Free ARDMS AB-Abdomen Practice Exam with Questions & Answers | Set: 3

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 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.”

Wooden foreign bodies are often difficult to detect on CT because of their low radiodensity, but they are highly echogenic with posterior shadowing or reverberation on ultrasound, making ultrasound superior for detecting retained wooden objects. Glass, metal, and stones are better visualized with CT due to their high radiodensity.

According to AIUM and musculoskeletal ultrasound literature:

“Wood is poorly visualized on CT but demonstrates high reflectivity and acoustic shadowing on ultrasound.”

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.

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.”

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

According to Rumack’s Diagnostic Ultrasound:

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

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.”

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.”

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

According to Zwiebel’s Introduction to Vascular Ultrasound:

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

The ultrasound image demonstrates a 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.