Abdominal and Pelvic Radiology Practice Questions

Q: Identify the lesion shown in the figure:

Rectus sheath hematoma. ***Rectus sheath hematoma*** - The abdominal X-ray (left image) shows a **large soft tissue mass** in the upper abdomen causing displacement of bowel loops. The CT scan (right image) demonstrates a **well-defined, high-attenuation lesion within the rectus sheath**, indicated by the arrow, consistent with a hematoma. - The appearance of a **fluid collection with high attenuation** on CT in the rectus sheath area, along with the mass effect seen on the plain film, is characteristic of a rectus sheath hematoma. *Small intestinal obstruction* - Small bowel obstruction typically presents with **dilated small bowel loops** and **air-fluid levels** on plain radiographs, which are not the primary finding here. - While there is some bowel gas displacement, the prominent finding is a soft tissue mass rather than classic obstructive patterns. *Large intestinal obstruction* - Large bowel obstruction involves **dilated large bowel loops**, often with **haustral folds**, and may present with a collapsed small bowel distal to the obstruction point. - The images do not show a pattern typical of dilated colon or specific features of large bowel obstruction. *Pneumoperitoneum* - Pneumoperitoneum refers to **free air in the peritoneal cavity**, often visible as air under the diaphragm on an upright chest X-ray or as free air outlining abdominal structures on supine films. - The provided images do not show evidence of free intraperitoneal air; instead, they demonstrate a contained soft tissue mass.

Q: What is the radiological sign demonstrated in the image provided?

Gas under diaphragm. ***Correct Option: Gas under diaphragm*** - The image clearly shows a crescent-shaped lucency (gas) beneath the diaphragm, indicated by the red arrow, which is characteristic of **pneumoperitoneum**. - This finding is a critical sign of a **perforated viscus** within the abdomen, such as a perforated peptic ulcer, perforated diverticulitis, or other hollow viscus perforation. - **Free air under the diaphragm** is best seen on an erect chest X-ray or erect abdominal film and is a surgical emergency. *Incorrect Option: Bat wing sign* - The **"bat wing"** or **"butterfly" sign** refers to bilateral perihilar infiltrates seen in conditions like **pulmonary edema** due to congestive heart failure or acute respiratory distress syndrome (ARDS). - This pattern is not present in the provided image; the lung fields appear relatively clear except for the presence of gas under the diaphragm. *Incorrect Option: Situs inversus* - **Situs inversus** is a congenital condition where the major visceral organs are reversed or mirrored from their normal positions, manifesting as the **heart shadow** on the right side and liver on the left side. - The image shows the heart on the normal left side, and there is no evidence of reversed organ positioning. *Incorrect Option: Money bag appearance* - The **"money bag appearance"** is a recognized radiological sign seen in conditions like **hydronephrosis** on intravenous pyelogram (IVP) or in **hiatal hernia** where the gastric fundus appears as a rounded sac above the diaphragm. - This finding is not demonstrated in the provided image, which clearly shows free gas beneath the diaphragm rather than a soft tissue mass or fluid-filled structure.

Q: Which of these is best for imaging a lesion in the kidney of a 60-year-old man?

Helical CT with contrast. ***Helical CT with contrast*** - **Helical CT with contrast** provides detailed anatomical imaging and information about vascularity, which is crucial for characterizing solid renal masses and distinguishing between benign and malignant lesions. - Given the patient's age and the appearance of the lesion (likely a solid mass based on context, potentially a renal cell carcinoma), contrast enhancement helps assess tumor extent, invasion, and metastatic disease. *USG* - **Ultrasound (USG)** is often the initial imaging modality for renal lesions due to its accessibility and lack of radiation. - However, it has limitations in fully characterizing solid masses and determining their exact nature or extent compared to CT or MRI. *Helical CT* - **Helical CT without contrast** is useful for identifying renal masses and detecting calcifications. - It lacks the ability to assess the vascularity of the lesion, which is vital for differentiating benign cysts from solid tumors, or characterizing the nature of a solid tumor. *MRI* - **MRI** is an excellent alternative to CT, especially in patients with renal insufficiency or contrast allergies. - While highly effective for characterizing renal masses, it is generally considered a second-line imaging option to CT with contrast for initial workup in most cases, or if CT findings are inconclusive.

Q: Comment on the diagnosis of the image shown below.

Coffee bean appearance. ***Coffee bean appearance*** - The image depicts a **dilated loop of colon**, characteristic of a **sigmoid volvulus**, which often resembles a coffee bean on plain abdominal radiographs. - This appearance is due to the **mesentery twisting around the bowel**, causing the dilated loop to fold upon itself. *Apple core appearance* - This describes a **constricting lesion** in the bowel, typically seen in **colorectal cancer**, where the lumen is severely narrowed with overhanging edges. - It denotes an **irregular, circumferential narrowing**, which is not seen in the provided image. *Claw sign* - The **"claw sign"** in the context of imaging refers to the way normal kidney tissue appears to "clasp" or surround an adjacent mass. - This sign is used to distinguish between intrarenal and extrarenal masses, which is irrelevant to the bowel pathology shown. *String sign of Kantor* - The **Kantor's string sign** is a radiologic finding in which the lumen of the terminal ileum is markedly narrowed, appearing as a thin, continuous string of barium. - This is classically associated with **Crohn's disease**, signifying severe inflammation and fibrosis, and is not seen in this image.

Q: A 32-year-old lady presents with history of first trimester miscarriage and underwent HSG. The diagnosis is: (Recent NEET Pattern 2018-19)

Unicornuate uterus. ***Unicornuate uterus*** - A **unicornuate uterus** develops from one **Müllerian duct**, resulting in a single functional uterine horn with a characteristic **banana-shaped** or crescent-shaped cavity. - On **HSG**, it appears as a single, elongated cavity that **deviates to one side** and is typically smaller than normal, associated with increased risk of **first trimester miscarriage**. *Bicornuate uterus* - Would show **two distinct uterine horns** separated by a deep fundal cleft, with the uterus appearing **heart-shaped** externally. - HSG would demonstrate **bifurcation** of the uterine cavity into two separate horns at the fundal level with an **intercornual angle >105 degrees**. *Uterus didelphys* - Complete duplication with **two separate uterine bodies**, cervices, and often vaginas resulting from total failure of **Müllerian duct fusion**. - HSG would show **two completely separate uterine cavities** with no communication, not consistent with the single cavity shown. *Arcuate uterus* - Mildest form of **Müllerian anomaly** with only a slight **fundal indentation** and essentially normal uterine cavity size. - HSG shows a **broad, smooth, mild concave contour** of the fundus, not consistent with the elongated, deviated cavity shown.

Q: What does the given chest X-ray show?

Pneumoperitoneum. ***Pneumoperitoneum*** - The chest X-ray shows **free air under the diaphragm**, visible as a lucent (dark) crescent between the liver/spleen and the diaphragm (indicated by the arrow on the right side of the patient). - This finding is diagnostic of **pneumoperitoneum**, which is often caused by a perforated abdominal viscus like a peptic ulcer or bowel perforation. *Emphysema* - **Emphysema** is a lung condition characterized by over-inflated alveoli and air trapping within the lungs, leading to hyperlucency of the lung fields and flattened diaphragms. - It does not present as free air below the diaphragm but rather as changes within the lung parenchyma. *Diaphragmatic hernia* - A **diaphragmatic hernia** involves the protrusion of abdominal organs into the chest cavity through a defect in the diaphragm. - This would typically show abdominal contents (e.g., bowel loops or stomach) above the diaphragm in the thoracic cavity, not free air below it. *Diaphragmatic eventration* - **Diaphragmatic eventration** is an abnormal elevation of part or all of an intact hemidiaphragm due to thinning and weakness of the diaphragmatic muscle. - It causes an elevated diaphragm but does not involve free air in the peritoneal cavity.

Q: The first imaging modality of choice for a 35-year-old lady, presenting to surgical emergency with complaints of colicky pain in right lower quadrant of abdomen and vomiting since last 2 days is:

Ultrasound abdomen. ***Ultrasound abdomen*** - Ultrasound is the **first-line imaging modality** for evaluating acute right lower quadrant pain in women of reproductive age due to its **safety (no ionizing radiation)**, availability, and cost-effectiveness. - It effectively visualizes the **appendix**, ovaries, uterus, and can detect **appendicitis**, ovarian pathology (e.g., cysts, torsion, ectopic pregnancy), and other causes of acute abdominal pain. - Follows the **ALARA principle** (As Low As Reasonably Achievable) for radiation exposure in young women. *Plain X-ray abdomen erect view* - Plain X-ray has **limited utility** for acute right lower quadrant pain as it cannot visualize soft tissue structures like the appendix or ovaries. - Primarily useful for detecting **bowel obstruction** (air-fluid levels) or **pneumoperitoneum** (free air under diaphragm), which are not suggested by this clinical presentation. *Contrast CT abdomen* - While highly sensitive for appendicitis and intra-abdominal pathologies, contrast CT involves **ionizing radiation** and **IV contrast administration**. - Should be **minimized in women of reproductive age** due to radiation risks (including potential pregnancy). - Reserved for cases where ultrasound is **inconclusive** or when detailed anatomical assessment is required. *Non-contrast CT abdomen* - Non-contrast CT exposes the patient to **ionizing radiation** without the diagnostic advantage of contrast enhancement. - **Less effective** than contrast-enhanced CT for detecting inflammatory processes and appendiceal pathology. - Not preferred as first-line imaging when ultrasound is available and appropriate.

Q: The 'claw sign' in barium enema study favours the diagnosis of :

Intussusception. ***Intussusception*** - The **"claw sign"**, or sometimes called the **"crescent sign"** or **"meniscus sign,"** on a barium enema is indicative of intussusception, where the contrast material fills the space between the intussusceptum and intussuscipiens, creating a claw-like appearance. - This sign represents the barium outlining the leading edge of the **intussusceptum** as it telescopes into the more distal bowel. *Sigmoid volvulus* - Sigmoid volvulus typically presents with a **"coffee bean sign"** or **"omega loop sign"** on plain abdominal radiographs due to the massively dilated, air-filled sigmoid colon. - Barium enema in sigmoid volvulus would show a **"bird's beak"** or **"ace of spades"** appearance at the site of the twist, representing the tapered narrowing. *Crohn's disease* - Crohn's disease is characterized by various findings on barium studies, such as **"skip lesions,"** **cobblestoning**, and **ulcerations**, but not a claw sign. - Strictures, fistulas, and thickened bowel walls are also common in Crohn's disease, creating different radiological patterns. *Gastro colic fistula* - A gastrocolic fistula is an abnormal connection between the stomach and the colon, most commonly seen in advanced gastric carcinoma or Crohn's disease. - On barium enema or upper GI series, it would be identified by the direct visualization of contrast flowing from the colon into the stomach or vice versa, not by a claw sign.

Q: Among the following, which is the investigation of choice for evaluation of common bile duct (CBD)?

MRCP. ***Correct: MRCP*** - **Magnetic Resonance Cholangiopancreatography (MRCP)** is the investigation of choice for comprehensive CBD evaluation - **Non-invasive technique** with high sensitivity (95%) and specificity (97%) for biliary pathology - **Provides detailed anatomical visualization** of the entire biliary tree without radiation or contrast agents - **Superior for detecting** CBD stones, strictures, and obstructions *Incorrect: CECT Abdomen* - Can visualize the CBD but provides less detailed luminal information compared to MRCP - More useful for assessing surrounding structures, tumor staging, and vascular involvement - Not the primary investigation of choice for biliary tree evaluation *Incorrect: HIDA scan* - Hepatobiliary Iminodiacetic Acid scan is a functional study that assesses gallbladder function and cystic duct patency - Tracks radioactive tracer flow but does not provide detailed anatomical imaging - Cannot visualize the cause of obstruction, making it unsuitable for primary CBD evaluation *Incorrect: Ultrasonography* - Initial screening modality that is readily available and non-invasive - Can detect CBD dilation and some stones but has limited sensitivity - Limited by bowel gas interference and operator dependency - Provides less detail than MRCP, especially for distal CBD segments

Q: Consider the following radiological signs : 1. Claw sign in barium enema 2. Apple core sign in barium enema 3. Multiple fluid levels with absent caecal gas in plain skiagram of abdomen 4. Single large fluid and air level in plain skiagram of abdomen Which of the above signs is/are suggestive of ileocolic intussusception?

1 only. ***1 only*** - The **claw sign** in a barium enema is a classic radiological finding in **ileocolic intussusception**, where the intussusceptum indents the barium column, forming a characteristic claw-like appearance - This sign indicates the presence of the invaginated bowel segment within the larger bowel, as the barium passes around it - It is the most specific radiological sign for intussusception on contrast studies *3 only* - **Multiple fluid levels** with absent caecal gas on plain skiagram are indicative of **small bowel obstruction**, which can be caused by intussusception but is **not specific** to it - This finding does not pinpoint intussusception specifically and can occur with adhesions, hernias, or other causes of obstruction - Alone, this does not diagnose ileocolic intussusception *1 and 2 only* - While the **claw sign** (1) is specific to intussusception, the **apple core sign** (2) is characteristic of a **constricting colonic malignancy**, not intussusception - The apple core sign represents irregular narrowing of the bowel lumen due to an annular carcinoma - Including sign 2 makes this option incorrect for intussusception *1, 2, 3 and 4* - Only the **claw sign** (1) is specifically suggestive of intussusception - The **apple core sign** (2) indicates colonic carcinoma, not intussusception - **Multiple fluid levels with absent caecal gas** (3) indicate bowel obstruction but lack specificity - A **single large fluid and air level** (4) suggests gastric outlet obstruction or closed loop obstruction, not specifically intussusception

Question 1

Identify the lesion shown in the figure:

Accepted Answer

Rectus sheath hematoma

Answer

Small intestinal obstruction

Answer

Large intestinal obstruction

Answer

Pneumoperitoneum

Question 2

What is the radiological sign demonstrated in the image provided?

Accepted Answer

Gas under diaphragm

Answer

Bat wing sign

Answer

Situs inversus

Answer

Money bag appearance

Question 3

Which of these is best for imaging a lesion in the kidney of a 60-year-old man?

Accepted Answer

Helical CT with contrast

Answer

USG

Answer

Helical CT

Answer

MRI

Question 4

Comment on the diagnosis of the image shown below.

Accepted Answer

Coffee bean appearance

Answer

Apple core appearance

Answer

Claw sign

Answer

String sign of Kantor

Question 5

A 32-year-old lady presents with history of first trimester miscarriage and underwent HSG. The diagnosis is: (Recent NEET Pattern 2018-19)

Accepted Answer

Unicornuate uterus

Answer

Uterus didelphys

Answer

Arcuate uterus

Answer

Bicornuate uterus

Question 6

What does the given chest X-ray show?

Accepted Answer

Pneumoperitoneum

Answer

Emphysema

Answer

Diaphragmatic hernia

Answer

Diaphragmatic eventration

Question 7

The first imaging modality of choice for a 35-year-old lady, presenting to surgical emergency with complaints of colicky pain in right lower quadrant of abdomen and vomiting since last 2 days is:

Accepted Answer

Ultrasound abdomen

Answer

Plain X-ray abdomen erect view

Answer

Contrast CT abdomen

Answer

Non-contrast CT abdomen

Question 8

The 'claw sign' in barium enema study favours the diagnosis of :

Accepted Answer

Intussusception

Answer

Sigmoid volvulus

Answer

Crohn's disease

Answer

Gastro colic fistula

Question 9

Among the following, which is the investigation of choice for evaluation of common bile duct (CBD)?

Accepted Answer

MRCP

Answer

CECT Abdomen

Answer

HIDA scan

Answer

Ultrasonography

Question 10

Consider the following radiological signs :

1. Claw sign in barium enema

2. Apple core sign in barium enema

3. Multiple fluid levels with absent caecal gas in plain skiagram of abdomen

4. Single large fluid and air level in plain skiagram of abdomen
Which of the above signs is/are suggestive of ileocolic intussusception?

Accepted Answer

1 only

Answer

3 only

Answer

1 and 2 only

Answer

1, 2, 3 and 4

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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