Abdominal and Pelvic Radiology Practice Questions

Q: What is the best imaging modality to differentiate between medical and surgical jaundice?

Ultrasound. **Explanation:** The primary objective in evaluating a jaundiced patient is to distinguish between **Medical Jaundice** (Hepatocellular/Intrahepatic) and **Surgical Jaundice** (Obstructive/Extrahepatic). **Why Ultrasound is the Correct Answer:** Ultrasound (USG) is the **initial and best screening modality** because of its high sensitivity in detecting **biliary ductal dilatation**. * **Surgical Jaundice:** Characterized by dilated intrahepatic biliary radicles (IHBRD) or a dilated common bile duct (CBD) due to mechanical obstruction (e.g., gallstones, malignancy). * **Medical Jaundice:** Characterized by non-dilated ducts, as the pathology lies at the cellular level (e.g., hepatitis, cirrhosis). USG is non-invasive, cost-effective, and lacks ionizing radiation, making it the gold standard for the first-line anatomical assessment of the biliary tree. **Analysis of Incorrect Options:** * **Options A, B, and C:** These represent biochemical markers. While Alkaline Phosphatase (ALP) and Bilirubin levels help confirm the *presence* of cholestasis, they cannot definitively differentiate between intrahepatic cholestasis (medical) and extrahepatic obstruction (surgical) as reliably as imaging. They provide functional data, whereas USG provides the necessary anatomical data to guide surgical intervention. **High-Yield Clinical Pearls for NEET-PG:** * **First Investigation:** Ultrasound. * **Gold Standard for CBD Stones:** MRCP (Non-invasive) or ERCP (Invasive/Therapeutic). * **Double Duct Sign:** Dilatation of both the CBD and Pancreatic duct on imaging; highly suggestive of Periampullary Carcinoma or Carcinoma Head of Pancreas. * **Shotgun Sign:** On USG, the parallel appearance of a dilated bile duct next to the portal vein (also called the "Double Barrel" sign).

Q: A plain abdominal X-ray in a patient with a sigmoid volvulus will show a distended bowel loop with its apex in which location?

Right hypochondrium. ### Explanation **1. Why the Correct Answer is Right:** Sigmoid volvulus occurs when the sigmoid colon twists around its mesenteric axis. Because the sigmoid colon is a mobile, redundant loop attached to a fixed base in the left iliac fossa, it distends massively when obstructed. As it expands, it follows the path of least resistance, moving **upward and toward the opposite side** of its origin. Consequently, the apex of the distended loop typically points toward the **Right Hypochondrium** (the right upper quadrant). This creates the characteristic **"Coffee Bean Sign"** or "Omega Sign" on a plain X-ray, where the two limbs of the loop are seen meeting at the site of the twist. **2. Why the Incorrect Options are Wrong:** * **Left Iliac Fossa (B):** This is the anatomical origin of the sigmoid colon. In a volvulus, the loop distends *away* from this site. * **Right Iliac Fossa (A):** This is the typical location for the apex of a **Cecal Volvulus**. In cecal volvulus, the cecum twists and displaces toward the left upper quadrant or epigastrium, whereas sigmoid volvulus moves toward the right upper quadrant. * **Left Hypochondrium (C):** The sigmoid loop rarely points here as it is already situated on the left; the massive distension forces it across the midline toward the right. **3. NEET-PG High-Yield Pearls:** * **Classic Signs:** "Coffee Bean Sign," "Omega Sign," or "Bent Inner Tube Sign." * **Barium Enema Finding:** "Bird’s Beak" or "Ace of Spades" appearance at the site of the twist. * **Demographics:** More common in elderly, institutionalized patients, or those with chronic constipation (megacolon). * **Management:** Initial treatment is often **sigmoidoscopic detorsion** (if no gangrene), followed by elective surgery to prevent recurrence.

Q: What is the preferred imaging modality for confirming choledocholithiasis?

Magnetic Resonance Cholangiopancreatography (MRCP). **Explanation:** **Choledocholithiasis** refers to the presence of gallstones within the Common Bile Duct (CBD). Selecting the "preferred" modality depends on whether the goal is initial screening, non-invasive confirmation, or therapeutic intervention. **1. Why MRCP is the Correct Answer:** MRCP is currently considered the **gold standard non-invasive investigation** for confirming choledocholithiasis. It utilizes T2-weighted MRI sequences where static fluid (bile) appears bright, and stones appear as signal voids. It boasts a sensitivity and specificity of over 90–95%. It is preferred for confirmation because it provides high-resolution anatomical detail without the risks of radiation or invasive complications like pancreatitis. **2. Analysis of Incorrect Options:** * **Ultrasound (USG):** This is the **initial investigation of choice** for biliary disease. While excellent for detecting gallstones (cholelithiasis), it has low sensitivity (~50%) for CBD stones due to overlying bowel gas. * **ERCP:** This was historically the gold standard. However, because it is invasive and carries a 5–10% risk of complications (post-ERCP pancreatitis, bleeding, perforation), it is now reserved as a **therapeutic modality** (for stone extraction) rather than a primary diagnostic tool. * **HIDA Scan:** This is the most sensitive test for **Acute Cholecystitis** (demonstrating gallbladder non-visualization). It is not the primary modality for visualizing CBD stones. **High-Yield Clinical Pearls for NEET-PG:** * **Initial/Screening Test:** USG Abdomen. * **Best Non-invasive/Confirmatory Test:** MRCP. * **Gold Standard (Invasive/Therapeutic):** ERCP. * **IOC for Acute Cholecystitis:** USG (Initial); HIDA (Most Sensitive). * **IOC for CBD Dilation (post-cholecystectomy):** MRCP.

Q: What pattern is described as "paint brush-like" in intravenous urography?

Medullary sponge kidney. **Explanation:** The **"paint brush" appearance** is a classic radiological sign seen on Intravenous Urography (IVU) in patients with **Medullary Sponge Kidney (MSK)**. **1. Why Medullary Sponge Kidney is correct:** MSK is characterized by congenital ectasia (dilatation) of the papillary collecting ducts. During an IVU, the contrast medium fills these dilated, cystic collecting ducts in the renal pyramids. This creates linear streaks of contrast radiating from the papilla into the medulla, resembling the bristles of a paintbrush or a "bouquet of flowers." **2. Why the other options are incorrect:** * **Medullary Cystic Kidney Disease (MCKD) & Nephronophthisis:** These are part of the same disease spectrum involving tubulointerstitial nephritis and cyst formation at the corticomedullary junction. Unlike MSK, these conditions typically result in **small, shrunken kidneys** with poor contrast excretion, rather than the characteristic ductal dilatation seen in MSK. * **Polycystic Kidney Disease (ADPKD):** This presents with massively enlarged kidneys and multiple large cysts throughout the cortex and medulla. On IVU, it shows the **"Spider Leg" appearance** due to the stretching and compression of the renal calyces by large cysts. **3. High-Yield Clinical Pearls for NEET-PG:** * **MSK Association:** Often associated with **Nephrocalcinosis** (calcium deposits in the pyramids) and recurrent calcium oxalate stones. * **Benign Course:** MSK is usually a benign, sporadic condition, unlike the progressive renal failure seen in MCKD or ADPKD. * **Radiological Mimic:** On plain X-ray, the clusters of stones in the dilated ducts may resemble "bunches of grapes."

Q: You are shown an AP view from a percutaneous trans-hepatic cholangiogram of a jaundiced patient. What is the MOST likely diagnosis?

Cholangiocarcinoma. ***Cholangiocarcinoma*** - **Percutaneous transhepatic cholangiogram (PTC)** typically shows **irregular stricture** with **rat-tail appearance** and **proximal biliary dilatation**, especially in **Klatskin tumors** at the hepatic duct confluence. - The **abrupt cutoff** and **asymmetric stricture** pattern with upstream ductal dilatation is characteristic of **cholangiocarcinoma** on cholangiography. *Pancreatic carcinoma* - PTC would show **smooth stricture** of the **lower common bile duct (CBD)** with **double duct sign** (pancreatic and bile duct dilatation). - The stricture location is typically at the **intrapancreatic portion** of the CBD, not at the hepatic duct confluence. *Sclerosing cholangitis* - Cholangiogram demonstrates **diffuse multifocal beading** and **alternating strictures and dilations** throughout the biliary tree. - The **string-of-beads appearance** affects both **intrahepatic and extrahepatic ducts** diffusely, not a focal stricture. *Cholelithiasis* - PTC would reveal **filling defects** (stones) within the bile ducts appearing as **radiolucent areas** surrounded by contrast. - **Mobile filling defects** that change position with patient positioning, unlike fixed strictures seen in malignancies.

Q: A 35-year-old male presents with a history of recurrent attacks of colicky abdominal pain. A barium meal follow-through was performed. What is the name of this radiological sign?

String sign of Kantor. ***String sign of Kantor*** - Characteristic **string-like narrowing** of the **terminal ileum** on barium meal follow-through due to **spasm and fibrosis** in **Crohn's disease**. - Represents **transmural inflammation** with **stricture formation**, indicating chronic involvement and potential complications like obstruction. *Goose neck appearance* - A **cardiac radiological sign** seen in **rheumatic mitral stenosis** on chest X-ray, not related to gastrointestinal pathology. - Shows characteristic **left atrial enlargement** with **straightening of the left heart border**, unrelated to abdominal imaging. *Fleishner's sign* - A **chest X-ray finding** indicating **pulmonary artery dilatation** in **pulmonary embolism**, not an abdominal sign. - Sometimes used to describe **appendiceal wall thickening** on CT, but not relevant to barium meal follow-through findings. *Umbrella sign* - A **barium enema finding** in **intussusception** showing **umbrella-like appearance** of the intussuscepted bowel. - Occurs in **large bowel** imaging, not in **small bowel** follow-through studies, and represents acute bowel telescoping.

Q: What are the true features of cholecystitis on ultrasonography?

All of the above. **Explanation:** Acute cholecystitis is a common surgical emergency, and ultrasonography (USG) is the initial imaging modality of choice due to its high sensitivity and specificity. The diagnosis is based on a combination of morphological changes in the gallbladder (GB) wall and the presence of obstructing calculi. **Analysis of Options:** * **Thickened GB Wall:** A wall thickness of **>3 mm** is a hallmark of cholecystitis. In chronic cases, this wall may become **fibrosed** and irregular. In acute phases, the thickening is often due to edema. * **Stone impacted at the neck:** Approximately 90-95% of cholecystitis cases are "calculous." A stone firmly lodged in the GB neck or cystic duct leads to luminal distension and inflammation. * **Perigallbladder halo:** This represents subserosal edema or localized fluid collection around the gallbladder, often seen as a hypoechoic (dark) rim. It is a specific sign of significant inflammation. Since all three features are classic sonographic markers of the disease, **Option D** is correct. **High-Yield Clinical Pearls for NEET-PG:** 1. **Sonographic Murphy’s Sign:** This is the most specific sign (92% specificity). It is positive when maximal tenderness is elicited by pressing the USG probe directly over the visualized gallbladder. 2. **Distended GB:** A transverse diameter **>4 cm** is considered abnormal. 3. **Emphysematous Cholecystitis:** Look for "dirty shadowing" or "ring-down artifacts" caused by gas within the GB wall/lumen (common in diabetics). 4. **Gangrenous Cholecystitis:** Suggested by asymmetric wall thickening and intraluminal membranes.

Q: All of the following statements regarding ileocaecal TB are TRUE, EXCEPT:

Apple core sign. **Explanation:** The **Apple core sign** (or napkin-ring sign) is the classic radiological hallmark of **Colorectal Carcinoma**, particularly of the descending and sigmoid colon. It represents a short-segment, concentric, irregular luminal narrowing with overhanging edges (shouldering). While tuberculosis can cause strictures, the "Apple core" appearance is highly specific to malignancy. **Analysis of Options:** * **A. Narrowing of terminal ileum:** In ileocaecal TB, the terminal ileum often shows ulceration and narrowing. This is known as the **Kantor’s String Sign** (also seen in Crohn’s disease), where the terminal ileum appears as a thin, string-like shadow. * **B. Obliteration of ileocaecal angle:** Chronic inflammation and fibrosis in TB lead to the contraction of the caecum and terminal ileum. This results in the loss of the normal right-angled junction between the two, known as the **Fleischner Sign** (inverted-T appearance). * **C. Caecum ascends up:** Due to extensive fibrosis and longitudinal shortening of the ascending colon, the caecum becomes shrunken, conical, and pulled upward into the subhepatic position. This is referred to as a **High-placed caecum** or **Purse-string caecum**. **High-Yield Clinical Pearls for NEET-PG:** * **Stierlin Sign:** Rapid emptying of the inflamed ileocaecal segment (barium does not stay in the diseased area). * **Goose-neck deformity:** Fixed patency of the ileocaecal valve with a narrowed terminal ileum. * **Most common site:** The ileocaecal region is the most common site for intestinal TB due to the abundance of lymphoid tissue (Peyer's patches) and physiological stasis. * **Differential Diagnosis:** Crohn’s disease is the closest mimic; however, TB typically involves the ileocaecal valve, whereas Crohn’s often spares it.

Question 1

Pseudo-flow Doppler signal (continuous flow) in the hepatic vein in the setting of Budd-Chiari syndrome indicates what?

Accepted Answer

Hepatic vein or suprahepatic inferior vena cava obstruction

Answer

Congenital web in the inferior vena cava

Answer

Portal vein thrombosis

Answer

Renal vein thrombosis

Question 2

What is the best imaging modality to differentiate between medical and surgical jaundice?

Accepted Answer

Ultrasound

Answer

Alkaline phosphatase level

Answer

Total and direct bilirubin with serum enzymes

Answer

Serum enzyme levels

Question 3

A plain abdominal X-ray in a patient with a sigmoid volvulus will show a distended bowel loop with its apex in which location?

Accepted Answer

Right hypochondrium

Answer

Right iliac fossa

Answer

Left iliac fossa

Answer

Left hypochondrium

Question 4

What is the preferred imaging modality for confirming choledocholithiasis?

Accepted Answer

Magnetic Resonance Cholangiopancreatography (MRCP)

Answer

Ultrasound (USG)

Answer

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Answer

Hepatobiliary Iminodiacetic Acid (HIDA) Scan

Question 5

Which imaging study has the highest pickup for a gastrojejunocolic fistula?

Accepted Answer

Barium enema

Answer

Barium swallow

Answer

Barium meal

Answer

Barium follow-through

Question 6

What pattern is described as "paint brush-like" in intravenous urography?

Accepted Answer

Medullary sponge kidney

Answer

Medullary cystic kidney disease

Answer

Nephronophthisis

Answer

Polycystic kidney disease

Question 7

You are shown an AP view from a percutaneous trans-hepatic cholangiogram of a jaundiced patient. What is the MOST likely diagnosis?

Accepted Answer

Cholangiocarcinoma

Answer

Pancreatic carcinoma

Answer

Sclerosing cholangitis

Answer

Cholelithiasis

Question 8

A 35-year-old male presents with a history of recurrent attacks of colicky abdominal pain. A barium meal follow-through was performed. What is the name of this radiological sign?

Accepted Answer

String sign of Kantor

Answer

Goose neck appearance

Answer

Fleishner's sign

Answer

Umbrella sign

Question 9

What are the true features of cholecystitis on ultrasonography?

Accepted Answer

All of the above

Answer

Thick fibrosed gallbladder wall

Answer

Stone impacted at the neck of the gallbladder

Answer

Perigallbladder halo

Question 10

All of the following statements regarding ileocaecal TB are TRUE, EXCEPT:

Accepted Answer

Apple core sign

Answer

Narrowing of terminal ileum

Answer

Obliteration of ileocaecal angle

Answer

Caecum ascends up

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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