QUESTION-1:
60 yo with vague abdominal pain:
Correct Answer: Calcified liver mets
- Granulomatous/Fungal Disease
- Parasitic
- Trauma
- Posttraumatic Hematoma
- Neoplasm
- Metastatic disease
Infection:
Differential Diagnosis:
- Mucinous adenocarcinoma (colon, endocrine pancreatic tumors, stomach)
- Osteosarcoma
- Chondrosarcoma
- Teratocarcinoma
- Neuroblastoma
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Correct Answer Explanation
QUESTION-2:
2 week follow to bilateral cystic kidneys:
Correct Answer: Oligohydramnios
- [MSD -- CRL] > 5mm (5.5 to 9 wks MA)
Second trimester:
- AFI 5 - 20 cm Normal
- Sum of deepest amniotic fluid pocket in each quadrant free of fetal parts or umbilical cord
Largest Single Cord Free Pocket:
- Less than 2 cm: Oligohydramnios
- 2 - 8cm Normal
- > 8 cm Polyhydramnios
- AFI
First trimester:
Differential Diagnosis:
- Fetal Demise
- Renal abnormality (agenesis, bilateral agenesis, renal dysplasia)
- IUGR
- Premature Rupture of the Membranes
- Post-term Pregnancy
- Chromosomal Abnormalities
Pearls:
- MCDK: most common cystic dz in infants, 2nd most common abdominal mass in neonate (1st hydro.)
- ADPKD: liver cysts, berry aneurysms, bilateral large cystic kidneys.
- ARPKD: Antenatal form is most common, 90% tubules‑cystic changes, oligohydramnios, periportal fibrosis, pancreatic fibrosis.
- VUR: incompetence of UVJ.
- Wilm's: 3rd most common mass.
- Dahnert 5th 929
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QUESTION-3:
52 yo with hx of prior colon cancer resection with new abdominal pain:
Correct Answer: Adenocarcinoma
Differential Diagnosis:
- Pancreatic Adenocarcinoma
- Endocrine Neoplasms (gastrinomas/insulin)
- Mets to Pancreas
- Lymphomatous involvement (NHL)
- Focal Pancreatitis
- Pancreatic Abscess (due to sign debris)
- Reactive/Infectious Lymphadenopathy
Pearls:
- Hypoechoic mass near the pancreatic head with double duct sign.
- Hemangiomas are hypoechoic in 20% and hyperechoic in 60-70%.
- Mucinous adenocarcinoma is hyperechoic in 54%.
- References: Rumack, p. 75; Dahnert 1993, pp. 440, 444, 450
- Pancreatic adeno CA: hypoechoic on US (Dahnert 5th p. 724)causes atrophy distally (atrophy of body/tail in 20%)pancreatic adenocarcinoma grows in a fibrous or schirrous manner. It tends to grow along tissue planes, and replaces the normal tissues in the region. It does not grow into a well defined mass, but has poor margins. It also encases (rather than displaces) vessels [SMA, portal vein, etc.], which can make it non-resectable Primer 3rd p. 240; GI Case Review p. 12
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QUESTION-4:
Follow up to distended renal pelvis:
Correct Answer: Posterior ureteral valve
Differential Diagnosis:
- Fetal hydronephrosis
- UPJ obstruction
- Apparent UVJ obstruction: ectopic ureterocele, megaureter, VUR
- Apparent urethral obstruction: posterior urethral valves, caudal regression anomaly (VUR), urethral atresia (male or female), megacystis-microcolon-intestinal-hypoperistalsis syndrome, persistent cloaca (female, VUR)
Pearls:
- Most common cause of urethral obstruction in male infants
- Valves are redundant folds of urethral mucosa causing varying degrees of obstruction
- US: dilated bladder (keyhole), bilateral hydronephrosis, oligohydramnios, dilated ureters
- After UPJ obstruction, posterior urethral valves is the next most common cause of hydronephrosis. They occur in the region of the verumontanum of the prostatic urethra—hence, the only occur in males. Dähnert 5th 983, 938; Peds
- Requisites, 2nd ed, 160-164
- Autosomal dominant polycystic kidney disease is occasionally detected in utero and may have normal or decrease amniotic fluid. The kidneys are enlarged but lack the sonolucent rim of infantile polycystic kidney disease. Occasional discrete cysts are visualized. Much less commonly seen in utero than is MCDK.
- Obstructive uropathy such as posterior urethral valves may result in cystic renal dysplasia. Affected kidneys are hydronephrotic, with increased parenchymal echogenicity and cysts of varying size. The kidneys may be dysplastic without cysts being visualized by ultrasound.. Brant & Helms, 2nd Ed, pp902-3.
- Dähnert 5th 928-929, 936-938
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Correct Answer Explanation
QUESTION-5:
60 yo man present for follow up:
Correct Answer: Medullary Cystic kidneys dz
Differential Diagnosis:
- Enlargement: due to acute toxin, insult or vascular compromise
- Enlarged Echogenic:
- Conditions in which antigen-antibody complexes and other debris clog kidney’s filtration system
- Conditions of Cellular infiltration
- Proliferative disorders
- Vasculitic process
- May have reversible or treatable component
Bilateral Echogenic Kidneys Normal to Increased Size:
- Proliferative disorders: Acute Glomerulonephritis
- Antigen-antibody complexes and other debris clog kidney’s filtration system
- Acute Interstitial Nephritis
- HIV Nephropathy
- Amyloidosis/Multiple Myeloma
- Cellular infiltration: Leukemia
- Vascular compromise
- Diabetes Mellitus
- Acute Tubular Necrosis
- Multisystem Disorders (PN; SLE, TTP)
Bilateral Echogenic Kidneys Normal to Increased Size:
Pearls:
- Human immunodeficiency virus-associated nephropathy:
- Increased parenchymal echogenicity and decreased renal sinus fat suggestive of renal edema.
- Medullary cystic renal disease. Usually smaller than expected and echogenic. Incompatible with life if bilateral.
- Medullary sponge kidney – nl size kidney and echogenic
- HIV- echogenic. Normal size to enlarged
References:
- https://bit.ly/3fjIhjZ
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Correct Answer Explanation
QUESTION-6:
First trimester patient with pelvic pain:
Correct Answer: Ectopic Pregnancy
Differential Diagnosis:
- First trimester bleeding • NL IUP: subchorionic hematoma • Abortion • Early pregnancy failure (anembryonic pregnancy) • Ectopic pregnancy • Gestational trophoblastic disease • For first trimester, always localize the GS, take standard measurements of embryo/fetus, check for fetal cardiac
- Motion, document the number of fetuses, evaluate the uterine anatomy and adnexae
- DDX: + BHCG
- NL IUP
- ABNORMAL IUP: Miscarriage, Hydatiform Mole
- ECTOPIC PREGNANCY
Signs and Symptoms:
- Pain 95% *
- Vaginal Bleeding 75% *
- Adnexal mass 25-70%*
- Amenorrhea 60%
- Classical triad < 50%*
Ectopic Pregnancy Locations:
- Ampulla 70-85%
- Isthmus/Interstitial 10-15%;
- Infundibulum (fimbriated end) rare
- Ovary 0.5%
- Uterus
- Cornual (2-4%)
- Cervical (0.1%)
- Rudimentary horn—rare
- Heterotopic IUP + EP: 1/30,000-1/7,000 births
- As high as 1/100 in patients with assisted reproduction
Ectopic Pregnancy:
- Any extraovarian noncystic adnexal mass has 96% likelihood of representing an EP (Sensitvity 84%, Specificity 99%)
- Any extraovarian complex or solid adnexal mass without a tubal ring, yolk sac, or live embryo has a 92% likelihood of representing an EP
- US findings are poor predictors of tubal rupture
Ectopic Pregnancy:
Pearls:
- A NL gestation will double b-HCG levels every 48 hours, whereas ectopic pregnancies will NOT. Molar pregnancies have very high b-HCG levels
- A double decidual sac is present in an early NL pregnancy, whereas a pseudogestational sac is present in an ECTOPIC pregnancy. The ectopic usually involves fallopian tube, uterus cornua, ovary, cervix, abdomen (rare)
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QUESTION-7:
Incidental findings on ultrasound:
Correct Answer: Cavernous Hemangioma
- Ultrasound demonstrates a homogenous, well-defined, hyperechoic mass. If the patient has hepatic steatosis, the hemangioma may appear as hypoechoic. When lesions are larger than 5 cm, some heterogeneity may be demonstrated.
- Giant hemangiomas are lobulated, heterogeneous masses with a hyperechoic border.
- Typical hemangioma demonstrates peripheral, discontinuous, nodular enhancement on arterial phase images with progressive centripetal filling on venous phase images.
- Percutaneous biopsy is generally not recommended due to the risk of fatal hemorrhage. Diagnosis can be complicated further in the setting of cirrhosis or extra-hepatic malignancy
Differential Diagnosis:
- HEPATIC LESIONS:
- Cysts - Caroli’s, ADPKD
- Abcess - bacteria, amoeba, hydatid, candida
- Hemangioma
- Mets
- HCC
- FNH
- Adenoma
- Angiosarcoma
Pearls:
- FNH = rare benign congenital hamartomatous malformation or repair process in focal injury. Iso/hypo/hyperechoic (33%), can have hyperechoic central scar (18%). Dähnert 5th p 703
- “Most small HCC are hypoechoic. Larger HCC are heterogeneous. Fibrolamellar HCC are hyperechoic.” “variable echotexture” Dähnert 5th p 714
- Lymphoma is one of the “hypoechoic liver mets” along with pancreas, cervical, lung and nasopharyngeal. Dähnert 5th p 721 Dähnert 5th p 721
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QUESTION-8:
Fetal US showing a hypoechoic lesion in the upper pole of the right kidney:
Correct Answer: Duplex collecting system with obstruction of upper pole moiety.
- The key to this question is that the abnormality only involves a portion of a single kidney (unilateral abnormality).
- US Requisites gives 3 causes:
- Obstructed upper pole from an ectopic (duplicated) ureter [see fig. 13-12 p. 286] Duplication in 1:500 live births, 60-85% unilateral Dähnert 5th p. 977.
- MCDK: multiple non-communicating cysts; “cluster of grapes”; no normal kidney tissue. Dahnert 5th 928-929
- UPJ obstruction (not a choice): “glove” appearance of true hydronephrosis
- Cyst – rare in the fetus
- ADPKD – usually not identified in the fetus, but may show large echogenic kidneys similar to infantile PCKD. Dahnert 5th 937
- ARPKD – remember, this gives “microcysts”, massively enlarged, hyperechoic kidneys (bilaterally). Dahnert 5th 938
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Correct Answer Explanation
QUESTION-9:
5 days post vag delivery:
Correct Answer: Retained product of conception
Differential Diagnosis:
- Hydaform mole
- Endometritis
- EM Carcinoma
- Submucosal Fibroid
Pearls:
- Post-partum retained products of conception (RPOC) >5mm (<2mm RPOC unlikely)
- A variable amount of echogenic or heterogeneous material within the endometrial cavity
- May presents like an endometrial or intrauterine mass
- Vascularity within the echogenic material supports the diagnosis
- The absence of color Doppler flow has a low negative predictive value because retained products of conception may be avascular
- Possible calcification present
- Retained products of conception can be suspected on ultrasound if the endometrial thickness is >10 mm following dilatation and curettage or spontaneous abortion (80% sensitive).
References:
- https://bit.ly/37fN1mL
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Correct Answer Explanation
QUESTION-10:
Follow up ultrasound:
Correct Answer: periventricular leukomalacia
- Hypoxic-ischemic injury
- Coagulation/necrosis of PV white matter
- Most prevalent in premie
- Occurs at frontal WM near foramina of Monroe and optic radiations at the trigone
= watershed areas of premie's brain - Spastic quadriplegia, blindness, with relative preservation of cognitive function
Differential Diagnosis:
- cerebral edema
- cerebral infection: e.g. TORCH infection
- subependymal cysts
- choroid plexus cysts
- porencephaly
Pearls:
- Choroid plexus cysts are found usually between 16 and 21 GA. They are always located in the lateral ventricle near the glomus of the choroid plexus. It is unusual to see them after 25-26 weeks. They are now known to be a common finding. They range from 0.5-2 cm. The larger cysts may expand the lateral ventricle. Cysts are usually benign.
- However, their presence has been associated with karyotype abnormalities by some authorities. Trisomy 18 is most commonly cited associated with karyotypic abnormality. All patients with choroid plexus cysts should undergo detailed sonographic examination and counseling. Almost all cysts regress. Source: Callen, Ultrasound in Obstetrics and
- Gynecology, pp 215-216.
- Dahnert 5th 270
- Congenital disorder that results in cystic degeneration and encephalomalacia and the formation of porencephalic cysts. Focal cystic area of encephalomalacia that communicates with the ventricular system and/or the subarachnoid space.
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QUESTION-11:
Which of the following finding is the most characteristic of benign pathology in thyroid lesions?:
Correct Answer: Rim-like calcifications
- Characteristics that increase the likelihood of a [thyroid] nodule being benign include a uniform, well-defined, hypoechoic rim; cystic components; peripheral eggshell calcifications; or an echogenicity greater than that of adjacent normal thyroid. One feature that should prompt particular concern is microcalcifications because these are more predictive of cancer than is any other sonographic finding. (* just like in the breast!) US Req. p. 451
Dahnert 5th 357,
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