Ch. 19 & 20 Flashcards
(194 cards)
1
Q
Why do people go to the ER
A
Trauma Chest/abd pain SOA N/V Broken bones
2
Q
Peritoneal lavage is used to
A
sample intraperitoneal space for evidence of damage to viscera and blood vessels
3
Q
Peritoneal lavage is a diagnostic technique is certain cases of
A
blunt abd trauma
4
Q
FAST stands for
A
Focused assessment with sonography for trauma
5
Q
FAST
A
limited exam of abd or pelvis to evaluate free fluid or pericardial fluid
6
Q
In context of traumatic injury, free fluid is usually due to
A
hemorrhage and contributes to the assessment of circulation
7
Q
FAST, where do we look
A
Perihepatic area (morrisons) Perisplenic region (splenorenal) Paracolic gutters Cul-de-sac Pericardium
8
Q
FAST takes about
A
4 minutes
9
Q
FAST: goal to scan (locations)
A
4 quadrants
Pericardial sac
Cul-de-sac for presence of free fluid or hemoperitoneum
10
Q
FAST: scan _ to look for pericardial effusion
A
subxiphoid
11
Q
FAST: RUQ
A
Diaphragm
dome of liver
Morrisons pouch
Rt kidney/flank
12
Q
FAST: LUQ
A
Diaphragm
Spleen
Lt kidney/flank
13
Q
FAST: also scan
A
liver texture
epigastrium
14
Q
Hemoperitoneum
A
bloody fluid in abdomen
15
Q
Fluid collects in
A
dependent portions of the abd
16
Q
Most common areas for fluid collection in the abd
A
subhepatic space & pelvis
17
Q
Sonographic appearance of hepatic and splenic injury varies according to
A
Type and time of the injury
18
Q
Sonography best at detecting liver lacerations or contusions such injuries appear
A
heterogeneous or hyperechoic.
19
Q
Hematomas and localized lacerations initially appear _ due to _
A
hypoechoic w/ low level echoes
RBC’s
20
Q
Hematomas and localized lacerations appear _ as blood begins to coagulate
A
echogenic
21
Q
Hematomas and localized lacerations appear more _ over time w/ onset of hemolysis
A
anechoic
22
Q
Clinical findings of cholecystitis
A
RUQ pain
Fever
N/V
Leukocystosis
23
Q
Sono: cholecystitis
A
Thickened GB wall
+ murphys sign
Pericholecystic fluid
Dilated GB (4-5cm in trans)
24
Q
Clinical findings of pancreatitis
A
Epigastric pain radiating to back Fever Leukocytosis Elevated amylase (1st) Elevated lipase
25
Sono: pancreatitis
Normal-edematous (swollen)
Hypoechoic texture
Irregular borders
Increased vascular flow
26
Clinical findings of aortic aneurysm/dissection
Abd/chest pain radiating to back
Syncope
Hypotension
27
Sono: aortic aneurysm/dissection
Look for false lumen
Look for intimal flap
Document location of aneurysm to renal arteries/veins
28
Most aortic aneurysms/dissections are
Ascending
29
Causes of aortic dissection
```
HTN (70-90%)
Marfan (16%)
Pregnancy
Acquired or congenital aortic stenosis
Coarctation of aorta
Trauma
Iatrogenic
```
30
Pericardial effusion: if inflammatory or malignant, may appear
Complex
31
Pericardial effusion: _ of effusion is important
Size
32
Clinical: Urolithiasis
```
Spasmodic flank pain
Pain may radiate into pelvis
Leukocytosis
Hematuria (85% of cases)
Fever
```
33
Sono: urolithiasis
Highly echogenic foci- posterior shadowing
possible hydronephrosis
Image the jets
34
Clinical: Appendicitis
```
Severe RLQ pain
N/V
Fever
Leukocytosis
Mcburneys sign
```
35
Sono: appendicitis
Distended append.
Noncompressible
"Target" lesion (trans)
36
Causes of paraumbilical hernia
Weak abd wall Inc. abd pressure from ascites
| Abd mass Obesity Repeated pregnancy
37
Sono: Paraumbilical hernia
Peristalsis of bowel within hernia during valsalva
Most contain colon, omentum, & fat
Complex due to fluid, fat, gas
Fat –echogenic
38
Causes of scrotal trauma & torsion
MVA, sports injury, straddle injury, etc
39
Scrotal trauma/torsion: determine if _
scrotal rupture
40
_% of testes are saved if sx is performed within _
90
| 72 hours
41
_ & _ are complications of trauma
Hematoceles
| Hydroceles
42
Sono: Scrotal rupture
Focal alteration of testicular parenchyma Irregular contour Interruption of outer layering: tunica albuginea
Scrotal wall thickening
Hematocele
43
Testicular torsion is due to _
abnormal mobility of testes (bell clapper)
44
Clinical: Test. torsion
Sudden pain & swelling on affected side
45
Sono: test. torsion
Possible normal appearance in early stage
4-6 hours: swollen & hypoechoic
24 hours: heterogeneous due to hemorrhage No color flow
46
Causes of extr. swelling & pain
DVT
Bakers cyst
Cellulitis
Abscess Hematoma Fasciitis
47
The most common reason for liver transplantation in the United States is
Cirrhosis due to chronic hepatitis C, followed by alcohol abuse
48
Other Causes/ Liver Diseases
```
Chronic hepatitis B and autoimmune hepatitis Nonalcoholic steatohepatitis (NASH)
Hemochromatosis
Wilson disease (copper)
Budd-Chiari
Biliary diseases
Cancer
```
49
MELD
Model for evaluating end stage liver disease
50
MELD is used to
prioritize pts for liver transplant
51
MELD: higher score =
Increased need for transplant
52
Cadaveric Liver Donation: The recipient portal vein is flushed & occluded with a clamp then an
end-to-end portal vein anastomosis is sewn with sutures
53
Cadaveric Liver Donation: The recipient common hepatic artery is flushed and occluded with a clamp. The _ are then sewn end-to-end using running sutures to create the arterial anastomosis
donor and recipient common hepatic arteries
54
Cadaveric Liver Donation: The arterial and portal venous _ are removedand the liver flushed with blood to begin reperfusion.
clamps
55
Cadaveric Liver Donation: a _ is then performed on the donor liver
Cholecystectomy
56
A _ is sewn between donor and recip. CBDs
choledochodochostomy
57
Living Donor Liver Donation: The surgical technique is _ when compared to a cadaveric liver.
Very similar
58
Living Donor Liver Donation: The allograft may demonstrate better func. more quickly due to
the decreased preservation time in a living donor
59
Living donor liver donation: The recip. will receive _
Part of a liver rather than a full organ
60
Living donor liver donation: The recipient usually receives _
right hepatic lobe
61
Eval of liver allograft: Days _, _, and _ scans
0,1,7
62
After liver transplant, the pts usually has a follow up US every _-_
6 months- 1 year if there are no complications
63
Living donor transplant: the liver donor receives
A cholecystectomy
64
After liver transplant, _ needs to be evaluated for intrahep. and extrahep. ductal dilation, wall thickening, and stones or sludge
Biliary tree
65
Venous and arterial color and spectral doppler needs to be obtained after transplant to look for signs of
thrombus or stenosis
66
It is critical to angle correct in the
rt, lt, and main HA's w/ pulse-wave doppler to accurately assess for stenosis
67
It is important to image _ (not routinely included)
Hepatic arteries
68
Measure _ to obtain the RI
the peak systolic and end diastolic velocities
69
A low RI can be strong indicator of
Proximal stenosis
70
A high RI may indicate
rejection or hepatic venous congestion
71
Sono: transplantedd liver
Liver parenchyma: smooth and homogeneous, isoechoic relative to the right renal cortex.
All vessels and biliary ducts should be anechoic.
Normal CHD: 3 -7 mm
CBD 5 -9 mm.
The HV’s and IVC lack a distinct wall
The PV’s, HA’s, and ducts have echogenic walls
72
Portal Vein
Monophasic, hepatopetal
| Low velocity, continuous flow toward the liver Flow velocity can increase after eating 13mm upper limits normal for PV
73
Hepatic Artery
Flow throughout diastole = low resistance
74
Hepatic Veins
Triphasic, hepatofugal
| Flow toward the IVC, away from transducer
75
IVC flow
Phasic
76
HA velocities should be
below 200cm/s
77
A normal RI in the HA
.5-.7
78
Urgent finding following liver transplant
HA thrombosis, PV, HV or IVC thrombus or occlusion, or active bleeding
79
After transplant, it is common to see
post op fluid collections
| These should resolve on their own
80
The most common cause for liver transplant failure
Rejection
81
Acute rejection occurs within the first
10 days
82
Signs and symp. of rejection
RUQ pain, fever, tachycardia, hepatomegaly, and ascites.
LFT’s may be elevated
Chronic rejection evolves over an extended part of time slowly deteriorating the liver graft causing fibrosis
83
Infection and Abscesses
Localized fluid collections of necrotic inflammatory tissue that contain purulent/infectious material
84
S&S of infection and abscesses
Fever
RUQ pain
Jaundice
85
Treatment for infection and abscesses
Percutaneous drainage
86
Sono: abscess
thick walls
hypoechoic and complex
air-fluid level with poorly defined borders
Gas bubbles may be present, will appear as a “dirty” shadow.
can have varied appearances: internal septations or appear solid mimicking a mass
87
Hepatic Vein and IVC Thrombosis and Stenosis occurs
less than 1% after transplant
88
Thrombosis and stenosis is most common to occur at
the anastomosissites due to size discrepancy between the native and transplant vessels or suprahepaticcavalkinking
89
Stenosis: The IVC can be narrowed from
compression from post-op edema or a large hematoma creating a stenosis.
90
Hepatic Vein and IVC Thrombosis and Stenosis: _ may be visualized
Color Doppler aliasing and tripling of the spectral Doppler waveform velocities demonstrating turbulence. HV dilation w/ dampened monophas. waveform
91
PV stenosis will demonstrate color & spectral doppler
Aliasing
92
Portal Vein Thrombus results from
caliber differences in the vessels, stretching of the PV near the anastomotic site, slow portal inflow, or hypercoagulable states. 3% of patients!
93
Fresh thrombus appears
echogenic and can be either occlusive or nonocclusive
94
Hep. art. stenosis: risk factors
rejection
| poor surgicl technique, or clamp
95
Hep. art. stenosis will see color and spectral doppler
aliasing w/ turbulent flow
96
Hep. art. stenosis: pulse-wave doppler will demonstrate
```
low RI (200cm/s
tardus parvus wave form
```
97
The most common vascular complication of liver transplantation is
HA thrombosis
98
HA thrombosis and stenosis can lead to
biliary ischemia
99
_ is the only vascular supply to the biliary ducts
HA
100
HA thrombosis: there will be absence of
color and no flow on spectral doppler
101
On greyscale, _ filling the HA lumen may be visualized
echogenic thrombus
102
In 85% of cases, hepatic infarction is associated with
HA complications
103
Ischemic areas within the liver can _ overtime and may become
liquefy
| infected and calcs may be present
104
Infarction:
Hypoechoic wedge shaped
105
In about 5% to 15% of liver transplant patients, _ occur
Biliary complications
106
Biliary complications typically occur within
the first 3 months after transplant
107
Biliary complications include
biliary ductal obstruction, stenosis or stricture at the anastomosis, stone formation, biliary necrosis, sphincter of Oddi dysfunction, and recurrent biliary disease
108
_ is the most common biliary complication
Obstruction
109
Biliary obstruction is usually caused from
a stricture at the anastomosis but may also be secondary to choledocholithiasis.
110
Most strictures are
extrahepatic and near the anastomosis caused from fibrotic tissue scarring
111
Biliary ductal ischemia is secondary to
HA thrombosis or stenosis as the ducts are dependent on the HA for their only blood supply.
112
Biliary necrosis occurs and _ may follow
biliary stenosis, bile leaks and bilomas
113
If angioplasty of the stenotic duct is not successful
retransplantation is often necessary.
114
Hematomas are most common along the
perihepatic spaces and near the vascular and biliary anastomoses sites
115
Most hematomas will
resolve spontaneously with no intervention needed
116
Hematomas typically have
irregular walls, ovoid in shape, and decrease in size over time. Fresh hematomas have more internal echoes and can appear echogenic
117
Seromas
clear, serous fluid collections that are usually found within the first few days after transplantation.
118
Seromas are most common along
perihepatic spaces and near the vascular and biliary anastomoses sites
119
Most seromas will
resolve spontaneously within a few weeks
120
Lymphoceles
A surgical disruption of lymphatic channels causes lymph fluid leakage into the soft tissue space
121
Lymphoceles are typically found in the
Groin or septations within the fluid collection may be seen
122
Bile leaks are most often located at the
biliary tube site with rare occurrences at the anastomotic site
123
Bile seeps into the peritoneal cavity and may form a
contained perihepatic collection, or biloma.
124
_ is usually present in small amounts in the early postoperative period. It may contain debris or blood products
Ascites
125
The ascites commonly resolves in
7-10 days
126
Patients who initially present with small HCC lesions with no extrahepatic involvement typically have a
reasonable long-term survival following liver transplantation
127
The recurrence of HCC is seen in about _ of pts after their liver transplant
40%
128
The most common site of HCC recurrence is the
lung followed by the liver
129
Hep. C reinfection occurs in
nearly all patients who receive a liver transplant for HCV cirrhosis
130
An infected liver will have a _ echotexture
heterogeneous and coarsened
131
Portal venous gas is a
Common finding on US in the early postop period
132
Beyond the early postop state, air visualized within the portal and mesenteric veins is assoc. w/
poor prognosis
133
Some underlying causes of the portal venous gas are
intestinal ischemia and necrosis, followed by ulcerative colitis, and intraabdominalabscess
134
Post-transplant lymphoproliferativedisorder (PTLD) is
one of the most severe complications found in solid organ as well as stem cell transplantation
135
PTLD can range from
benign reactive hyperplasia of tissue to malignant lymphoma
136
The location of PTLD can be
focal or diffuse and more commonly seen extrahepatic
137
On ultrasound imaging, PTLD usually appears
as a hypoechoicsoft tissue mass and may encase the hepatic hilum.
138
TIPS is created to
lower portal HTN
139
TIPS is placed by using
jugular access
140
TIPS is placed between
RHV & RPV
141
Routine doppler eval of TIPS is utilized in
6 month intervals
142
A widely patent TIPS, the RPV and LPV will demonstrate
Hepatofugal flow
143
TIPS malfunction: _ shunt velocity
Low
| <50cm/s
144
TIPS malfunction: _ focal shunt velocity
High
| >190cm/s
145
TIPS malfunction: LPV & RPV flow
Hepatopetal
146
TIPS malfunction: MPV
Hepatofugal
147
TIPS malfunction: absent _
shunt flow
148
The most common cause for needing a renal transplant is
chronic end-stage renal disease or renal failure. (ESRD)
149
Symptoms of renal failure begin when the kidney only has _ functioning tissue
10%
150
Causes of renal failure
Diabetes (most common that leads to transplant)
HTN and RAS or RVT
Obstruction
Inherited kidney disease
151
S&S renal disease
```
Decreased urine output Lower extremity edema
SOA
Fatigue
Confusion
Chest pain
```
152
Commonly, the renal transplant will be placed into the
Right iliac fossa
153
If combined renal and panc transplant, kidney is typically placed _ and panc is placed _
left iliac fossa
| right iliac fossa
154
In cadaveric renal transplants, the main renal artery is harvested with an attached portion of donor aorta which is then anastomosed
end-to side to the recipient external iliac artery
155
Live donor transplants involve a direct end-to-side renal arterial graft to the
external iliac artery or an end-to-end anastomosis with the internal iliac artery
156
The main renal vein is almost always grafted to the recipient
external iliac vein in an end-to-side manner
157
Urinary drainage is usually restored by implanting the donor ureter into the
bladder dome (ureteroneocystostomy) although it can also be implanted to the native ureter or renal pelvis
158
Renal autotransplantation: the pts own kidney is
removed from the retroperitoneum and reimplaneted into the iliac fossa
159
Autotransplantation is performed to help treat or manage
Ureteral injuries or stenosis due to retroperitoneal fibrosis, renovascular disease such as renal artery stenosis or aneurysms, renal cell carcinoma (RCC), ureteral cancer, severe cases of nephrolithiasis, and severe loin pain-hematuria syndrome when all other conventional methods have failed
160
Following kidney transplant, obtain US
24-48 hours post op
161
After kidney transplant look for
Hydronephrosis, masses, fluid collections, or ascites
162
After transplant renal parenchyma should appear
Hypoechoic relative to liver w/ the sinus fat being echogenic
163
The collecting system should be
Free of fluid or debris
164
It is common to see _ after renal transplant
mildly dilated renal pelvis or extrarenal pelvis due to high urinary output through a single functioning kidney
165
The RA will be _ on color doppler
Red
166
Renal: Spectral waveform demonstrates a
rapid systolic upstroke with continuous diastolic flow above baseline demonstrating a low resistance waveform
167
RA velocities should be
Below 250cm/s
168
A normal RI in arcuate arteries
.6-.7
169
Renal transplant: Normal RI
170
If RI = 1.0
diastole is absent
171
Renal dysfunction results in
loss of diastolic flow thus increased RA resistance
172
Normal intrarenal arteries
Low resistance
| RI
173
Renal transplant: urgent findings
RA severe stenosis or kinking of vessel affecting the flow within the renal parenchyma
RA, RV, CFA, iliac artery or vein thrombus or occlusion
An identified source of active bleeding
174
It is common to perform routine protocol parenchymal biopsies around
4 months after transplant, follwed by 1yr, 5yr, and 10yr
175
If pt is symptomatic with pain, fever, or elevated creatinine, a _ may be ordered
biopsy
176
Biopsy complications may occur with _ being the most common
Bleeding
177
_ is also a risk factor for bleeding
HTN
178
After a biopsy, a _ can form outside of the kidney capsule and the patient may or may not develop pain
hematoma
179
Biopsy: Needle path may cross small vessels for a potential risk creating an
AVF
180
Biopsy: Inadvertent damage to the collecting system or ureter can also create _
A urine leak forming a urinoma
181
Biopsy: the radiologist will aim
as lateral as possible within the cortex to retrieve enough glomeruli for pathologist to eval while staying away from the renal hilum
182
Causes of graft dysfunction or failure
Rejection
Acute tubular necrosis (ATN)
Drug nephrotoxicity
pyelonephritis-occurs in 80% of recipients in the first year
183
Chronic parenchymal disease and chronic rejection will eventually lead to
Renal failure
184
Renal: The most common complications immediately postoperative and within the first year of transplantation are
Acute rejection and ATN
185
In the early stages following transplantation, _ is the most common cause of hypertension
acute rejection
186
More than 80% of renal transplant recipients develop _ within the 1st year
One infection
187
Debris or low level echoes within a dilated collecting system suggests
Pyonephrosis in a patient who presents with fever
188
Urinary obstruction is seen in about _ of renal transplant recipients and almost always within the first _ months after transplantation
2%
| 6
189
The most common site of obstruction is at the site of
ureteral implantation into the bladder
190
Ureteral stenoses are found in the distal third in more than _% of these patients.
90
191
Narrowing distally may be due to
scarring caused from ischemia or rejection, surgical technique, or kinking.
192
Renal transplant recipients are at a higherrisk for developing
Urinary calculi
193
If the patient’s renal function is quickly declining, _ are considered
Renal stones
194
Twinkle
Stones
