Abdominal and Pelvic Radiology Practice Questions

Q: Which condition is characterized by the 'accordian sign'?

Pseudomembranous colitis. **Explanation:** The **'Accordion Sign'** is a classic radiological finding most commonly associated with **Pseudomembranous colitis** (caused by *Clostridioides difficile* infection). **1. Why Pseudomembranous Colitis is correct:** The sign occurs when oral contrast material becomes trapped between thickened, edematous haustral folds. On CT, the alternating layers of high-density contrast and low-density inflamed mucosa resemble the bellows of an accordion. This indicates severe colonic wall thickening and mucosal edema. **2. Analysis of Incorrect Options:** * **Intussusception:** Characterized by the **'Target sign'** or **'Doughnut sign'** on transverse ultrasound/CT, and the **'Pseudokidney sign'** on longitudinal views. * **Ileocecal TB:** Typically presents with a **'Conical cecum'**, **'Stierlin’s sign'** (rapid emptying of the inflamed segment), or the **'Fleischner sign'** (inverted umbrella appearance of the ileocaecal valve). * **Ischemic colitis:** Often shows **'Thumbprinting'** on plain X-ray or barium studies due to submucosal hemorrhage and edema, but lacks the specific "trapped contrast" pattern of the accordion sign. **3. NEET-PG High-Yield Pearls:** * **Pseudomembranous Colitis:** Look for a history of recent antibiotic use (especially Clindamycin or Fluoroquinolones). The gold standard for diagnosis is the detection of *C. difficile* toxins in stool. * **Other signs of Colitis:** **'Lead pipe appearance'** is seen in chronic Ulcerative Colitis due to loss of haustrations. * **Differential:** While highly suggestive of *C. difficile*, the accordion sign can occasionally be seen in other causes of severe edema, such as Crohn’s disease or infectious colitis, but for exam purposes, it is the hallmark of Pseudomembranous colitis.

Q: The 'bent inner tube' sign is radiographically observed in which of the following conditions?

Volvulus. **Explanation:** The **'bent inner tube' sign** (also known as the **'coffee bean' sign**) is a classic radiographic finding pathognomonic for **Sigmoid Volvulus**. This condition occurs when the sigmoid colon twists on its mesenteric axis, leading to a closed-loop obstruction. On an abdominal X-ray, the massively dilated, gas-filled sigmoid loop rises out of the pelvis, appearing as a smooth, U-shaped loop that resembles a bent inner tube or a coffee bean, with the "seam" representing the opposed inner walls of the dilated bowel. **Analysis of Options:** * **Volvulus (Correct):** Specifically Sigmoid Volvulus. The torsion creates a massive distension of the loop. Another key sign is the **'bird’s beak' appearance** seen on a gastrografin enema at the site of the twist. * **Intussusception:** Characterized radiographically by the **'target sign'** or **'pseudokidney sign'** on ultrasound, and the **'claw sign'** or **'coiled spring' appearance** on a barium enema. * **Intestinal Obstruction:** Small bowel obstruction typically presents with multiple **dilated central loops** and a **'step-ladder' pattern** of air-fluid levels, rather than a single massive U-shaped loop. * **Gastric Antral Vascular Ectasia (GAVE):** This is an endoscopic diagnosis, not a radiographic one. It is characterized by the **'watermelon stomach'** appearance due to longitudinal erythematous strips in the antrum. **High-Yield Clinical Pearls for NEET-PG:** * **Sigmoid Volvulus:** Most common in elderly, institutionalized, or psychiatric patients with chronic constipation. * **Management:** Initial treatment is **sigmoidoscopic detorsion** (using a flatus tube) unless gangrene is suspected. * **Cecal Volvulus:** Presents with a **'comma-shaped'** or **'fetal' appearance**, with the loop pointing toward the left upper quadrant.

Q: Corkscrew esophagus in barium swallow is characteristic of which of the following conditions?

Diffuse esophageal spasm. ### Explanation **Correct Answer: C. Diffuse esophageal spasm (DES)** **Why it is correct:** Diffuse esophageal spasm is a motility disorder characterized by high-amplitude, non-peristaltic (uncoordinated) contractions of the esophageal smooth muscle. On a **Barium Swallow**, these simultaneous contractions compartmentalize the esophagus into multiple segments, creating a classic undulating appearance known as a **"Corkscrew esophagus"** or **"Rosary bead esophagus."** Clinically, patients present with intermittent chest pain (mimicking angina) and dysphagia to both solids and liquids. **Why the other options are incorrect:** * **Achalasia cardia:** Characterized by a failure of the Lower Esophageal Sphincter (LES) to relax and absent peristalsis. The classic Barium Swallow finding is a **"Bird’s beak"** or "Rat-tail" appearance due to a dilated proximal esophagus and a narrow distal segment. * **Esophageal cancer:** Typically presents with an irregular, eccentric narrowing of the lumen. The classic radiological sign is an **"Apple-core" appearance** or a "Shouldering effect" due to the malignant mass. * **Diverticulum:** This refers to an outpouching of the esophageal wall. For example, **Zenker’s diverticulum** (a pulsion diverticulum through Killian’s dehiscence) appears as a contrast-filled sac posterior to the esophagus. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Manometry is the most sensitive test for DES, showing repetitive, high-amplitude, simultaneous contractions (>20% of swallows). * **Treatment:** First-line includes Calcium Channel Blockers (CCBs) or Nitrates to relax smooth muscle. Surgical option: Long Esophageal Myotomy. * **Nutcracker Esophagus:** Often confused with DES; it involves high-pressure peristaltic waves (>180 mmHg) rather than uncoordinated ones. It does *not* typically show a corkscrew appearance.

Q: The X-ray image provided (img-41.jpeg) shows multiple cylindrical objects in the abdominal area. Which of the following conditions is most likely represented by this image?

Body packer syndrome. ***Body packer syndrome*** - The X-ray shows multiple, well-defined, uniformly shaped, dense, cylindrical objects throughout the gastrointestinal tract, a classic radiographic finding for **body packer syndrome**. - These objects are ingested packets containing illicit drugs, often showing a "double-condom sign" (a thin lucent rim of air trapped in the wrapping), confirming their manufactured nature. *Bezoar* - A **bezoar** is a mass of indigestible material (like hair or vegetable fiber) that appears as a single, mottled, intraluminal mass on X-ray, not multiple discrete packets. - The objects in the image have a uniform shape and density, which is inconsistent with the heterogeneous appearance of a bezoar. *Pica due to anaemia* - **Pica** involves the ingestion of non-nutritive substances, which would result in radiopaque foreign bodies of various, irregular shapes (e.g., coins, stones), not uniform cylindrical packets. - While associated with conditions like **iron-deficiency anaemia**, the radiographic findings of pica do not match the organized, manufactured appearance of the objects shown. *Constipation due to fecalith* - A **fecalith** is a hardened mass of stool that appears as a mottled density within the colon, conforming to the haustral pattern, and lacks the smooth, well-defined borders seen here. - While severe **constipation** leads to significant stool burden, it does not present as multiple, encapsulated, geometrically regular objects.

Q: A 30 year old apparently healthy man who was carrying laxatives and enema apparatus developed abdominal pain at the airport and an x-ray was done which appears as shown below. Which of the following is the likely diagnosis?

Body packer syndrome. ***Body packer syndrome*** - This diagnosis is indicated by the presence of multiple, well-defined, uniformly shaped, and hyperdense foreign bodies within the gastrointestinal tract, as seen on the abdominal X-ray. - The clinical context of being at an airport with laxatives and enema apparatus is highly suggestive of an individual attempting to smuggle illicit drugs by ingesting them in packets. *Bezoar syndrome* - A **bezoar** is a mass of indigestible material (like hair or vegetable fibers) trapped in the GI tract, which appears on X-ray as a mottled, heterogeneous mass, not as multiple discrete, uniform packets. - Bezoars typically conform to the shape of the stomach or bowel lumen and lack the smooth, regular outlines seen in this image. *Pica due to anaemia* - **Pica** is the ingestion of non-nutritive substances and might show foreign objects on an X-ray, but these would typically be of varied shapes and sizes (e.g., coins, dirt, paint chips), not uniform packets. - The clinical presentation does not suggest anaemia, and the scenario points towards illegal activity rather than a compulsive eating disorder. *Constipation due to fecalith* - A **fecalith** is a hardened mass of stool that appears as a mottled density within the colon, consistent with retained feces. - The objects in the X-ray have sharp, smooth borders and a uniform density, which is inconsistent with the appearance of a fecalith.

Q: A 65-year-old patient presents with abdominal distension and constipation. What is the most likely diagnosis based on the abdominal X-ray shown?

Sigmoid Volvulus. ***Sigmoid Volvulus*** - The abdominal X-ray shows a classic **coffee bean sign**, which is a massively dilated, inverted U-shaped loop of the sigmoid colon rising from the pelvis. - The loop is characteristically **ahaustral** (lacking haustra) and its apex points towards the right upper quadrant, confirming the diagnosis of sigmoid volvulus. *Caecal Volvulus* - A caecal volvulus typically appears as a **kidney-shaped** or comma-shaped dilated loop of bowel, often located in the left upper quadrant or mid-abdomen. - Unlike the sigmoid, the dilated caecum in a volvulus usually retains its **haustral markings**. *Intestinal Obstruction* - While a volvulus does cause an intestinal obstruction, this option is a general finding rather than the specific diagnosis indicated by the classic radiographic sign. - General large bowel obstruction typically shows colonic dilation proximal to the blockage, without the specific twisted appearance of the **coffee bean sign**. *Small Bowel Volvulus* - A small bowel volvulus would involve dilated loops of the small bowel, which would typically show **valvulae conniventes** (plicae circulares). - This condition is rare in adults and the image clearly shows a dilated, **ahaustral** segment of the large bowel, which is inconsistent with small bowel anatomy.

Q: A patient presents with a history of dysphagia, which is more pronounced for liquids than solids. Which radiological sign is most likely to be seen?

Rat-tail sign. ***Rat-tail sign*** - Dysphagia that is more pronounced for liquids (**paradoxical dysphagia**) than solids is the hallmark symptom of **Achalasia**, a primary esophageal motility disorder. - The **rat-tail sign** (or **bird-beak sign**) seen on **barium swallow** is due to the non-relaxed, smoothly tapered distal esophagus resulting from **Lower Esophageal Sphincter (LES) failure** to relax. *Filling defect* - This is a general radiological term indicating any mass lesion protruding into the esophageal lumen, such as a **polyp**, **foreign body**, or a large tumor mass. - It is not specific to motility disorders like Achalasia, which cause smooth, concentric narrowing rather than a discrete filling absence. *Corkscrew esophagus* - This classic radiographic finding is characteristic of **Diffuse Esophageal Spasm (DES)**, where uncoordinated and severe contractions occur intermittently throughout the esophagus. - DES typically causes intermittent dysphagia and significant non-cardiac **chest pain**, and the dysphagia pattern is usually not strictly *liquids more than solids*. *Apple-core lesion* - The **apple-core lesion** (or **napkin-ring sign**) is the classical appearance of an infiltrative, malignant stricture, most commonly seen in cases of advanced **esophageal carcinoma**. - Malignant strictures cause progressive dysphagia, typically starting with difficulty swallowing **solids before liquids**, which contradicts the patient’s presentation.

Q: A male patient presented with complaints of hematuria and recurrent urinary tract infection. You notice the following finding in his CECT. What is the likely condition indicated by the arrow in the image?

Horseshoe kidney. ***Horseshoe kidney*** - The CECT image shows the **fusion of the lower poles** of the kidneys across the midline, anterior to the great vessels, forming a characteristic U-shape. This connecting bridge of renal tissue is called an **isthmus**. - This congenital anomaly is associated with an increased risk of complications like **recurrent UTIs**, **nephrolithiasis** (kidney stones), and **hematuria** due to impaired urinary drainage and vesicoureteral reflux, which aligns with the patient's presentation. *Polycystic kidney disease* - This genetic disorder is characterized by the presence of **multiple, bilateral cysts** throughout the renal parenchyma, causing massive enlargement of the kidneys. - The provided image shows a fusion anomaly with relatively normal-appearing renal parenchyma, not the cystic changes typical of polycystic kidney disease. *Hydronephrosis* - Hydronephrosis refers to the **dilation of the renal pelvis and calyces** due to an obstruction of urine outflow. It is a finding, not a primary diagnosis of a structural anomaly. - While a horseshoe kidney can lead to hydronephrosis, the primary abnormality indicated by the arrows is the **renal fusion**, not a dilated collecting system. *Pancake kidney* - A pancake (or fused pelvic) kidney is a rare anomaly where the kidneys are completely fused into a **single, disc-shaped mass** located in the pelvis. - In contrast, a horseshoe kidney involves fusion typically at the lower poles, with two distinct renal masses still identifiable, as seen in the image.

Q: A 55-year-old male patient presents with hematuria and a mass in the left kidney on a CT scan, as shown below. What is the diagnosis?

Renal angiomyolipoma. ***Renal angiomyolipoma*** - This is a benign renal tumor composed of three tissue types: blood vessels (**angio**), smooth muscle (**myo**), and fat (**lipoma**). The presence of macroscopic fat on a CT scan is a key diagnostic feature. - Patients can be asymptomatic or present with **hematuria** or flank pain, particularly if the tumor is large. There is a strong association with **tuberous sclerosis**. *Renal cell carcinoma* - This is the most common malignant kidney tumor in adults, often presenting with **hematuria**, flank pain, and a palpable mass (the classic triad). - On imaging, it typically appears as a heterogeneously enhancing solid mass and crucially, **lacks macroscopic fat**, which helps differentiate it from an angiomyolipoma. *Renal oncocytoma* - This is a benign epithelial tumor that can be difficult to distinguish from renal cell carcinoma on imaging alone. - It may show a characteristic **central stellate scar** on contrast-enhanced CT, but it does not contain significant fat tissue. *Renal cyst* - A simple renal cyst appears on CT as a well-defined, thin-walled, non-enhancing lesion filled with fluid of **water density**. - The image and description indicate a solid, **neovascular mass**, which is inconsistent with the avascular nature of a simple cyst.

Q: Identify the investigation modality shown in the image.

X-ray defecogram. ***X-ray defecogram*** - This is a dynamic fluoroscopic study, also known as **evacuation proctography**, which visualizes the rectum and anal canal during the act of defecation. - The images show contrast material within the rectum and its expulsion, allowing for the assessment of anorectal angle, pelvic floor descent, and identification of pathologies like **rectocele**, **enterocele**, or **intussusception**. *Barium swallow* - A barium swallow is a radiographic study used to examine the **upper gastrointestinal tract**, specifically the pharynx, esophagus, and stomach. - The image clearly depicts the pelvic anatomy and rectum, not the upper GI tract. *MR defecogram* - While also a dynamic study of defecation, an MR defecogram utilizes **magnetic resonance imaging (MRI)**, which provides superior soft-tissue contrast and does not use ionizing radiation. - The image shown is a plain radiograph (X-ray), which has a different appearance compared to an MRI scan. *X-ray barium enema* - A barium enema is used to visualize the anatomy of the **entire large intestine** to detect structural abnormalities like polyps, tumors, or diverticula. - It is typically a static study of the colon's morphology, whereas a defecogram is a functional study focused on the dynamics of evacuation.

Question 1

Which condition is characterized by the 'accordian sign'?

Accepted Answer

Pseudomembranous colitis

Answer

Intussusception

Answer

Ileocecal TB

Answer

Ischemic colitis

Question 2

The 'bent inner tube' sign is radiographically observed in which of the following conditions?

Accepted Answer

Volvulus

Answer

Intussusception

Answer

Intestinal obstruction

Answer

Gastric antral vascular ectasia

Question 3

Corkscrew esophagus in barium swallow is characteristic of which of the following conditions?

Accepted Answer

Diffuse esophageal spasm

Answer

Achalasia cardia

Answer

Esophageal cancer

Answer

Diverticulum

Question 4

The X-ray image provided (img-41.jpeg) shows multiple cylindrical objects in the abdominal area. Which of the following conditions is most likely represented by this image?

Accepted Answer

Body packer syndrome

Answer

Pica due to anaemia

Answer

Bezoar

Answer

Constipation due to fecalith

Question 5

A 30 year old apparently healthy man who was carrying laxatives and enema apparatus developed abdominal pain at the airport and an x-ray was done which appears as shown below. Which of the following is the likely diagnosis?

Accepted Answer

Body packer syndrome

Answer

Pica due to anaemia

Answer

Bezoar syndrome

Answer

Constipation due to fecalith

Question 6

A 65-year-old patient presents with abdominal distension and constipation. What is the most likely diagnosis based on the abdominal X-ray shown?

Accepted Answer

Sigmoid Volvulus

Answer

Caecal Volvulus

Answer

Intestinal Obstruction

Answer

Small Bowel Volvulus

Question 7

A patient presents with a history of dysphagia, which is more pronounced for liquids than solids. Which radiological sign is most likely to be seen?

Accepted Answer

Rat-tail sign

Answer

Corkscrew esophagus

Answer

Apple-core lesion

Answer

Filling defect

Question 8

A male patient presented with complaints of hematuria and recurrent urinary tract infection. You notice the following finding in his CECT. What is the likely condition indicated by the arrow in the image?

Accepted Answer

Horseshoe kidney

Answer

Polycystic kidney disease

Answer

Pancake kidney

Answer

Hydronephrosis

Question 9

A 55-year-old male patient presents with hematuria and a mass in the left kidney on a CT scan, as shown below. What is the diagnosis?

Accepted Answer

Renal angiomyolipoma

Answer

Renal cell carcinoma

Answer

Renal oncocytoma

Answer

Renal cyst

Question 10

Identify the investigation modality shown in the image.

Accepted Answer

X-ray defecogram

Answer

Barium swallow

Answer

MR defecogram

Answer

X-ray barium enema

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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