Liver

Question 1

You are scanning a patient with a known mass in the left medial segment of the liver. What anatomic landmark can you use to identify the left medial segment separate from the right anterior segment of the liver?

Answer 1

Middle hepatic vein

Question 2

You suspect enlargement of the caudate lobe in a patient with liver disease. What structure located at the anterior border of the caudate lobe will help you to identify this lobe of the liver?

Answer 2

Fissure for the ligamentum venosum

Question 3

You are asked to rule out the presence of a recannalized paraumbilical. Which anatomic structureis a useful landmark in location of this structure?

Answer 3

Ligamentum teres ** the left portal vein is in contact with the ligamentum teres. A paraumbilical vein begins at the left portal vein and exits the liver at the ligamentum teres. Images of the ligamentum teres will demonstrate the prescence or abscence of the pathologic finding **

Question 4

Which vessel courses within the main lobar fissure?

Answer 4

Middle hepatic vein

Question 5

Oxygenated blood is supplied to the liver via the?

Answer 5

Portal vein and hepatic artery

Question 6

You are performing a sonogram on a slender female and notice a long, thin extension of the inferior aspect of the right lobe of the liver. This most likely represents?

Answer 6

Reidel’s lobe

Question 7

Which of the following forms the caudal border of the left portal vein? A) ligamentum venosum B) Hepatoduodenal ligament C) Main lobar fissure D) Coronary ligament E) Ligamentum teres

Answer 7

Ligamentum teres

Question 8

What ligament divides the left lobe of the liver into medial and lateral segments?

Answer 8

Ligamentum teres

Question 9

You are asked to perform a doppler study on the hepatic veins in the liver. What differentiates the hepatic veins from the portal veins? A) the hepatic veins converge towards the porta hepatis B) The hepatic veins have brightly echogenic walls C) The portal veins are largest near the dome of the liver D) The portal veins are accompanied by branches of the biliary tree and hepatic artery

Answer 9

D) The portal veins are accompanied by branches of the biliary tree and hepatic artery

Question 10

You have detected a mass anterior and to the left of ligamentum venosum. This mass is located in what lobe of the liver?

Answer 10

Left lobe

Question 11

The thin capsule surrounding the liver is known as?

Answer 11

Glisson’s capsle

Question 12

Which of the following course interlobar and intersegmental within the liver?

Answer 12

Hepatic Veins

Question 13

What lobe of the liver does the letter A represent?

Answer 13

Left lobe

Question 14

What structure does the letter B represent?

Answer 14

Ligamentum venosum

Question 15

What lobe of the liver does the letter C represent?

Answer 15

Caudate lobe

Question 16

Identify the structure labeled A in this image of the liver.

Answer 16

Ligamentum teres

Question 17

Identify the anatomy labeled A.

Answer 17

Right posterior portal vein branch

Question 18

Vessel A is located in what lobe of the liver?

Answer 18

Posterior segment right lobe

Question 19

Identify the anatomy labeled C.

Answer 19

Left portal vein

Question 20

The arrow labeled D is pointing to what lobe of the liver?

Answer 20

Caudate lobe

Question 21

You are performing an ultrasound exam of the liver on a small patient with a 5 MHz curbed linear array. Although you have increased the overall gain to its maximum setting, the posterior border of hte liver and diaphragm are not visualized. What should you do?

A) Call the service representative to repair your equipment.

B) Decrease the transmit power on the ultrasound unit.

C) Move the focal zoneinto the near field.

D) Rescan the liver with a higher frequency transducer

E) Rescan the liver with a lower frequency transducer

Answer 21

E) Rescan the liver with a lower frequency transducer

** Lower-frequency transducers provide greater penetration than higher-frequency transducer. Another way to increase the penetration is to increase the transmit power. Decreasing the transmit power will decrease the penetration. Moving the focal zone into the near field will not improve penetration. **

Question 22

Which of the following correctly describes the probe placement and imaging plane you would use to demonstrate the three hepatic veins and inferior vena cava in one view?

Answer 22

Subcostal oblique approach with the probe angled superiorly and to the patient’s right.

Question 23

You are performing a follow up sonogram on a patient in which a 5 mm cyst was previously identified at the anterior border of the left lobe of the liver. Although you are using a 3.5 MHz curved linear array probe, you do not see the cyst. Which of the following would be most helpful in improving visibility of this cyst?

A) Increase the overall gain

B) increase the dynamic range

C) increase the trasmit power

D) rescan the left lobe with a higher frequency transducer

E) rescan the left lobe with a lower frequency linear array transducer

Answer 23

D) rescan the left lobe with a higher frequency transducer

** Visibility of small cysts is limited by spatial resolution. To improve spatial resolution, the best option is to increase the imaging frequency. **

Question 24

You are imaging a patient with a high liver. Subcostal images do not clearly demonstrate the liver tissue. What should you do?

Answer 24

Scan the patient in deep inspiration

Question 25

A patient is referred for ultrasound evaluation of a questionable mass in the dome of the liver seen on CAT scan. Which method below would improve visualization in this area of the liver? A) perform a subcostal scan with the probe angled superior and the patient in deep inspiration B) perform an intercostal scan with the probe in coronal plane and the patient in expiration C) perform a subcostal scan with the patient performing a Valsava maneuver D) roll the patient into a right lateral decubitus position and scan from a subcostal approach with the patient in expiration E) the dome of the liver cannot be seen with ultrasound

Answer 25

A) perform a subcostal scan with the probe angled superiorly and the patient in deep inspiration.

Question 26

A patient is referred for a liver ultrasound with the clinical history of a raised serum alpha-fetoprotein level. What should you look for? A) Focal nodular hyperplasia B) Fatty liver C) Hepatocellular carcinoma D) Hydatid disease E) Increased alpha-fetoprotein levels are not associated with liver disease

Answer 26

Hepatocellular carcinoma \*\* a non pregnant patient with elevated levels of serum alpha-fetoprotein (AFP) may have hepatocellular carcinoma. However, low levels of AFP do not rule out the presence of hepatocellular carcenoma. Other abnormalities associated with high levels of AFP include germ cell tumour of gonadal, retroperitoneal, or mediastinal origin. Occasionally, serum AFP levels may be abnormally high with cancer of the pancreas, stomach or biliary system. Hepatitis and cirrhosis may produce modest serum AFP elevations\*\*

Question 27

You are reviewing lab work prior to performing an abdominal ultrasound exam. Elevated lab values include Gamma-glutamyl transpeptidase (GGT) and alkaline phosphatase. which statement below is true? A) elevation of both GGT and alkaline phosphatase suggests the source of elevated alkaline phosphatase is due to metastatic bone cancer B) elevation of both GGT and alkaline phosphatase is a sensitive indicator of pancreatitis C) if both GGT and alkaline phosphatase are elevated, the lab work is invalid and must be repeat D) concomitant elevation of both GGT and alkaline phosphatase indicates the source of the elevated alkaline phosphatase is the liver E) concomitant elevation of both of these lab values is highly specific for hepatocellular carcinoma.

Answer 27

D) concommitant elevation of both GGT and alkaline phosphatase indicates that the source of the elevated alkaline phosphatase is the liver. \*\* alkaline phosphatase may be elevated with multiple conditions including skeletal disease, hyperparathyroism, and acute hepatocellular disease. GGT is used with alkaline phosphatase to suggest the source of elevated alkaline phosphatase levels. If both alkaline phosphatase and GGT levels are elevaetd, the source of the alkaline phosphatase is probably the liver, indicating hepatocellular dysfunction. \*\*

Question 28

Which of the following lab tests is not used in evaluation of liver function? A) gamma-glutamyl transpeptidase GGT B) Asparatate aminotransferase AST C) Direct bilirubin D) Indirect bilirubin E) Lipase

Answer 28

E) Lipase \*\* **lipase** is used to evaluate acute pancreatitis. **Direct bilirubin** usually indicates biliary obstruction, which may be intrahepatic (due to hepaitis or cirrhosis) or extrahepatic (due to gallstones, gallbladder or pancreatic cancer). **Indirect bilirubin** may be elevated with hepatocellular dysfunction such as hepatitis. **AST** is used in evvaluation of acute hepatic disease. it may also be elevated with recent myocardial infarction. **GGT** is used with alkaline phosphatase to suggest the source of elevated alkaline phosphatase levels.

Question 29

A patient is reffered with right upper quadrant tenderness and a history of oral contraceptive use. A solid, hypoechoic mass is identified in the right lobe of the liver. Color doppler reveals hypervascularity of the mass. which of the following scenarios is most likely? A) Hydatid liver disease B) Hepatic lipoma C) Hepatic abcess D) Hepatic adenoma

Answer 29

D) Hepatic adenoma \*\* The incidence or hepatic adenomas has increased in the US since the 70s. There is a clear association with the used of oral contraceptives. Hepatic adenomas tend to show hypervascularity with color doppler. The ultrasound appearance is qite variable and adenoma cannot be differentiated from focal nodular hyperplasia by gray-scale or doppler appearance. Hepatic adenomas have a propensity to hemorrhage and shock may result from tumor rupture and hemoperitoneum. Hepatic lipomas are quite rare, they are usually asymptomatic well defined and higly echogenic masses. \*\*

Question 30

A liver ultrasound on a 49 year old obese male demonstrates diffuse increased echogenicity with a focal hypoechoic area anterior to the portal vein. This most liekely represents; A) liver cirrhosis with hepatocellular carcinoma B) hydatid disease C) fatty metamorphosis of the liver with focal sparing D) metastatic disease most likely due to a colon primary E) Normal liver parenchyma with a simple cyst

Answer 30

C) fatty metamorphosis of the liver with focal sparing \*\* focal fatty sparing is commonly seen as a hypoechoic mass anterior to the portal vein \*\*

Question 31

A 52 year old male with known liver cirrhosis presents for an abdominal ultrasound. You will carefully evaluate the liver to rule out the presence of any focal mass because of which true statement below? A) patients with liver cirrhoiss are at increased risk for hepatocellualar carcinoma B) patients with liver cirrhosis tend to develop multiple cysts in their liver and pancreas C) metastatic disease occurs commonly with cirrhosis D) the presence of regenerative nodules rules out cirrhosis E) all of the above are correct

Answer 31

A) Patients with liver cirrhosis are at increased risk for hepatocellular carcinoma

Question 32

You are scanning a patient with suspected liver cirrhosis. All of the following are sonographic features of cirrhosis EXCEPT; A) Surface nodularity B) Shrunken caudate lobe C) Altered echo texture D) Ascites E) Regenerative nodules

Answer 32

B) Shrunken caudate lobe \*\* In liver cirrhosis, the caudate lobe is most commonly enlarged compared to the right lobe due to sparing. \*\*

Question 33

An ultrasound evaluation of liver cirrhosis should include a search for which associated complication? A) biliary dilatation B) Mesenteric ischemia C) Splenic infarction D) Kaposi's sarcoma E) Portal Hypertension

Answer 33

E) Portal hypertention \*\* Cirrhosis is the most common cause of intrahepatic portal hypertension in the US \*\*

Question 34

Ultrasound findings of an abdominal study on a 51 year old female include elargement of the hepatic veins and inferior vena cava in an otherwise normal appearing liver. These findings are most consistant with which of the following? A) Budd-Chiari syndrome B) Right-sided heart failure C) Liver cirrhosis D) Portal hypertension E) Sarcoidosis

Answer 34

B) Right sided heart failure

Question 35

Focal fatty liver is most commony found in which location?

Answer 35

Anterior to the portal vein at the porta hepatis

Question 36

You have performed an ultrasound study on a patient with an enlarged caudate lobe, shrunken right lobe and splenomegaly. The hepatic veins could not be identified. No other abnormalities were discovered. What should you do? A) Scan the pelvis to rule out a pelvic mass B) Have the patient perform a Valsava maneuver and reexamine the heptatic veins C) Evaluate the hepatic veins and IVC with color doppler to confirm patency D) Have the patient return in a week for a repeat study to evaluate the hepatic veins E) Nothing, you have completed the exam

Answer 36

C) Evaluate the hepatic veins and IVC with color doppler to confirm patency. \*\* In liver cirrhosis, the thin-walled hepatic veins may become compressed and difficult to identify by B-mode imaging. Color doppler is very helpful in confirming patency of the hepatic veins in this setting. If one or more of the hepatic veins cannot be identified with color doppler, Budd-Chiari syndrome should be suspected. \*\*

Question 37

A patient is reffered to rule out hepatomegaly. All of the following are useful indicators of hepatomegaly Except; A) Rouding of the inferior border of the liver B) Longitudinal measurement of the right lobe exceeding 15.5 cm C) Extension of the right lobe inferior to the lower pole of the right kidney D) Increased diameter of the main portal vein greater than 1 cm E) Increased anteroposterior measurement of the right lobe

Answer 37

D) increased diameter of the main portal vein greater than 1 cm \*\* enlargement of the portal vein is a finding associated with portal hypertension but is not a measurement of hepatomegaly. \*\*

Question 38

You have identified a single homogeneous hyperechoic lesion measuring 2.4 cm in the posterior aspect of the right lobe of the liver. What is the most common etiology of a mass fitting this description? A)Hepatic Adenoma B)Carvernous hemangioma C)Hepatocellular carcinoma D)Focal fatty sparing

Answer 38

B) Carvernous hemangioma

Question 39

A patient is referred for a sonogram of the liver to rule out metastatic disease. Which of the following describes the sonographic appearance of liver metastasis? A) Single hypoechoic mass B) Multiple hyperechoic masses C) Masses of mixed echogenicity D) Cystic masses E) All of the above appearances of liver metastasis may be encoutered

Answer 39

E) All of the above

Question 40

Which of the following is NOT a feature of hepatic cyts? A) Thin walled B) Posterior acoustic enhancement C) Anechoic D) Increased attenuation E) Increased through transmission

Answer 40

D) Increased attenuation \*\* Attenuation through a cyst is decreased rather than increased \*\*