Abdominal and Pelvic Radiology Practice Questions

Q: A 28-year-old male presents with sudden onset of severe, colicky right lower abdominal pain. Ultrasound KUB showed mild hydronephrosis of the right kidney but no evidence of stones. Renal function tests and creatinine levels were normal. Urine culture was negative. What is the most appropriate next step?

CT scan KUB to rule out the presence of renal calculi. ### Explanation **1. Why Option A is Correct:** The clinical presentation of sudden onset, severe, colicky abdominal pain is classic for **ureteric colic**. While Ultrasound (USG) is often the initial screening tool, it has limited sensitivity (approx. 70%) for detecting small ureteric stones, especially those in the mid-ureter or those not causing significant obstruction. **Non-Contrast Computed Tomography (NCCT) KUB** is the **gold standard** and the most appropriate next step because it has a sensitivity and specificity of >95% for detecting urolithiasis. In this case, the presence of hydronephrosis on USG is a secondary sign of obstruction, necessitating a CT scan to locate the stone and plan management. **2. Why Other Options are Incorrect:** * **Option B (Pyelonephritis):** Pyelonephritis typically presents with fever, chills, and flank pain rather than "colicky" pain. Furthermore, the negative urine culture and normal renal function make an infectious etiology less likely. * **Option C (Ample Hydration):** While hydration is part of supportive management, it is not a diagnostic "next step." One must first confirm the diagnosis and assess the size/location of the stone, as forced diuresis in the presence of a complete obstruction can worsen the pain and hydronephrosis. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** NCCT KUB is the investigation of choice for acute flank pain/ureteric colic. * **Radiolucent Stones:** All stones (including Uric acid and Xanthine stones) are **radio-opaque on CT**, except for Indinavir stones (seen in HIV patients). * **Secondary Signs on CT:** Look for the "Rim sign" (edema around the stone) and "Stranding" of perinephric fat. * **USG Limitation:** USG is excellent for identifying hydronephrosis and renal stones but poor at visualizing the mid-ureter.

Q: Which of the following is NOT a radiological sign of acute pancreatitis?

Cullen's sign. The correct answer is **B. Cullen's sign**. ### **Explanation** The distinction here lies between **radiological signs** (seen on imaging like X-ray or CT) and **clinical signs** (observed during physical examination). 1. **Why Cullen's sign is the correct answer:** Cullen’s sign is a **clinical sign** characterized by periumbilical ecchymosis (bruising) due to the tracking of hemoperitoneum into the falciform ligament. While it indicates severe necrotizing pancreatitis, it is a physical exam finding, not a radiological sign. 2. **Analysis of Radiological Signs (Incorrect Options):** * **Colon cut-off sign (Option A):** An abdominal X-ray finding where there is abrupt termination of gas in the splenic flexure. This occurs because inflammatory exudate from the pancreas spreads to the phrenicocolic ligament, causing functional spasm of the colon. * **Renal halo sign (Option C):** Seen on CT or X-ray, this represents edema or fluid collection in the pararenal space, which outlines the kidney, making it appear as if it has a "halo." * **Sentinel loop sign (Option D):** A localized paralytic ileus of a loop of small bowel (usually the jejunum) located near the inflamed pancreas. It appears as a single, dilated air-filled bowel loop in the left upper quadrant on X-ray. ### **NEET-PG High-Yield Pearls** * **Grey Turner’s sign:** Ecchymosis of the flanks (also a clinical sign of hemorrhagic pancreatitis). * **Gold Standard Imaging:** Contrast-Enhanced CT (CECT) is the investigation of choice for staging and detecting complications (best done 48–72 hours after symptom onset). * **Pancreatic Calcification:** The most specific radiological sign for **Chronic** Pancreatitis. * **Ground glass appearance:** May be seen on X-ray due to ascites or massive peripancreatic fluid collection.

Q: Scrambled egg appearance is seen in which of the following conditions?

Pancreatic carcinoma. **Explanation:** The "Scrambled Egg Appearance" is a classic radiological sign associated with **Pancreatic Carcinoma**, specifically when it involves the head of the pancreas and invades the duodenum. **1. Why Pancreatic Carcinoma is correct:** When a tumor in the head of the pancreas infiltrates the second part of the duodenum, it causes mucosal destruction, irregular filling defects, and ulceration. On a **Barium Meal** study, this creates a disorganized, mottled, and fragmented appearance of the contrast within the duodenal lumen, resembling "scrambled eggs." This sign indicates advanced local invasion of the pancreatic malignancy into the adjacent bowel. **2. Analysis of Incorrect Options:** * **Carcinoma of the Stomach:** Typically presents with a "Leather bottle" appearance (Linitis Plastica) or a "Carman’s Meniscus sign" for malignant ulcers. * **Carcinoma of the Gallbladder:** Often shows a "Porcelain gallbladder" (pre-malignant) or a fixed filling defect on cholecystography, but not the scrambled egg sign. * **Renal Carcinoma (RCC):** Characterized by the "Stretching of calyces" (Spider leg appearance) on Intravenous Urogram (IVU) due to the mass effect. **3. High-Yield Clinical Pearls for NEET-PG:** * **Frostberg’s Inverted ‘3’ Sign:** Another classic barium sign for Pancreatic Head Carcinoma, caused by the tumor fixing the duodenal mucosa at the Ampulla of Vater. * **Courvoisier’s Law:** In a patient with painless obstructive jaundice, if the gallbladder is palpable, the cause is unlikely to be gallstones (usually pancreatic or periampullary malignancy). * **Double Duct Sign:** Seen on ERCP/MRCP, representing simultaneous dilatation of the Common Bile Duct and Pancreatic Duct.

Q: The 'drooping water lily' sign is seen in which of the following conditions?

Upper pole renal mass. **Explanation:** The **'Drooping Water Lily' sign** is a classic radiological finding seen on an Intravenous Urogram (IVU). It occurs in the presence of a **duplex collecting system** or a large **upper pole renal mass** (such as a Wilms' tumor or a large cyst). **Why Option D is correct:** In a duplex kidney (specifically the Weigert-Meyer law), the upper pole moiety often becomes obstructed (due to an ectopic ureterocele), leading to hydronephrosis. This dilated upper pole system acts as a mass that displaces the functioning lower pole collecting system **downward and laterally**. On an IVU, the opacified lower pole calyces appear tilted and pushed away from the spine, resembling a wilted or "drooping water lily." **Why other options are incorrect:** * **A & B (Splenic/Liver tumors):** While these are upper abdominal masses, they are extrinsic to the renal fascia. They may displace the entire kidney inferiorly but do not typically cause the specific architectural distortion of the calyces required to produce this sign. * **C (Suprarenal mass):** An adrenal mass (like Neuroblastoma) typically displaces the entire kidney downward (caudad) without distorting the internal relationship between the upper and lower calyces in the same characteristic "drooping" fashion. **High-Yield Clinical Pearls for NEET-PG:** * **Weigert-Meyer Law:** In a duplex system, the ureter from the **upper** pole inserts **ectopically** (inferomedial to the normal orifice) and is prone to **obstruction/ureterocele**. The **lower** pole ureter inserts normally but is prone to **reflux**. * **Differential:** While classically associated with a duplex system, any large non-functioning upper pole mass (like a tumor) can produce this appearance. * **Maiden Hair Ureter:** Another high-yield sign seen in ureteric tuberculosis (long, thin, thread-like ureter).

Q: The "mushroom cap sign" in MRI is most commonly seen in which of the following conditions?

Rectal endometriosis. **Explanation:** The **"Mushroom Cap Sign"** is a classic MRI finding highly specific for **deep infiltrating endometriosis (DIE)** involving the rectum or rectosigmoid colon. **1. Why Rectal Endometriosis is Correct:** The sign occurs when an endometriotic plaque implants on the serosal surface of the bowel and infiltrates the muscularis propria. On T2-weighted MRI sequences, the hypertrophied, dark (hypointense) muscularis propria represents the "cap" of the mushroom. This contrasts with the displaced, hyperintense (bright) mucosa and submucosa, which represent the "stem" of the mushroom protruding into the bowel lumen. **2. Why Other Options are Incorrect:** * **Ileocecal Tuberculosis:** Typically presents with the "Stierlin sign" or "Fleischner sign" (inverted umbrella sign) on barium studies, characterized by a narrowed terminal ileum and a gaping ileocecal valve. * **Pulmonary Endometriosis:** Usually presents with catamenial pneumothorax or hemoptysis; imaging shows nonspecific nodules or ground-glass opacities, not the mushroom cap sign. * **Ovarian Endometriosis:** Characteristically presents as an **"Endometrioma"** (Chocolate cyst). On MRI, it shows the **"Shading Sign"** (T2-weighting shows loss of signal/darkening compared to T1 due to high iron/protein content). **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Endometriosis:** Laparoscopy with biopsy. * **MRI Sequence of Choice:** T2-weighted imaging (without fat suppression) is best for identifying the mushroom cap sign. * **Kissing Ovaries Sign:** Seen in severe pelvic endometriosis where ovaries are adhered to each other in the Pouch of Douglas. * **Powder-burn lesions:** The classic laparoscopic appearance of peritoneal endometriosis.

Q: A middle-aged female presents with chronic right-sided abdominal pain and intermittent fever. Clinical examination revealed mild hepatomegaly. A contrast-enhanced CT abdomen was performed. Based on the imaging characteristics of the focal lesion, what is the most likely diagnosis?

Hydatid cyst. ***Hydatid cyst*** - Imaging shows **daughter cysts** within the parent cyst creating a **"water-lily sign"** on CT, pathognomonic for hydatid disease. - **Peripheral calcification** of the cyst wall and chronic right-sided abdominal pain in a middle-aged female are classic features of hepatic echinococcosis. *Liver abscess* - CT typically shows **air-fluid levels** within the lesion and **thick irregular wall enhancement** with surrounding inflammatory changes. - Usually presents with **acute onset** high fever and leukocytosis, unlike the chronic presentation described here. *Hepatocellular carcinoma (HCC)* - Shows characteristic **arterial phase enhancement** followed by **washout** in portal venous phase on contrast CT. - Associated with **elevated AFP levels** and underlying cirrhosis, which are not mentioned in this case. *Hepatic adenoma* - Appears as a **well-defined lesion** with **homogeneous arterial enhancement** without daughter cysts or calcification. - Typically occurs in **young women** on oral contraceptives and lacks the chronic inflammatory presentation seen here.

Q: Spot the diagnosis in the following IVU image?

Ectopic kidney. ***Ectopic kidney*** - Shows a **kidney located outside the normal renal fossa**, typically in the **pelvic region** with a **short ureter** on IVU. - The **collecting system** appears normal but is positioned abnormally low, distinguishing it from other pelvic masses. *Horseshoe kidney* - Would show **two kidneys connected by an isthmus** across the midline, typically at the **lower poles**. - Characteristic **medially rotated calyces** and **malrotated kidneys** would be visible on IVU. *Bladder diverticulum* - Appears as an **outpouching from the bladder wall** that fills with contrast during the **cystographic phase**. - Would not show **renal parenchyma** or **collecting system** like a kidney would. *Pelvic mass* - Would appear as a **space-occupying lesion** causing **displacement** or **compression** of surrounding structures. - **Non-functioning mass** would not concentrate contrast or show **calyceal patterns** typical of renal tissue.

Q: Bosniak classification is used for the assessment of which of the following?

Renal cysts. The **Bosniak classification** is a standardized system used to evaluate and categorize **renal cysts** based on their appearance on contrast-enhanced CT scans. Its primary purpose is to predict the risk of malignancy and guide clinical management (observation vs. surgical intervention). ### **Why "Renal Cysts" is Correct** The classification divides renal cystic masses into five categories based on features like wall thickness, septations, calcification, and enhancement: * **Category I:** Simple benign cyst (0% malignancy risk). * **Category II:** Minimally complex, benign (e.g., thin septa, fine calcification). * **Category IIF:** "Follow-up" required; moderately complex. * **Category III:** Indeterminate; thick/irregular walls or septa (approx. 50% malignancy risk). * **Category IV:** Clearly malignant; solid components with enhancement (approx. 100% malignancy risk). ### **Why Other Options are Incorrect** * **Renal Tuberculosis:** Diagnosed via urine culture (Lowenstein-Jensen medium) or PCR. Imaging shows "putty kidney" or "thimble bladder," but Bosniak is not used. * **Renal Cell Carcinoma (RCC):** While Bosniak helps identify if a cyst is actually a cystic RCC, the classification itself is specifically for the *assessment of cystic lesions*, not the staging or grading of solid RCC. * **Vesicoureteric Reflux (VUR):** Assessed using the **International Study of Kidney Disease in Children (ISKDC) grading** (Grades I-V) via Voiding Cystourethrogram (VCUG). ### **High-Yield Clinical Pearls for NEET-PG** * **Bosniak I & II:** No follow-up needed. * **Bosniak IIF:** Requires serial imaging. * **Bosniak III & IV:** Usually require surgical intervention (Partial or Radical Nephrectomy). * **Gold Standard Imaging:** Contrast-Enhanced CT (CECT) is the modality of choice for Bosniak grading.

Q: Spider leg appearance on intravenous urography is typically seen in which of the following conditions?

Congenital Polycystic Kidney Disease. The **"Spider Leg Appearance"** on an Intravenous Urography (IVU) is a classic radiological sign of **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**. ### Why the correct answer is right: In ADPKD, the renal parenchyma is replaced by multiple large, expanding cysts. As these cysts grow, they exert pressure on the internal collecting system. This leads to the **elongation, narrowing, and stretching** of the renal calyces. On an IVU, the attenuated and stretched calyces resemble the long, thin legs of a spider, while the enlarged renal pelvis represents the spider's body. ### Why the other options are incorrect: * **Hydronephrosis:** Characterized by the **dilation** of the renal pelvis and calyces (clubbing), rather than the thinning and stretching seen in ADPKD. * **Renal stone:** Typically presents as a radiopaque shadow on a plain KUB film or a **filling defect** on IVU. It may cause secondary hydronephrosis but not the spider leg deformity. * **Renal cell carcinoma:** Usually presents as a localized mass causing focal displacement or distortion of a single calyx (the **"Dromedary hump"** or space-occupying lesion effect), rather than the diffuse, bilateral stretching seen in polycystic disease. ### High-Yield Clinical Pearls for NEET-PG: * **ADPKD:** Most common inherited kidney disease; associated with **PKD1 (Chr 16)** and **PKD2 (Chr 4)** mutations. * **Extra-renal manifestations:** Berry aneurysms (Circle of Willis), hepatic cysts (most common extra-renal site), and mitral valve prolapse. * **Swiss Cheese Appearance:** Seen on **Nephrotomography** in Polycystic Kidney Disease due to multiple radiolucent cysts. * **Flower Vase Appearance:** Seen in **Horseshoe Kidney** due to the anterior displacement of the lower poles.

Question 1

A 28-year-old male presents with sudden onset of severe, colicky right lower abdominal pain. Ultrasound KUB showed mild hydronephrosis of the right kidney but no evidence of stones. Renal function tests and creatinine levels were normal. Urine culture was negative. What is the most appropriate next step?

Accepted Answer

CT scan KUB to rule out the presence of renal calculi

Answer

Treat as pyelonephritis

Answer

Provide ample hydration

Answer

None of the above

Question 2

Which of the following is NOT a radiological sign of acute pancreatitis?

Accepted Answer

Cullen's sign

Answer

Colon cut-off sign

Answer

Renal halo sign

Answer

Sentinel loop sign

Question 3

Scrambled egg appearance is seen in which of the following conditions?

Accepted Answer

Pancreatic carcinoma

Answer

Carcinoma of the stomach

Answer

Carcinoma of the gallbladder

Answer

Renal carcinoma

Question 4

The 'drooping water lily' sign is seen in which of the following conditions?

Accepted Answer

Upper pole renal mass

Answer

Splenic tumor

Answer

Liver tumor

Answer

Suprarenal mass

Question 5

The "mushroom cap sign" in MRI is most commonly seen in which of the following conditions?

Accepted Answer

Rectal endometriosis

Answer

Ileocecal tuberculosis

Answer

Pulmonary endometriosis

Answer

Ovarian endometriosis

Question 6

Gas shadow in the heart and vessels is seen in which condition?

Accepted Answer

Intrauterine device (IUD)

Answer

Stillbirth

Answer

Abortion

Answer

Intrauterine growth restriction (IUGR)

Question 7

A middle-aged female presents with chronic right-sided abdominal pain and intermittent fever. Clinical examination revealed mild hepatomegaly. A contrast-enhanced CT abdomen was performed. Based on the imaging characteristics of the focal lesion, what is the most likely diagnosis?

Accepted Answer

Hydatid cyst

Answer

Liver abscess

Answer

Hepatocellular carcinoma (HCC)

Answer

Hepatic adenoma

Question 8

Spot the diagnosis in the following IVU image?

Accepted Answer

Ectopic kidney

Answer

Horseshoe kidney

Answer

Bladder diverticulum

Answer

Pelvic mass

Question 9

Bosniak classification is used for the assessment of which of the following?

Accepted Answer

Renal cysts

Answer

Renal tuberculosis

Answer

Renal cell carcinoma (RCC)

Answer

Vesicoureteric reflux (VUR)

Question 10

Spider leg appearance on intravenous urography is typically seen in which of the following conditions?

Accepted Answer

Congenital Polycystic Kidney Disease

Answer

Hydronephrosis

Answer

Renal stone

Answer

Renal cell carcinoma

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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