Abdominal and Pelvic Radiology Practice Questions

Q: Which of the following is an investigation for small intestine abnormalities, excluding one option?

USG enteroclysis. **Explanation:** The correct answer is **D. USG enteroclysis**. In clinical practice, **enteroclysis** refers to a technique where a large volume of contrast or fluid is infused directly into the small bowel via a nasojejunal tube (passed beyond the ligament of Treitz) to achieve controlled distension. While USG is excellent for screening bowel wall thickening or intussusception, "USG enteroclysis" is not a standard or recognized clinical investigation for small bowel abnormalities. **Analysis of Options:** * **Enteroclysis (Conventional):** This is the traditional fluoroscopic method using barium and methylcellulose (double-contrast). It is highly sensitive for detecting mucosal lesions, strictures, and small bowel tumors. * **Radionuclide Imaging:** Nuclear medicine plays a specific role in small bowel pathology. For example, a **Technetium-99m pertechnetate scan** (Meckel’s scan) is the investigation of choice for detecting ectopic gastric mucosa in Meckel’s diverticulum, and **99mTc-labeled RBC scans** are used to localize obscure gastrointestinal bleeding. * **CT Enteroclysis:** This combines the distension of enteroclysis with the cross-sectional capabilities of MDCT. It is considered the gold standard for diagnosing small bowel obstructions and Crohn’s disease as it visualizes both the lumen and the extraluminal extent of the disease. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice (IOC)** for Small Bowel Obstruction: **CT Enteroclysis/Enterography.** * **IOC for Meckel’s Diverticulum:** **99mTc-pertechnetate scan.** * **IOC for Celiac Disease:** Upper GI Endoscopy with D2 (duodenal) biopsy. * **String Sign of Kantor:** Classic radiological finding in Crohn’s disease (terminal ileum) seen on barium studies.

Q: A 54-year-old man presents with a 2-day history of mild abdominal pain, bloating, nausea, vomiting, and poor appetite. His past medical history is significant for recent pneumonia. Radiographic examination reveals a paralytic ileus. Which of the following signs would most likely be found during a physical examination?

Absent bowel sounds. **Explanation:** **Paralytic ileus** (also known as adynamic ileus) is a condition characterized by the failure of intestinal peristalsis without the presence of a mechanical obstruction. It is commonly triggered by abdominal surgery, electrolyte imbalances (hypokalemia), medications (opioids), or systemic infections like pneumonia (as seen in this patient). 1. **Why the correct answer is right:** In paralytic ileus, there is a global "stunning" or inhibition of the enteric nervous system and smooth muscle activity. Since there is no peristaltic movement to propel gas and fluid through the bowel loops, the characteristic physical finding is **absent or significantly diminished bowel sounds** on auscultation. 2. **Why the incorrect options are wrong:** * **Increased bowel sounds & Borborygmi (Options A & C):** These are characteristic of **Mechanical Small Bowel Obstruction (SBO)**. In mechanical obstruction, the proximal bowel hyper-perfuses and contracts vigorously to overcome the blockage, leading to high-pitched, "tinkling" sounds or loud rumbling (borborygmi). * **Crampy abdominal pain (Option D):** While patients with ileus experience discomfort and bloating, the pain is typically **dull and diffuse**. Sharp, colicky, or "crampy" paroxysmal pain is the hallmark of mechanical obstruction, reflecting the bowel's rhythmic attempts to push against a physical barrier. **High-Yield NEET-PG Pearls:** * **Radiology:** X-ray shows uniform dilatation of both the small and large intestines with gas seen in the rectum. In contrast, mechanical obstruction shows a "cut-off" sign with no gas in the rectum. * **Commonest Cause:** Post-operative state (Physiological ileus is expected for 24–72 hours). * **Electrolyte Trigger:** Hypokalemia is the most frequent metabolic cause. * **Management:** Usually conservative (NPO, IV fluids, and treating the underlying cause).

Q: What is the type of Gharbi classification of the given hydatid cyst?

III. ***III*** - Type III hydatid cysts show **multivesicular appearance** with **daughter cysts** arranged in a **honeycomb** or **rosette pattern**. - This classification indicates a **fertile cyst** with **viable protoscolices** and represents an **active infection** requiring treatment. *I* - Type I represents a **simple cystic lesion** with **anechoic fluid** and **well-defined walls** without internal septations. - This **unilocular** appearance lacks the **daughter cysts** characteristic of the given image. *II* - Type II shows **fluid collection** with **detached membranes** creating a **floating membrane sign** or **water lily sign**. - This type represents **partial cyst rupture** but lacks the **multivesicular honeycomb pattern** seen in the image. *IV* - Type IV appears as a **heterogeneous mass** with **pseudosolid echogenic content** and **thick calcified walls**. - This **degenerative type** shows **inactive cyst** with **no viable parasites**, unlike the active multivesicular pattern shown.

Q: A TVS (Transvaginal Sonography) demonstrates which of the following endometrial findings?

Postmenopausal endometrium. ***Postmenopausal endometrium*** - Appears as a **thin homogeneous hyperechoic stripe** measuring **<5mm** on TVS, which is characteristic of estrogen-deficient state. - Shows **uniform echogenicity** without the distinct layering patterns seen in reproductive-age women due to atrophic changes. *Proliferative endometrium* - Demonstrates a distinctive **trilaminar pattern** with alternating hyperechoic and hypoechoic layers measuring **4-8mm** in thickness. - Shows **progressive thickening** during the follicular phase with clear **three-line sign** representing the functional and basal layers. *Secretory endometrium* - Appears as a **thick hyperechoic layer** measuring **7-14mm** due to increased glandular secretions and stromal edema. - Shows **uniform bright echogenicity** without the trilaminar pattern, reflecting progesterone-induced changes in the luteal phase. *Endometrium in the menstrual phase* - Appears **thin and irregular** with **mixed echogenicity** due to sloughing of the functional layer and blood collection. - Shows **disrupted architecture** with **hypoechoic areas** representing menstrual blood and debris within the endometrial cavity.

Q: Which area of the colon is least visualized by barium studies?

Sigmoid colon. The **sigmoid colon** is the most challenging segment to visualize during barium studies (Barium Enema) due to its unique anatomy. ### Why Sigmoid Colon is the Correct Answer: 1. **Redundancy and Overlapping:** The sigmoid colon is an intraperitoneal, S-shaped structure with a long mesentery (sigmoid mesocolon). This results in multiple redundant loops that frequently overlap one another on a standard 2D radiograph, obscuring mucosal detail and small lesions like polyps or early diverticula. 2. **Pelvic Location:** Its deep position within the bony pelvis further complicates visualization due to overlying pelvic structures. 3. **Technical Requirement:** To overcome this, specialized views like the **Chassard-Lapine view** or "angled" sigmoid views are required to "uncoil" the loops. ### Why Other Options are Incorrect: * **Hepatic and Splenic Flexures:** While these areas can be tricky due to their high anatomical position and potential overlap with the ribs or liver/spleen, they are generally fixed in position. Proper patient positioning (oblique views) easily clears these areas. * **Caecum:** As the most proximal part of the large bowel, the caecum is a large, relatively fixed pouch. Once barium reaches the caecum and refluxes into the terminal ileum (the hallmark of a complete study), it is usually well-visualized in the right iliac fossa. ### High-Yield Clinical Pearls for NEET-PG: * **"Coffee Bean" Appearance:** Classic radiological sign of **Sigmoid Volvulus**. * **Apple Core Sign:** Characteristic of annular constricting carcinoma, most commonly seen in the **sigmoid colon**. * **Investigation of Choice:** While barium enema was historical, **Colonoscopy** is now the gold standard for visualizing the sigmoid colon, as it allows for direct visualization and biopsy. * **Water-soluble contrast (Gastrografin):** Used instead of Barium if perforation is suspected.

Q: A patient presents with abdominal distension. X-ray of the patient is shown below. What is the probable diagnosis?

Caecal volvulus. ***Caecal volvulus*** - Characterized by a **coffee-bean or kidney-shaped** distended bowel loop displaced to the **left upper quadrant** on plain X-ray. - Shows **absence of gas** in the right colon with a **single fluid level** in the displaced cecum, creating the classic radiological appearance. *Sigmoid volvulus* - Presents with an **omega-shaped or inverted-U loop** typically located in the **pelvis** rather than the left upper quadrant. - Shows **double haustral markings** converging toward the pelvis with a **coffee-bean appearance** but in a different location. *Midgut volvulus* - Primarily occurs in **neonates and infants** due to **malrotation**, not typically in adult presentations. - X-ray shows **duodenal obstruction** with a **double bubble sign** rather than the large bowel distension seen here. *None of the above* - The radiological findings clearly match a **specific volvulus pattern** with characteristic displacement and morphology. - The **coffee-bean appearance** in the left upper quadrant is pathognomonic for **caecal volvulus**, making this option incorrect.

Q: Pipe stem appearance in barium enema is characteristic of which condition?

Ulcerative colitis. **Explanation:** The **"Pipe stem" (or Lead pipe) appearance** is a classic radiological sign of **Chronic Ulcerative Colitis (UC)** seen on a barium enema. This appearance occurs due to the loss of normal haustral markings, shortening of the colon, and narrowing of the bowel lumen. The underlying pathology involves chronic inflammation leading to mucosal hypertrophy and fibrosis of the muscularis propria, making the colon appear as a rigid, featureless tube. **Analysis of Options:** * **Ulcerative Colitis (Correct):** In the chronic stage, the colon loses its redundancy and haustra, resulting in the "lead pipe" look. Other findings include "granular mucosa" (early) and "pseudopolyps." * **Crohn’s Disease:** Characterized by "String sign of Kantor" (due to terminal ileal spasm/stricture), "Cobblestone appearance" (due to deep longitudinal fissures), and "Skip lesions." It typically involves the entire bowel wall (transmural). * **Schistosomiasis:** While it can cause colonic strictures and polyps, it does not typically present with the diffuse, symmetrical loss of haustra seen in UC. * **Carcinoma of the Colon:** Classically presents as an **"Apple core lesion"** or a "Napkin ring sign," representing a short, irregular, circumferential narrowing of the lumen with overhanging edges. **High-Yield Clinical Pearls for NEET-PG:** * **Backwash Ileitis:** Involvement of the terminal ileum in UC (occurs in ~10% of cases). * **Toxic Megacolon:** A life-threatening complication of UC where the colon diameter exceeds 6 cm. * **Stove-pipe appearance:** Another synonym for the lead pipe appearance in chronic UC. * **Thumbprinting:** Seen in Ischemic Colitis due to mucosal edema/hemorrhage.

Q: What is the diagnosis?

Duodenal perforation. ***Duodenal perforation*** - The classic finding is **pneumoperitoneum** (free air under the diaphragm) on **erect chest X-ray**, indicating gastrointestinal perforation. - **Duodenal perforation** commonly occurs due to peptic ulcer disease, presenting as **Rigler's sign** (air outlining both sides of bowel wall). *Pneumothorax* - Shows **pleural air** between the lung and chest wall, not **subphrenic air** as seen in perforation. - Presents with **collapsed lung margin** and **absent lung markings** peripherally, distinct from pneumoperitoneum. *Hiatus hernia* - Demonstrates **gastric bubble above the diaphragm** in the thoracic cavity, not free air under diaphragm. - Shows **retrocardiac opacity** with **air-fluid level** representing herniated stomach contents. *Pleural effusion* - Presents as **opacification** at the **costophrenic angle** with **blunting** of the normal sharp angle. - Shows **fluid collection** in pleural space, not **free air** beneath the diaphragm as in perforation.

Q: A 20-year-old male presents with multiple bruises on the anterior chest and abdominal regions. The attending surgeon suspects pneumoperitoneum and requests a chest X-ray. What is the best radiological view to detect pneumoperitoneum?

Erect chest X-ray. **Explanation:** **1. Why Erect Chest X-ray is the Correct Answer:** The Erect Chest X-ray (CXR) is the gold standard and most sensitive initial screening tool for detecting pneumoperitoneum. Free air in the peritoneal cavity (extraluminal air) naturally rises to the highest point due to gravity. In the upright position, this air collects under the domes of the diaphragm, appearing as a thin, radiolucent crescent (the **"Gas under Diaphragm"** sign). An erect CXR is preferred over an erect abdominal film because the diaphragm is better visualized, and even as little as **1–2 ml of free air** can be detected. **2. Analysis of Incorrect Options:** * **Left lateral decubitus with horizontal beam (Option B):** This is the **second-best** alternative. It is used when the patient is too unstable to stand or sit. Air rises to collect between the liver and the right lateral abdominal wall. * **Right lateral decubitus with horizontal beam (Option A):** This is incorrect because air would collect between the stomach/spleen and the left lateral wall. This makes it difficult to distinguish free air from the normal gastric fundus gas bubble. * **Left lateral decubitus with vertical beam (Option D):** A vertical beam in a decubitus position does not allow air to layer against the body wall in a way that creates a tangential interface, making it ineffective for detecting small amounts of free air. **3. High-Yield Clinical Pearls for NEET-PG:** * **Rigler’s Sign:** Visualization of both the inner and outer walls of the bowel loop due to free air (requires large amounts of air). * **Football Sign:** A large ovoid radiolucency seen on a supine film in massive pneumoperitoneum. * **Cupola Sign:** Air trapped under the central tendon of the diaphragm. * **Positioning:** For a lateral decubitus film, the patient should remain in that position for **10–20 minutes** before the X-ray to allow air to migrate.

Question 1

Which of the following is an investigation for small intestine abnormalities, excluding one option?

Accepted Answer

USG enteroclysis

Answer

Enteroclysis

Answer

Radionuclide imaging

Answer

CT enteroclysis

Question 2

A 54-year-old man presents with a 2-day history of mild abdominal pain, bloating, nausea, vomiting, and poor appetite. His past medical history is significant for recent pneumonia. Radiographic examination reveals a paralytic ileus. Which of the following signs would most likely be found during a physical examination?

Accepted Answer

Absent bowel sounds

Answer

Increased bowel sounds

Answer

Borborygmi

Answer

Crampy abdominal pain

Question 3

What is the type of Gharbi classification of the given hydatid cyst?

Accepted Answer

III

Answer

I

Answer

II

Answer

IV

Question 4

Barium esophagogram findings in carcinoma esophagus include all EXCEPT:

Accepted Answer

Edges of filling defect are not clear-cut

Answer

Distortion of the esophageal lumen

Answer

Annular stricture

Answer

Irregular "rat-tail" filling defect of the distal esophagus

Question 5

A TVS (Transvaginal Sonography) demonstrates which of the following endometrial findings?

Accepted Answer

Postmenopausal endometrium

Answer

Proliferative endometrium

Answer

Secretory endometrium

Answer

Endometrium in the menstrual phase

Question 6

Which area of the colon is least visualized by barium studies?

Accepted Answer

Sigmoid colon

Answer

Hepatic flexure

Answer

Splenic flexure

Answer

Caecum

Question 7

A patient presents with abdominal distension. X-ray of the patient is shown below. What is the probable diagnosis?

Accepted Answer

Caecal volvulus

Answer

Sigmoid volvulus

Answer

Midgut volvulus

Answer

None of the above

Question 8

Pipe stem appearance in barium enema is characteristic of which condition?

Accepted Answer

Ulcerative colitis

Answer

Crohn's disease

Answer

Schistosomiasis

Answer

Carcinoma of the colon

Question 9

What is the diagnosis?

Accepted Answer

Duodenal perforation

Answer

Pneumothorax

Answer

Hiatus hernia

Answer

Pleural effusion

Question 10

A 20-year-old male presents with multiple bruises on the anterior chest and abdominal regions. The attending surgeon suspects pneumoperitoneum and requests a chest X-ray. What is the best radiological view to detect pneumoperitoneum?

Accepted Answer

Erect chest X-ray

Answer

Right lateral decubitus with horizontal beam

Answer

Left lateral decubitus with horizontal beam

Answer

Left lateral decubitus with vertical beam

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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