Abdominal and Pelvic Radiology Practice Questions

Q: Fleischner sign on barium study is seen in which of the following conditions?

Ileocecal tuberculosis. **Explanation:** **Fleischner sign** is a classic radiological feature of **Ileocecal Tuberculosis**. It refers to a gaping, wide-open, and incompetent ileocecal valve caused by the thickening of the valve lips and ulceration. On a barium study, this results in the rapid reflux of barium from the cecum into the terminal ileum. **Why the correct answer is right:** In abdominal TB, the ileocecal region is the most common site of involvement due to the abundance of lymphoid tissue (Peyer's patches) and physiological stasis. The inflammatory process leads to the destruction of the ileocecal valve's competency. Another closely related sign is the **Stierlin sign**, where the inflamed cecum is so irritable that it does not retain barium, appearing as a narrow, rigid segment. **Why the other options are incorrect:** * **Crohn’s Disease:** While it also affects the terminal ileum, it typically presents with the **"String sign of Kantor"** (marked narrowing of the terminal ileum due to spasm or fibrosis) and "Proud flesh" (widely spaced loops). * **Small Bowel Carcinoid:** Usually presents with a kinking or angulation of bowel loops due to an intense desmoplastic reaction (fibrosis) in the mesentery, often showing a "starburst" appearance on CT. * **Typhoid:** Primarily causes longitudinal ulcers in the ileum and may lead to perforation, but it does not typically produce the specific valvular changes seen in the Fleischner sign. **High-Yield Clinical Pearls for NEET-PG:** * **Fleischner Sign:** Incompetent/Gaping ileocecal valve (TB). * **Stierlin Sign:** Rapid emptying of the cecum (TB). * **Conical Cecum:** Shrunken, inverted cecum due to fibrosis (TB). * **String Sign of Kantor:** Narrowed terminal ileum (Crohn’s). * **Goose-neck deformity:** Seen in the cecum in TB.

Q: Non-visualization of the kidney is seen in all EXCEPT?

Ectopic kidney. **Explanation:** The question refers to the **non-visualization of the kidney in its normal anatomical position (the renal fossa)** during imaging, typically on an Intravenous Urogam (IVU) or ultrasound. **Why Ectopic Kidney is the correct answer:** In **Ectopic Kidney**, the kidney is present and functional but failed to ascend to its normal lumbar position during development. It is most commonly found in the pelvis (**Pelvic Kidney**). While it is not in the "normal" location, it is still **visualized** on imaging if the radiologist scans the lower abdomen and pelvis. It will show normal contrast excretion on IVU, unlike the other conditions listed where the kidney is either absent or non-functional. **Analysis of Incorrect Options:** * **Unilateral Renal Agenesis:** The kidney is congenitally absent on one side. Therefore, it cannot be visualized anywhere in the body. * **Bilateral Renal Agenesis:** Both kidneys are absent (associated with Potter sequence). No renal tissue is present to be visualized. * **Renal Vein Thrombosis:** This causes severe congestion, edema, and loss of renal function. On an IVU, the affected kidney will be a **"non-visualized" or "silent" kidney** because it cannot filter and excrete the contrast medium. **NEET-PG High-Yield Pearls:** * **Most common site for Ectopy:** Pelvis. * **Horseshoe Kidney:** The most common fusion anomaly; the isthmus usually lies anterior to the aorta at the level of **L3-L4** (trapped by the Inferior Mesenteric Artery). * **Pancake Kidney:** A rare anomaly where both kidneys fuse into a single mass in the pelvis. * **Mnemonic for "Silent Kidney" on IVU:** "REVEAL" (Renal agenesis, Ectopy, Vascular (thrombosis), Excretion failure (obstruction), Abnormality (MCKD), Late-stage GN). Note that while Ectopy is on the list, it is "visualized" once the pelvis is scanned.

Q: What is the investigation of choice for extra-adrenal pheochromocytoma?

CT. **Explanation:** The investigation of choice for localizing an extra-adrenal pheochromocytoma (also known as a paraganglioma) is **Contrast-Enhanced Computed Tomography (CECT)**. 1. **Why CT is the Correct Answer:** CT is the initial imaging modality of choice due to its high spatial resolution and excellent sensitivity (90–100%) for detecting tumors in the abdomen and pelvis. In the context of extra-adrenal pheochromocytomas—which most commonly occur at the **Organ of Zuckerkandl** (near the aortic bifurcation)—CT provides precise anatomical localization and assessment of the relationship with adjacent vascular structures, which is critical for surgical planning. 2. **Why Other Options are Incorrect:** * **MRI:** While MRI is superior for detecting tumors in specific locations (e.g., intracardiac, juxtavascular) or in patients where radiation/contrast is contraindicated (pregnant women/children), it is generally considered a second-line anatomical imaging tool after CT. * **X-ray:** This lacks the soft-tissue resolution required to identify small retroperitoneal or pelvic masses. * **MIBG Scan ($^{123}$I-MIBG):** This is a **functional** imaging study. While highly specific, it is not the "investigation of choice" for initial localization. It is reserved for cases where the primary tumor is not found on CT/MRI, to screen for metastatic disease, or to confirm that a mass seen on CT is indeed a pheochromocytoma. **Clinical Pearls for NEET-PG:** * **Rule of 10s:** 10% are extra-adrenal, 10% are bilateral, 10% are malignant, and 10% occur in children. * **Biochemical Screening:** Always perform biochemical tests (plasma or 24-hour urinary metanephrines) **before** imaging to confirm the diagnosis. * **Scintigraphy:** If MIBG is negative but suspicion is high, **$^{68}$Ga-DOTATATE PET/CT** is now considered the most sensitive functional imaging for paragangliomas (especially those associated with SDHB mutations).

Q: What is the diagnosis demonstrated in the barium esophagogram?

Carcinoma esophagus. ***Carcinoma esophagus*** - Shows classic **rat-tail** or **apple-core appearance** with irregular stricture and **shouldering** on barium esophagogram. - Demonstrates **abrupt cutoff** with mucosal irregularity and asymmetric narrowing characteristic of malignant lesions. *Achalasia* - Presents with **bird-beak appearance** showing smooth, symmetric tapering at the gastroesophageal junction. - Associated with **esophageal dilatation** proximally and absence of the irregular stricture seen in malignancy. *Schatzki's ring* - Appears as a **smooth, thin ring** at the gastroesophageal junction without irregular margins. - Represents a **benign web** that causes intermittent dysphagia, lacking the shouldering of carcinoma. *Nutcracker esophagus* - This is a **functional disorder** with no characteristic findings on barium esophagogram at rest. - Diagnosis requires **manometry** showing high-amplitude peristaltic contractions, not radiographic abnormalities.

Q: A given cystogram appearance is a characteristic feature of which of the following conditions?

Neurogenic bladder. ***Neurogenic bladder*** - Shows characteristic **"Christmas tree"** or **trabeculated appearance** on cystography due to detrusor muscle hypertrophy and irregular bladder wall thickening. - Results from **neurological disorders** affecting bladder innervation, leading to incomplete emptying and compensatory muscle changes. *Congenital anomalies of the genitourinary tract* - Cystographic findings are highly **variable** depending on the specific anomaly (duplications, diverticula, etc.). - Do not produce the characteristic **trabeculated pattern** seen in neurogenic bladder dysfunction. *Tuberculosis* - Produces a **"thimble bladder"** appearance with severe contracture and reduced capacity on cystography. - Shows **irregular, contracted bladder walls** with calcifications, distinct from the Christmas tree pattern. *Schistosomiasis* - Causes **calcified, contracted bladder** with "eggshell calcification" visible on plain radiographs. - Results in **reduced bladder capacity** and smooth wall thickening, not the trabeculated Christmas tree appearance.

Q: What is the minimum size of a liver metastasis that can be detected by contrast-enhanced computed tomography (CECT)?

5 mm. **Explanation:** The detection of liver metastases on Contrast-Enhanced Computed Tomography (CECT) depends on the spatial resolution of the scanner and the contrast difference between the lesion and the surrounding liver parenchyma. * **Why 5 mm is correct:** Modern multidetector CT (MDCT) scanners, using thin-section collimation (typically 1–2 mm slices) and optimal intravenous contrast enhancement, have a high sensitivity for focal liver lesions. The practical threshold for reliable detection and characterization of a metastasis is **5 mm**. Lesions smaller than this often fall below the resolution limits or are obscured by "partial volume averaging," where the density of the small lesion is averaged with the surrounding healthy tissue. * **Why other options are incorrect:** * **1 mm:** This is below the spatial resolution of standard clinical CT. While micro-metastases exist, they cannot be visualized by current imaging modalities. * **1 cm:** While 1 cm lesions are easily seen, this is not the *minimum* size. CECT is significantly more sensitive than this. * **2 cm:** This was the threshold in the early days of single-slice CT. With modern technology, waiting for a lesion to reach 2 cm would represent a significant diagnostic delay. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** While CECT is the initial workup of choice, **MRI with hepatocyte-specific contrast agents (e.g., Gadoxetic acid/Primovist)** is the most sensitive modality for detecting small liver metastases (<1 cm). * **Vascularity:** Most liver metastases are **hypovascular** (e.g., Colorectal CA) and are best seen in the **portal venous phase**. * **Hypervascular Metastases:** Metastases from Renal Cell Carcinoma (RCC), Thyroid CA, Melanoma, and Neuroendocrine tumors are best seen in the **late arterial phase**. * **Hypodense Appearance:** On CECT, most metastases appear as well-defined hypodense areas relative to the enhancing liver.

Q: Comment on the diagnosis shown below?

Drooping water lily sign. ***Drooping water lily sign*** - This is the **classic radiological appearance** of a **hydatid cyst** (echinococcosis) where the detached **inner endocyst membrane** floats on fluid like a water lily on water surface. - Also known as the **camalote sign**, it indicates **cyst rupture** or **membrane detachment** and is pathognomonic for echinococcal cysts on imaging. *Horse shoe kidney* - This refers to a **congenital renal fusion anomaly** where both kidneys are connected at the lower poles, creating a horseshoe shape. - Typically shows **bilateral renal masses** connected across the midline with **malrotation** of the collecting systems. *Flower Vase kidney* - This describes the appearance of **chronic pyelonephritis** where there is **cortical scarring** overlying **dilated calyces**. - The kidney shows a **club-shaped calyceal dilatation** with overlying cortical thinning, resembling a flower vase shape. *Duplication of kidney* - This refers to **complete or incomplete duplication** of the **collecting system** with two separate ureters or a bifid ureter. - Shows **two distinct pelvicalyceal systems** within the same kidney, often with the upper pole ureter inserting ectopically.

Q: What is the diagnosis suggested by the barium X-ray findings?

Carcinoma of the esophagus. ***Carcinoma of the esophagus*** - Classic barium swallow findings include **irregular filling defect**, **shouldering**, and **mucosal destruction** with an **apple-core or rat-tail appearance**. - Shows **abrupt transition** from normal to abnormal mucosa, indicating **malignant stricture** with tissue destruction. *Achalasia* - Barium swallow demonstrates **smooth, symmetric bird-beak tapering** at the gastroesophageal junction without mucosal irregularity. - Shows **retained contrast** in a dilated esophagus due to **failure of lower esophageal sphincter relaxation**. *Plummer-Vinson Syndrome* - Characterized by a **smooth, thin postcricoid web** in the upper esophagus on barium swallow. - Associated with **iron deficiency anemia** and typically affects the **cervical esophagus**, not causing irregular filling defects. *Gastroesophageal reflux disease (GERD)* - Barium swallow may show **reflux of contrast** into the esophagus during fluoroscopy but **no structural lesion**. - May demonstrate **hiatal hernia** or **esophagitis** but lacks the irregular filling defect seen in malignancy.

Question 1

Fleischner sign on barium study is seen in which of the following conditions?

Accepted Answer

Ileocecal tuberculosis

Answer

Crohn's disease

Answer

Small bowel carcinoid

Answer

Typhoid

Question 2

Non-visualization of the kidney is seen in all EXCEPT?

Accepted Answer

Ectopic kidney

Answer

Unilateral renal agenesis

Answer

Bilateral renal agenesis

Answer

Renal vein thrombosis

Question 3

What is the investigation of choice for extra-adrenal pheochromocytoma?

Accepted Answer

CT

Answer

MRI

Answer

X-ray

Answer

MIBG scan

Question 4

What is the diagnosis demonstrated in the barium esophagogram?

Accepted Answer

Carcinoma esophagus

Answer

Achalasia

Answer

Schatzki's ring

Answer

Nutcracker esophagus

Question 5

A given cystogram appearance is a characteristic feature of which of the following conditions?

Accepted Answer

Neurogenic bladder

Answer

Congenital anomalies of the genitourinary tract

Answer

Tuberculosis

Answer

Schistosomiasis

Question 6

What is the most common cause of widening of the C-loop of the duodenum?

Accepted Answer

Carcinoma of the head of the pancreas

Answer

Pancreatitis

Answer

Choledochal cyst

Answer

Retroperitoneal masses

Question 7

What is the minimum size of a liver metastasis that can be detected by contrast-enhanced computed tomography (CECT)?

Accepted Answer

5 mm

Answer

1 mm

Answer

1 cm

Answer

2 cm

Question 8

What is the investigation of choice for small bowel tumors?

Accepted Answer

Enterolysis

Answer

CT

Answer

Barium meal and follow through

Answer

MRI

Question 9

Comment on the diagnosis shown below?

Accepted Answer

Drooping water lily sign

Answer

Horse shoe kidney

Answer

Flower Vase kidney

Answer

Duplication of kidney

Question 10

What is the diagnosis suggested by the barium X-ray findings?

Accepted Answer

Carcinoma of the esophagus

Answer

Achalasia

Answer

Plummer-Vinson Syndrome

Answer

Gastroesophageal reflux disease (GERD)

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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