Abdominal and Pelvic Radiology Practice Questions

Q: Which of the following is NOT a diagnostic feature of gallstone ileus on a plain abdominal radiograph?

Stone < 2.5 cm in size within the intestine. **Explanation:** **Gallstone ileus** is a mechanical small bowel obstruction caused by the impaction of a large gallstone that has migrated through a cholecysto-enteric fistula (most commonly into the duodenum). **Why Option B is the correct answer:** For a gallstone to cause a mechanical obstruction (ileus), it typically needs to be **at least 2.5 cm** in diameter. Smaller stones usually pass through the ileocecal valve without causing obstruction. Therefore, a stone smaller than 2.5 cm is not a classic diagnostic feature of this pathology; rather, the presence of a **large** ectopic stone is the hallmark. **Analysis of Incorrect Options (Rigler’s Triad):** The diagnosis of gallstone ileus on a plain radiograph is based on **Rigler’s Triad**, which includes: * **Option A (Ectopic gallstone):** A calcified stone seen outside the gallbladder fossa, often in the right iliac fossa (the ileum is the narrowest part of the small bowel). * **Option C (Small bowel obstruction):** Dilated small bowel loops with air-fluid levels due to the mechanical blockage. * **Option D (Pneumobilia):** Gas within the biliary tree occurs because the fistula allows air from the gut to enter the bile ducts. **NEET-PG High-Yield Pearls:** * **Rigler’s Triad:** Pneumobilia + Small bowel obstruction + Ectopic gallstone (seen in ~30-35% of cases on X-ray). * **Most common site of impaction:** Terminal ileum (narrowest part). * **Most common fistula:** Cholecystoduodenal fistula. * **Bouveret Syndrome:** A specific type of gallstone ileus where the stone impacts in the duodenum, causing gastric outlet obstruction. * **Investigation of Choice:** CT abdomen (highly sensitive for identifying the stone and the fistula).

Q: Thickened gastric folds are found in which of the following conditions?

All of the above. Thickened gastric folds (hypertrophic gastropathy) are a significant radiological and endoscopic finding characterized by rugae exceeding 5 mm in width. This appearance results from infiltration of the gastric wall by inflammatory cells, malignant cells, or excessive mucosal proliferation. **Explanation of Options:** * **Lymphoma (Option A):** Gastric lymphoma (most commonly MALToma or DLBCL) typically presents with massive, irregular, and "soft" fold thickening. Unlike adenocarcinoma, lymphoma often preserves gastric pliability and distensibility despite extensive infiltration. * **Menetrier’s Disease (Option B):** This is a protein-losing gastropathy characterized by massive hyperplasia of surface mucous cells and atrophy of parietal cells. It classically involves the **fundus and body**, sparing the antrum, and presents with "giant" folds resembling cerebral convolutions. * **Carcinoma (Option C):** Specifically, **Linitis Plastica** (diffuse-type adenocarcinoma) causes significant wall thickening and fold distortion. In these cases, the stomach becomes rigid and non-distensible (the "leather bottle" appearance). **Why "All of the Above" is Correct:** All three conditions involve pathological processes—neoplastic infiltration (Lymphoma/Carcinoma) or mucosal hyperplasia (Menetrier’s)—that increase the volume of the gastric wall layers, leading to the radiological appearance of thickened folds. **NEET-PG High-Yield Pearls:** * **Zollinger-Ellison Syndrome:** Another classic cause of thickened folds due to hypergastrinemia-induced parietal cell hyperplasia. * **Menetrier’s Disease Triad:** Giant gastric folds + Hypoalbuminemia (protein loss) + Achlorhydria. * **Imaging Modality:** While Barium swallow shows "filling defects" or "cobblestone" patterns, **CT scan** is the preferred modality to assess wall thickness and extragastric extension.

Q: Which imaging modality is used for the initial assessment of acute pancreatitis?

CT scan. **Explanation:** The diagnosis of acute pancreatitis is primarily clinical, based on the presence of at least two of the following: characteristic abdominal pain, serum amylase/lipase levels >3 times the upper limit of normal, and characteristic findings on imaging. **Why CT Scan is the Correct Answer:** Contrast-Enhanced Computed Tomography (CECT) is the **gold standard** and the most reliable modality for the initial assessment of acute pancreatitis. It is used to confirm the diagnosis (if biochemical tests are inconclusive), assess the severity (using the Balthazar Score or CT Severity Index), and identify complications like necrosis, pseudocysts, or abscesses. For optimal results in detecting necrosis, CECT is ideally performed **72 hours** after the onset of symptoms. **Analysis of Incorrect Options:** * **USG (Ultrasonography):** While often the first test performed to look for **etiology** (e.g., gallstones), it is poor at visualizing the pancreas itself due to overlying bowel gas (ileus), which is common in pancreatitis. * **X-ray:** Plain films (e.g., "sentinel loop" or "colon cut-off sign") are non-specific and are mainly used to rule out other causes of acute abdomen, such as hollow viscus perforation. * **MRI:** Highly sensitive and useful for detecting choledocholithiasis (MRCP), but it is not the initial modality due to high cost, limited availability, and longer scan times. **High-Yield Clinical Pearls for NEET-PG:** * **Best Initial Test for Etiology:** USG (to check for gallstones). * **Most Sensitive Biochemical Marker:** Serum Lipase (remains elevated longer than Amylase). * **Modified Glasgow and Ranson’s Criteria:** Used for predicting prognosis. * **Sentinel Loop Sign:** Dilated loop of proximal jejunum near the pancreas seen on X-ray.

Q: The "collar button" sign is associated with which condition?

Ulcerative colitis. The **"collar button" sign** is a classic radiological finding in **Ulcerative Colitis (UC)**, typically seen on a double-contrast barium enema. ### 1. Why Ulcerative Colitis is Correct In the acute phase of UC, inflammation leads to the formation of deep, penetrating ulcers. These ulcers extend through the mucosa and undermine the submucosa. On a barium study, the contrast fills these ulcers, appearing as a narrow neck (at the mucosal level) that expands into a wider base (in the submucosa). This shape resembles a traditional shirt collar button or a "T-shaped" projection. ### 2. Why Other Options are Incorrect * **Hirschsprung disease:** Characterized by a "transition zone" on barium enema, where a narrow aganglionic distal segment leads to a dilated proximal colon (megacolon). * **Plummer-Vinson syndrome:** Associated with esophageal webs, iron deficiency anemia, and dysphagia. On imaging, it shows a thin, horizontal shelf-like projection in the upper esophagus. * **Chilaiditi syndrome:** A radiological curiosity where a loop of colon (usually the hepatic flexure) is interposed between the liver and the diaphragm, mimicking pneumoperitoneum. ### 3. NEET-PG High-Yield Pearls * **Lead Pipe Colon:** Seen in chronic UC due to loss of haustrations and bowel shortening. * **Pseudopolyps:** Islands of regenerating mucosa surrounded by areas of ulceration. * **Thumbprinting:** Seen in ischemic colitis (due to submucosal edema/hemorrhage). * **String Sign of Kantor:** Associated with Crohn’s disease (terminal ileum narrowing). * **Cobblestone Appearance:** Classic for Crohn’s disease due to longitudinal and transverse ulcers.

Q: A 56-year-old male presents with burning micturition, increasing frequency, and hesitancy. An intravenous pyelogram was performed, and the radiograph is shown. What is the most likely diagnosis?

Pelvic lipomatosis. ***Pelvic lipomatosis*** - Presents with **pear-shaped bladder** and **radiolucent halo** around the bladder on IVP, caused by excess **fatty tissue** in the pelvis compressing the bladder - Commonly affects **middle-aged males** causing **lower urinary tract symptoms** (LUTS) including burning micturition, frequency, and hesitancy due to bladder compression *Multicystic dysplastic kidney disease* - A **congenital condition** typically diagnosed in **infancy or childhood**, not in a 56-year-old male - Shows **multiple non-communicating cysts** replacing normal renal parenchyma on imaging, not the pear-shaped bladder deformity seen here *Aortic aneurysm* - Would present with **pulsatile abdominal mass** and potential **back pain**, not primarily urinary symptoms - IVP would show **lateral displacement** of ureters or kidneys, not the characteristic bladder changes described *Renal cell carcinoma* - Typically presents with **hematuria**, **flank pain**, and **palpable mass** (classic triad), not lower urinary tract symptoms - IVP would show **renal mass effect** or **calyceal distortion**, not the pear-shaped bladder configuration

Q: Which of the following is NOT a typical ultrasound finding of Autosomal Recessive Polycystic Kidney Disease (ARPKD)?

Cysts greater than 3 cm in diameter. **Explanation:** **Autosomal Recessive Polycystic Kidney Disease (ARPKD)** is a genetic disorder characterized by the non-obstructive ectasia (dilation) of the renal collecting ducts. **Why Option D is the Correct Answer:** In ARPKD, the cysts are microscopic (usually 3 cm) are characteristic of **Autosomal Dominant Polycystic Kidney Disease (ADPKD)** or simple renal cysts, but are not a feature of the infantile/neonatal presentation of ARPKD. **Analysis of Incorrect Options:** * **Option A:** Despite massive enlargement, the kidneys typically **retain their reniform (kidney-like) shape** because the dilation is uniform across the collecting system. * **Option B:** Since the kidneys are dysfunctional in utero, there is decreased fetal urine production, leading to **oligohydramnios**, which can result in Potter sequence (pulmonary hypoplasia, clubbed feet, and flattened facies). * **Option C:** The diffuse involvement of the collecting ducts throughout the parenchyma leads to a **loss of corticomedullary differentiation**, as the entire kidney becomes uniformly hyperechoic. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Mutation in the **PKHD1 gene** on chromosome 6, encoding the protein **fibrocystin**. * **Liver Involvement:** ARPKD is invariably associated with **Congenital Hepatic Fibrosis**. On imaging, look for biliary hamartomas or Caroli disease. * **Classic USG Sign:** "Large echogenic kidneys" in a neonate. * **Contrast Imaging:** On IVP, it may show a "sunburst" or "radial streaking" appearance due to contrast filling the dilated tubules.

Q: An X-ray of the abdomen shows multiple fluid levels. What is the most likely diagnosis?

Intestinal obstruction. **Explanation:** **1. Why Intestinal Obstruction is Correct:** The presence of **multiple air-fluid levels** on an erect abdominal X-ray is a classic radiological hallmark of **mechanical intestinal obstruction**. When the normal forward flow of contents is blocked, gas and liquid accumulate in the dilated loops of the bowel. Gravity causes the fluid to settle at the bottom while gas rises to the top, creating a distinct horizontal interface (the fluid level). * **Small Bowel Obstruction (SBO):** Typically shows multiple central loops with a "step-ladder" appearance. More than 2–3 fluid levels are considered pathological. * **Large Bowel Obstruction:** Shows peripheral loops with haustral markings. **2. Why Other Options are Incorrect:** * **B. Hollow Viscus Perforation:** The characteristic radiological finding here is **pneumoperitoneum** (free air under the diaphragm on an erect chest/abdominal X-ray), not multiple fluid levels within the bowel. * **C. Pyoperitoneum:** This refers to pus in the peritoneal cavity. While it may cause a generalized "ground-glass" haziness (ascites appearance) or an adynamic ileus, it does not typically present with the classic multiple fluid levels seen in mechanical obstruction. **3. NEET-PG High-Yield Pearls:** * **Step-ladder pattern:** Classic sign of SBO on an erect film. * **String of beads/pearls sign:** Small bubbles of gas trapped between valvulae conniventes in a fluid-filled small bowel; highly suggestive of SBO. * **Coffee bean sign:** Pathognomonic for Sigmoid Volvulus. * **Coiled spring appearance:** Seen on contrast studies/ultrasound in Intussusception. * **Rule of 3-6-9:** Normal bowel diameter is <3cm (Small bowel), <6cm (Large bowel), and <9cm (Cecum). Anything above this suggests dilatation/obstruction.

Q: Minimal ascites can be best detected by which imaging modality?

Ultrasound (USG). **Explanation:** **1. Why Ultrasound (USG) is the Correct Answer:** Ultrasound is the most sensitive and preferred initial modality for detecting minimal ascites. It can detect as little as **5–10 mL** of fluid in the peritoneal cavity. Its high sensitivity is due to the fact that fluid is anechoic (black), providing a sharp contrast against the echogenic (bright) surfaces of the liver and pelvic organs. The best site to detect minimal fluid in a supine patient is **Morison’s pouch** (hepatorenal recess) or the **Pouch of Douglas** in the pelvis. **2. Why Other Options are Incorrect:** * **Plain X-ray Abdomen:** This is the least sensitive modality. Ascites only becomes visible on X-ray when the volume exceeds **500–1000 mL**. Signs like "ground-glass appearance" or "Dog’s ear sign" (fluid in the paravesical fossae) indicate massive, not minimal, ascites. * **CT Scan:** While CT is highly accurate and can detect small amounts of fluid (approx. 30 mL), it is not the "best" first-line choice due to ionizing radiation, higher cost, and the fact that USG is more sensitive for trace amounts of free fluid. * **MRI:** Although sensitive, MRI is never the primary modality for detecting ascites due to its high cost, lack of portability, and long scan times. **3. High-Yield Clinical Pearls for NEET-PG:** * **Minimum fluid for clinical detection:** 500–1500 mL (via shifting dullness). * **Puddle Sign:** A physical exam maneuver used to detect small amounts of fluid (approx. 120 mL), though USG remains superior. * **FAST Scan (Focused Assessment with Sonography for Trauma):** Uses USG to quickly identify hemoperitoneum (blood) in the perihepatic, perisplenic, pelvic, and pericardial spaces. * **Order of sensitivity for fluid detection:** USG > CT > Clinical Exam > X-ray.

Q: Balthazar grading is used for acute pancreatitis based on findings on which imaging modality?

Computed Tomography (CT). **Explanation:** The **Balthazar score** is a radiological grading system used to assess the severity of **acute pancreatitis** specifically based on **Contrast-Enhanced Computed Tomography (CECT)** findings. It evaluates the presence of pancreatic inflammation and peripancreatic fluid collections to predict prognosis and the risk of complications. **Why CT is the correct answer:** CECT is the gold standard for diagnosing complications of acute pancreatitis. The Balthazar grading (Grades A to E) assesses the size, shape, and contour of the pancreas along with the number of fluid collections. When combined with the degree of pancreatic necrosis, it forms the **CT Severity Index (CTSI)**, which correlates strongly with patient morbidity and mortality. **Why other options are incorrect:** * **Ultrasound (USG):** While often the first-line investigation to look for gallstones (etiology), USG is limited by overlying bowel gas and cannot accurately grade the severity or necrosis of the pancreas. * **MRI:** Though MRI (MRCP) is excellent for visualizing the biliary tree and detecting "walled-off necrosis," the Balthazar score was historically developed and validated specifically for CT. * **ERCP:** This is an invasive therapeutic procedure used to remove ductal stones or place stents; it is not a diagnostic grading tool for parenchymal inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Balthazar Grades:** A (Normal), B (Enlargement), C (Inflammation/Peripancreatic fat stranding), D (Single fluid collection), E (Two or more collections or gas). * **CT Severity Index (CTSI):** Balthazar Score (0–4 points) + Necrosis Score (0–6 points). A score of 7–10 indicates severe disease. * **Timing:** CECT is most accurate for assessing necrosis **48–72 hours** after the onset of symptoms. * **Modified CTSI:** A newer version that includes extrapancreatic complications (e.g., pleural effusion, ascites).

Question 1

Which of the following is NOT a diagnostic feature of gallstone ileus on a plain abdominal radiograph?

Accepted Answer

Stone < 2.5 cm in size within the intestine

Answer

Ectopic calcified gallstone

Answer

Signs of small intestinal obstruction

Answer

Gas within the biliary tree

Question 2

What is the most sensitive and specific investigation in renal artery hypertension?

Accepted Answer

MRI

Answer

Captopril-enhanced renal scan

Answer

Doppler ultrasound

Answer

CT scan

Question 3

Thickened gastric folds are found in which of the following conditions?

Accepted Answer

All of the above

Answer

Lymphoma

Answer

Menetrier's disease

Answer

Carcinoma

Question 4

Which imaging modality is used for the initial assessment of acute pancreatitis?

Accepted Answer

CT scan

Answer

USG

Answer

X-ray

Answer

MRI

Question 5

The "collar button" sign is associated with which condition?

Accepted Answer

Ulcerative colitis

Answer

Hirschsprung disease

Answer

Plummer-Vinson syndrome

Answer

Chilaiditi syndrome

Question 6

A 56-year-old male presents with burning micturition, increasing frequency, and hesitancy. An intravenous pyelogram was performed, and the radiograph is shown. What is the most likely diagnosis?

Accepted Answer

Pelvic lipomatosis

Answer

Multicystic dysplastic kidney disease

Answer

Aortic aneurysm

Answer

Renal cell carcinoma

Question 7

Which of the following is NOT a typical ultrasound finding of Autosomal Recessive Polycystic Kidney Disease (ARPKD)?

Accepted Answer

Cysts greater than 3 cm in diameter

Answer

Retention of reniform shape of kidneys

Answer

Oligohydramnios

Answer

Loss of corticomedullary differentiation

Question 8

An X-ray of the abdomen shows multiple fluid levels. What is the most likely diagnosis?

Accepted Answer

Intestinal obstruction

Answer

Hollow viscus perforation

Answer

Pyoperitoneum

Answer

None of the above

Question 9

Minimal ascites can be best detected by which imaging modality?

Accepted Answer

Ultrasound (USG)

Answer

Plain X-ray abdomen

Answer

Magnetic Resonance Imaging (MRI)

Answer

Computed Tomography (CT) Scan

Question 10

Balthazar grading is used for acute pancreatitis based on findings on which imaging modality?

Accepted Answer

Computed Tomography (CT)

Answer

Ultrasound (USG)

Answer

Magnetic Resonance Imaging (MRI)

Answer

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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