Abdominal and Pelvic Radiology Practice Questions

Q: What is the initial investigation for an amoebic liver abscess?

USG. **Explanation:** **A. USG (Correct):** Ultrasonography is the **initial investigation of choice** for a suspected amoebic liver abscess (ALA) due to its high sensitivity (75-95%), low cost, wide availability, and lack of ionizing radiation. On USG, an ALA typically appears as a well-defined, round or oval hypoechoic lesion, usually located in the right lobe (posterosuperior segment), with internal echoes and no significant wall enhancement. It is also used to guide therapeutic aspiration if required. **B. Exploratory Laparotomy:** This is an invasive surgical procedure and is never the initial investigation. It is reserved for complications like a ruptured abscess leading to peritonitis when percutaneous drainage or medical management fails. **C. CT Scan:** While Contrast-Enhanced CT (CECT) is more sensitive than USG for detecting small abscesses and evaluating complications (like rupture), it is not the *initial* step. It is considered the "gold standard" for localization but is reserved for cases where USG is inconclusive. **D. Technetium-99 Scan:** Nuclear imaging (using Tc-99m sulfur colloid) shows a "cold" spot in ALA (as it is avascular). While it helps differentiate ALA from a Pyogenic Abscess (which may show "hot" spots on Gallium scans), it is not a primary diagnostic tool. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Right lobe of the liver (due to the bulk of blood flow from the superior mesenteric vein). * **Classic appearance:** "Anchovy sauce" pus (chocolate brown, odorless). * **Diagnosis:** Combination of **USG + Serology** (ELISA for Entamoeba histolytica antibodies) is the most definitive non-invasive approach. * **Drug of Choice:** Metronidazole. * **Indications for Aspiration:** Large abscess (>10 cm), risk of rupture (left lobe abscess), or failure to respond to medical therapy within 48-72 hours.

Q: A patient complains of epigastric pain, radiating to the back off and on. What is the investigation of choice?

CT scan. **Explanation:** The clinical presentation of epigastric pain radiating to the back is a classic hallmark of **pancreatic pathology**, most commonly acute or chronic pancreatitis or pancreatic malignancy. **Why CT Scan is the Correct Answer:** Contrast-Enhanced Computed Tomography (CECT) is the **investigation of choice** for pancreatic evaluation. It provides superior anatomical detail, allows for the staging of inflammation (Balthazar scoring), detects complications like necrosis or pseudocysts, and is the gold standard for staging pancreatic adenocarcinoma (resectability). Its high sensitivity, specificity, and rapid acquisition make it the preferred initial diagnostic modality in a clinical setting. **Analysis of Incorrect Options:** * **USG (Ultrasound):** While often the *first-line* screening tool for abdominal pain, it is frequently limited by overlying bowel gas, which obscures the pancreas. It is excellent for detecting gallstones but lacks the sensitivity of CT for parenchymal details. * **MRI/MRCP:** While highly sensitive for ductal anatomy and certain cystic lesions, it is more expensive, time-consuming, and generally reserved for cases where CT is inconclusive or contrast is contraindicated. * **Radio nucleotide scan:** This has no primary role in the acute or routine diagnosis of pancreatic inflammatory or neoplastic conditions. **Clinical Pearls for NEET-PG:** * **Investigation of choice for Acute Pancreatitis:** CECT (ideally performed after 48–72 hours to accurately assess necrosis). * **Most sensitive test for Chronic Pancreatitis:** Endoscopic Ultrasound (EUS). * **Gold Standard for Pancreatic Duct Anatomy:** MRCP (non-invasive) or ERCP (invasive/therapeutic). * **Double Duct Sign on CT:** Suggests a tumor in the head of the pancreas (dilatation of both CBD and Pancreatic duct).

Q: Which of the following is a radiological finding of a benign gastric ulcer?

All of the above. In radiology, distinguishing between benign and malignant gastric ulcers is a high-yield topic for NEET-PG. The correct answer is **All of the above** because these features collectively indicate a non-neoplastic, inflammatory process. ### **Explanation of Radiological Findings:** 1. **Hampton Line (Option A):** This is a thin (1–2 mm), sharp lucent line across the neck of the ulcer crater. It represents the undermined but intact gastric mucosa at the ulcer edge. It is a hallmark of a benign ulcer. 2. **Ulcer Collar (Option B):** This is a thicker, translucent band at the neck of the ulcer caused by edema of the submucosa. Unlike the Hampton line, it is more prominent but still indicates a benign inflammatory response. 3. **Projection from the Lumen (Option C):** Benign ulcers typically represent a "hole" in the wall; therefore, when viewed in profile, the ulcer crater **projects beyond the normal predicted gastric contour**. In contrast, malignant ulcers (Carman Meniscus Sign) appear as excavations *within* a mass, staying within the gastric lumen. ### **Why other options are part of the correct set:** Since A, B, and C are all classic signs of benignity on a double-contrast barium swallow, "All of the above" is the most accurate choice. ### **High-Yield Clinical Pearls for NEET-PG:** * **Benign Ulcer:** Smooth margins, radiating mucosal folds that reach the very edge of the crater, and projection beyond the lumen. * **Malignant Ulcer:** Irregular base, nodular/heaped-up margins, and mucosal folds that stop short or are clubbed/fused before reaching the crater. * **Carman Meniscus Sign:** A semi-lunate (crescent) shaped ulcer with the convexity directed toward the gastric wall, pathognomonic for a large **malignant** gastric ulcer. * **Location:** Benign ulcers are most commonly found on the **lesser curvature** or posterior wall.

Q: Yoyo reflux is most commonly associated with which of the following conditions?

Duplication of ureter. **Explanation:** **Yoyo reflux** (also known as uretero-ureteral reflux) is a classic radiological and physiological phenomenon seen in cases of **incomplete duplication of the ureter** (bifid ureter). 1. **Why Option A is correct:** In a bifid ureter, two ureters drain a single kidney but join together before entering the bladder. During peristalsis, urine travels down one limb; however, when it reaches the point of bifurcation, some urine may be diverted retrograde (backwards) up the other limb instead of continuing into the common ureter. This "to-and-fro" movement of urine between the two ureteral limbs is termed "Yoyo reflux." It can lead to stasis, recurrent urinary tract infections (UTIs), and ureteral dilatation. 2. **Why other options are incorrect:** * **Polycystic Kidney Disease (ADPKD):** Characterized by multiple bilateral renal cysts; it does not involve ureteral duplication or this specific reflux pattern. * **Medullary Sponge Kidney:** Involves cystic dilatation of the collecting ducts (ectasia) presenting with a "paintbrush" appearance on IVP; it is not a structural ureteral anomaly. * **Pseudo kidney:** This is an ultrasound sign (concentric rings) typically associated with **intussusception** or bowel tumors, not a urological reflux pattern. **High-Yield Clinical Pearls for NEET-PG:** * **Weigert-Meyer Law:** Applies to **complete** duplication. The ureter from the **upper pole** inserts **ectopically** (inferior and medial) and is prone to **obstruction/ureterocele**. The **lower pole** ureter inserts normally but is prone to **vesicoureteral reflux (VUR)**. * **Yoyo reflux** is specific to **incomplete (bifid)** ureters, whereas **VUR** is more common in **complete** duplication. * **Investigation of choice:** Voiding Cystourethrogram (VCUG) for VUR; IVP or MRU for visualizing duplication anatomy.

Q: What condition is associated with the "comb sign" on CT abdomen?

Crohn's disease. The **Comb Sign** is a classic radiological hallmark of active, hemodynamically significant **Crohn’s disease**. ### 1. Why Crohn’s Disease is Correct The "comb sign" refers to the appearance of prominent, engorged, and widely spaced **vasa recta** (the small arteries supplying the bowel) within the mesentery. In active Crohn’s disease, transmural inflammation leads to increased blood flow and fibrofatty proliferation (creeping fat). On a contrast-enhanced CT, these dilated vessels align parallel to each other, resembling the teeth of a comb. This sign is highly specific for **active inflammation** and helps differentiate acute flares from chronic fibrostenotic disease. ### 2. Why Other Options are Incorrect * **Ulcerative Colitis:** This condition primarily involves the mucosa and submucosa rather than the full thickness of the wall. Mesenteric vascular engorgement is rare; instead, CT may show "lead pipe" appearance or "target sign" due to mucosal edema. * **Tuberculosis (Abdominal):** While it can cause bowel wall thickening, it typically presents with necrotic mesenteric lymphadenopathy and asymmetric involvement of the ileocecal junction, rather than prominent vasa recta. * **Intestinal Lymphoma:** This usually presents with "aneurysmal dilatation" of the bowel lumen and bulky, non-necrotic lymphadenopathy. It does not typically cause the hypervascular mesenteric response seen in Crohn’s. ### 3. NEET-PG High-Yield Pearls * **String Sign of Kantor:** Narrowing of the terminal ileum due to spasm or fibrosis (seen on Barium studies). * **Creeping Fat:** Mesenteric fat wrapping around the bowel circumference, a precursor to the comb sign. * **Proud Flesh:** Inflammatory polyps (pseudopolyps) seen in the colon. * **Skip Lesions:** Segmental involvement of the bowel, a key differentiator from the continuous involvement in Ulcerative Colitis.

Q: Intravenous urogram shows a 'flower vase' appearance. What is the most likely diagnosis?

Horse-shoe kidney. **Explanation:** The **'flower vase' appearance** on an Intravenous Urogram (IVU) is a classic radiological sign of a **Horse-shoe kidney**. This occurs because the lower poles of both kidneys are fused across the midline (usually by an isthmus at the level of L4). This fusion prevents the normal lateral rotation of the kidneys; instead, the kidneys remain vertically oriented or medially rotated. Consequently, the long axes of the kidneys are directed downwards and medially, and the ureters arise from the anterior surface, draping over the isthmus before descending, mimicking the shape of a flower vase. **Analysis of Options:** * **A. Duplex system with upper moiety ureterocele:** Characterized by the **'Drooping Lily'** appearance, where the obstructed upper pole moiety displaces the lower pole moiety downwards and outwards. * **B. Polycystic kidney disease:** Typically shows bilateral enlarged kidneys with a **'Spider leg'** appearance due to the elongation and compression of the calyces by multiple cysts. * **C. Horse-shoe kidney:** Correct. The fusion of lower poles leads to the characteristic 'flower vase' or 'hand-holding' appearance. * **D. Retro-caval ureter:** Characterized by a **'Fish-hook'** or **'J-shaped'** ureter, where the right ureter passes behind the Inferior Vena Cava. **High-Yield Pearls for NEET-PG:** * **Embryology:** The ascent of the horse-shoe kidney is arrested by the **Inferior Mesenteric Artery (IMA)**. * **Most common site of fusion:** Lower poles (90%). * **Complications:** Increased risk of PUJ obstruction, nephrolithiasis, and infections. * **Associated Malignancy:** Increased incidence of **Wilms tumor** (in children) and **Transitional Cell Carcinoma**.

Q: Which of the following findings is not typically seen on imaging of acute pyelonephritis?

Increased vascularity. **Explanation:** Acute pyelonephritis is a clinical diagnosis, but imaging (USG or CT) is often used to assess complications. The hallmark of acute pyelonephritis on imaging is **decreased perfusion**, not increased. **Why "Increased Vascularity" is the correct answer (the finding NOT seen):** In acute pyelonephritis, the inflammatory process leads to interstitial edema and leukocyte infiltration. This causes compression of the small intrarenal vessels and capillaries. Consequently, Doppler ultrasound or contrast-enhanced CT typically shows **decreased/absent vascularity** or "striated nephrograms" in the affected segments. Increased vascularity is more characteristic of tumors or certain chronic inflammatory conditions, but not acute bacterial infection of the renal parenchyma. **Analysis of Incorrect Options:** * **A. Grossly enlarged kidney:** Edema and inflammatory cell infiltration cause the kidney to swell, leading to global or focal reniform enlargement. * **B. Focal areas of hypoechogenicity:** On ultrasound, the edema reduces the echogenicity of the renal parenchyma compared to the normal cortex. * **C. Perinephric edema:** Inflammation often spreads to the surrounding Gerota’s fascia, manifesting as "stranding" on CT or fluid collections/thickening on ultrasound. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Imaging:** Contrast-Enhanced CT (CECT) is the most sensitive modality for diagnosing pyelonephritis and its complications (e.g., abscess). * **Striated Nephrogram:** A classic CT finding characterized by linear bands of delayed enhancement due to tubular obstruction and interstitial edema. * **Emphysematous Pyelonephritis:** A life-threatening necrotizing infection (common in diabetics) characterized by **gas** within the renal parenchyma.

Question 1

What is the initial investigation for an amoebic liver abscess?

Accepted Answer

USG

Answer

Exploratory laparotomy

Answer

CT scan

Answer

Technetium-99 scan

Question 2

A patient complains of epigastric pain, radiating to the back off and on. What is the investigation of choice?

Accepted Answer

CT scan

Answer

MRI

Answer

USG

Answer

Radio nucleotide scan

Question 3

Which of the following is a radiological finding of a benign gastric ulcer?

Accepted Answer

All of the above

Answer

Hampton line

Answer

Collar at the neck of the ulcer

Answer

Projection from the lumen of the stomach

Question 4

Yoyo reflux is most commonly associated with which of the following conditions?

Accepted Answer

Duplication of ureter

Answer

Polycystic kidney disease

Answer

Medullary sponge kidney

Answer

Pseudo kidney

Question 5

What is the best method to visualize the proximal bile duct?

Accepted Answer

Percutaneous transhepatic cholangiogram

Answer

Endoscopic ultrasonography (EUS)

Answer

Endoscopic retrograde cholangiopancreatography (ERCP)

Answer

Transabdominal ultrasonography

Question 6

What condition is associated with the "comb sign" on CT abdomen?

Accepted Answer

Crohn's disease

Answer

Ulcerative colitis

Answer

Tuberculosis

Answer

Intestinal lymphoma

Question 7

Intravenous urogram shows a 'flower vase' appearance. What is the most likely diagnosis?

Accepted Answer

Horse-shoe kidney

Answer

Duplex system with upper moiety ureterocele

Answer

Polycystic kidney disease

Answer

Retro-caval ureter

Question 8

Which is the best investigation to detect pneumoperitoneum?

Accepted Answer

Plain X-ray chest, erect

Answer

Plain X-ray abdomen, erect

Answer

Left lateral decubitus radiograph

Answer

CT scan

Question 9

Which of the following MR imaging findings distinguishes vaginal atresia from Mullerian agenesis?

Accepted Answer

Presence of a cervix

Answer

Amount of upper vaginal dilatation

Answer

Length of the atresia

Answer

Hymeneal ring appearance

Question 10

Which of the following findings is not typically seen on imaging of acute pyelonephritis?

Accepted Answer

Increased vascularity

Answer

Grossly enlarged kidney

Answer

Focal areas of hypoechogenicity

Answer

Perinephric edema

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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