Abdominal and Pelvic Radiology Practice Questions

Q: A 10-year-old female presented with recurrent attacks of cholangitis. CECT was done; what is the most likely diagnosis based on CECT findings?

Type 5 choledochal cyst. ***Type 5 choledochal cyst*** - Recurrent **cholangitis** in a child with **multiple intrahepatic biliary dilatations** on CECT is pathognomonic of **Type 5 choledochal cyst (Caroli disease)**. - CECT shows the characteristic **central dot sign** representing portal vein branches within dilated intrahepatic bile ducts, confirming the diagnosis. *Type 1 choledochal cyst* - Presents as **fusiform dilatation of the common bile duct** with normal intrahepatic ducts on imaging. - Would not show **multiple intrahepatic cystic dilatations** as seen in this case with recurrent cholangitis. *Type 3 choledochal cyst* - Involves **choledochocele** - cystic dilatation of the **distal common bile duct** within the duodenal wall. - CECT would show a **small cystic lesion** in the pancreaticoduodenal region, not intrahepatic changes. *Type 4 choledochal cyst* - Features **both extrahepatic and intrahepatic** bile duct dilatations with **fusiform CBD dilatation**. - Differs from Type 5 as it includes **extrahepatic involvement** and lacks the pure intrahepatic cystic pattern seen here.

Q: A liver lesion showing multiseptate cystic areas with eggshell or mural calcifications on CT scan is suggestive of?

Hydatid Cyst. **Explanation:** The correct answer is **Hydatid Cyst** (caused by *Echinococcus granulosus*). The CT findings described—multiseptate cystic areas and mural calcification—are classic hallmarks of this parasitic infection. **Why Hydatid Cyst is correct:** * **Multiseptate/Daughter Cysts:** As the mother cyst matures, internal budding produces daughter cysts, giving a "cyst-within-a-cyst" or "spoke-wheel" appearance. * **Eggshell Calcification:** Calcification occurs in the ectocyst (pericyst). While it can be seen in about 20-30% of cases, curvilinear or "eggshell" calcification is highly suggestive of a Hydatid cyst. * **Water Lily Sign:** Detachment of the endocyst membrane results in the "floating membrane" appearance on imaging. **Why other options are incorrect:** * **Hemangioma:** The most common benign liver tumor. On CT, it shows **peripheral globular enhancement** with centripetal fill-in (delayed enhancement). It is typically solid, not multiloculated cystic. * **Amebic Liver Abscess:** Usually presents as a single, poorly defined hypodense collection (often in the right lobe) with a "shaggy" wall. It lacks internal daughter cysts and eggshell calcification. * **Hepatocellular Carcinoma (HCC):** A solid tumor characterized by **arterial phase enhancement** and **venous phase washout**. While it can undergo central necrosis, it does not present as a multiseptate calcified cyst. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Classification:** Uses the **Gharbi Classification** for ultrasound staging. * **Serology:** ELISA for IgG antibodies is the screening test of choice. * **Treatment:** PAIR (Puncture, Aspiration, Injection, Re-aspiration) is used for certain stages, always covered by **Albendazole** to prevent anaphylaxis from spillage.

Q: A patient presents with recent loss of hypertension control and a creatinine of 4.2 mg/dL. Renal ultrasound shows size discrepancy in the kidneys and no signs of obstruction. What should be the next investigation?

Ultrasound Doppler. **Explanation:** The clinical presentation of sudden loss of blood pressure control (suggestive of renovascular hypertension) combined with a significant size discrepancy between the kidneys and elevated creatinine (4.2 mg/dL) strongly points toward **Renal Artery Stenosis (RAS)** leading to ischemic nephropathy. **Why Ultrasound Doppler is correct:** In a patient with advanced renal failure (Creatinine > 3.0 mg/dL), the choice of imaging is dictated by safety. **Color Doppler Ultrasound** is the initial investigation of choice because it is non-invasive, does not require contrast, and carries no risk of nephrotoxicity. It can evaluate peak systolic velocity (PSV) and the resistive index to diagnose stenosis. **Why other options are incorrect:** * **Intravenous Pyelography (IVP):** This is contraindicated in patients with elevated creatinine due to the high risk of contrast-induced nephropathy (CIN). Furthermore, it is a poor modality for evaluating vascular structures. * **Magnetic Resonance Angiography (MRA):** While excellent for visualizing renal arteries, gadolinium-based contrast agents are contraindicated in patients with a GFR < 30 mL/min (Creatinine 4.2 mg/dL) due to the risk of **Nephrogenic Systemic Fibrosis (NSF)**. * **Retrograde Pyelography:** This is used to visualize the collecting system and ureters when there is an obstruction. Since the ultrasound already ruled out obstruction (hydronephrosis), this procedure is not indicated. **Clinical Pearls for NEET-PG:** * **Gold Standard for RAS:** Digital Subtraction Angiography (DSA). * **Screening Test for RAS:** Renal Doppler. * **Size Discrepancy:** A difference of >1.5 cm in renal longitudinal length is a significant indicator of unilateral renal artery stenosis. * **ACE Inhibitors:** These are contraindicated in bilateral renal artery stenosis as they can precipitate acute renal failure.

Q: A lobulated mass extending into the gastric bubble with rat tail tapering of the lower esophagus in a barium swallow is indicative of which condition?

Esophageal cancer (Ca esophagus). ### Explanation The correct answer is **Esophageal cancer (Ca esophagus)**. **1. Why it is correct:** The description provided is a classic radiological presentation of a malignant growth at the gastroesophageal (GE) junction. * **Rat-tail tapering:** This refers to an irregular, eccentric, and abrupt narrowing of the esophageal lumen caused by an infiltrating circumferential tumor. This is in contrast to the "bird-beak" appearance seen in Achalasia, which is smooth and symmetrical. * **Lobulated mass in the gastric bubble:** This indicates that the esophageal tumor has extended inferiorly into the cardia or fundus of the stomach, creating a filling defect within the normal air-filled gastric bubble on a barium swallow. **2. Why the other options are incorrect:** * **Diffuse esophageal spasm:** Characterized by a **"Corkscrew esophagus"** or "Rosary bead" appearance due to tertiary non-peristaltic contractions. It does not present with a mass or rat-tail tapering. * **Hypertrophic pyloric stenosis:** This is a pediatric condition affecting the gastric outlet (pylorus), not the esophagus. Classic signs include the **"String sign"** or "Double track sign" on barium studies. * **Gastroesophageal reflux (GERD):** Chronic GERD may lead to peptic strictures, which typically show smooth, tapered narrowing, or Barrett’s esophagus, but not a lobulated mass or irregular rat-tail tapering. **3. NEET-PG Clinical Pearls:** * **Bird-beak appearance:** Achalasia Cardia (Smooth tapering). * **Rat-tail/Shouldering effect:** Esophageal Carcinoma (Irregular tapering). * **Corkscrew esophagus:** Diffuse Esophageal Spasm. * **Bread crumb appearance:** Seen in a barium swallow in cases of esophageal candidiasis. * **Most common histological type:** Squamous cell carcinoma (worldwide), though Adenocarcinoma is rising in the West due to Barrett’s esophagus.

Q: Micturating cystourethrogram is not used in which of the following conditions?

Renal tumours. **Explanation:** A **Micturating Cystourethrogram (MCUG)**, also known as a Voiding Cystourethrogram (VCUG), is a dynamic fluoroscopic study used primarily to evaluate the **lower urinary tract** (bladder and urethra) and the presence of **vesicoureteral reflux (VUR)**. **Why Renal Tumours is the Correct Answer:** Renal tumours (such as Wilms' tumour or Renal Cell Carcinoma) are pathologies of the **renal parenchyma**. The gold standard for evaluating renal masses is **Contrast-Enhanced CT (CECT)** or MRI. Since MCUG involves filling the bladder via a catheter to visualize the outflow tract, it provides no diagnostic information regarding the solid tissue of the kidney. **Analysis of Incorrect Options:** * **Hydronephrosis:** MCUG is a first-line investigation in pediatric hydronephrosis to rule out VUR or Posterior Urethral Valves (PUV) as the underlying cause. * **Urinary Obstruction:** It is the definitive test for diagnosing infravesical obstructions, most notably **Posterior Urethral Valves (PUV)** in male infants, showing a dilated posterior urethra. * **Recurrent UTI:** In children, recurrent UTIs necessitate an MCUG to check for VUR, which predisposes the kidneys to scarring and pyelonephritis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** MCUG is the gold standard for diagnosing **Vesicoureteral Reflux (VUR)** and **Posterior Urethral Valves (PUV)**. * **Timing:** It should ideally be performed 4–6 weeks after a UTI has resolved to avoid false positives due to bladder inflammation. * **Key Finding:** A "Christmas tree bladder" on MCUG/cystography suggests a **neurogenic bladder**. * **Prophylaxis:** Antibiotic coverage is mandatory before performing the procedure to prevent iatrogenic sepsis.

Q: Fir tree appearance of the bladder is seen in which condition?

Neurogenic bladder. **Explanation:** The **"Fir tree" (or Christmas tree) appearance** of the bladder is a classic radiological sign seen on a cystogram, most commonly associated with a **Neurogenic Bladder** (specifically the spastic or hyperreflexic type). **1. Why Neurogenic Bladder is correct:** In conditions like spinal cord injury or multiple sclerosis, there is chronic detrusor-sphincter dyssynergia. The detrusor muscle must contract against a closed or non-relaxing sphincter, leading to high intravesical pressures. This causes **detrusor hypertrophy** and the formation of **trabeculations, sacculations, and diverticula**. On imaging, the bladder appears elongated, pointed at the dome, and has irregular, thickened walls, mimicking the silhouette of a fir tree. **2. Why other options are incorrect:** * **Schistosomiasis:** Characteristically shows **"fetal head" calcification** or linear calcification of the bladder wall due to the deposition of *Schistosoma haematobium* eggs. * **Tuberculosis:** Typically results in a **"Thimble bladder"** (a small-capacity, contracted, and fibrotic bladder) due to extensive scarring. * **Pelvic Abscess:** This would cause extrinsic compression or displacement of the bladder rather than intrinsic wall changes like trabeculations. **Clinical Pearls for NEET-PG:** * **Thimble Bladder:** Tuberculosis. * **Fetal Head Calcification:** Schistosomiasis. * **Teardrop Bladder:** Seen in pelvic hematoma or pelvic lipomatosis (extrinsic compression). * **Hourglass Bladder:** Can be congenital or due to urachal diverticulum/urachal remnants. * **Pinecone Bladder:** Another synonym for the Fir tree appearance in neurogenic bladder.

Q: Which of the following imaging techniques is NOT used for the evaluation of uterine anomalies?

CT guided HSG. **Explanation:** The evaluation of uterine anomalies (Müllerian duct anomalies) focuses on visualizing the external contour of the uterus and the internal shape of the endometrial cavity. **Why CT guided HSG is the correct answer:** Computed Tomography (CT) is **not** a standard modality for evaluating uterine anomalies. It provides poor soft-tissue contrast for the myometrium compared to MRI and involves significant ionizing radiation to the pelvis, which is contraindicated in women of reproductive age seeking fertility evaluation. There is no clinical procedure termed "CT guided HSG" used for this purpose. **Analysis of other options:** * **Hysterosalpingography (HSG):** Traditionally the first-line test for assessing the uterine cavity and tubal patency. While it cannot visualize the external uterine contour (making it difficult to differentiate between a septate and bicornuate uterus), it remains a core diagnostic tool. * **MRI (and MRI guided/enhanced techniques):** MRI is the **Gold Standard** for diagnosing uterine anomalies. It provides excellent soft-tissue characterization, allowing for clear visualization of both the internal cavity and the external fundal contour without radiation. * **Ultrasonography (USG):** 2D-USG is often the initial screening tool. **3D-USG** is highly accurate and is now considered comparable to MRI for classifying Müllerian duct anomalies. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Uterine Anomalies:** MRI. * **Best Initial Investigation:** USG (specifically 3D-USG if available). * **Differentiating Septate vs. Bicornuate:** Look at the fundal contour. A fundal cleft >1 cm indicates a bicornuate uterus; a flat or convex fundus indicates a septate uterus. * **Most common anomaly associated with renal agenesis:** Didelphys uterus. * **Most common Müllerian anomaly:** Septate uterus (also associated with the highest rate of infertility/miscarriage).

Q: The feathery appearance seen in the jejunum is due to which of the following structures?

Valvulae conniventes. **Explanation:** The characteristic **"feathery appearance"** of the jejunum on a barium study is due to the **Valvulae conniventes** (also known as Plicae circulares or Kerckring folds). These are permanent mucosal folds that project into the intestinal lumen. In the jejunum, these folds are tall, thick, and numerous, creating a dense, feathered pattern when coated with contrast. **Analysis of Options:** * **Valvulae conniventes (Correct):** These folds are most prominent in the proximal small bowel (jejunum). On X-ray, they appear as thin lines that cross the **entire width** of the bowel lumen. In the ileum, they become sparse and shorter, leading to a smoother appearance. * **Haustrations:** These are characteristic of the **large intestine**. Unlike valvulae, haustral folds are incomplete and do **not** cross the entire diameter of the bowel. They give the colon a sacculated appearance, not a feathery one. * **Luminal gas:** Gas provides a negative contrast (black) on X-ray. While it can outline the bowel, it does not create the specific feathery mucosal pattern. * **Vascular network:** While the jejunum has a rich blood supply (vasa recta), these are located within the mesentery and wall; they are not responsible for the intraluminal mucosal pattern seen on contrast studies. **High-Yield NEET-PG Pearls:** 1. **Stack of Coins Appearance:** When the small bowel is dilated (as in obstruction), the valvulae conniventes become prominent and parallel, resembling a stack of coins. 2. **Jejunum vs. Ileum:** Jejunum is characterized by a "feathery" pattern; Ileum is characterized by a "featureless" or smooth appearance. 3. **Rule of 3-6-9:** Normal diameter limits are <3 cm for small bowel, <6 cm for colon, and <9 cm for the cecum. 4. **Moulage Sign:** Loss of the feathery pattern (appearing like "poured wax") is seen in Celiac disease due to mucosal atrophy.

Q: Which of the following is an initial investigation for acute abdomen?

Ultrasound (USG). **Explanation:** In the clinical evaluation of an **acute abdomen**, the choice of imaging depends on the suspected pathology, but **Ultrasound (USG)** is considered the **initial investigation** of choice. This is primarily due to its high accessibility, lack of ionizing radiation, cost-effectiveness, and real-time imaging capabilities. It is particularly superior for evaluating the hepatobiliary system (e.g., acute cholecystitis), pelvic pathologies in females (e.g., ectopic pregnancy, ovarian torsion), and pediatric cases (e.g., intussusception, appendicitis). **Analysis of Options:** * **B & C (MDCT/CECT):** While **Contrast-Enhanced CT (CECT)** is the **Gold Standard** and the most sensitive investigation for most causes of acute abdomen (like acute pancreatitis, bowel ischemia, or perforation), it is not the *initial* step due to radiation exposure, cost, and potential nephrotoxicity of contrast. It is usually reserved for cases where USG is inconclusive. * **D (X-ray):** While an Erect Abdominal X-ray is useful for detecting pneumoperitoneum (free air under the diaphragm) or bowel obstruction, its sensitivity is much lower than USG for a broad range of abdominal pathologies. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice (IOC) for Acute Cholecystitis:** USG. * **Gold Standard for Acute Pancreatitis:** CECT (performed after 48–72 hours for maximum accuracy). * **IOC for Ureteric Colic:** Non-Contrast CT (NCCT) KUB. * **IOC for Intestinal Perforation:** X-ray Chest PA view (Erect) to see free gas under the diaphragm. * **FAST (Focused Assessment with Sonography for Trauma):** The initial USG screening tool used in hemodynamically unstable blunt trauma patients.

Question 1

Which of the following imaging findings is diagnostic of Adenomyosis?

Accepted Answer

Calcifications seen on CT scan.

Answer

Thickness of low signal intensity junctional zone >12mm on T2-weighted images.

Answer

Rain shower appearance of myometrium with coarsened echotexture.

Answer

Linear striations and subendometrial echogenic nodular appearance on USG.

Question 2

A 10-year-old female presented with recurrent attacks of cholangitis. CECT was done; what is the most likely diagnosis based on CECT findings?

Accepted Answer

Type 5 choledochal cyst

Answer

Type 1 choledochal cyst

Answer

Type 3 choledochal cyst

Answer

Type 4 choledochal cyst

Question 3

A liver lesion showing multiseptate cystic areas with eggshell or mural calcifications on CT scan is suggestive of?

Accepted Answer

Hydatid Cyst

Answer

Hemangioma

Answer

Amebic Liver abscess

Answer

Hepatocellular Carcinoma (HCC)

Question 4

A patient presents with recent loss of hypertension control and a creatinine of 4.2 mg/dL. Renal ultrasound shows size discrepancy in the kidneys and no signs of obstruction. What should be the next investigation?

Accepted Answer

Ultrasound Doppler

Answer

Intravenous pyelography (IVP)

Answer

Magnetic resonance angiography (MRA)

Answer

Retrograde pyelography

Question 5

A lobulated mass extending into the gastric bubble with rat tail tapering of the lower esophagus in a barium swallow is indicative of which condition?

Accepted Answer

Esophageal cancer (Ca esophagus)

Answer

Diffuse esophageal spasm

Answer

Hypertrophic pyloric stenosis

Answer

Gastroesophageal reflux

Question 6

Micturating cystourethrogram is not used in which of the following conditions?

Accepted Answer

Renal tumours

Answer

Hydronephrosis

Answer

Urinary obstruction

Answer

Recurrent UTI

Question 7

Fir tree appearance of the bladder is seen in which condition?

Accepted Answer

Neurogenic bladder

Answer

Schistosomiasis

Answer

Tuberculosis

Answer

Pelvic abscess

Question 8

Which of the following imaging techniques is NOT used for the evaluation of uterine anomalies?

Accepted Answer

CT guided HSG

Answer

Hysterosalpingography (HSG)

Answer

MRI guided HSG

Answer

Ultrasonography (USG)

Question 9

The feathery appearance seen in the jejunum is due to which of the following structures?

Accepted Answer

Valvulae conniventes

Answer

Haustrations

Answer

Luminal gas

Answer

Vascular network

Question 10

Which of the following is an initial investigation for acute abdomen?

Accepted Answer

Ultrasound (USG)

Answer

Multidetector CT

Answer

Contrast-enhanced CT

Answer

X-ray

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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