Abdominal and Pelvic Radiology Practice Questions

Q: Examine the abdominal X-ray shown. What is the most likely diagnosis based on the findings?

Intestinal Obstruction. ***Intestinal Obstruction*** - The abdominal X-ray demonstrates **distended loops of bowel** with **multiple air-fluid levels**, which are classic radiographic signs of intestinal obstruction. - The presence of multiple, wide air-fluid levels visible in a **stepladder pattern** is a hallmark of bowel obstruction. - **Valvulae conniventes** (transverse folds crossing the entire width of bowel) suggest **small bowel** involvement when visible with distension. *Small bowel ileus* - While ileus can show distended bowel loops, it typically presents with **gas distributed throughout the small and large bowel** without a clear transition point. - Ileus shows **less pronounced air-fluid levels** and lacks the characteristic stepladder pattern seen in mechanical obstruction. - The clinical context and presence of multiple distinct air-fluid levels favor mechanical obstruction over ileus. *Large bowel obstruction* - Large bowel obstruction would show **dilated colon** with **haustrations** (incomplete folds that don't cross the entire lumen). - The obstruction would typically show dilation **proximal to the obstruction** with collapsed bowel distally. - The pattern in this image is more consistent with small bowel or generalized intestinal obstruction rather than isolated large bowel obstruction. *Pneumoperitoneum* - Pneumoperitoneum (free air in the peritoneal cavity) appears as **air under the diaphragm** on upright films or as **Rigler's sign** (both sides of bowel wall visible) on supine films. - This is a sign of **bowel perforation**, not obstruction with air-fluid levels within the bowel lumen. - The air-fluid levels seen here are **intraluminal**, not free intraperitoneal air.

Q: Identify the condition based on the non-contrast CT scan of a patient given below.

Hydatid cyst. ***Hydatid cyst*** - The image distinctly shows a **large, well-defined cyst with internal septations**, consistent with the daughter cysts and collapsed membranes within a hydatid cyst (the "**water lily sign**"). - The thick, often calcified wall surrounding the lesion is a characteristic feature often seen in **Echinococcus granulosa** infection. *Hepatocellular carcinoma* - **Hepatocellular carcinoma (HCC)** typically appears as a **solid, enhancing mass** (especially on contrast-enhanced CT) and does not usually present with clearly defined internal septations or "water lily" sign on non-contrast imaging. - While HCC can show necrosis, it does not form the characteristic cystic structure seen here. *Liver abscess* - A **liver abscess** would typically appear as a ill-defined, fluid-filled lesion that may have a rim of enhancement on contrast CT, but it generally lacks the **distinct internal septations** or daughter cysts characteristic of a hydatid cyst. - Abscesses are often associated with signs of infection like fever and elevated inflammatory markers. *Fibronodular hyperplasia* - **Focal nodular hyperplasia (FNH)** is a benign liver lesion characterized by a central scar and is typically **isodense or slightly hypodense** to the liver parenchyma on non-contrast CT. - It does not present as a cystic lesion with internal daughter cysts or calcified walls.

Q: Double bleb sign seen in early pregnancy is due to?

Yolk sac and amniotic sac. ***Yolk sac and amniotic sac*** - The **double bleb sign** on ultrasound refers to the separate visualization of the **yolk sac** and the **amniotic sac** within the gestational sac. - This sign is a crucial indicator of a **viable intrauterine pregnancy** in the early stages, typically between 5.5 and 6.5 weeks of gestation. *Amnion and chorion* - The **amnion** and **chorion** are membranes that form later in pregnancy and eventually fuse. - While they are distinct structures, their visualization does not constitute the "double bleb sign," which specifically refers to the distinct spaces of the yolk sac and amniotic sac. *Chorion and decidua* - The **chorion** is the outer fetal membrane, and the **decidua** is the modified endometrium during pregnancy. - While both are important structures in early pregnancy, they are not the structures visualized in the double bleb sign. *Twin pregnancy* - A **twin pregnancy** would involve two separate gestational sacs or, in the case of monochorionic-diamniotic twins, two amniotic sacs within one chorion, each containing a fetus. - The double bleb sign is a feature of a **single intrauterine pregnancy** and is not indicative of twins.

Q: A 45-year-old patient presented with vague abdominal pain. On USG, he was found to have a renal cyst of Bosniak class III. CECT was done, as shown below. What imaging modality is shown?

CT scan. ***CT scan*** - The image provided is an **axial view** showing internal organs with different densities, characteristic of a **Computed Tomography (CT) scan**. - A CT scan uses X-rays and computer processing to create detailed cross-sectional images of the body. *Contrast Dye study* - A contrast dye study typically refers to the **administration of a contrast agent** to enhance visibility of structures in imaging, it is not an imaging modality itself but an adjunct. - While a CECT (Contrast-Enhanced CT) was mentioned in the clinical scenario, "Contrast Dye study" alone doesn't describe the image type. *Angiography* - **Angiography** is a specialized imaging technique used to visualize blood vessels, typically involving the injection of contrast media. - The image provided shows **parenchymal structures** like the liver and kidneys, not just blood vessels, making angiography an unlikely description. *X-ray* - A general **X-ray** (radiograph) produces a 2D projection of internal structures and does not provide the detailed cross-sectional view seen in this image. - X-rays are typically less sensitive for soft tissue differentiation compared to a CT scan.

Q: During rounds, your senior was discussing the given image. Which of the following investigations does this image represent?

CT scan. ***CT scan*** - The image shows multiple **axial slices** with detailed cross-sectional anatomy of the abdomen, which is characteristic of a **Computed Tomography (CT) scan**. - CT scans provide excellent detail of both **soft tissues** and **bone structures** in cross-sectional format, which is the standard appearance of abdominal CT imaging. *X-ray* - Plain X-rays produce **2D projection images**, not the axial cross-sectional slices seen here. - While CT technology uses X-rays, in medical terminology **"X-ray"** refers to conventional radiographs, not cross-sectional imaging. *Contrast Dye study* - This is **not an imaging modality** but rather an enhancement technique used with various imaging methods. - **Contrast agents** improve visualization but don't define the type of investigation being performed. *Angiography* - Angiography is specifically designed to visualize **blood vessels**, often using contrast injection. - This image shows comprehensive **abdominal anatomy**, not the focused vascular imaging typical of angiographic studies.

Q: Double decidual sign is seen in?

Uterine gestational sac. ***Uterine gestational sac*** - The **double decidual sign** is a normal sonographic finding in early **intrauterine pregnancies**, representing the interface between the decidua capsularis and the decidua parietalis/vera. - It indicates a **viable intrauterine pregnancy** and helps differentiate it from a pseudogestational sac or ectopic pregnancy. *Pseudo gestational sac* - A pseudogestational sac is a collection of fluid within the **endometrial cavity** associated with an ectopic pregnancy. - It typically lacks the **double decidual sign** and may show internal echoes or irregular shape. *Threatened Abortion* - While it involves an intrauterine pregnancy, a threatened abortion is characterized by **vaginal bleeding** and/or mild cramping, with a closed cervix. - The presence of a **double decidual sign** confirms an intrauterine gestation but does not rule out the threat of abortion, as the viability is assessed by the presence of a fetal pole and heart activity. *Ectopic pregnancy* - An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, most commonly in the **fallopian tubes**. - It will **not show a double decidual sign** within the uterus, although a pseudogestational sac might be present.

Q: Which of the following is a gold standard investigation for diagnosis of renal stone?

Helical CT with Non-contrast. ***Helical CT with Non-contrast*** - **Non-contrast helical CT** (also known as CT KUB) is considered the **gold standard** due to its high sensitivity and specificity for detecting all types of urinary tract calculi, regardless of their composition. - It rapidly identifies stones, their location, size, and associated complications like **hydronephrosis**, without the need for IV contrast. *USG* - **Ultrasound** is a good initial screening tool and can detect larger stones and hydronephrosis, but its sensitivity is lower than CT, especially for smaller stones or those in the ureters. - Its diagnostic accuracy is highly **operator-dependent**, and it may miss stones obscured by bowel gas or bone. *Helical CT with contrast* - While helical CT is excellent, the use of **IV contrast** is generally avoided for routine stone detection as it can obscure the highly dense stones from the contrast-enhanced renal collecting system. - Contrast is primarily useful for evaluating **renal masses**, infection, or vascular abnormalities, not for primary stone diagnosis. *MRI* - **MRI** has limited utility in detecting typical renal stones because most calculi are not well-visualized on standard MRI sequences due to their lack of free water and low signal intensity. - It may be considered in specific populations, such as **pregnant women** or children, to avoid radiation exposure, but it is not the gold standard for stone detection.

Q: Pulsatile Doppler signal (continuous flow) in the hepatic vein in the setting of Budd-Chiari syndrome indicates:

Partial IVC obstruction. ***Partial IVC obstruction*** - A **pulsatile Doppler signal** (continuous flow) in the **hepatic vein** in the context of Budd-Chiari syndrome suggests **partial impedance** to hepatic venous outflow, often due to a **partial obstruction of the IVC**. - This pattern indicates that the normal triphasic flow in the hepatic veins, which is influenced by right atrial pressure, is maintained but with some degree of *dampening* or *modification* due to the obstruction. *Congenital web in IVC* - A **congenital web** in the IVC, while a cause of Budd-Chiari, would typically cause a more **complete obstruction** of hepatic venous outflow. - This would result in a **monophasic** or **absent flow** in the hepatic veins, rather than a pulsatile continuous pattern. *Renal vein thrombosis* - **Renal vein thrombosis** primarily affects the renal veins and would not directly cause a **pulsatile continuous flow** in the hepatic veins. - While it can be associated with hypercoagulable states that also lead to Budd-Chiari, it's not the direct cause of this specific hepatic vein Doppler finding. *Portal vein thrombosis* - **Portal vein thrombosis** affects inflow to the liver, leading to **portal hypertension**, but it does not directly impact the outflow dynamics of the hepatic veins in a way that would cause a **pulsatile continuous flow**. - Hepatic vein flow patterns are primarily determined by pressures within the **right atrium** and **hepatic venous outflow**.

Q: One of the following is characterised by RIM sign?

Hydronephrosis (Gross). ***Hydronephrosis (Gross)*** - The **RIM sign** refers to the visualization of a thick, echogenic rim of compressed renal parenchyma surrounding a dilated collecting system, a characteristic finding in gross hydronephrosis on imaging. - This sign indicates significant **urine outflow obstruction**, leading to the accumulation of urine and subsequent dilation of the renal pelvis and calyces. *Polycystic kidney* - Characterized by the presence of numerous **cysts of varying sizes** throughout the renal parenchyma, which are typically anechoic (fluid-filled) structures. - Does not typically present with a "RIM sign" as the primary imaging feature; instead, the parenchyma is replaced by cysts. *Chronic pyelonephritis* - Involves scarring and focal or diffuse cortical thinning of the kidney, often with blunted calyces, a finding known as **clubbing of calyces**. - The imaging features are primarily related to **cortical atrophy** and scarring, not a distinct RIM sign around a dilated system. *Hypernephroma* - Also known as **renal cell carcinoma**, it presents as a solid, often heterogeneous mass within the kidney, which can be vascular. - Imaging focuses on identifying the mass, its vascularity, and any local or distant spread, not a "RIM sign."

Q: The best investigation for air in the peritoneal cavity is:

X-ray. ***X-ray*** - An **X-ray**, particularly an erect chest X-ray or an erect abdominal X-ray, is the **most sensitive and readily available investigation** to detect **free air under the diaphragm** (pneumoperitoneum). - This free air, indicating a perforated viscus, appears as a **Crescent-shaped lucency** shadowing the diaphragm. *USG* - While ultrasound can sometimes detect free air, it is **less sensitive and specific** than X-ray for this purpose, especially in early or small perforations. - Its utility is more in detecting other intra-abdominal pathologies like fluid collections or organomegaly. *Laparoscopy* - **Laparoscopy** is a **surgical procedure** that allows direct visualization of the peritoneal cavity. - While it can definitively identify free air and its source, it is an **invasive procedure** and not the primary diagnostic investigation for suspected pneumoperitoneum. *Laparotomy* - **Laparotomy** is an **open surgical procedure** involving a large incision to access the abdominal cavity. - It is used for definitive diagnosis and treatment, but it is **highly invasive** and not a diagnostic investigation in the initial workup for air in the peritoneal cavity.

Question 1

Examine the abdominal X-ray shown. What is the most likely diagnosis based on the findings?

Accepted Answer

Intestinal Obstruction

Answer

Small bowel ileus

Answer

Pneumoperitoneum

Answer

Large bowel obstruction

Question 2

Identify the condition based on the non-contrast CT scan of a patient given below.

Accepted Answer

Hydatid cyst

Answer

Hepatocellular carcinoma

Answer

Liver abscess

Answer

Focal nodular hyperplasia

Question 3

Double bleb sign seen in early pregnancy is due to?

Accepted Answer

Yolk sac and amniotic sac

Answer

Amnion and chorion

Answer

Twin pregnancy

Answer

Chorion and decidua

Question 4

A 45-year-old patient presented with vague abdominal pain. On USG, he was found to have a renal cyst of Bosniak class III. CECT was done, as shown below. What imaging modality is shown?

Accepted Answer

CT scan

Answer

Contrast Dye study

Answer

Angiography

Answer

X-ray

Question 5

During rounds, your senior was discussing the given image. Which of the following investigations does this image represent?

Accepted Answer

CT scan

Answer

Contrast Dye study

Answer

Angiography

Answer

X-ray

Question 6

Double decidual sign is seen in?

Accepted Answer

Uterine gestational sac

Answer

Pseudo gestational sac

Answer

Threatened Abortion

Answer

Ectopic pregnancy

Question 7

Which of the following is a gold standard investigation for diagnosis of renal stone?

Accepted Answer

Helical CT with Non-contrast

Answer

USG

Answer

Helical CT with contrast

Answer

MRI

Question 8

Pulsatile Doppler signal (continuous flow) in the hepatic vein in the setting of Budd-Chiari syndrome indicates:

Accepted Answer

Partial IVC obstruction

Answer

Congenital web in IVC

Answer

Renal vein thrombosis

Answer

Portal vein thrombosis

Question 9

One of the following is characterised by RIM sign?

Accepted Answer

Hydronephrosis (Gross)

Answer

Polycystic kidney

Answer

Chronic pyelonephritis

Answer

Hypernephroma

Question 10

The best investigation for air in the peritoneal cavity is:

Accepted Answer

X-ray

Answer

USG

Answer

Laparoscopy

Answer

Laparotomy

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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