Abdominal and Pelvic Radiology Practice Questions

Q: A 24-year-old man presents to the emergency department with a 12-hour history of intermittent, crampy abdominal pain and five episodes of vomiting. He denies any rectal bleeding. On examination, his abdomen is distended with absent bowel sounds. Per-rectal examination is normal. An abdominal X-ray reveals findings suggestive of a specific condition. Based on the X-ray findings, which of the following statements are true?

Haustra are not visible.. ***Haustra are not visible*** - In **small bowel obstruction**, haustra are absent because haustra are characteristic features of the **large bowel** (colon), not the small bowel. - The absence of haustra on X-ray helps differentiate **small bowel** from **large bowel obstruction**, making this a key diagnostic feature. *Distribution of intestinal loops is mainly in the center* - While small bowel loops are typically **centrally located**, this distribution can vary and is not as definitive as other radiological features. - **Large bowel** can also occupy central areas, making this feature less reliable for distinguishing small bowel obstruction. *No visible plicae circulares* - **Plicae circulares** (valvulae conniventes) are actually **visible** in small bowel obstruction and are a characteristic feature of the small bowel. - These **mucosal folds** extend across the full width of the small bowel lumen and help identify small bowel on X-ray. *String of beads sign is present* - The **string of beads sign** represents alternating **gas and fluid levels** and can be seen in small bowel obstruction, but it's not consistently present. - This sign is more suggestive than diagnostic and may not be visible in all cases of **small bowel obstruction**.

Q: Which of the following is a specific diagnostic criterion for Budd-Chiari syndrome?

Intrahepatic collaterals. ### Explanation **Budd-Chiari Syndrome (BCS)** is characterized by the obstruction of hepatic venous outflow, occurring at any level from the small hepatic veins to the junction of the inferior vena cava (IVC) and the right atrium. **Why Option A is Correct:** **Intrahepatic collaterals** are considered a **specific** radiologic sign of BCS. When the primary hepatic veins are thrombosed or stenosed, the liver attempts to decompress itself by forming new vascular pathways. These typically appear as "comma-shaped" or "tortuous" vessels connecting the obstructed hepatic veins to systemic circulation or patent accessory veins. Their presence is highly suggestive of chronic BCS. **Analysis of Incorrect Options:** * **B. Dilated paraumbilical vein:** This is a sign of **portal hypertension**, not specifically BCS. While BCS can lead to portal hypertension, a dilated paraumbilical vein (part of the *Caput Medusae* complex) is more commonly associated with cirrhosis of any etiology. * **C. Post-acoustic shadowing:** This is an ultrasound artifact seen behind highly attenuating structures like gallstones or calcifications. It has no diagnostic relevance to venous outflow obstruction. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Abdominal pain, ascites, and hepatomegaly. * **Caudate Lobe Hypertrophy:** The most common imaging finding. The caudate lobe often enlarges because its venous drainage (directly into the IVC) is usually spared. * **"Spider-web" Appearance:** Seen on hepatic venography when small collateral vessels form around an occluded main hepatic vein. * **Contrast Enhancement:** On CT, the liver may show a "nutmeg" appearance (mottled enhancement) due to venous congestion. * **US Doppler:** The gold standard initial screening tool, showing absent or reversed flow in hepatic veins.

Q: What is the diagnosis suggested by the intravenous urogram (IVU) study?

Congenital megaureter. ***Congenital megaureter*** - **Markedly dilated distal ureter** (>7mm diameter) with **hydroureter** extending to the ureterovesical junction, classic IVU finding in congenital megaureter. - IVU shows **normal renal pelvis** without **pelviureteric junction obstruction**, distinguishing it from other obstructive uropathies. *Vesicoureteral reflux (VUR)* - **Cannot be diagnosed on IVU** as it requires **voiding cystourethrogram (VCUG)** to demonstrate retrograde flow of urine from bladder to ureter. - IVU may show **secondary changes** like calyceal blunting or scarring but cannot directly visualize the reflux mechanism. *Duplication of a renal pelvis* - IVU would show **two separate renal pelves** and **collecting systems** within the same kidney, creating a distinctive "double outline" appearance. - Often associated with **duplex ureter** which may be complete or incomplete, clearly different from isolated ureteral dilatation. *Post-caval ureter* - IVU demonstrates characteristic **medial deviation** of the ureter at **L3-L4 vertebral level** as it courses behind the inferior vena cava. - Creates a distinctive **"fishhook" or "J-shaped" appearance** of the ureter on IVU, not generalized ureteral dilatation.

Q: Early arterial phase enhancement on CECT scan of the liver indicates which of the following?

Hepatocellular carcinoma (HCC). ### Explanation **Correct Answer: B. Hepatocellular carcinoma (HCC)** **The Underlying Concept:** The liver has a dual blood supply: the **portal vein (75%)** and the **hepatic artery (25%)**. Normal liver parenchyma derives most of its blood from the portal vein. However, **Hepatocellular Carcinoma (HCC)** is a highly vascular tumor that derives its blood supply almost exclusively (90-100%) from the **hepatic artery**. On a Triple-Phase Contrast-Enhanced CT (CECT), HCC exhibits a classic enhancement pattern: 1. **Early Arterial Phase:** Intense, "bright" enhancement (Hypervascularity) as the contrast enters via the hepatic artery. 2. **Portal Venous/Delayed Phase:** Rapid "washout," appearing hypodense compared to the surrounding liver which is now enhancing via the portal vein. **Why the other options are incorrect:** * **A. Hydatid Cyst:** Typically appears as a well-defined fluid-density lesion with a "cyst-within-a-cyst" appearance (daughter cysts) and peripheral wall calcification. It does not show internal arterial enhancement. * **C. Hepatic Abscess:** Usually presents as a low-attenuation collection with **peripheral rim enhancement** (target sign), not diffuse early arterial enhancement. * **D. Simple Hepatic Cyst:** These are benign, fluid-filled structures that show **no enhancement** in any phase (0-10 HU). **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad for HCC on CT:** Arterial enhancement + Portal venous washout + Pseudocapsule. * **Tumor Marker:** Elevated **Alpha-fetoprotein (AFP)** is highly suggestive of HCC. * **Hemangioma:** Shows peripheral globular enhancement with "centripetal fill-in" (contrast moves from periphery to center). * **Focal Nodular Hyperplasia (FNH):** Shows intense arterial enhancement with a characteristic **central stellate scar**.

Q: What is the location of the stricture in the given RGU?

Bulbar urethra. ***Bulbar urethra*** - The **bulbar urethra** is the most common site of urethral strictures, particularly following **trauma** or **infection**. - On **retrograde urethrography (RGU)**, bulbar strictures appear as **smooth narrowing** in the **posterior penile/perineal region**, which is the typical location seen in most imaging studies. *Membranous urethra* - The **membranous urethra** is located within the **urogenital diaphragm** and is less commonly affected by strictures. - **RGU** may not adequately visualize this segment due to its **short length** and **deep pelvic location**. *Penile urethra* - The **penile urethra** extends from the **penoscrotal junction** to the **external meatus** and is less frequently involved in stricture formation. - **Penile strictures** typically result from **hypospadias repair** or **lichen sclerosus**, which are less common causes. *Prostatic urethra* - The **prostatic urethra** is rarely affected by **inflammatory strictures** and is better evaluated by **voiding cystourethrography (VCUG)**. - **RGU** has limited ability to visualize the **prostatic segment** due to **contrast flow limitations** in retrograde studies.

Q: An X-ray shows findings suggestive of:

Pseudopneumoperitoneum. ***Pseudopneumoperitoneum*** - Shows **bowel haustrations** beneath the right hemidiaphragm, indicating **Chilaiditi sign** (bowel interposition between liver and diaphragm). - This is a **benign condition** where the colon mimics free air but contains characteristic **colonic markings**. *Pseudopneumomediastinum* - Would show **mediastinal air-like appearance** caused by **bowel gas** in the mediastinum, not subdiaphragmatic location. - Typically involves **esophageal** or **gastric** structures creating false mediastinal air impression. *Pneumoperitoneum* - Shows **true free air** in the peritoneal cavity without **bowel wall markings** or haustrations. - Usually indicates **bowel perforation** requiring urgent surgical intervention, unlike the benign Chilaiditi sign. *Pneumomediastinum* - Presents as **actual air** in the mediastinal space, often outlining cardiac borders and great vessels. - Commonly caused by **alveolar rupture**, **esophageal perforation**, or **chest trauma** with air tracking into mediastinum.

Q: A 24-year-old man presented with a retroperitoneal, necrotic, heterogeneously enhancing mass on CT near the hilum of the left kidney. What is the most probable diagnosis?

Metastatic germ cell tumor. **Explanation:** The correct answer is **Metastatic germ cell tumor (GCT)**. In a young male (20–40 years), a retroperitoneal mass near the renal hilum is a classic presentation of metastatic spread from a primary testicular tumor. The lymphatic drainage of the testes follows the gonadal veins, leading directly to the **para-aortic and inter-aortocaval lymph nodes** (near the renal hilum). Radiologically, metastatic GCTs (especially non-seminomatous types) are characterized by large, bulky nodes that frequently undergo **central necrosis**, appearing as heterogeneous enhancement on CT. **Analysis of Incorrect Options:** * **Metastatic melanoma:** While melanoma can metastasize to the retroperitoneum, it is less common than GCT in this age group and typically presents with a known primary cutaneous lesion. * **Lymphoma:** This is a common cause of retroperitoneal lymphadenopathy; however, lymphoma typically presents as a "sandwich sign" (encasing vessels) and is usually **homogeneous** and non-necrotic. Necrosis in lymphoma is rare unless post-treatment. * **Metastatic transitional cell tumor:** This usually occurs in older patients and is associated with primary bladder or ureteral malignancies. **NEET-PG High-Yield Pearls:** * **Left Testis Drainage:** Drains to the left para-aortic nodes near the left renal vein. * **Right Testis Drainage:** Drains to the inter-aortocaval nodes. * **Scrotal Skin Drainage:** Drains to the **superficial inguinal lymph nodes** (not para-aortic). * **Imaging Hallmark:** A bulky, necrotic retroperitoneal mass in a young male should always prompt a physical examination of the testes and an ultrasound of the scrotum to rule out an occult primary tumor.

Question 1

A 24-year-old man presents to the emergency department with a 12-hour history of intermittent, crampy abdominal pain and five episodes of vomiting. He denies any rectal bleeding. On examination, his abdomen is distended with absent bowel sounds. Per-rectal examination is normal. An abdominal X-ray reveals findings suggestive of a specific condition. Based on the X-ray findings, which of the following statements are true?

Accepted Answer

Haustra are not visible.

Answer

Distribution of intestinal loops is mainly in the center.

Answer

No visible plicae circulares.

Answer

String of beads sign is present.

Question 2

Semen analysis of a young man presenting with primary infertility revealed low volume, fructose-negative ejaculate with azoospermia. Which of the following is the most useful imaging modality to evaluate the cause of his infertility?

Accepted Answer

Transrectal ultrasonography

Answer

Colour duplex ultrasonography of the scrotum

Answer

Retrograde urethrography

Answer

Spermatic venography

Question 3

Which of the following is a specific diagnostic criterion for Budd-Chiari syndrome?

Accepted Answer

Intrahepatic collaterals

Answer

Dilated paraumbilical vein

Answer

Post-acoustic shadowing

Answer

None of the above

Question 4

Which imaging modality is BEST used to detect distant metastasis in pancreatic cancer?

Accepted Answer

Positron-emission tomography with fluorodeoxyglucose (PET-FDG)

Answer

Magnetic Resonance Cholangiopancreatography (MRCP)

Answer

Dual phase, contrast-enhanced spiral CT

Answer

Endoscopic Ultrasound (EUS)

Question 5

What is the diagnosis suggested by the intravenous urogram (IVU) study?

Accepted Answer

Congenital megaureter

Answer

Vesicoureteral reflux (VUR)

Answer

Duplication of a renal pelvis

Answer

Post-caval ureter

Question 6

Early arterial phase enhancement on CECT scan of the liver indicates which of the following?

Accepted Answer

Hepatocellular carcinoma (HCC)

Answer

Hydatid cyst

Answer

Hepatic abscess

Answer

Simple hepatic cyst

Question 7

What is the location of the stricture in the given RGU?

Accepted Answer

Bulbar urethra

Answer

Membranous urethra

Answer

Penile urethra

Answer

Prostatic urethra

Question 8

An X-ray shows findings suggestive of:

Accepted Answer

Pseudopneumoperitoneum

Answer

Pseudopneumomediastinum

Answer

Pneumoperitoneum

Answer

Pneumomediastinum

Question 9

An asymptomatic male presented for ultrasonography of the abdomen for medical fitness. A focal lesion was found in his liver on ultrasound. The patient was informed that this is the most common benign hepatic tumor. Which of the following is a false statement about this lesion?

Accepted Answer

The most sensitive and specific investigation is a triphasic contrast-enhanced CT scan.

Answer

Most of these lesions are asymptomatic.

Answer

Characteristic centripetal fill-in enhancement is seen on postcontrast imaging.

Answer

Angiography shows a characteristic 'cotton-wool' appearance.

Question 10

A 24-year-old man presented with a retroperitoneal, necrotic, heterogeneously enhancing mass on CT near the hilum of the left kidney. What is the most probable diagnosis?

Accepted Answer

Metastatic germ cell tumor

Answer

Metastatic melanoma

Answer

Lymphoma

Answer

Metastatic transitional cell tumor

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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