AB-Abdomen Abdomen Sonography Examination Questions and Answers

In biliary obstruction (such as at the ampulla of Vater), dilation begins proximally and progresses peripherally. The intrahepatic peripheral bile ducts are the last to dilate because backpressure takes time to propagate. Early dilation is typically seen in the common bile duct and common hepatic duct.

According to Rumack’s Diagnostic Ultrasound:

“The intrahepatic peripheral bile ducts dilate last in the setting of progressive biliary obstruction.”

Salivary glands are superficial structures, and high-frequency transducers (10–15 MHz) are optimal to obtain high spatial resolution. Lower frequencies are inappropriate as they lack sufficient resolution for superficial structures. A 12 MHz transducer provides excellent detail necessary for detecting small lesions, duct abnormalities, and vascular structures.

According to Rumack et al., Diagnostic Ultrasound:

"High-frequency linear transducers (10–15 MHz) are recommended for evaluating superficial structures such as salivary glands." (Rumack CM et al., Diagnostic Ultrasound, 5th ed.).

A thyroglossal duct cyst is the most common congenital cystic anomaly in the anterior midline neck. It arises from persistent remnants of the thyroglossal duct, typically located inferior to the hyoid bone.

According to Rumack’s Diagnostic Ultrasound:

“Thyroglossal duct cysts are located in the midline anterior neck and are the most common congenital cystic neck lesions.”

The celiac trunk arises from the abdominal aorta and immediately divides into three primary branches:

Left gastric artery

Common hepatic artery

Splenic artery

The proper hepatic and gastroduodenal arteries are secondary branches of the common hepatic artery.

According to Moore’s Clinically Oriented Anatomy:

“The celiac trunk trifurcates into the left gastric, common hepatic, and splenic arteries.”

Thyroid adenomas typically present as well-defined nodules surrounded by a thin, hypoechoic peripheral halo representing compressed thyroid parenchyma or fibrous capsule. Irregular margins suggest malignancy.

According to Rumack’s Diagnostic Ultrasound:

“A thin hypoechoic halo is characteristic of benign thyroid adenomas.”

An ultrasound of a fetus AI-generated content may be incorrect.

The ultrasound image shows a transverse (axial) view of the fetal abdomen. Notably, there is abnormal continuity of renal parenchyma across the midline anterior to the aorta, forming a U- or horseshoe-shaped structure. This is characteristic of a congenital anomaly known as a horseshoe kidney.

Horseshoe kidney is the most common fusion anomaly of the kidneys, occurring in approximately 1 in 400–600 live births. It results from fusion of the lower poles of both kidneys during fetal development. On prenatal ultrasound, this anomaly can be suspected when the kidneys appear closer to the midline than usual and are connected by an isthmus of renal tissue or fibrous band that crosses anterior to the spine and great vessels.

Typical sonographic findings include:

Abnormally located kidneys, often lower than expected

Renal fusion across the midline (usually at the lower poles)

Possible associated hydronephrosis or malrotation

Comparison to other anomalies:

This is not consistent with polycystic kidney disease (which would show diffusely echogenic kidneys with poor corticomedullary differentiation).

Duplex kidney would show duplicated collecting systems but not fusion across the midline.

Renal agenesis would demonstrate absence of renal tissue.

Posterior urethral valves would show a distended bladder with bilateral hydronephrosis, not midline fusion.

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.”

Pancreatic pseudocysts most commonly develop in the lesser sac, which lies between the posterior wall of the stomach and the anterior surface of the pancreas. This space allows for the accumulation of pancreatic fluid collections following pancreatitis or pancreatic ductal disruption.

The left anterior pararenal space (B) is a secondary location.

The right subdiaphragmatic space (C) and left pericolic gutter (D) are less common sites.

Reference Extracts:

Mortele KJ, Wiesner W, et al."Pancreatic pseudocysts: imaging features and diagnostic difficulties." Radiographics. 2004;24(4):1005-1020.

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

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The Doppler spectral waveform shown in this image of the right testis demonstrates low-resistance, forward-flowing arterial waveforms with continuous diastolic flow — this is characteristic of normal testicular perfusion. The presence of both color Doppler flow and a resistive index (RI) of 0.66 further supports normal testicular arterial circulation.

Key Doppler features of a normal testicular waveform:

Low-resistance waveform (RI typically 0.5–0.75)

Continuous diastolic flow

No reversal of flow or spectral broadening

Color Doppler confirms uniform intratesticular vascularity

Clinical context:

Normal testicular flow on Doppler imaging excludes testicular torsion, infarction, or significant inflammation.

Testicular torsion would show either absent or very high-resistance (reduced or absent diastolic flow) waveform.

Epididymo-orchitis may show hyperemia with low resistance but often presents with other gray-scale findings like heterogeneous echotexture or scrotal wall thickening.

Differentiation from other options:

B. Increased resistance: RI >0.75 and reduced or reversed diastolic flow; may indicate impending torsion or ischemia.

C. Tardus parvus: A slow systolic upstroke and diminished amplitude; indicates proximal arterial stenosis.

D. Triphasic: Normal waveform in peripheral arteries, such as extremities, not seen in testicular circulation.

Malignant lymph nodes are often round in shape (short axis/long axis ratio approaches 1), while benign lymph nodes are typically oval (short axis/long axis ratio < 0.5). Rounded shape in post-thyroidectomy patients raises suspicion for metastatic disease.

According to AIUM and ACR Thyroid Imaging Guidelines:

“A rounded lymph node shape is suspicious for malignancy, especially in patients with thyroid cancer.”

The image provided is a right upper quadrant (RUQ) ultrasound—typically performed during a FAST (Focused Assessment with Sonography in Trauma) exam or for abdominal assessment. The arrow points to an anechoic (black) fluid collection seen above the diaphragm and posterior to the liver.

This fluid collection lies within the thoracic cavity, confirming the diagnosis of a pleural effusion. Pleural effusions are seen sonographically as an anechoic or hypoechoic area superior to the diaphragm in the thoracic cavity and often appear triangular or crescent-shaped. The diaphragm is visualized as a curvilinear echogenic structure separating the liver (or spleen) below from the lung space above.

Comparison of answer choices:

A. Retroperitoneal hemorrhage would be seen in the posterior abdomen, not above the diaphragm.

B. Pleural effusion is correct—anechoic fluid above the diaphragm is classic for this condition.

C. Mirror image artifact occurs when liver echoes are mirrored across the diaphragm and lung—this is not a mirror artifact.

D. Ascites collects inferior to the diaphragm and around the abdominal organs, not in the thoracic cavity.

Nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery (SMA) and the aorta. This can cause hematuria, flank pain, and pelvic congestion due to impaired venous drainage.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“In nutcracker syndrome, the left renal vein is compressed between the aorta and SMA, resulting in venous hypertension.”

The ultrasound image shows an anechoic (black) fluid collection in the perihepatic and perirenal spaces. The fluid outlines the liver (LIV) and right kidney (RK), which is characteristic of free fluid in the peritoneal cavity — consistent with ascites.

Sonographic features of ascites:

Anechoic (or hypoechoic) fluid in dependent areas of the abdomen

Seen surrounding the liver, spleen, and intestines

Can be free-flowing or loculated

Bowel loops may be floating or displaced centrally

This image is consistent with a typical finding of ascites: free fluid in Morison’s pouch (hepatorenal recess), a common site for fluid accumulation.

Differentiation from other options:

A. Hydropic gallbladder: Refers to an enlarged gallbladder filled with clear bile; not visible in this image.

B. Hemoperitoneum: May appear similar to ascites, but usually has complex echogenicity or layering if acute; clinical context (trauma, bleeding) is essential for diagnosis.

C. Bowel obstruction: Would show dilated, fluid-filled bowel loops with peristalsis or to-and-fro motion, not evident here.

Hepatitis A is primarily transmitted via the fecal-oral route, often through contaminated food or water. Hepatitis B, C, and D are transmitted through blood and body fluids.

According to CDC and WHO guidelines:

“Hepatitis A virus (HAV) is transmitted primarily by the fecal-oral route via ingestion of contaminated food or water.”

The hallmark feature of focal nodular hyperplasia (FNH) is a central stellate scar seen on imaging. This fibrous scar may not always be seen on ultrasound but is a classic distinguishing feature from hepatic adenomas, which usually lack a central scar.

According to Rumack’s Diagnostic Ultrasound:

“Focal nodular hyperplasia often demonstrates a central stellate scar, which may be echogenic or isoechoic.”

On ultrasound, tendons appear as cord-like hyperechoic structures with linear fibrillar echotexture when imaged in long axis. The fibrils are highly reflective, creating the typical hyperechoic appearance. Posterior shadowing is not typical unless there is calcification.

According to Rumack’s Diagnostic Ultrasound:

“Tendons have a highly organized hyperechoic linear fibrillar pattern when examined along their long axis.”

The ultrasound image clearly demonstrates a thickened and elongated pyloric muscle with a visible channel, which is characteristic of hypertrophic pyloric stenosis (HPS). This condition is most commonly seen in male infants between 2 and 8 weeks of age who present with non-bilious projectile vomiting, dehydration, and a palpable “olive-like” mass in the right upper quadrant.

Ultrasound is the imaging modality of choice and is highly sensitive and specific for diagnosing pyloric stenosis.

Key sonographic criteria for HPS:

Muscle thickness >3 mm

Pyloric channel length >15–17 mm

“Target sign” or “doughnut sign” on transverse imaging (concentric rings)

“Cervix” or “railroad track sign” on longitudinal imaging (elongated canal with echogenic center)

Differentiation from other options:

A. Intussusception: Also shows a target sign, but it occurs in the right lower quadrant or periumbilical region, not in the gastric antrum.

C. Hydronephrosis: Refers to dilation of the renal pelvis and calyces — not gastrointestinal.

D. Gastritis: May show gastric wall thickening but lacks the distinct elongated, thickened pyloric muscle seen here.

Pancreatic ductal adenocarcinoma is by far the most common pancreatic malignancy, accounting for approximately 85–90% of pancreatic cancers. It typically arises from the exocrine portion of the pancreas, most frequently in the pancreatic head. Islet cell (neuroendocrine) tumors and cystic neoplasms (e.g., mucinous cystadenocarcinoma) are far less common.

According to Rumack’s Diagnostic Ultrasound:

“Adenocarcinoma is the most common malignant neoplasm of the pancreas, representing the vast majority of pancreatic cancers.”

A varicocele is an abnormal dilatation of the pampiniform plexus veins, usually seen on the left side due to the perpendicular insertion of the left testicular vein into the left renal vein, making it more susceptible to elevated venous pressure. Sonographically, varicoceles appear as multiple serpiginous anechoic tubular structures that show venous flow on color Doppler, often accentuated with Valsalva maneuver.

Hydrocele (A) is a fluid collection surrounding the testis.

Hematocele (C) is blood within the tunica vaginalis.

Spermatocele (D) is a cystic lesion arising from the epididymis.

Reference Extracts:

Dogra VS, Bhatt S. "Sonographic evaluation of testicular varicoceles." Journal of Ultrasound in Medicine. 2004;23(6): 829-838.

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

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The structure indicated by the arrow in the ultrasound image is the adrenal gland. On ultrasound, the adrenal gland in neonates and infants is relatively large and has a distinctive “Y” or “V” shape in the transverse view. It is located superior and slightly medial to the upper pole of the kidney.

In this image, the arrow is pointing to a hypoechoic, curved structure with a thin echogenic central stripe, representing the fetal adrenal gland. This echogenic stripe corresponds to the adrenal medulla, while the surrounding hypoechoic area represents the cortex.

Differential features:

A. Kidney: While the kidney is visualized posterior to the adrenal gland and shows a reniform shape with a central echogenic sinus and peripheral cortex, it is not the structure being directly pointed to by the arrow.

B. Bowel loop: Bowel has variable echogenicity with peristalsis and shadowing from air. It does not have the consistent morphology or location seen in the image.

C. Diaphragm: Appears as a thin, hyperechoic linear structure separating the thoracic cavity from the abdomen. It is seen more superiorly than the indicated structure and lacks the “Y” or “V” adrenal configuration.

Key Anatomical Landmarks:

The adrenal glands are located in the retroperitoneum, superior to the kidneys, and appear prominent on ultrasound in neonates.

In transverse view, the right adrenal gland is anterior to the crus of the diaphragm and posterior to the inferior vena cava (IVC).

An accessory spleen (splenule) is a congenital variant, commonly located near the splenic hilum, and has identical echogenicity to the native spleen. This finding is benign and often incidental.

According to Rumack’s Diagnostic Ultrasound:

“Accessory spleens are typically found near the splenic hilum and are isoechoic to the normal splenic parenchyma.”

Significant proteinuria, especially if persistent or in the nephrotic range, may indicate glomerular disease and is a common indication for renal biopsy. Leukocytosis and hypercalcemia are not specific for renal biopsy. Hematuria may warrant biopsy if accompanied by proteinuria.

According to KDIGO Clinical Practice Guidelines:

“Persistent proteinuria is one of the strongest indications for renal biopsy to evaluate underlying glomerular pathology.”

The transverse ultrasound image of the liver shows a solid, hypoechoic mass located in the posterior aspect of the right lobe of the liver. In this view:

The anterior aspect of the liver is at the top of the image (near the transducer).

The posterior aspect is at the bottom (deeper).

The right lobe occupies the majority of the screen on transverse imaging when the probe is placed in the epigastrium or right upper quadrant.

Anatomically, the right lobe of the liver is divided into anterior and posterior segments by the right hepatic vein in the coronal plane. In transverse imaging:

The right anterior segment lies closer to the anterior abdominal wall.

The right posterior segment lies deeper (posteriorly).

Given that the mass is seen deep within the liver on the right side of the image, it is best localized to the right posterior segment (Segment VI or VII depending on the exact craniocaudal level).

Comparison of answer choices:

A. Left lateral is located far to the left of the image and typically appears higher and more anterior on transverse scans.

B. Left medial lies near the midline and would appear adjacent to the ligamentum teres or falciform ligament.

C. Right anterior lies closer to the transducer (top of the image), not posteriorly.

D. Right posterior — Correct. This is the segment shown deep in the right lobe of the liver.

Conn syndrome (primary hyperaldosteronism) results from excessive aldosterone secretion, often due to an adrenal adenoma, leading to hypertension, hypokalemia, and metabolic alkalosis. Cushing disease involves cortisol, Addison disease involves adrenal insufficiency, and Waterhouse-Friderichsen is associated with adrenal hemorrhage.

According to Rumack’s Diagnostic Ultrasound:

“Conn syndrome is due to excessive secretion of aldosterone, often secondary to adrenal cortical adenoma.”

The image shows a small hepatic lesion located very close to the anterior liver capsule, as indicated by the arrow. When imaging very superficial or near-field structures like subcapsular hepatic lesions, using a standoff pad is the most effective technique for optimizing visualization.

A standoff pad (also known as an acoustic stand-off or gel pad) helps increase the distance between the transducer and the superficial target. This improves the focus and beam shape for near-field imaging and minimizes reverberation and ring-down artifacts. It allows better evaluation of superficial lesions by positioning them within the focal zone of the transducer, which is usually set a few millimeters below the probe surface.

Differentiation from other options:

A. Decrease depth: While reducing depth can help center deeper lesions in the field of view, it does not address issues with near-field resolution.

B. Scan in upright position: This may help in gallbladder or fluid positioning but is not optimal for improving visualization of superficial liver lesions.

C. Move the transducer focus: Adjusting focus deeper into the image won't enhance resolution of very superficial structures unless a standoff is used to bring the lesion into the focal zone.

Portal veins course horizontally within the liver and have echogenic walls due to their fibrous sheath. In contrast, hepatic veins course vertically toward the IVC and lack echogenic walls. Hepatic veins also demonstrate a triphasic waveform.

According to Rumack’s Diagnostic Ultrasound:

“Portal veins course horizontally within the liver and are easily recognized by their echogenic walls.”

The grayscale ultrasound image demonstrates a uniformly enlarged, hypoechoic (dark), and heterogeneous testis without signs of surrounding scrotal wall thickening or a discrete fluid collection. This pattern is highly suggestive of testicular torsion in the setting of acute scrotal pain.

Sonographic features of testicular torsion on grayscale imaging:

Enlarged testis

Diffusely hypoechoic parenchyma

Loss of normal homogeneity

Absence of internal vascular flow on Doppler imaging (not shown here but critical in confirming diagnosis)

Testicular torsion occurs due to twisting of the spermatic cord, leading to vascular compromise and eventual infarction if not promptly corrected. It is a surgical emergency and typically presents in adolescent males with sudden-onset, severe unilateral testicular pain.

Comparison of answer choices:

A. Scrotal abscess appears as a complex fluid collection with irregular margins and posterior enhancement.

B. Testicular rupture would show discontinuity of the tunica albuginea, heterogeneous texture, and often a hematocele.

C. Testicular torsion — Correct. The enlarged, hypoechoic, heterogeneous testis is characteristic, particularly in the acute phase.

D. Epididymitis typically shows an enlarged, hypervascular epididymis and may extend to the testis (epididymo-orchitis), but vascularity is usually increased rather than absent.

A complex pleural effusion often contains internal septations or fibrin strands, distinguishing it from simple anechoic effusion. These septations suggest exudative processes such as infection, malignancy, or hemothorax.

According to Rumack’s Diagnostic Ultrasound:

“Complex pleural effusions demonstrate internal septations or loculations, often related to infection or malignancy.”

Direct inguinal hernias protrude through Hesselbach's triangle, which lies medial to the inferior epigastric artery. In contrast, indirect inguinal hernias pass lateral to the inferior epigastric artery via the deep inguinal ring.

According to Moore’s Clinically Oriented Anatomy:

“Direct inguinal hernias occur medial to the inferior epigastric vessels, within Hesselbach's triangle.”

Downstream from a significant renal artery stenosis, the acceleration time is prolonged due to delayed systolic upstroke (“tardus-parvus waveform”). This is a sensitive Doppler parameter for detecting hemodynamically significant stenosis. Spectral broadening usually occurs at the stenotic site, not distal to it.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“Prolonged acceleration time and reduced acceleration index characterize tardus-parvus waveforms distal to renal artery stenosis.”

The clinical presentation—tender, swollen breast with erythema and fever—in a lactating female strongly suggests acute mastitis. The sonographic findings support this diagnosis. In the image, the breast parenchyma shows diffuse, hypoechoic, and heterogeneous echotexture with increased vascularity, which is consistent with inflammatory changes typical of mastitis.

Mastitis is a common complication during lactation, particularly in the first few weeks postpartum. It results from milk stasis and subsequent bacterial infection, commonly due to Staphylococcus aureus. Ultrasound features of mastitis include:

Ill-defined, hypoechoic, edematous areas in the breast parenchyma

Increased Doppler flow due to hyperemia

Skin thickening

Ductal dilatation may also be present

If left untreated, mastitis may progress to abscess formation, which would appear as a localized, complex fluid collection with peripheral hyperemia and internal debris. However, the image does not show a well-formed fluid collection consistent with abscess.

Option B (Ductal carcinoma): Inappropriate here due to the acute clinical scenario and patient age. Ductal carcinoma typically presents as a hypoechoic mass with irregular margins and posterior shadowing, not diffuse edema or inflammatory changes.

Option D (Galactocele): This benign milk-filled retention cyst typically appears anechoic or with fluid–fluid levels but lacks signs of inflammation and systemic symptoms such as fever.

Option A (Abscess): This could be a differential, but abscesses usually present with a well-defined anechoic or complex mass. The absence of a discrete collection and the diffuse appearance makes mastitis more likely.

A wandering spleen occurs when the spleen is not adequately anchored by its supporting ligaments, allowing it to move freely within the abdomen. This increases the risk of splenic torsion, which compromises vascular supply and may result in infarction if not corrected.

According to Rumack’s Diagnostic Ultrasound:

“The most serious complication of a wandering spleen is torsion, which may result in splenic infarction.”

The ultrasound image demonstrates findings consistent with hypertrophic pyloric stenosis (HPS). This condition typically affects infants between 2 and 8 weeks of age and presents clinically with non-bilious projectile vomiting, weight loss, and dehydration.

In the ultrasound image, the classic “target” or “donut” sign can be seen in the transverse view of the hypertrophied pyloric muscle. Key sonographic criteria for HPS include:

Pyloric muscle thickness ≥3 mm

Pyloric channel length ≥15–18 mm

This imaging appearance strongly correlates with the clinical presentation of projectile vomiting (Choice D), which is the hallmark symptom of HPS.

Comparison of answer choices:

A. Abnormal prenatal ultrasound (Choice A) is not typically associated with HPS, which develops postnatally.

B. Neonatal hyperbilirubinemia (Choice B) is not an indication for a pyloric ultrasound and affects liver/biliary imaging.

C. Red currant jelly stools (Choice C) are indicative of intussusception, not HPS.

D. Projectile vomiting (Choice D) is the most common clinical indication leading to an ultrasound exam that reveals HPS.

The image shows a transverse view of the left lobe of the liver with the portal triads clearly visible. The "parallel channel" or "double barrel" sign is observed—where dilated intrahepatic bile ducts run alongside the portal veins, creating a characteristic sonographic pattern of paired anechoic (black) tubular structures.

This sonographic feature is diagnostic for dilated intrahepatic bile ducts and is typically seen in obstructive jaundice or biliary obstruction from conditions such as:

Choledocholithiasis (stone in the common bile duct)

Stricture or mass compressing the bile ducts

Cholangiocarcinoma

The intrahepatic bile ducts normally are too small to visualize clearly unless dilated. Their dilation gives the liver a "too many tubes" appearance, where bile ducts become as prominent as the portal veins.

Comparison of answer choices:

A. Normal intrahepatic ducts are not usually seen this clearly or prominently on ultrasound.

B. Dilated intrahepatic — Correct. The parallel channel sign supports this diagnosis.

C. Dilated common bile duct would be visualized extrahepatically, typically anterior to the portal vein near the head of the pancreas.

D. Dilated common hepatic duct is also extrahepatic and seen in the porta hepatis, not within the liver parenchyma.

A normal renal artery waveform demonstrates rapid systolic upstroke (acceleration) with continuous forward flow in diastole due to the kidney's low-resistance vascular bed. Slow acceleration or blunted peaks may indicate significant renal artery stenosis.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“Normal renal artery waveforms demonstrate a rapid systolic acceleration with a sharp systolic peak.”

The ultrasound image demonstrates a fluid-filled structure in the posterior knee region, consistent with a Baker cyst (also called a popliteal cyst). A Baker cyst is a synovial fluid-filled sac arising from the posterior medial aspect of the knee joint, typically extending between the medial head of the gastrocnemius and the semimembranosus tendon.

The history of delayed-onset claudication (pain in the calf when walking) two weeks after this image was obtained is strongly suggestive of a ruptured Baker cyst. When a Baker cyst ruptures, synovial fluid may track inferiorly into the calf, producing pain, swelling, and clinical symptoms that mimic deep vein thrombosis (DVT) or arterial insufficiency (e.g., pseudothrombophlebitis syndrome).

Ultrasound findings consistent with a ruptured Baker cyst:

Complex fluid collection tracking along muscle fascial planes (hypoechoic to anechoic)

Posterior calf swelling and tenderness

Absence of thrombus in the deep venous system

Crescent-shaped fluid may be seen between muscle compartments

Why the other choices are incorrect:

A. Neuropathy: Would not show fluid-filled structures on ultrasound and would not present with calf swelling.

B. Infected hematoma: May appear complex, but would require a history of trauma or anticoagulation and systemic signs (fever, redness).

C. Thrombophlebitis: Involves a thrombosed superficial vein with wall thickening and surrounding inflammation, which is not seen in this image.

The normal hepatic vein Doppler waveform is triphasic, reflecting cardiac cycle variations in central venous pressure transmitted from the right atrium through the IVC. Loss of triphasicity may suggest elevated right atrial pressures or hepatic venous obstruction.

According to Rumack’s Diagnostic Ultrasound:

“The normal hepatic vein waveform is triphasic due to transmitted right atrial pressure variations.”

The coronary vein (left gastric vein) is a common collateral pathway in portal hypertension. It often becomes dilated and may demonstrate hepatofugal (reversed) flow as blood diverts from the high-pressure portal system into systemic collaterals.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“The left gastric (coronary) vein is a frequent site of hepatofugal flow in portal hypertension, reflecting collateral development.”

The image shows a color Doppler ultrasound of the main portal vein (MPV), which appears irregular and replaced by multiple small, serpiginous vascular channels — a hallmark of cavernous transformation. Cavernous transformation of the portal vein is a late complication of chronic portal vein thrombosis, in which collateral vessels develop around the thrombosed portal vein to bypass the obstruction.

Key Doppler ultrasound features of cavernous transformation:

Absence of a normal portal vein

Multiple tortuous vessels in the porta hepatis

Color Doppler shows hepatopetal flow in these channels

Low velocity, continuous waveform flow in collateral vessels

Differentiation from other options:

B. Portal vein thrombosis: Would show an absence of color flow within the portal vein lumen and possibly echogenic material within the vessel. There would be no serpiginous collateral vessels yet if it's an acute process.

C. Portal hypertension: Often diagnosed with other sonographic findings (e.g., splenomegaly, reversed portal flow, varices) but not characterized by the replacement of the portal vein by collateral vessels.

D. Tumor extension: Typically appears as echogenic intraluminal material within the portal vein with arterial waveforms on Doppler due to neovascularity. Tumor thrombus can be seen in hepatocellular carcinoma or pancreatic cancer, not multiple small collateral vessels.

Urinomas are collections of urine in the retroperitoneum that result from trauma, surgery, or obstruction causing urine leakage. Trauma is a frequent cause of urinoma formation due to disruption of the urinary tract.

According to Rumack’s Diagnostic Ultrasound:

“Urinomas may develop as a complication of trauma, surgery, or obstructive uropathy with urinary extravasation into the retroperitoneum.”

Splenosis refers to autotransplantation of splenic tissue following splenic trauma or splenectomy. After rupture, splenic fragments may implant throughout the peritoneal cavity and vascularize, forming multiple nodules of functional splenic tissue. Splenosis is typically asymptomatic and discovered incidentally on imaging.

Splenule (A) is a congenital accessory spleen, not related to trauma.

Hamartoma (C) is a benign primary splenic lesion.

Target lesion (D) generally refers to sonographic appearance seen in metastases or infections, not post-trauma.

Reference Extracts:

Mortelé KJ, et al. "Multimodality imaging of splenic lesions and the spleen." Radiographics. 2004;24(4):1137-1163.

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

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The ultrasound image demonstrates a heterogeneous and echogenic spleen with evidence of atrophy and multiple areas of calcification—consistent with autosplenectomy. This appearance is classically associated with chronic sickle cell anemia.

In sickle cell disease, repeated vaso-occlusive episodes result in infarctions, fibrosis, and progressive calcification of the spleen. Over time, this leads to functional asplenia or complete autosplenectomy (involution and shrinkage of the spleen). The hallmark sonographic features include:

A small, echogenic spleen

Multiple coarse calcifications

Irregular contour or atrophic appearance

These findings are not typically seen in other conditions:

A. Trauma may cause subcapsular hematomas or lacerations, but not chronic atrophy with calcifications.

C. Immunocompromised patients may develop abscesses or infections but not the classic features of autosplenectomy.

D. Portal hypertension typically causes splenomegaly and varices, not atrophic and calcified spleens.

Addison disease (primary adrenal insufficiency) results in insufficient production of cortisol and aldosterone. The hallmark laboratory findings include:

Hyponatremia (low sodium)

Hyperkalemia (high potassium)

Elevated liver enzymes (due to nonspecific hepatic involvement)

Fatigue, weight loss, and hypotension are common clinical features.

Conn syndrome (B) causes hyperaldosteronism, leading to hypokalemia (not hyperkalemia).

Acute pancreatitis (C) would typically show elevated amylase/lipase.

Hepatocellular carcinoma (D) may present with elevated liver enzymes but not the electrolyte pattern described.

Reference Extracts:

Nieman LK. "Diagnosis and Treatment of Primary Adrenal Insufficiency." J Clin Endocrinol Metab. 2011;96(7):1957-1966.

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

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Von Hippel-Lindau (VHL) syndrome is a genetic disorder associated with multiple pancreatic cysts, pancreatic neuroendocrine tumors, and other systemic neoplasms. While cystic fibrosis can produce thickened pancreatic secretions, it rarely causes true pancreatic cysts.

According to Rumack’s Diagnostic Ultrasound:

“Multiple pancreatic cysts are strongly associated with Von Hippel Lindau syndrome.”

The normal gallbladder wall measures up to 3 mm. Thickening beyond 3 mm may suggest cholecystitis, heart failure, hepatitis, or hypoalbuminemia. Measurements should be taken with the patient fasting, using the anterior gallbladder wall.

According to Rumack’s Diagnostic Ultrasound:

“The gallbladder wall is considered thickened if it measures greater than 3 mm.”

The tunica albuginea is a dense fibrous capsule surrounding the testis. Discontinuity of the tunica albuginea on ultrasound is diagnostic of testicular rupture — a urologic emergency that requires immediate surgical repair to preserve testicular function and viability. Early surgical intervention within 72 hours has a high success rate for testicular salvage (up to 90%).

Intratesticular hematoma (A) may be managed conservatively if the tunica albuginea is intact.

Heterogeneity of the parenchyma (C) indicates injury but not necessarily rupture.

Increased vascularity (D) may be seen with inflammation or reperfusion but does not mandate surgery unless rupture is present.

Reference Extracts:

Dogra VS, Bhatt S. "Acute painful scrotum: ultrasound evaluation." Radiologic Clinics of North America. 2004; 42(2):349-363.

Middleton WD, Kurtz AB, Hertzberg BS.Ultrasound: The Requisites. 3rd ed. Elsevier, 2015.

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