AB-Abdomen Questions and Answers

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 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.”

The ultrasound images show two views of the same groin region — one without compression (left image labeled “W/O COMPRESSION”) and one with graded probe compression (right image labeled “W/ COMPRESSION”).

In the non-compression image, a hypoechoic mass-like structure is visible protruding through the abdominal wall, consistent with a hernia sac. On the compression image, the herniated content is no longer visible, indicating that the contents have been pushed back into the abdominal cavity. This is the hallmark feature of a reducible hernia.

Key characteristics of a reducible hernia on ultrasound:

Herniated contents are visible without pressure.

Contents disappear or reduce back into the abdomen with graded probe compression or Valsalva release.

Typically includes omental fat or bowel, but reduction confirms lack of incarceration or strangulation.

Comparison of answer choices:

A. Fat only refers to the hernia content type, not the behavior or reducibility shown here.

B. Reducible — Correct. The change in hernia appearance between images demonstrates successful reduction with compression.

C. Incarcerated hernia would remain visible and not compressible or reducible.

D. Strangulated hernia would show signs of ischemia (bowel wall thickening, absent perfusion, hyperechoic mesentery), and would also not reduce with compression.

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.

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 technique shown in the video is compression. In ultrasound imaging—especially of soft tissue masses, the bowel, or venous structures—compression is used to evaluate the compressibility of structures. The image demonstrates a classic grayscale ultrasound view of a lesion or structure being compressed with the probe.

Compression sonography is particularly important in:

Evaluating venous patency (e.g., for deep vein thrombosis)

Differentiating cystic from solid structures

Evaluating bowel wall abnormalities or intussusception

Assessing lymph nodes and soft tissue masses (as shown here)

When a structure compresses easily under probe pressure, it suggests that the lesion is fluid-filled or soft. In contrast, incompressibility may indicate a solid mass or thrombus.

Differentiation from other options:

B. Valsalva: Involves forced expiration against a closed airway, used primarily to assess venous reflux or inguinal hernias—not what is demonstrated here.

C. Exhalation: A respiratory maneuver that passively alters thoracoabdominal pressure, not actively performed by the operator or causing focal structural change.

D. Deep inspiration: Used to improve visualization of the liver, diaphragm, or gallbladder—not to evaluate the compressibility of soft tissue.

The spleen lies in the left hypochondrium, superior and lateral to the fundus of the stomach, and directly contacts the diaphragm. It occupies the space between the stomach and diaphragm. The liver and kidneys are located more medially or inferiorly.

According to Gray’s Anatomy for Students:

“The spleen lies posterolateral to the fundus of the stomach, separated from the diaphragm by its fibrous capsule.”

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.”

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.

An abdominal aortic aneurysm (AAA) measuring ≥5.5 cm represents a significantly increased risk of rupture and often requires surgical evaluation. The sonographer must report this critical finding immediately to the interpreting physician. The sonographer should never disclose a diagnosis directly to the patient.

According to AIUM and SRU Guidelines:

“An aortic diameter of 5.5 cm or greater should be promptly reported to the interpreting physician due to the high risk of rupture.”

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.”

In mild acute pancreatitis, the pancreas often appears diffusely enlarged and slightly hypoechoic due to edema and inflammation. However, in very early or mild cases, the pancreas may still appear normal. Heterogeneous echotexture may develop in more severe or necrotizing pancreatitis.

According to Rumack’s Diagnostic Ultrasound:

“In mild pancreatitis, the pancreas is commonly enlarged and hypoechoic due to inflammatory edema.”

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 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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Adrenal adenomas are the most common adrenal tumors in adults. They are often discovered incidentally (adrenal incidentalomas) and are usually nonfunctioning, though some may secrete cortisol or aldosterone. Neuroblastoma is common in children, pheochromocytomas are rarer catecholamine-producing tumors, and adrenal cortical carcinoma is malignant but much less common than adenomas.

According to Rumack’s Diagnostic Ultrasound:

“Adrenal adenomas are the most common adrenal masses in adults, frequently identified incidentally on imaging studies.”

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.

The superior mesenteric vein (SMV) lies directly anterior to the uncinate process of the pancreas. The uncinate process wraps around the posterior aspect of the SMV and SMA. The portal vein and IVC lie more posteriorly in relation to the pancreatic head.

According to Moore’s Clinically Oriented Anatomy:

“The superior mesenteric vein crosses anterior to the uncinate process of the pancreas.”

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.

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.”

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.”

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.”

Alpha-fetoprotein (AFP) is commonly elevated in patients with hepatocellular carcinoma (hepatoma), particularly in those with underlying cirrhosis or chronic hepatitis B/C. AFP is not typically elevated in adenomas, cholangiocarcinoma, or FNH.

According to Rumack’s Diagnostic Ultrasound:

“Serum AFP levels are elevated in 50–70% of patients with hepatocellular carcinoma.”

Angiomyolipomas are benign renal tumors composed of fat, smooth muscle, and blood vessels. They are strongly associated with tuberous sclerosis and may be multiple and bilateral in these patients. While RCC may occur, angiomyolipomas are much more characteristic.

According to Rumack’s Diagnostic Ultrasound:

“Angiomyolipomas are frequently multiple and bilateral in patients with tuberous sclerosis.”

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.”

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 demonstrates a dilated common bile duct (CBD), measuring approximately 7.7 mm in diameter. A normal CBD should generally measure less than 6 mm in a patient under 60 years old and may increase approximately 1 mm per decade thereafter or after cholecystectomy.

In the absence of gallstones within the CBD, one of the most concerning causes of CBD dilation is distal obstruction due to an extrinsic compressive lesion. The most common and clinically significant cause of distal CBD obstruction is a mass at the head of the pancreas.

A pancreatic head mass (e.g., adenocarcinoma) may compress the distal CBD and pancreatic duct simultaneously, resulting in the “double duct sign” — dilation of both the CBD and pancreatic duct. This is a classic finding in pancreatic cancer.

Comparison of answer choices:

A. Liver mass — unlikely to cause isolated CBD dilation unless invading the porta hepatis.

B. Cystic duct stone — may cause gallbladder hydrops but typically not CBD dilation unless Mirizzi syndrome is present.

C. Pancreatic head mass — Correct. This is the most likely cause of painless progressive CBD dilation without visible intraductal stones.

D. Gallbladder stones — These may be associated with biliary colic or cholecystitis but typically do not cause CBD dilation unless the stone has migrated and obstructed the distal duct.

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.

The ultrasound image shown is a transverse endorectal (transrectal) ultrasound, commonly used to evaluate the prostate and adjacent structures. The two hypoechoic (dark) oval-shaped structures seen superior and posterior to the prostate are characteristic of the seminal vesicles.

The seminal vesicles are paired, elongated glands located superior and posterior to the base of the prostate and are best visualized in transverse planes on endorectal imaging. They appear as hypoechoic or anechoic structures with internal septations, depending on the degree of fluid content.

In contrast:

The urethra appears as a central echogenic linear structure within the prostate.

The prostate base is more inferior in the scan and is visualized just above the urethra.

The ejaculatory ducts are usually not as prominently visualized and are located medial to the seminal vesicles, entering the prostate near the verumontanum.

This image most clearly demonstrates the bilateral seminal vesicles.

The inferior vena cava (IVC) is formed by the confluence of the right and left common iliac veins at the level of approximately L5. The hepatic veins drain into the IVC superiorly but do not form it. The superior mesenteric and splenic veins join to form the portal vein, not the IVC.

According to Moore’s Clinically Oriented Anatomy:

“The IVC begins at the level of L5 by the union of the right and left common iliac veins.”

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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The ultrasound image shows a classic “target sign” or “donut sign,” characterized by concentric rings of alternating echogenicity. This sonographic finding is pathognomonic for intussusception, particularly when seen in the transverse plane.

Intussusception occurs when a segment of bowel telescopes into an adjacent segment, typically in children aged 6 months to 3 years. It commonly presents with intermittent abdominal pain, vomiting, and sometimes “red currant jelly” stools.

Key ultrasound features of intussusception:

Target sign in transverse view (concentric rings of bowel layers)

Pseudokidney or sandwich sign in longitudinal view

May show intraluminal mesenteric fat or vessels dragged in with the intussusceptum

Comparison of answer choices:

A. Bowel obstruction may show dilated loops of bowel with air-fluid levels and to-and-fro peristalsis but lacks the concentric ring sign.

B. Diverticulitis typically shows bowel wall thickening and pericolic fat stranding; not the concentric target appearance.

C. Appendicitis may appear as a blind-ending tubular structure (>6 mm), not with concentric ring pattern.

D. Intussusception — Correct. The image demonstrates the classic target sign seen with this condition.

Type I choledochal cyst, characterized by fusiform dilatation of the common bile duct, is the most common form, accounting for 80-90% of cases. Other types are much less frequent.

According to Rumack’s Diagnostic Ultrasound:

“Type I fusiform dilatation of the extrahepatic bile duct is the most common type of choledochal cyst.”

Graded compression technique is the gold standard for ultrasound evaluation of the appendix. It displaces gas and compresses overlying bowel loops to visualize the noncompressible, blind-ending tubular appendix directly at the point of maximal tenderness.

According to Rumack’s Diagnostic Ultrasound:

“Graded compression using steady, increasing pressure displaces gas and bowel to optimize visualization of the appendix.”

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.

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.”

The ultrasound image demonstrates a well-defined, ovoid, hypoechoic to isoechoic mass within the subcutaneous tissue of the abdominal wall. The lesion appears compressible and shows linear striations parallel to the skin surface — a classic appearance of a lipoma.

Lipomas are the most common benign soft tissue tumors and frequently arise in the subcutaneous tissue. They are composed of mature adipose tissue and are typically asymptomatic unless large or compressing adjacent structures.

Sonographic features of a lipoma:

Isoechoic to mildly hyperechoic or hypoechoic relative to subcutaneous fat

Oval or elliptical in shape with well-defined margins

Internal linear striations or “feathered” echotexture

Compressible and non-vascular on Doppler imaging

Located in subcutaneous fat plane parallel to the skin surface

Differentiation from other options:

B. Fibroma: Typically appears as a homogeneous, hypoechoic mass but is far less common in the abdominal wall.

C. Desmoid: Appears as an ill-defined or infiltrative mass within deeper soft tissues; more heterogeneous and may distort surrounding tissue planes.

D. Metastasis: Often more irregular, heterogeneous, and may show increased vascularity or invasion into adjacent structures.

The ultrasound image shows a transverse section through the upper abdomen. The arrow is pointing to a vascular structure running posterior to the pancreas and anterior to the left kidney. This vessel is the splenic vein.

Anatomically:

The splenic vein runs along the posterior border of the pancreas.

It courses medially to join the superior mesenteric vein (SMV) and form the portal vein.

It receives tributaries from the spleen, short gastric veins (draining the stomach), and the inferior mesenteric vein.

In this case, the question asks which organ is primarily drained via the vessel marked by the arrow. The splenic vein's main tributary is from the spleen.

Comparison of answer choices:

A. Spleen — Correct. The splenic vein is the primary drainage vessel for the spleen.

B. Stomach — Some gastric veins drain into the splenic vein, but the primary drainage is via left and right gastric veins into the portal system.

C. Left kidney — Drains into the left renal vein, not the splenic vein.

D. Duodenum — Drains mainly into the superior mesenteric vein (SMV).

The ultrasound image demonstrates a complex, heterogeneous hypoechoic collection within the abdominal wall, with mixed echogenicity and ill-defined margins. The lesion appears to contain internal debris but lacks definitive signs of vascularity or air (which would be seen in an abscess). There is no peristalsis, herniated bowel, or fat to suggest hernia.

Given the history of atrial fibrillation — a condition commonly treated with anticoagulation therapy (e.g., warfarin, apixaban) — this clinical background raises high suspicion for a rectus sheath or abdominal wall hematoma.

Key ultrasound features of hematomas:

Early (acute): hyperechoic or heterogeneous

Chronic/resolving: complex or cystic with fluid-debris levels

No internal vascularity on Doppler

May be confined to muscle or fascial planes

This is consistent with a hematoma, particularly in patients on anticoagulation therapy.

Comparison of answer choices:

A. Hernia — typically shows bowel or fat with movement/peristalsis passing through a fascial defect.

B. Lipoma — usually homogeneous and echogenic, not complex or fluid-filled.

C. Abscess — often presents as a complex fluid collection with peripheral hyperemia and possibly air, plus systemic signs of infection.

D. Hematoma — Correct. The image and clinical history (anticoagulation due to atrial fibrillation) strongly support this diagnosis.

The most serious long-term complication of undescended testis (cryptorchidism) is an increased risk of testicular malignancy, especially seminoma. Although torsion and hernia may also occur, seminoma is the most concerning complication due to its life-threatening potential.

According to Rumack’s Diagnostic Ultrasound:

“Cryptorchidism is associated with a significantly increased risk of seminoma, the most common malignancy in undescended testes.”

The sonographic image shows a complex fluid collection within the liver parenchyma, with internal echoes and possibly septations, consistent with an abscess. In the clinical context of post-procedural fever following a liver biopsy, a liver abscess is the most likely diagnosis.

A liver abscess appears on ultrasound as a hypoechoic or complex fluid collection that may contain internal debris, septations, or gas (which may produce reverberation artifacts). These features distinguish it from other post-procedural complications.

A cyst (Option A) typically appears as an anechoic, well-defined lesion with posterior acoustic enhancement and no internal debris—this does not match the image or clinical setting.

A biloma (Option B) is a bile collection that can appear similar to a cyst or fluid collection but typically occurs due to bile leak; however, fever and internal complexity on ultrasound more strongly suggest abscess.

A hematoma (Option D) may also appear complex but usually presents with pain and not fever unless secondarily infected. Over time, hematomas evolve in appearance but lack septations and gas unless superinfected.

The sonographic images depict an acute thrombotic process involving the portal venous system. The absence of cavernous transformation in the setting of portal vein thrombus indicates that the process is acute. In chronic portal vein thrombosis, collateral vessels form in the porta hepatis to bypass the obstruction, a process known as cavernous transformation.

Sonographic features suggesting acute portal vein thrombosis:

Echogenic thrombus within the portal vein lumen

Absence of flow on color Doppler

Enlarged portal vein diameter early in the process

No evidence of cavernous transformation (i.e., no serpiginous collateral vessels at porta hepatis)

Cavernous transformation is a hallmark of chronic portal vein thrombosis and takes weeks to months to develop. Therefore, its absence on ultrasound supports an acute diagnosis.

Differentiation from other options:

A. Free fluid: Non-specific and may or may not be present in hepatic vascular thrombosis.

B. Ductal dilatation: Related to biliary obstruction, not portal or hepatic venous thrombosis.

C. Hepatic vein thrombosis: Seen in Budd-Chiari syndrome, which affects hepatic outflow, not portal inflow.

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.

The image demonstrates a gallbladder with a possible echogenic focus (likely a gallstone) and posterior acoustic shadowing. This is suggestive of cholelithiasis. To differentiate uncomplicated gallstones from acute cholecystitis, the most effective technique is to assess for a positive sonographic Murphy sign.

A positive sonographic Murphy sign refers to the presence of focal tenderness over the gallbladder when it is directly palpated with the ultrasound transducer. It is a strong indicator of acute cholecystitis when combined with other features such as gallbladder wall thickening, pericholecystic fluid, and gallstones.

Sonographic Murphy sign — key points:

Assessed during real-time scanning

Localized tenderness when pressure is applied over the gallbladder

Highly sensitive for acute cholecystitis (especially in the presence of stones)

Differentiation from other options:

A. Use compound imaging: Improves image quality by reducing artifacts but does not verify tenderness or confirm acute inflammation.

B. Change the patient’s position: Helpful to confirm mobility of gallstones, but not diagnostic of inflammation.

C. Ask patient to perform Valsalva: Used primarily in vascular studies (e.g., assessing for varicocele or venous reflux), not relevant here.