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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана
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A.Reflection
B.Refraction
C.Absorption
D.Scattering
30.A26-year-oldfemalewithleftflankpainunderwentCTscanningusingrenalstoneprotocol,which
showedahypoattenuatingrighthepaticlobe mass. Arightupperquadrantultrasoundwasperformedfor
furtherevaluationofthemass.Whichoneofthefollowingfeaturesiscommonlyseeninthistypeofliver
lesion?
A.Posterioracousticshadowing
B.LackofcolorDopplerflow
C.Internalhemorrhage
D.Primarymalignancy
31. A 60-year-old male presents with abdominal pain and elevated liver enzymes. Which of the
followingwouldbethemostappropriatenextimagingtestforconfirmationofthefindingsshown?
A.Hepatobiliaryiminodiaceticacid(HIDA)scan
B.Magneticresonancecholangiopancreatography(MRCP)
C.PancreaticmassprotocolCT
D.Endoscopicultrasound(EUS)
AnswersandExplanations
1.AnswerA. The firstimageshows amarkedly thickenedandstriatedgallbladder wall. Thesecond
image shows a part of the liver parenchyma that appears normal. The gallbladder wall is considered
thickenedwhenitisover3mm.Diffusegallbladderwallthickeningoccursinthesettingofbothbiliary
andnonbiliaryprocesses.Biliaryetiologiesincludecholecystitis,gallbladdercancer,adenomyomatosis,
primarysclerosingcholangitis,andAIDScholangitis.Nonbiliarycausesduetoedemaincludehepatitis,
ascites,cirrhosis,portalhypertension,hypoproteinemia,andlymphaticobstruction.Theinitialevaluation
of gallbladder wall thickening should include a careful assessment for gallstones and a sonographic
Murphysigntoexcludeacutecholecystitis.
Thispatient overdosedon Tylenol.Gallbladderwall thickeningcanbetheonlysonographicsignof
acutehepatitis.Gallbladderwallthickeningishypothesizedtobeduetoaninflammatoryreaction,suchas
hyperemia, in the serosal and muscular layers adjacent to the liver in response to necrosis and
inflammationofthelivertissues.Hepatomegalyandperiportaledema (withrelativeechogenicityofthe
biliarytriads—“starrysky”appearance)canalsobeseen,especiallyinviralhepatitis.
Thehepaticechotexturewouldbeexpectedtobecoarsenedinapatientwithcirrhosis(answerchoice
B), and it is normal in this case. No gallbladder distension or gallstones are shown to support the
diagnosisofacutecholecystitis (answer choiceC). Acalculouscholecystitis (answer choiceD) usually
occursincriticallyillICUpatients,andthegallbladderwouldbeexpectedtobedistendedinthatcaseas
well.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:46–48.
Smith EA, Dillman JR, Elsayes KM, et al. Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J
Roentgenol2009;192(1):188–196.
2a.AnswerA.Focalthickeningofthewallofthegallbladderfundusisnotedtocontainbotharounded
cysticfocusandanechogenicreflectorwithcomet-tailartifact.Thepresenceofanechogenicfocuswith
comet-tailartifactishighlyspecificforadenomyomatosisandistheresultofcholesterolcrystalswithin
Rokitansky-Aschoff sinuses. Adenomyomatosis is relatively common and is a hyperplastic
cholesterolosisofthegallbladderwall,abenigncondition.Therefore,nofurtherwork-upisneeded.
2b.AnswerB.Althoughsomedatasuggestapossibleassociationofadenomyomatosisandgallbladder
carcinoma,thereisnoconclusiveevidenceyetfortheincreasedriskforgallbladdercarcinoma.Thereis
aclearassociationofadenomyomatosis (especially segmentaltype)withgallstones,possibly relatedto
fundalstasis.
References: BoscakAR,Al-HawaryM, RamsburghSR.Best cases from the AFIP: adenomyomatosis of thegallbladder. RadioGraphics
2006;26:941–946.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:45–46.
3a. AnswerC. Thedifferentialdiagnosis for cystic lesionswithin the porta hepatis includeshepatic
cyst, enteric duplication cysts, pancreatic pseudocyst, biliary cysts, and hepatic artery aneurysm. The
imagesshowafusiformcysticstructurecontainingechogenicnonmobiletissuewithpapillaryprojections.
The structure communicates directly with the hepatic ducts (left side of image 1), indicating a
choledochocele. Type I choledochal cyst is the most common type of choledochal cyst,accounting for
80%to90%,andisconfinedtotheextrahepaticbileduct.TypeIcholedochocelesareassociatedwithan
increasedriskofbothcholangiocarcinomaandgallbladdercancer.Thepapillaryconfigurationandstatic
natureoftheintraluminallesionareparticularly concerning fora cholangiocarcinoma.ERCP wouldbe
appropriateforfurtherevaluationandwouldpermittissuesamplingfordiagnosis.
3b.AnswerD. Althoughcholangiocarcinoma isthe mostominous complication,itisthesecondmost
commoncomplicationbehindcalculusformationwithinthebiliary tree,choledochocele,gallbladder,or
pancreaticduct.Otherpotentialcomplicationsinclude pancreatitis,rupturein infantsand neonates,and,
rarely,cholangitis,liverabscesses,portalhypertension,andascites.
3c.AnswerC.Alargemajority(~90%)ofcarcinomasrelatedtocholedochalcystsoccurwithintypesI
(fusiform extrahepatic)andIV(multiple intra-andextrahepatic).Hence,the generalrecommendation is
for those cysts to be completely removed. Patients with type II cysts can often be treated with cyst
excision, and those with type III cysts can be treated with sphincterotomy or endoscopic resection.
Choledochalcystsareapremalignantstate,withcanceroccurringmorefrequentlyandearlierthaninthe
general population. The risk increases with age. Observed cancer types in these patients include
adenocarcinoma (73% to 84%), anaplastic carcinoma (10%), undifferentiated cancer (5% to 7%),
squamouscellcarcinoma(5%),andothercarcinoma(1.5%).Thesitesofmalignancyaretheextrahepatic
bileduct(50%to62%),usuallywithinthecholedochalcyst;gallbladder(38%to46%);intrahepaticbile
ducts (2.5%); and liver and pancreas (0.7% each). Most of the cancers are associated with type I
choledochalcysts(68%)followedbytypeIVcholedochalcysts(21%)and<10%forothertypes.
References:
KimOH,ChungHJ,ChoiBG.Imagingofthecholedochalcyst.RadioGraphics1995;15:69–88.
LawR,TopazianM.Diagnosisandtreatmentofcholedochoceles.ClinGastroenterolHepatol2014;12(2):196.
SinghamJ,YoshidaEM,ScudamoreCH.Choledochalcystspart1of3:classificationandpathogenesis.CanJSurg2009;52(5):434–440.
4a.AnswerB.TheechogenicmasswithinthegallbladderfunduswithpowerDopplerflowindicatesa
solidmass.Theechogenicwallisinterruptedanteriorlyatthesiteofthemass.Althoughthedifferential
diagnosisforapolypoidlesioncontainingDopplerflowincludesbothgallbladdercarcinomaandbenign
polyp,the largesizeandreplacementofthe gallbladderlumen are features concerningfor malignancy.
Walldiscontinuityisanespeciallyominoussignoftransmuraltumorspread,indicatingatleastanAJCC
stageIIItumor(notacandidateforcurativeresection)withapoorprognosis.Althoughring-downartifact
is a feature of adenomyomatosis, the absence of ring-down artifact alone does not exclude
adenomyomatosis.
4b.AnswerD.Gallstonesarepresentin70%to90%ofpatientswithgallbladdercancer.Theriskfor
malignancyishigherinpatientswithlargergallstonesandlongerdurationofcholelithiasis.
4c.AnswerA.40%to65%ofpatientswithgallbladdercarcinomaatinitialdetectionarefoundtohave
a mass nearly filling or replacing the gallbladder lumen. Gallbladder carcinoma presents as focal or
diffuse wall thickening in 20% to 30% of cases. In 15% to 25% of cases, gallbladder carcinoma is
initiallydetectedasapolypoidlesion.
References:
Franquet T, Montes M, Ruiz de Azua Y, et al.Primary gallbladder carcinoma: imaging findings in 50 patientswith pathologic correlation.
GastrointestRadiol1991;16:143–148.
Hsing AW, Gao YT, Han TQ, et al. Gallstones and the risk of biliary tract cancer: a population-based study in China. Br J Cancer
2007;97(11):1577–1582.
LevyAD,MurakataLA,RohrmannCA.Gallbladdercarcinoma:radiologic–pathologiccorrelation.RadioGraphics2001;21:295–314.
5. Answer C. Image A: irregular intrahepatic biliary ductal dilatation is shown with intraluminal
echogenictissue alongwith a complex cysticintrahepaticcollection.ImagesBandC: spectralhepatic
arterialwaveformsshowaparvustarduswaveformindicatinganupstreamstenosis.Theconstellationof
findings is compatible with hepatic arterial anastomotic stenosis resulting in biliary injury, known as
ischemic typebiliarylesion (ITBL).Biliarycomplicationsoccurringafter liver transplantationinclude
bile leaks, anastomotic strictures, nonanastomotic strictures, and ampullary dysfunction. The biliary
epithelium is particularly vulnerable to ischemic injury because of its reliance on hepatic arterial
perfusion,whereasthehepaticparenchymareceivesdualbloodsupplyfromtheportalvenousandhepatic
arterial system. Ischemic injury canresultin biliary necrosis, cast formation, scarring, and multifocal
stenosis.
Reference: Seehofer D, Eurich D, Veltzke-Schlieker W, et al. Biliary complications after liver transplantation: old problems and new
challenges.AmJTransplant2013;13:253–265.
6.AnswerC. Qualitycontrol(QC)istheprocess bywhich adesired levelofquality is verifiedand
maintainedinaproductorservice.QCrequiresplanning,useofproperequipment,continuedinspection,
andcorrectiveactionasnecessary.ArangeofacceptablequalityisdeterminedtoguideQCmeasures.
Quality assurance (QA) is an older, less often used term, referring to a reactive, generally
retrospectiveprocessofdeterminingwhowasatfaultafteramedicalerroriscommittedandsometimes
involvingpunitivemeasures.
Quality improvement (QI) is a continuous process of improving quality, often focusing on finding
weaknesses in the system in order to prevent errors from occurring rather than attributing blame to
individuals. QI activities involve measuring quality and determining how to make things better in an
ongoingfashion.
Reference: Quality and safety domain specification and resource guide, core exam study guide. Tucson, AZ: American Board of
Radiology,2016:5.
7a.AnswerC.Cholecystectomyisrecommendedforgallbladderpolypsthatmeasure>1cmbecauseof
riskofmalignancy.Follow-upimagingcanbeperformedforgallbladderpolypsthatmeasure>6mmbut
<10mm.ThereisnoroleforMRIorhepatobiliarycholescintigraphyinfurthercharacterizationofthese
lesions.
7b.AnswerC.Size>10mmismostpredictiveofmalignancy.
Reference: CorwinMT,SiewertB,SheimanRG,etal.Incidentallydetectedgallbladderpolyps:isfollow-upnecessary?—Long-termclinical
andUSanalysisof346patients.Radiology2011;258(1):277–282.
8.AnswerB. The imageshowsanexampleofsidelobe artifactfromechogenicbowelbeing located
adjacenttotheanechoicgallbladderlumen.Inadditiontothemainultrasoundbeam,anultrasoundprobe
emits off-center ultrasound pulses. When a strong reflector is encountered by one of these off-center
pulses,itcanbereflectedbacktotheultrasoundprobeandinterpretedasbeinglocatedinthepathofthe
main ultrasound beam. This artifact is generally only a problem when imaging anechoic, fluid-filled
structures like thebladder orgallbladder,astheartifactfrom the side lobe is generallyonly detectable
whenimagingananechoicstructure.However,itstilloccurswhenimagingsolidorgans,buttheartifactis
usuallyimperceptible.
Theimage(onthefollowingpage)showsthegallbladderfromaslightlydifferentanglethanfromthe
image in the question. This image more convincingly shows the echogenic structure “within” the
gallbladderlumentobe artifactual.An additionalclue thattheechogenicstructure inthegallbladder is
notagallstonebutratherartifactualisthelackofcleanshadowingposteriortotheechogenicfocusthat
would be expected from a stone. In this case, there is dirty shadowing posterior to the gallbladder,
suggestive ofbowel gas. The use ofharmonic imagingcan effectivelyminimize side lobe artifacts,so
turning off harmonics would accentuate this artifact. Increasing transducer power will increase the
amplitudesofboththeprimarybeamandsidelobes,sotheartifactwillincrease.Increasingthedepthof
imagingwillnotdecreasethisartifact.
Reference:FeldmanMK,KatyalS,BlackwoodMS.USartifacts.RadioGraphics2009;29(4):1179–1189.
9.AnswerC.ImageAshowsasmallamountofperihepaticascites.ImageBshowsmarkedgallbladder
wallthickening,andImageCshowsreversalofflowinthemainportalvein.Basedontheclinicalhistory
andthe providedimages,the best answer is C, sinusoidal obstruction syndrome(SOS), also known as
venoocclusivedisease(VOD).
SOS/VODisthoughttoresultdirectlyfromchemotherapyorradiation-induceddestructionofhepatic
microvasculature during cytoreductive HSCT (hematopoietic stem cell transplant) conditioning and
represents the mostcommoncause ofliver disease during the first 20 days after stem cell transplant,
affecting10%to60%ofpatients.Clinically,thepatientpresentswithweightgain,painfulhepatomegaly,
jaundice,andascites,usuallywithin3 weeksfollowinghematopoieticstemcell transplantation.It may
also happen following some forms of chemotherapy and liver transplantation. Imaging findings mimic
those of graft versus host disease (GVHD). Ultrasound findings include hepatosplenomegaly, ascites,
gallbladder/periportaledema,hepatofugalflowintheportalveinonDoppler,andelevatedRI(>0.75).
Chemotherapy-inducedsteatosisisnotthebestchoicebecausetheliverisnotmoreechogenicthanthe
adjacentkidney, asone wouldexpectwith steatosis. Also,theportal triads anddiaphragm are visible
indicatingnormalacousticpenetration.Additionally,thisdoesnotexplainthefindingsofgallbladderwall
thickeningandascites.Acutecholecystitisisnotthebestchoicebecausethegallbladderisnotdistended.
Italsodoesnotexplainthefindingsofascitesandhepatofugalflowintheportalvein.Cirrhosisisnotthe
bestchoicebecauseitdoesnotexplainthemarkedgallbladderwallthickening,norisitthebestfitforthe
clinicalscenario.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:68–69.
MahgereftehSY,SosnaJ,BogotN,etal. Radiologicimagingand interventionforgastrointestinal andhepaticcomplicationsofhematopoietic
stemcelltransplantation.Radiology2011;258(3):660–671.
10.Answerkey:
Caudatelobe
Leftlateralsegment
Fissureforligamentumvenosum
Umbilicalportionofleftportalvein
Mainportalvein
Commonbileduct
Righthepaticartery
11.AnswerC.Thethreeimagesshowthegallbladderwithmultiplesmallpolyps,theso-called“balls
on the wall” sign seen in cholesterolosis. Cholesterolosis is a benign condition in which cholesterol
estersaredepositedwithinthelaminapropriaofthegallbladder.Cholesterolpolypsarebyfarthemost
common type of gallbladder polyp. They are enlarged papillary fronds filled with lipid-laden
macrophagesandarenottrueneoplasms.Theyareadherenttothewallbyaslenderstalk,whichisrarely
seen.Theyare usually5mm orless insizeandrarely growlargerthan10mm.Theyare distinguished
fromstonesbytheirlackofshadowingandnonmobility.Theirnonmobilitydistinguishesthemfromsludge
balls.Iftherearemultiplesmallpolyps,theyarealmostcertainlycholesterolpolypsandcanbeignored.
Therefore,answerchoiceCisthecorrectanswer.
Thereis no associationofcholesterolpolypswithgallbladdercancer;thereforeanswer choiceAis
notcorrect.Thecauseisunknown,butthereisnoassociationwithserumlipidlevels;therefore,answer
choiceBisincorrect.Cholesterolosishasthesameriskfactorsascholelithiasis,butthetwoconditions
rarelycoexist.Therefore,answerchoiceDisanincorrectstatement.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:44–45.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:209–210.
12.AnswerA.Increasingthedepthorwidthofthefieldofviewwillincreasetheimagesizeandreduce
theframerate.Ithasnoeffectonacousticimpedance.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:11.
13.AnswerB.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:4.
14. Answer D. The ultrasound images show mild biliary dilatation in the setting of a prior liver
transplant as well as nonshadowing echogenic material within the extrahepatic bile duct. The hepatic
arteryshowsa“parvusettardus”waveform,thetypicalDopplerwaveformofanarterydownstreamfrom
an area of stenosis. Because of the biliary epithelium’s reliance on hepatic arterial perfusion, biliary
complications are common in the setting of hepatic arterial stenosis. Biliary cast syndrome (BCS) is
among these potential complications and has been reported in 4% to 18% of liver transplants. Casts
consistingofbilirubin,collagen,bileacids,andcholesterolformwithinthebileductlumenandleadto
biliaryobstruction.
BCSisassociatedwithincreasedmorbidity,mortality,andgraftrejection.Theincreasedechogenicity
withinthecommonductinthis caseistypicalofbiliarycastsyndrome.AnoncontrastCTimageshows
tubularhyperattenuatingmaterialwithinthebiliarytreealsorepresentingcast.Giventheconstellationof
findingstypicalofBCS,choledocholithiasis(answerchoiceC)andanobstructingmass(answerchoice
A)arelesslikely.Portalbiliopathy(answerchoiceB)isbiliaryobstructionthatcanoccurinthesetting
of cavernous transformation of the portal vein. The numerous collateral vessels formed following
thrombosisofthemainportalveinintheportahepatisresultinbiliaryobstruction.
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