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calcifiedlesions.Traumaticinjurymayresultinsingleorafewcalcifications.Sicklecellanemiaresults
inmultipleinfarctions,eventuallyleadingtoasmalldenselycalcifiedspleen.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:197.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:160.
18a. Answer B.The first image demonstrates retroperitoneal fluid adjacent to the right kidney. The
presence of perinephric fluid in the setting of epigastric pain raises the possibility of an acute
pancreatitis.Thesecondimageshowsanengorged,heterogeneouspancreaticheadanduncinateprocess
(P).Notetherelationshipsofthegallbladder(G),secondportionofduodenum(D),andpancreatichead
on theultrasoundandcorresponding contrast-enhancedCTatthesamelevel.Also,notethepresenceof
acuteperipancreaticcollectionsonbothsonographyandCT.
18b.AnswerD.Acarefulexamination ofthe gallbladderand bileducts forgallstonesis the focus of
most sonogramsperformed foracute pancreatitis. There are numerouscauses ofacutepancreatitis, but
80%ofallcasesareduetogallstonesandalcoholabuse.Allpatientswithacutepancreatitis,including
knownalcoholics,needtobeevaluatedforthepresenceofgallstonesorbiliaryductaldilatationbecause
cholecystectomy with removal of common duct stones will prevent the recurrence of gallstone
pancreatitis.
Ultrasoundevaluationofthepancreascanalsoplayanimportantroleindiagnosingunsuspectedacute
pancreatitisor toconfirmthe diagnosis. Themostcommonand least subjective sonographic findingis
extrapancreatic fluid and inflammatory change. Inflammation or fluid may be found within the
prepancreatic retroperitoneum, left and right anterior pararenal spaces, the perirenal spaces, and the
transverse mesocolonand is recognizedby its anechoic appearance. More subjective findings include
pancreaticenlargementanddecreasedorheterogeneousglandularechogenicity.
Assessmentforpancreaticnecrosis anddifferentiationbetweennecroticandnonnecroticcollections
are best accomplished using contrast-enhanced CT. However, ultrasound is often used to guide
aspirationsanddrainagesofpancreatitis-associatedcollections.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:192–198.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:227–236.
19. AnswerD. Thereare two cysticlesionswithin thespleen.The largerlesioncontainsscantlow-
level internal echoes but no internal color flow. The most common cause ofa splenic cyst is trauma.
Splenichematomasevolveandbecomeliquefiedseromassurroundedbyapseudocapsule.Thecystwall
maysometimescalcify.Truecystsarerareandarefelttobecongenital.Althoughanoldliquefiedsplenic
infarctmayalsowalloff,thisislesscommon.
Echinococcal cystsare usuallycaused by the tapeworm,Echinococcusgranulosus. Although most
commonlyinvolvingtheliver,otherorgansincludingthespleencanalsobeaffected.Echinococcalcysts
haveanexternalmembrane andan internalgerminallayer.Thehost formsafibrouscapsulearoundthe
cyst. Hydatidcysts canhave a variety ofsonographic morphologies. Theycanappearassimplecysts,
cystscontainingmultipledaughtercysts,orcystscontainingfloatingmembranesordebris.Theymayalso
haveinternalorperipheralcalcification.
Vascular lesions can mimic cystic splenic lesions as well. These include aneurysms,
pseudoaneurysms, varices, and vascular malformations. These are distinguished by the presence of
Dopplerflow.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:192–193.
20. Answer C. The causes of splenomegaly are varied and numerous, including hematologic,
rheumatologic, infectious, congestive, and infiltrative processes. The most common are infection,
lymphoproliferativedisorders,andcirrhosis.
Reversalofflowwithinthemainportalveinorextrahepaticportalveintributarysuchasthesplenic
vein is a specific sign of portal hypertension. As a result of portal hypertension, a spontaneous
splenorenal shunt may form. Portal venous blood is diverted in a retrograde manner into the
retropancreaticsegmentofthe splenicvein, through the shunt, andthenintotheleftrenalvein whereit
mixeswiththesystemicvenousblood.SplenicvaricesmayalsobedemonstratedonDopplerimaging.
Splenicechogenicityisnotareliablewaytodifferentiatethecausesofsplenomegaly.Thedegreeof
splenomegaly in general is not helpful to determine the cause of splenomegaly although massive
splenomegaly(>18cm)ismoreoftenduetohematologicdisorderssuchasthalassemiamajor;infections
due to leishmaniasis, malaria, and Mycobacterium avium-intracellulare complex; and infiltrative
disorderslikelymphomas,myeloproliferativeneoplasms,andGaucherdisease.
The presence of ascites is a nonspecific sign and can be associated with a number of processes
causingsplenomegaly.
References: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:152–154.
WachsbergRH,BahramipourP, SofocleousCT, etal.Hepatofugalflow in theportal venoussystem:pathophysiology,imagingfindings, and
diagnosticpitfalls.RadioGraphics2002;22(1):123–140.
21. AnswerA. The image shows onlya small amount ofascites and dilatedfluid-filled bowel. The
patient’sbloatingappearstobe relatedtodilatedbowelin additiontoascites.Identificationofdilated
bowel should trigger a search for a cause on ultrasound. A CT should be performed subsequently to
confirmthepresenceofa bowelobstructionandtoassessfora cause.Becauseofthesmallamountof
ascites and thepresenceof dilated bowel loops closely apposed to the abdominal wall, a therapeutic
paracentesisshouldnotbeperformedatthistime.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:296–299.
22. Answer A. The first image shows a normal size, shape, and echotexture of the spleen. Color
Doppler signal is demonstrated within the spleen. On the second image, obtained 2 weeks later, the
appearanceofthespleenhasbeenmarkedlyaltered.Marked coarseningoftheparenchymalechotexture
andnewcapsularirregularityandretractionareconsistentwitha globalsplenicinfarct.ColorDoppler
signalisnolongerdemonstrated.Thesplenicinfarctwasduetointervalsplenicarteryembolizationfora
pseudoaneurysm.
References: Goerg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications. Radiology
1990;174(3):803–807.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:198.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:163.
23.AnswerB.AsmallcysticlesionwithinthepancreaticneckcontainingnoDopplersignalisshown.
The differentialdiagnosis forunilocular cysticpancreaticlesionsincludespancreaticpseudocyst,sidebranchintraductalpapillarymucinousneoplasm(IPMN),andunilocularserouscystadenoma.Pancreatic
cysts canalso occur in association withvon Hippel-Lindau syndrome, autosomal-dominant polycystic
kidneydisease,andcysticfibrosis.Pancreaticpseudocystmaybesuggestedbyahistoryofpancreatitisor
if there are imaging findings of pancreatitis. IPMNs are most commonly found in older patients, and
communicationwiththemainpancreaticductisanimportantcomponentinmakingaconfidentdiagnosis.
Serouscystadenomasare typically multilocular microcysticlesionsbut mayuncommonlybe unilocular.
UnlikeIPMNs,theyshouldnotcommunicatewiththepancreaticduct.
Reference: Sahani DV,KambadakoneA,MacariM,etal.Diagnosisand management ofcystic pancreaticlesions.AJR AmJ Roentgenol
2013;200(2):343–354.
24.AnswerC.Paretochartisusedtovisuallydisplayarankorderingofquality,safety,orriskfactor
issuesbyimportanceorimpact.AParetochartisarrangedwiththehighestvalueatthetopandthelowest
valueatthebottomsothat themajorfactorscontributingtoaparticulareffectarevisuallydisplayed.It
contains both bars and a line graph. The bars represent individual values, andthe line represents the
cumulativetotal.Properorderingisa vital stepbecauseitguides the teamtoconcentrateits effortson
factors with the greatestimpact. TheParetoprinciple (PP) statesthat whenmultiplevariables affect a
situation,afewofthemareactuallyresponsibleformostoftheimpact.
Flowchartsaregraphicdiagramsormapsthatillustratethestepsanddecisionpointsthatmakeupa
work process. Theyrepresent a commonunderstanding of the process andenable the team to examine
individualstepsinordertoidentifyproblemsandimprovementopportunities.
ROC (receiveroperating characteristic) curvesareusedtoanalyze the performanceofa diagnostic
system.An ROCcurve isa plotoftest sensitivity (plottedonthey-axis) versus itsfalse-positive rate
(FPR)(or1−specificity)(plottedonthex-axis).Oneofthemostpopularmeasuresoftheaccuracyofa
diagnostictestistheareaundertheROCcurve.TheROCcurveareacantakeonvaluesbetween0.0and
1.0.Atest withan areaunder the ROCcurveof1.0is perfectly accuratebecausethesensitivity is 1.0
whentheFPRis0.0.Incontrast,atestwithanareaof0.0isperfectlyinaccurate.TheROCcurveisnot
affectedbytheprevalenceofdisease.
Controlchartsaimtoanalyzetheperformanceofaprocessinacommonlanguageandasafunctionof
time. By analyzing performance, a control chart is used to control, monitor, and enhance process
performanceovertimebyrecognizingchangesandtheirsources.Acontrolchartusessamplesofsuccess
asthenumeratorandtotalopportunitiesasthedenominator,andtheeventsaregraphedtoevaluatehowa
processchangesovertime. Alinecanbe usedtoillustratedeviationsofthedatafrom theaverage,and
upper and lower control limits can be used to represent the acceptable range. These lines can help
determinewhethertheprocesschangeovertimeisstable(consistent)orisunstable(unpredictable).This
helpsdeterminewhetherprocessvariationsareinoroutofcontrol.
Reference:TheAmericanBoardofRadiology.Quality&safetydomainspecification&resourceguide.
25.Answers
A.Superiormesentericartery
B.Leftrenalvein
C.Rightrenalartery
D.Celiacartery
E.Superiormesentericartery
F.Splenicvein
G.Pancreas
H.Distalesophagus
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:180.
26.Answers
A.Liver
B.Stomach
C.Portalconfluence
D.Splenicvein
E.Pancreas
F.Superiormesentericvein
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:179–180.
27. Answer C. The patient underwent renal ultrasound and was incidentally found to have a large
spleniclesion.Thelesionishomogeneousandhyperechoicwithoutevidenceofinternalvascularity.The
lesion most likely represents a splenic hemangioma. Although hemangiomas in the liver can have a
variableappearance,majorityofthoseinthespleenarehomogeneousandhyperechoic.Theyarethemost
commonbenignsplenictumors.Hamartomasandlymphangiomasarelesscommonthanhemangiomas.
Spleniclymphoma canbe unifocal or multifocaland isalmostalways hypoechoic. It isonlyrarely
hyperechoic.Splenicmetastasescanhaveavariableappearanceonultrasound.However,inmostcases,
splenicmetastasesarepresentwhen apatienthaswidespreadmetastaticdisease. It will bean unlikely
incidentalfindingsuchasinthiscase.Thesonographicappearance ofsplenichematomawillvarywith
the phase when it is detected. Regardless, hematoma will usually have a more complex appearance
comparedtothehemangiomashowninthiscase.Intheacutephase,itisusuallycomplexandhypoechoic.
Whenclotforms,itcanbecomeisoechoictothesplenicparenchyma.Inthechronicphase,withlysisand
liquefactionofclot,itwillbehypoechoictoanechoic.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:194–195.
28. Answer C. The CT shows a complex cystic lesion in the head of the pancreas. Endoscopic
ultrasoundshowsananechoiclesionwithlobulatedmarginsandseveralinternalseptationsthatconverge
radiallywithappearanceofacentralstellatescar.Thissonographicappearanceis suggestiveofserous
cystadenomaofthepancreas.
Serouscystadenomaofthepancreasisabenigncystictumorseenusuallyinmiddle-agedandelderly
women.Itismostoften presentin thepancreatichead.Itcontainsmultiple tinycysts (usually>6),each
smallerthan2cmin diameter.Ifthecystsareverysmall,thelesionmayappearsolidonUS.Acentral
scar may be present and may appear as a central solid hyperechoic structure sometimes with
calcifications.Pancreaticductaldilatationandparenchymalatrophyareusuallynotseen.Inmostcasesof
cysticpancreaticlesions,thecombinationoflesionmorphologyandanalysisoffineneedleaspiratecan
provideadefinitivediagnosis.Fluidaspiratefromserouscystadenomashowslowlevelsofamylase,low
carcinoembryonicantigen(CEA),andlowcarbohydrateantigen19-9(CA19-9)levels.
Pancreaticadenocarcinomasaresolid,hypoechoicinfiltrativelesionsthattypicallycausepancreatic
ductaldilatationandglandularatrophy.Mucinouscystictumorsoccur99.7%ofthetimeinwomen.They
are premalignant or malignant lesions.Comparedtoserouscystadenomas, theyoccuratanearlierage,
approximately around 50 years. They are most commonly located in the pancreatic body and tail.
Mucinouscystictumorsarecomposedofadominantcystandareencapsulated.Thecystsarelargerand
fewerintheselesions.Thefluidaspiratehaslowamylase,highCEA,and,whenmalignant,alsohighCA
19-9. Pancreatic pseudocysts are the most common cystic lesions of the pancreas. They develop as a
complicationofacuteorchronicpancreatitisorsecondarytopancreatictrauma.Pseudocystsaredefined
asfluidcollectionsthatbecomeencapsulatedandareseenmorethan4weeksaftertheonsetofsymptoms.
Theyareusuallylocatednearthepancreas,areanechoic,ormaycontainlow-levelinternalechoesfrom
debrisorhemorrhage.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:188–190.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:249.
ZamboniGA,AmbrosettiMC,D’OnofrioM,etal.Ultrasonographyofthepancreas.RadiolClinNorthAm2012;50(3):395–406.
3 UrinaryTractandAdrenalGlands
Questions
1.A26-year-oldfemalewithrenalfailureunderwentrenalultrasound.Whatisthemostcommoncause
ofthefindingshownintheimages?
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