ARDMS AB-Abdomen Abdomen Sonography Examination Exam Practice Test

A full bladder provides an acoustic window that displaces bowel gas and distends the bladder walls, allowing optimal visualization of any bladder masses or lesions. An empty bladder may collapse, obscuring masses.

According to Rumack’s Diagnostic Ultrasound:

“Bladder evaluation should be performed with the bladder optimally distended to visualize its walls and any intraluminal masses.”

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.”

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 demonstrates a transverse view of the abdominal vasculature, where the arrow is pointing to a circular vascular structure anterior to the aorta and posterior to the body of the pancreas — consistent with the superior mesenteric artery (SMA).

The SMA originates from the anterior aspect of the abdominal aorta just below the level of the celiac trunk and courses anterior to the left renal vein and uncinate process of the pancreas. On transverse ultrasound, it is often seen in cross-section as a round, pulsatile structure with echogenic walls, situated just anterior to the aorta. This appearance is known as the “target sign” or “bull's-eye” appearance.

Vessel Position Landmarks (transverse plane):

Aorta: Posterior and central

SMA: Just anterior to the aorta

Left renal vein: Passes between the aorta and SMA (nutcracker location)

Right renal artery: Courses posterior to the IVC toward the right kidney

Differentiation from other options:

A. Proper hepatic artery: Typically visualized within the liver hilum (portal triad), not in this anatomic location.

C. Left renal vein: Seen in transverse as a longer, oval structure crossing anterior to the aorta and posterior to the SMA.

D. Right renal artery: Arises laterally from the aorta and courses posterior to the IVC — not visualized in this axial midline location.

A urachal cyst arises from incomplete closure of the urachus, a remnant of the fetal allantoic duct connecting the bladder to the umbilicus. It appears as a midline, anechoic, nonvascular mass located between the bladder dome and the umbilicus.

According to Rumack’s Diagnostic Ultrasound:

“A urachal cyst is a midline, anechoic structure located between the bladder and umbilicus, resulting from incomplete obliteration of the urachus.”

Transitional cell carcinoma (TCC) typically presents as a non-mobile, polypoidal, focal intraluminal mass projecting from the bladder wall. Mobility of the lesion helps differentiate TCC from blood clots or debris.

According to Rumack’s Diagnostic Ultrasound:

“Bladder TCC most often appears as a non-mobile, polypoid mass attached to the bladder wall.”

The ultrasound image shows a classic longitudinal view of a markedly thickened pyloric muscle with an elongated pyloric channel. This finding is consistent with hypertrophic pyloric stenosis (HPS), a condition most commonly seen in male infants between 2 and 8 weeks of age.

The most characteristic clinical finding associated with HPS is an “olive-shaped” palpable mass in the right upper quadrant or epigastric region, which represents the hypertrophied pylorus.

Clinical presentation of HPS includes:

Non-bilious projectile vomiting (due to gastric outlet obstruction)

Dehydration and weight loss

A palpable “olive” mass on physical exam

Visible peristalsis may be noted on the abdominal wall

Sonographic diagnostic criteria for HPS:

Pyloric muscle thickness ≥ 3 mm

Pyloric channel length ≥ 15–17 mm

“Cervix sign” or “target sign” (transverse view)

Failure of gastric contents to pass through the pylorus on real-time imaging

Differentiation from other options:

B. Fever of unknown origin: Not characteristic of HPS.

C. Red currant jelly stools: Classic for intussusception.

D. Bilious vomiting: Seen in distal duodenal or jejunal obstruction, not in pyloric stenosis (vomiting is non-bilious in 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.

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.”

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.”

The arrow in this Doppler ultrasound image of the kidney is pointing to vessels located at the corticomedullary junction, arching over the bases of the medullary pyramids. This vascular pattern is characteristic of the arcuate arteries.

Renal arterial anatomy follows a specific branching hierarchy:

Segmental arteries branch off the main renal artery.

Interlobar arteries travel between renal pyramids.

Arcuate arteries arch over the base of the pyramids at the corticomedullary junction.

Interlobular arteries extend into the cortex from the arcuate arteries.

Key characteristics of arcuate arteries on ultrasound:

Located at the corticomedullary junction (between the medullary pyramids and renal cortex).

Run perpendicular to the long axis of the kidney, often forming an arching or curving pattern.

Commonly targeted in Doppler studies to assess resistive index (RI) in renal perfusion studies.

Comparison of answer choices:

A. Interlobular arteries are smaller vessels that extend perpendicularly from the arcuate arteries into the cortex—not visible at this level.

B. Arcuate — Correct. The arrow is indicating these vessels arching over the medullary pyramids.

C. Segmental arteries are larger and deeper, branching off the renal artery near the hilum.

D. Interlobar arteries course between the pyramids but do not arch along their base.

An intimal flap in the aorta is a hallmark ultrasound finding of aortic dissection, which can present with tearing chest/abdominal pain and differential blood pressures between arms. The flap represents separation of the intimal and medial layers of the aortic wall.

According to Rumack’s Diagnostic Ultrasound:

“An intimal flap visualized within the aorta is diagnostic of an aortic dissection.”

The spectral Doppler image demonstrates excessive noise along the baseline, including a “fuzzy” or filled-in spectral window. This artifact is known as spectral broadening or “blossoming,” and it typically results from excessive Doppler gain.

When Doppler gain is set too high, it amplifies not only the true Doppler signal but also the background noise. This results in a falsely broadened waveform that can obscure diagnostic information such as peak velocities or flow turbulence. The best way to correct this artifact is to reduce the Doppler gain (Option A).

Key points regarding gain-related artifact:

Excessive gain exaggerates spectral display by amplifying weak signals and noise.

Reducing gain restores the clarity of the spectral window and accurate envelope definition.

The goal is to optimize gain just enough to see the real flow signals without cluttering the display.

Differentiation from other options:

B. Adjust baseline: Useful in avoiding aliasing but does not affect gain-related noise.

C. Increase wall filter: Removes low-frequency signals from vessel wall motion but not background spectral noise.

D. Increase pulse repetition frequency (PRF): Used to reduce aliasing in high-velocity flow, not to address gain-related spectral clutter.

De Quervain thyroiditis (subacute granulomatous thyroiditis) is often triggered by a viral infection. Patients may present with painful thyroid enlargement, elevated inflammatory markers, and transient hyperthyroidism. Hashimoto’s and Graves' diseases are autoimmune in nature.

According to Braverman’s The Thyroid:

“Subacute (De Quervain) thyroiditis typically follows a viral upper respiratory tract infection and is characterized by thyroid pain and transient thyrotoxicosis.”

Lipase is the most sensitive and specific laboratory marker for diagnosing acute pancreatitis. It rises earlier, remains elevated longer (up to 14 days), and is more pancreas-specific than amylase. Amylase may normalize within 48-72 hours and may also be elevated in non-pancreatic conditions.

According to ACG (American College of Gastroenterology) Guidelines:

“Serum lipase is preferred over amylase due to its higher sensitivity, specificity, and prolonged elevation in pancreatitis.”

The ultrasound image demonstrates a dilated duodenum with a hypoechoic soft tissue structure encircling it. This is a classic sonographic appearance suggestive of an annular pancreas. In annular pancreas, pancreatic tissue completely or partially encircles the second portion of the duodenum, which can lead to duodenal narrowing or obstruction.

Annular pancreas is a congenital anomaly that results from failure of the ventral pancreatic bud to rotate properly during embryologic development. As a result, pancreatic tissue encircles the duodenum. It may present in neonates with symptoms of duodenal obstruction or in adults with abdominal pain, pancreatitis, or vomiting.

Ultrasound Findings:

Hypoechoic pancreatic tissue encircling the duodenum

Evidence of duodenal dilatation proximal to the obstruction

“Double bubble” sign may be seen in neonates

Differentiation from other options:

A. Supernumerary kidney: Refers to an accessory kidney. It would be seen in the retroperitoneum and is unrelated to the duodenum or pancreas.

B. Pancreas divisum: A ductal anomaly best diagnosed on MRCP or ERCP. It is not typically visible on conventional ultrasound.

D. Horseshoe kidney: A renal fusion anomaly where the lower poles of the kidneys are fused. It is seen in the pelvis or lower abdomen and does not involve the duodenum or pancreas.

The ultrasound image shows the liver in a transverse view with the arrow pointing to the middle hepatic vein (MHV). The MHV is a key sonographic landmark that anatomically divides the right and left lobes of the liver.

According to Couinaud's segmental anatomy, which is the basis for surgical and radiological liver segmentation:

The middle hepatic vein runs within the main lobar fissure.

It separates the right lobe (segments V–VIII) from the left lobe (segments II–IV).

This division is crucial in liver surgery and interventional procedures.

Comparison of answer choices:

A. Right anterior and posterior segments are divided by the right hepatic vein, not the middle hepatic vein.

B. Right and left lobes — Correct. The middle hepatic vein, shown by the arrow, defines this boundary.

C. Left medial and lateral segments are divided by the left hepatic vein or falciform ligament.

D. Left superior and inferior is not a standard anatomic division in liver segmentation.

Acute pyelonephritis is a bacterial infection of the renal parenchyma and collecting system. Classic clinical findings include fever, flank pain, leukocytosis (elevated white blood cells), and pyuria (white blood cells in urine). Ultrasound may demonstrate renal enlargement, decreased echogenicity, and loss of corticomedullary differentiation.

Nephrocalcinosis (A) involves calcium deposition without infection.

Staghorn calculus (B) may lead to infection but is primarily characterized by obstructive uropathy.

Renal cell carcinoma (C) presents with hematuria and mass formation rather than infection symptoms.

Reference Extracts:

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

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

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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.”

After successful TIPS placement, the intrahepatic portal venous branches continue to exhibit hepatopetal (toward the liver) flow, while the stent itself shows continuous, relatively high-velocity monophasic flow. Hepatofugal flow in intrahepatic branches may indicate shunt dysfunction.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“Normal post-TIPS Doppler shows hepatopetal flow in the intrahepatic portal veins and continuous high-velocity flow within the stent.”

The FAST exam is primarily used to detect free intraperitoneal or pericardial fluid in trauma patients, serving as a rapid, bedside assessment tool. While organ injuries may be suspected, the FAST exam is not primarily designed to assess for solid organ lacerations.

According to AIUM and ACEP guidelines:

“The primary goal of the FAST exam is to detect the presence of free fluid suggestive of hemorrhage in trauma patients.”

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.”

Chronic rejection presents sonographically as cortical thinning, decreased renal size, and increased echogenicity of the renal sinus fat. Acute rejection typically causes an enlarged, edematous kidney with increased parenchymal echogenicity but preserved size early on.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“In chronic rejection, the allograft becomes smaller with cortical thinning, increased echogenicity, and prominence of the central sinus fat.”

Branchial cleft cysts are congenital epithelial cysts that typically occur laterally in the neck, often anterior to the sternocleidomastoid muscle, and lateral to the thyroid gland. The second branchial cleft cyst is the most common type and is found in the lateral neck region.

Medial (B) would be more consistent with thyroglossal duct cysts.

Anterior (C) or posterior (D) do not specifically describe branchial cyst location relative to the thyroid.

Reference Extracts:

Som PM, Curtin HD. Head and Neck Imaging. 5th ed. Elsevier, 2011.

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

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The ultrasound image provided shows a transverse view of the abdominal aorta, with a clearly measured aortic diameter of 5.71 cm. A normal adult abdominal aorta should measure less than 3.0 cm in anterior-posterior diameter. Any measurement exceeding this threshold is defined as an abdominal aortic aneurysm (AAA).

In this case, the dilation is well beyond the 3.0 cm threshold, confirming the presence of an aneurysm. The rounded, anechoic/heterogeneous central lumen surrounded by echogenic arterial wall layers further supports this diagnosis.

Comparison of answer choices:

A. Stenosis: Would show a narrowed lumen with turbulent, aliasing flow on Doppler, not a dilated aorta.

B. Dissection: Typically shows an echogenic intimal flap separating true and false lumens; no flap is visible here.

C. Aneurysm: Correct. The aorta’s transverse diameter (5.71 cm) confirms the presence of an aneurysm.

D. Occlusion: Would appear as a lack of flow with thrombus or echogenic content filling the lumen, not dilation.

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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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.”

Retroperitoneal fibrosis can encase and compress the ureters, leading to obstructive uropathy and hydronephrosis. It may also involve other retroperitoneal structures but hydronephrosis is the most common significant complication.

According to Rumack’s Diagnostic Ultrasound:

“Retroperitoneal fibrosis frequently results in ureteral obstruction, leading to hydronephrosis.”

The ultrasound image labeled “SAG RUQ KIDNEY” demonstrates a midline sagittal view showing a renal parenchymal structure that extends across the midline anterior to the aorta and vertebral bodies, suggesting the presence of a horseshoe kidney.

A horseshoe kidney is a congenital renal anomaly in which the lower poles of both kidneys are fused across the midline by a parenchymal or fibrous isthmus. This isthmus typically lies anterior to the aorta and inferior vena cava and can be seen as a hypoechoic band of tissue crossing the midline on ultrasound.

Ultrasound findings characteristic of a horseshoe kidney:

Abnormally low position of the kidneys in the abdomen

Renal tissue (isthmus) bridging the lower poles anterior to the great vessels

Renal axes may be more horizontal than usual

Kidneys may appear closer together or “kissing” the spine anteriorly

Differentiation from other options:

A. Duplicated collecting system: Manifests as two separate collecting systems within one kidney, often with a central renal sinus split into two — not typically midline bridging.

B. Crossed renal ectopia: Involves one kidney crossing midline and fusing with the other on the opposite side, but they do not form a midline isthmus.

D. Pelvic kidney: A single kidney located in the pelvis due to failed ascent — it does not appear as midline fusion of two kidneys.

The ultrasound image shows an ovoid, homogeneously hypoechoic soft tissue structure located in the inguinal canal, surrounded by echogenic fat and soft tissue. This is consistent with an undescended testis, also known as cryptorchidism.

Cryptorchidism refers to the failure of one or both testes to descend into the scrotal sac. On ultrasound, the undescended testis typically appears:

Ovoid in shape

Homogeneous and hypoechoic compared to scrotal testis

Located in the inguinal canal or, less commonly, within the abdomen

Smaller in size than a normally descended testis

Comparison of answer choices:

A. Bell clapper deformity refers to an anatomic predisposition for testicular torsion where the tunica vaginalis surrounds the entire testis and epididymis—usually a clinical rather than directly sonographic diagnosis.

B. Inguinal hernia appears as bowel or omentum within the inguinal canal or scrotum with peristalsis or fat—no bowel loops are seen here.

C. Pyocele is a complex fluid collection around the testis (usually with septations and internal echoes)—not evident in this image.

D. Cryptorchidism — Correct. The findings match those of an undescended testis in the inguinal canal.

Acute tubular necrosis (ATN) is the most common cause of early graft dysfunction following renal transplantation. It results from ischemia-reperfusion injury during the transplantation process. Ultrasound findings may be nonspecific but Doppler may show elevated resistive indices.

Ureterocele (A) is a congenital anomaly.

Transplant artery stenosis (C) is a late complication.

Transitional cell carcinoma (D) is rare and not typically an early complication.

Reference Extracts:

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

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.

Tissue harmonic imaging significantly reduces reverberation and side-lobe artifacts by utilizing nonlinear propagation of ultrasound waves. This produces clearer images of fluid-filled structures like the gallbladder, improving visualization of wall thickness and intraluminal contents.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“Harmonic imaging effectively reduces reverberation artifact, improving image quality in gallbladder and cystic structure evaluation.”

In percutaneous procedures such as biopsies or drainages, maintaining a sterile field is critical to avoid introducing infection. While the transducer is covered by a sterile cover, the gel placed inside this cover (between the probe and the cover) must also be sterile, as it contacts the sterile field. The transducer itself and machine controls are not sterile but are handled appropriately to avoid field contamination.

According to the AIUM Guidelines:

"Sterile coupling gel must be used inside the sterile probe cover during all invasive or percutaneous procedures." (AIUM Guidelines for Cleaning and Preparing Ultrasound Transducers, 2021).

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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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.”

The superior mesenteric artery (SMA) is typically visualized surrounded by an echogenic fat pad in the mesentery, producing a characteristic "echogenic ring" appearance on ultrasound. This is a helpful landmark for identifying the SMA in the transverse abdominal aortic plane.

According to Rumack’s Diagnostic Ultrasound:

“The superior mesenteric artery is often seen as a round anechoic structure surrounded by echogenic fat at its origin from the anterior aorta.”

The ultrasound image demonstrates a tubular, non-compressible, blind-ending structure located in the right lower quadrant (RLQ) with associated echogenic periappendiceal fat and possibly adjacent fluid or phlegmon. These features are consistent with appendicitis. Given the clinical history of fever and RLQ pain, along with the irregular borders and complex periappendiceal findings, the diagnosis of a ruptured appendix is most likely.

Key sonographic features of ruptured appendicitis include:

Non-visualization or distortion of the normal appendiceal wall architecture

Periappendiceal fluid collection or abscess

Disruption of the echogenic submucosal layer

Surrounding fat stranding (hyperechoic inflammatory changes)

Clinical correlation with fever and peritonitis

Comparison of answer choices:

A. Bowel obstruction typically shows dilated bowel loops with air-fluid levels, not a tubular structure like the appendix.

B. Intussusception presents with a target or “donut” sign in a transverse view, not a linear tubular structure.

C. Enlarged lymph nodes are usually round or oval and hypoechoic with a central echogenic hilum, without a tubular appearance.

D. Ruptured appendix — Correct. The ultrasound features and clinical presentation match.

Littoral cell angioma is a rare, benign vascular tumor of the spleen, arising from the littoral cells lining the splenic sinusoids. In contrast, lymphoma, metastasis, and angiosarcoma are malignant splenic neoplasms.

According to WHO Classification and Rumack’s Diagnostic Ultrasound:

“Littoral cell angioma is a rare benign vascular neoplasm of the spleen with characteristic imaging findings.”

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.”

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.”

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 most common symptom of cholelithiasis (gallstones) is biliary colic, characterized by intermittent right upper quadrant or epigastric pain often triggered by fatty meals. Jaundice occurs in complications such as choledocholithiasis.

According to Rumack’s Diagnostic Ultrasound:

“Gallstones may cause biliary colic — episodic upper abdominal pain often related to food intake.”

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.

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.

D. Acute medical renal disease: Affects the kidneys, often with bilateral renal enlargement and increased cortical echogenicity—again not related to liver imaging.

Hepatic adenomas are benign liver tumors strongly associated with long-term use of oral contraceptives and are most frequently found in women under 40. Hepatoblastoma is seen in children; hepatoma (HCC) is a malignant tumor typically found in cirrhotic livers. Cavernous hemangioma is unrelated to oral contraceptives.

According to Rumack’s Diagnostic Ultrasound:

“Hepatic adenomas occur predominantly in young women with a history of oral contraceptive use.”

Lateral decubitus positioning allows shifting of internal echoes within the bladder, helping differentiate mobile debris (such as blood clots or sediment) from adherent masses like tumors. This technique is helpful in evaluating questionable bladder filling defects.

According to Rumack’s Diagnostic Ultrasound:

“Changing the patient’s position, such as turning to the lateral decubitus, can help distinguish mobile debris from attached bladder wall lesions.”

Most thyroid cancer recurrences are found in the ipsilateral neck—particularly in the central (level VI) or lateral (levels II-V) compartments on the same side as the original malignancy.

According to AIUM Practice Parameters:

“Post-thyroidectomy recurrence most frequently occurs ipsilateral to the original tumor, commonly involving regional lymph nodes.”

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.