Abdominal and Pelvic Radiology Practice Questions

Q: A 58-year-old male presents with a 3-month history of altered bowel habits, passage of blood mixed with stool, and a 6 kg weight loss. Colonoscopy was incomplete due to a tight stricture in the sigmoid colon. A barium enema is performed and the image is shown in Image 3. Which radiological sign is demonstrated, and with which pathology is it classically associated?

A. Apple-core sign — annular carcinoma of the colon. ***A. Apple-core sign — annular carcinoma of the colon*** - The **apple-core sign** (or napkin-ring sign) represents a **short, circumferential stricture** with overhanging edges and mucosal destruction, characteristic of **annular carcinoma**. - This patient's clinical presentation of **altered bowel habits**, **blood in stool**, and **significant weight loss** is highly suspicious for **colorectal malignancy**. *B. Bird-beak sign — sigmoid volvulus* - The **bird-beak sign** is a feature seen on contrast studies where there is a **smooth, tapered narrowing** at the site of colonic torsion. - It is classically associated with **acute-intestinal obstruction** due to **sigmoid volvulus**, which does not typically present with chronic weight loss. *C. Thumb-printing sign — ischaemic colitis* - **Thumb-printing** indicates **submucosal edema** or hemorrhage, appearing as rounded indentations on the bowel wall during a barium study. - This sign is typically seen in **ischaemic colitis** and presents with **acute-onset abdominal pain** and hematochezia rather than a progressive stricture. *D. Coffee-bean sign — closed-loop large bowel obstruction* - The **coffee-bean sign** is a classic **plain abdominal radiograph** finding representing a massively dilated loop of the sigmoid colon during **volvulus**. - It indicates a **closed-loop obstruction** and is identified by the apposition of the inflamed bowel walls, which is distinct from a **malignant stricture**.

Q: Which of the following radiographic presentations cannot be seen in a patient with intussusception?

Corkscrew sign. **Explanation:** Intussusception occurs when a proximal segment of the bowel (intussusceptum) invaginates into a distal segment (intussuscipiens). **Why Corkscrew Sign is the Correct Answer:** The **Corkscrew sign** is a classic radiological finding seen on a barium swallow or follow-through in cases of **Midgut Volvulus** (associated with malrotation). It represents the spiral appearance of the distal duodenum and jejunum as they wrap around the superior mesenteric artery (SMA). It is not a feature of intussusception. **Analysis of Incorrect Options:** * **Target Sign (or Bull’s eye sign):** This is a hallmark of intussusception. On a plain radiograph or CT, it represents the layers of the intussusceptum and intussuscipiens seen in cross-section. On ultrasound, it is often called the "Doughnut sign." * **Crescent Sign (Meniscus sign):** This occurs when the leading edge of the intussusceptum protrudes into a gas-filled pocket in the distal bowel, creating a crescent-shaped lucency. It is a highly specific sign for intussusception on plain X-rays. * **Normal Radiograph:** In the early stages of intussusception, up to **25% of plain abdominal radiographs can appear completely normal**. A normal X-ray does not rule out the diagnosis, which is why ultrasound is the gold standard for screening. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Ultrasound (look for the "Pseudokidney" or "Target" sign). * **Classic Triad:** Colicky abdominal pain, palpable sausage-shaped mass, and "red currant jelly" stools (though the full triad is seen in <40% of cases). * **Treatment:** Non-operative reduction using **Hydrostatic (saline/barium)** or **Pneumatic (air) enema** is the first-line treatment in stable patients. * **Lead Point:** In children, it is usually idiopathic (hypertrophied Peyer’s patches); in adults, it is usually due to a pathological lead point (e.g., malignancy or Meckel’s diverticulum).

Q: What is this study?

Retrograde Pyelogram. ***Retrograde Pyelogram*** - Shows **contrast injected via ureteral catheter** with **pelvicalyceal system opacification** without nephrogram phase, characteristic of retrograde approach. - **Catheter visible** ascending from below through the ureter, confirming retrograde contrast injection technique. *Ultrasound* - Uses **sound waves** without any contrast material, producing grayscale images of organ structure. - Cannot demonstrate the **detailed pelvicalyceal anatomy** with contrast opacification seen in this study. *X Ray KUB* - Plain radiograph showing **bones and soft tissue shadows** without any contrast enhancement. - Would not show the **opacified collecting system** or ureteral catheter as clearly demonstrated here. *Contrast CT KUB* - Provides **cross-sectional images** in axial, coronal, and sagittal planes with contrast enhancement. - Would show **nephrogram phase** with parenchymal enhancement, unlike this study which shows only collecting system opacification.

Q: Which of the following is NOT an ultrasound finding consistent with the diagnosis of adenomyosis?

Encapsulated hypoechoic lesion. **Explanation:** The correct answer is **D. Encapsulated hypoechoic lesion**. This finding is characteristic of a **uterine leiomyoma (fibroid)**, not adenomyosis. Fibroids are well-circumscribed, encapsulated tumors that displace surrounding myometrium. In contrast, adenomyosis is a diffuse process where endometrial glands and stroma invade the myometrium, leading to an ill-defined, non-encapsulated "shaggy" appearance. **Analysis of Options:** * **Uterine enlargement (Option A):** Adenomyosis typically causes a "globular" enlargement of the uterus, often with an asymmetrical thickening of the posterior wall. * **Subendometrial echogenic linear striations (Option B):** This is a highly specific sign of adenomyosis. It represents the invasion of endometrial tissue into the myometrium, creating "fan-shaped" shadowing or "venetian blind" appearance. * **Thickening of the transitional zone (Option C):** On ultrasound (and more clearly on MRI), a thickened junctional zone (usually >12 mm) is a hallmark diagnostic feature of adenomyosis. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, menorrhagia, and a symmetrically enlarged, "boggy" (soft) uterus. * **Mnemonic for USG findings:** "RAIN" – **R**ay-like shadows (striations), **A**symmetrical wall thickening, **I**sland-like cysts (myometrial cysts), and **N**on-capsulated. * **Gold Standard Diagnosis:** Histopathology (post-hysterectomy); however, **MRI** is the most accurate non-invasive imaging modality. * **Key Distinction:** Unlike fibroids, adenomyotic lesions cannot be easily "shelled out" during surgery because they lack a surgical capsule.

Q: Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?

Intussusception. ### Explanation **Correct Answer: A. Intussusception** Intussusception occurs when a proximal segment of the bowel (intussusceptum) invaginates into a distal segment (intussuscipiens). This creates characteristic imaging patterns: * **Doughnut/Target Sign:** On **ultrasound** (transverse view), the concentric layers of the bowel walls appear as a hypoechoic outer ring and a hyperechoic center. * **Coiled Spring Appearance:** On a **barium or air enema**, the contrast trickles into the narrow space between the intussusceptum and the intussuscipiens, resembling a coiled spring. * **Pseudokidney Sign:** On longitudinal ultrasound, the layered bowel resembles a kidney. **Why the other options are incorrect:** * **B. Meckel’s Diverticulum:** Typically diagnosed via a **Technetium-99m pertechnetate scan** (Meckel’s scan), which identifies ectopic gastric mucosa. It does not produce concentric ring signs. * **C. Intestinal Malrotation:** Characterized by the **Whirlpool sign** (SMV twisting around the SMA) on ultrasound/CT and a "corkscrew" appearance of the duodenum on upper GI contrast studies. * **D. Volvulus:** Sigmoid volvulus classically shows a **"Coffee Bean" sign** or "Omega" sign on X-ray and a "Bird’s Beak" appearance on contrast enema. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Intermittent abdominal pain, palpable "sausage-shaped" mass, and **"Red currant jelly" stools**. * **Lead Point:** In children, it is usually idiopathic (preceded by viral URTI/hypertrophied Peyer’s patches); in adults, it is often due to a malignancy. * **Treatment:** Non-operative reduction using **hydrostatic (saline) or pneumatic (air) enema** is the first-line treatment in stable pediatric cases.

Q: What condition is characterized by an "upside down" stomach appearance on a Barium meal study?

Mesenteroaxial gastric volvulus. **Explanation:** **Mesenteroaxial gastric volvulus** is the correct answer because it involves rotation of the stomach around its short axis (a line connecting the mid-lesser curvature to the mid-greater curvature). In this condition, the antrum and pylorus rotate superiorly, while the fundus moves inferiorly. On a Barium meal, this results in the **"upside down" stomach** appearance, where the antrum lies above the fundus. This type is less common than organoaxial but is more frequently associated with acute presentation and ischemia. **Analysis of Incorrect Options:** * **Organoaxial gastric volvulus:** This is the most common type (60%). Rotation occurs around the long axis (connecting the cardia to the pylorus). It typically presents with the greater curvature lying superior to the lesser curvature, but not the classic "upside down" antrum-above-fundus configuration. * **Large gastric adenocarcinoma:** While it can cause gastric outlet obstruction and significant distension, it does not cause the anatomical rotation required to produce an "upside down" appearance. * **Rolling (Paraesophageal) hiatus hernia:** In this condition, the fundus herniates alongside the esophagus into the chest. While the stomach is displaced, it does not necessarily undergo the specific mesenteroaxial rotation that characterizes the "upside down" stomach. **Clinical Pearls for NEET-PG:** * **Borchardt’s Triad (Acute Volvulus):** 1. Sudden epigastric pain, 2. Violent unproductive retching, 3. Inability to pass a nasogastric tube. * **Organoaxial Volvulus:** Often associated with diaphragmatic defects (e.g., Bochdalek hernia). * **Mesenteroaxial Volvulus:** Often associated with laxity of gastric ligaments; less common but carries a higher risk of strangulation.

Q: Elevation of which of the following metabolites in Magnetic Resonance Spectroscopy suggests a possibility of carcinoma of the prostate?

Choline. **Explanation:** Magnetic Resonance Spectroscopy (MRS) is a functional imaging technique that measures the concentration of specific metabolites in tissues. In the context of prostate cancer, the diagnosis relies on the ratio of **Choline** and **Citrate**. * **Why Choline is Correct:** Choline is a marker of cell membrane turnover (phospholipid metabolism). In malignant tissues like prostate carcinoma, there is rapid cell proliferation and increased membrane synthesis, leading to a significant **elevation of Choline**. Conversely, healthy prostate tissue is rich in **Citrate** (produced by the glandular epithelium). Therefore, a high **(Choline + Creatine) / Citrate ratio** is highly suggestive of malignancy. * **Why other options are incorrect:** * **Citrate:** In prostate cancer, the normal glandular architecture is destroyed, leading to a **decrease** in Citrate levels. An increase in Citrate would suggest healthy or hyperplastic tissue. * **Acetate:** While Acetate can be used in PET imaging for prostate cancer, it is not a primary metabolite measured in standard clinical MRS for prostate evaluation. * **NAA (N-acetylaspartate):** This is a marker of neuronal integrity. It is the hallmark metabolite for **Brain MRS** (decreased in tumors/strokes) and has no relevance in prostate imaging. **High-Yield Clinical Pearls for NEET-PG:** * **Prostate MRS Signature:** ↑ Choline, ↓ Citrate. * **Brain MRS Signature (Glioma):** ↑ Choline, ↓ NAA, ↑ Lactate (if anaerobic metabolism/necrosis). * **Multiparametric MRI (mpMRI):** This is the current gold standard, combining T2-weighted imaging, Diffusion-Weighted Imaging (DWI), and Dynamic Contrast Enhancement (DCE). MRS is often used as an adjunct. * **PI-RADS:** The scoring system used to communicate the probability of clinically significant prostate cancer on MRI.

Question 1

A 58-year-old male presents with a 3-month history of altered bowel habits, passage of blood mixed with stool, and a 6 kg weight loss. Colonoscopy was incomplete due to a tight stricture in the sigmoid colon. A barium enema is performed and the image is shown in Image 3. Which radiological sign is demonstrated, and with which pathology is it classically associated?

Accepted Answer

A. Apple-core sign — annular carcinoma of the colon

Answer

B. Bird-beak sign — sigmoid volvulus

Answer

C. Thumb-printing sign — ischaemic colitis

Answer

D. Coffee-bean sign — closed-loop large bowel obstruction

Question 2

A 65-year-old male presents with a 4-month history of epigastric pain, early satiety, and progressive weight loss. He has a history of Helicobacter pylori infection treated 10 years ago. Haemoglobin is 9.2 g/dL. A barium meal fluoroscopy study is shown in Image 1. Which of the following best describes the radiological sign visible and its significance?

Accepted Answer

A. Carman meniscus sign — indicates a malignant gastric ulcer with rolled, shelf-like edges that collect barium centrally in a crescent shape

Answer

B. Hampton's line sign — indicates a benign gastric ulcer with a thin lucent line across the ulcer neck

Answer

C. Niche sign of Haudek — indicates a benign penetrating ulcer projecting beyond the gastric wall on the lesser curvature

Answer

D. Leather bottle stomach (linitis plastica) — indicates diffuse submucosal infiltration producing a rigid, narrowed stomach without a focal ulcerating mass

Question 3

Which of the following radiographic presentations cannot be seen in a patient with intussusception?

Accepted Answer

Corkscrew sign

Answer

Target sign

Answer

Crescent sign

Answer

Normal radiograph

Question 4

What is this study?

Accepted Answer

Retrograde Pyelogram

Answer

Ultrasound

Answer

X Ray KUB

Answer

Contrast CT KUB

Question 5

Which of the following conditions typically presents with a 'pseudokidney sign' on ultrasound?

Accepted Answer

Carcinoma of the stomach

Answer

Trichobezoar

Answer

Carcinoma of the kidney

Answer

Polycystic kidney disease

Question 6

Which of the following is NOT an ultrasound finding consistent with the diagnosis of adenomyosis?

Accepted Answer

Encapsulated hypoechoic lesion

Answer

Uterine enlargement

Answer

Subendometrial echogenic linear striations

Answer

Thickening of the transitional zone

Question 7

Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?

Accepted Answer

Intussusception

Answer

Meckel's diverticulum

Answer

Intestinal malrotation

Answer

Volvulus

Question 8

What is the typical CECT finding that suggests the diagnosis of pseudomyxoma peritonei?

Accepted Answer

Scalloping of the visceral surfaces of the liver and spleen

Answer

Ascites with increased HU units

Answer

Peritoneal seedlings

Answer

Pseudokidney sign

Question 9

What condition is characterized by an "upside down" stomach appearance on a Barium meal study?

Accepted Answer

Mesenteroaxial gastric volvulus

Answer

Organoaxial gastric volvulus

Answer

Large gastric adenocarcinoma at the antral end

Answer

Rolling type of hiatus hernia

Question 10

Elevation of which of the following metabolites in Magnetic Resonance Spectroscopy suggests a possibility of carcinoma of the prostate?

Accepted Answer

Choline

Answer

Citrate

Answer

Acetate

Answer

NAA

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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