvoisier sign describes the clinical finding of painless jaundice combined with a palpable, distended gallbladder. This typically results from obstruction at the distal common bile duct, often due to pancreatic head carcinoma or cholangiocarcinoma, leading to bile accumulation and gallbladder distention. In contrast, Mirizzi syndrome involves compression of the common hepatic duct by an impacted stone in the cystic duct.

According to Rumack's Diagnostic Ultrasound and standard clinical references:

''Courvoisier sign refers to a palpable, enlarged gallbladder due to obstruction of the distal bile duct, often from malignancy.''

Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th ed. Elsevier, 2017.

Moore KL. Clinically Oriented Anatomy. 8th ed. Wolters Kluwer, 2018.

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Answer : B

Wooden foreign bodies are often difficult to detect on CT because of their low radiodensity, but they are highly echogenic with posterior shadowing or reverberation on ultrasound, making ultrasound superior for detecting retained wooden objects. Glass, metal, and stones are better visualized with CT due to their high radiodensity.

According to AIUM and musculoskeletal ultrasound literature:

''Wood is poorly visualized on CT but demonstrates high reflectivity and acoustic shadowing on ultrasound.''

Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Springer, 2007.

AIUM Practice Parameter for Musculoskeletal Ultrasound, 2020.

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Answer : B

The spleen is suspended in the left upper quadrant by several peritoneal ligaments, including:

Lienorenal (splenorenal) ligament --- attaches spleen to the left kidney.

Gastrosplenic ligament --- attaches spleen to the stomach.

Phrenocolic ligament --- supports the spleen inferiorly between diaphragm and colon.

These ligaments stabilize the spleen's position while allowing some mobility.

According to Moore's Clinically Oriented Anatomy:

''The spleen is connected to the stomach by the gastrosplenic ligament and to the posterior abdominal wall (near the left kidney) by the splenorenal (lienorenal) ligament. The phrenocolic ligament provides inferior support.''

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 8th ed. Wolters Kluwer, 2018.

Gray's Anatomy for Students, 4th ed., Elsevier, 2019.

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Answer : B

The ultrasound image demonstrates diffuse increased echogenicity of the liver parenchyma with posterior beam attenuation (acoustic shadowing), findings that are consistent with hepatic steatosis (fatty liver disease). The liver appears brighter than normal, and the vascular markings, particularly of the portal veins, are obscured due to the increased parenchymal echogenicity.

Hepatic steatosis refers to the abnormal accumulation of fat within hepatocytes and is commonly associated with obesity, diabetes, alcohol use, and metabolic syndrome.

Classic sonographic features of hepatic steatosis include:

Diffuse hyperechogenicity (''bright liver'')

Poor visualization of intrahepatic vessels and diaphragm

Posterior acoustic attenuation

Increased hepatic echogenicity relative to the renal cortex

Differentiation from other options:

A . Acute hepatitis: Usually presents with normal or slightly decreased echogenicity, 'starry sky' appearance due to prominent portal triads and periportal edema.

C . Medullary sponge kidney: A renal condition with echogenic medullary pyramids, not hepatic.

Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th Edition. Elsevier, 2018. Chapter: Liver, pp. 93--97.

American College of Radiology (ACR) Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum, 2021.

Radiopaedia.org. Fatty liver (ultrasound): https://radiopaedia.org/articles/fatty-liver-ultrasound

Answer : D

Adrenal adenomas are the most common adrenal tumors in adults. They are often discovered incidentally (adrenal incidentalomas) and are usually nonfunctioning, though some may secrete cortisol or aldosterone. Neuroblastoma is common in children, pheochromocytomas are rarer catecholamine-producing tumors, and adrenal cortical carcinoma is malignant but much less common than adenomas.

According to Rumack's Diagnostic Ultrasound:

''Adrenal adenomas are the most common adrenal masses in adults, frequently identified incidentally on imaging studies.''

Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound. 5th ed. Elsevier, 2017.

ACR Incidental Findings Committee Guidelines for Adrenal Masses, 2017.

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