Abdominal and Pelvic Radiology Practice Questions

Q: Double decidual sac sign is indicative of?

Intrauterine pregnancy. ***Intrauterine pregnancy*** - The **double decidual sac sign** refers to the visualization of two concentric rings of decidua surrounding the gestational sac, which is a characteristic feature of an **early intrauterine pregnancy**. - It signifies the presence of both the **parietal decidua** (lining the uterine cavity) and the **capsular decidua** (surrounding the gestational sac), distinguishing a true gestational sac from a pseudogestational sac. *Ectopic pregnancy* - In an **ectopic pregnancy**, the gestational sac is located outside the uterus, and therefore, the double decidual sac sign will **not be present**. - A pseudogestational sac, which lacks the double decidual sac sign, can sometimes be seen in the uterus in cases of ectopic pregnancy. *H. mole* - A **hydatidiform mole** (H. mole) is characterized by abnormal proliferation of trophoblastic tissue and typically presents as a "snowstorm" appearance on ultrasound, with **no identifiable gestational sac or embryo**. - The double decidual sac sign is a marker of a well-formed gestational sac within the uterus and is absent in molar pregnancies. *Twin pregnancy* - While a twin pregnancy involves two gestational sacs or a single sac with two embryos, the **double decidual sac sign** itself is an indicator of the presence of any single normal gestational sac within the uterus, regardless of the number of fetuses. - The sign confirms the intrauterine location and viability of a pregnancy, but additional features are needed to diagnose a multiple gestation.

Q: In which of the following conditions is air under both sides of diaphragm visualized -

Perforation of duodenal ulcer. ***Perforation of duodenal ulcer*** - A perforated duodenal ulcer is the **most classic and common cause** of pneumoperitoneum (free air under the diaphragm). - Perforation creates a communication between the gastrointestinal tract and the peritoneal cavity, allowing **free air to escape into the abdomen**. - This free air, being less dense than surrounding tissues, rises and collects **bilaterally under the diaphragm**, creating the classic **"football sign"** or crescents of air on upright chest X-ray. - Duodenal ulcer perforation is the **most frequently tested** cause of this radiological finding in medical examinations. *Perforated Meckel's diverticulum* - A perforated Meckel's diverticulum would also allow **intraluminal gas to escape into the peritoneal cavity**, causing pneumoperitoneum. - However, this is a **much rarer condition** compared to duodenal ulcer perforation. - Meckel's diverticulum perforation occurs in only 10-30% of symptomatic cases, making it less common than duodenal ulcer perforation. - While technically correct that it would show free air, duodenal ulcer perforation is the **primary answer** due to its higher frequency. *Uterine rupture following illegal abortion* - Uterine rupture would primarily involve **blood and uterine contents** spilling into the peritoneal cavity, rather than free air. - While instrumentation during illegal abortion could potentially introduce air, significant **bilateral subdiaphragmatic free air** is not a typical or diagnostically significant finding. - The hallmark findings would be **hemoperitoneum and pelvic fluid collections**, not pneumoperitoneum. *All of the options* - This option is incorrect because uterine rupture (as explained above) typically does not cause diagnostically significant pneumoperitoneum. - While both GI perforations can cause free air, only duodenal ulcer perforation is the **classic and most common** cause being tested here.

Q: Claw sign seen in?

Intussusception. ***Intussusception*** - The **claw sign** is a characteristic radiological finding in **intussusception**, seen on barium enema or ultrasound - It represents the **intussusceptum** (the invaginated bowel segment) within the **intussuscipiens** (the receiving bowel segment), creating a claw-like appearance at the margins - The claw-like projections are formed by the opposing walls of the intussusception *Malrotation* - Malrotation presents with **midgut volvulus** and shows the **whirl sign** (twisted mesentery) on imaging - May show **duodenal obstruction** with double bubble sign, not claw sign - The claw sign is not a feature of malrotation *Volvulus* - **Volvulus** typically presents with a **"coffee bean sign"** (sigmoid volvulus) or **"whirl sign"** (cecal/midgut volvulus) on imaging - These signs indicate twisted bowel loops around the mesentery - The **claw sign** is not associated with volvulus; it is specific to the telescoping of bowel segments seen in intussusception *Both* - This option is incorrect as the **claw sign** is specific to **intussusception** only - While intussusception, malrotation, and volvulus can all cause bowel obstruction, their radiographic signs are distinct and diagnostically important

Q: USG findings of focal anechoic lesion with floating membranes indicate which liver pathology?

Hydatid cyst. ***Hydatid cyst*** - A **hydatid cyst** often presents on ultrasound as a **focal anechoic lesion** with characteristic **floating membranes** (water lily sign) due to detachment of the endocyst. - These cysts are caused by tapeworm larvae (*Echinococcus granulosus*) and can have daughter cysts within the main cyst. *Pyogenic abscess* - A **pyogenic abscess** typically appears as an **ill-defined, hypoechoic liver lesion** with internal debris, sometimes showing gas. - While it can be anechoic, the presence of **floating membranes** is not a characteristic feature. *Hemangioma* - A **hemangioma** is usually a **well-defined, hyperechoic lesion** on ultrasound, without any internal fluid or floating membranes. - Its appearance is distinct from cystic lesions and it often shows characteristic peripheral nodular enhancement on contrast-enhanced imaging. *Amoebic abscess* - An **amoebic abscess** typically presents as a **hypoechoic, often round or oval lesion** with fine internal echoes and poorly defined walls, usually without floating membranes. - It is frequently located in the right lobe of the liver and can be difficult to differentiate from a pyogenic abscess based on imaging alone.

Q: X-Ray appearance of CBD stone on cholangiography is:

Meniscus appearance. ***Meniscus appearance*** - A **meniscus appearance** on cholangiography is characteristic of a **filling defect** caused by a common bile duct (CBD) stone. The contrast material outlines the stone, creating a curved, crescent-shaped border. - This image clearly demonstrates the classic **meniscus sign** where the contrast agent partially outlines the stone, showing its superior surface as a curved line, with dilated CBD just proximal to it. *Sudden cut off* - A **sudden cut off** might suggest a complete obstruction, but it typically implies **malignancy** or extrinsic compression that completely obliterates the lumen, rather than an intraluminal stone. - While a large stone can cause severe obstruction, it rarely presents as a perfectly abrupt, sharp block on cholangiography without some outlining. *Eccentric occlusion* - **Eccentric occlusion** usually means partial blockage from one side, which could be due to a stone, but it often implies the stone is **not completely obstructing** the lumen or is adherent to one wall. - While stones can cause eccentric occlusion, "meniscus appearance" more specifically describes the classic imaging finding of a stone within the lumen. *Smooth tapering* - **Smooth tapering** is usually indicative of a **benign stricture** or inflammatory process, where the duct gradually narrows. - It does not suggest an intraluminal filling defect like a stone; rather, it implies a gradual constriction of the duct wall.

Q: Gas absent from intestine (gasless abdomen) on x-ray is seen in which condition?

Acute pancreatitis. ***Acute pancreatitis*** - In **severe acute pancreatitis**, a **gasless or relatively gasless abdomen** may be seen due to profound **ileus** with fluid accumulation displacing intestinal gas. - The marked inflammatory process can lead to complete loss of intestinal motility and fluid sequestration (third-spacing), resulting in minimal visible bowel gas on X-ray. - **Note**: Classic signs include **sentinel loop sign** (dilated jejunal loop) or **colon cut-off sign**, but in severe cases with massive ascites or fluid collections, a gasless pattern may occur. *Ulcerative colitis* - Typically presents with **dilated loops of large bowel** with visible gas and **toxic megacolon** in severe cases. - Inflammatory changes cause bowel wall thickening, but gas is usually **present and often increased**. *Intussusception* - May show a **target sign** or **meniscus sign** on imaging, with bowel loops dilated proximal to the obstruction. - Gas is typically **present** within the bowel or proximal to the invagination, not absent from the entire abdomen. *Necrotizing enterocolitis* - Characterized by **pneumatosis intestinalis** (gas in the bowel wall) and **portal venous gas**, features directly contradicting a gasless abdomen. - Shows dilated loops with gas and evidence of bowel wall necrosis - **gas is prominently present**.

Q: Causes of thickened gallbladder wall on ultrasound examination are all except:

Kawasaki disease. ***Kawasaki disease*** (Correct - NOT a typical cause of gallbladder wall thickening) * Although **Kawasaki disease** can cause systemic inflammation and **gallbladder hydrops** (distension) in children, it typically does NOT present with primary gallbladder wall thickening as a diagnostic finding. * The gallbladder manifestation in Kawasaki disease is **hydrops** (distension without stones), which is distinct from wall thickening. * Other hallmark features include **coronary artery aneurysms**, mucocutaneous manifestations, rash, and lymphadenopathy. * Gallbladder wall thickening is **not a recognized criterion** or common ultrasound finding in Kawasaki disease. --- *Congestive cardiac failure* (Incorrect - DOES cause thickening) * **Right-sided heart failure** leads to systemic venous congestion, causing **edema** in the gallbladder wall and subsequent thickening on ultrasound. * The thickening results from increased **hydrostatic pressure** and fluid accumulation in the wall. * This is a well-recognized cause of gallbladder wall thickening in the setting of hepatic congestion and ascites. *Postprandial state* (Incorrect - DOES cause thickening) * After a meal, especially one rich in fats, the gallbladder **contracts physiologically** to expel bile into the duodenum. * The contracted gallbladder wall appears **thickened** due to muscular contraction and reduced luminal volume. * This is a **normal physiological response**, not pathology; the thickening is *transient*, *symmetric*, and resolves on follow-up imaging after fasting. *Cholecystitis* (Incorrect - DOES cause thickening) * **Acute cholecystitis** involves inflammation of the gallbladder, directly causing **edema** and cellular infiltration of the gallbladder wall. * Wall thickening (>3 mm) is a **primary ultrasound diagnostic criterion** for acute cholecystitis. * Often accompanied by *pericholecystic fluid*, gallstones, and positive **sonographic Murphy's sign**.

Q: A dense persistent nephrogram may be seen in all of the following except:

Systemic hypertension. ***Systemic hypertension*** - **Systemic hypertension** is not typically associated with a dense, persistent nephrogram on imaging. While chronic hypertension can cause renal damage, it does not directly lead to the characteristic prolonged parenchymal enhancement. - A dense, persistent nephrogram suggests impaired contrast excretion or increased reabsorption, neither of which is a primary manifestation of systemic hypertension itself. *Severe hydronephrosis* - **Severe hydronephrosis** leads to impaired urine flow and delayed transit of contrast medium through the renal tubules, resulting in a persistent nephrogram. - The dilated collecting system and compressed parenchyma can retain contrast for an extended period due to reduced glomerular filtration rate (GFR) in the affected kidney. *Dehydration* - In cases of **dehydration**, the kidneys attempt to conserve water, leading to increased reabsorption of water from the renal tubules. - This process can concentrate the contrast medium within the tubules, resulting in a denser and more persistent nephrogram as it slowly transits through the kidney. *Acute ureteral obstruction* - **Acute ureteral obstruction** causes a build-up of pressure within the renal collecting system, impairing glomerular filtration and slowing the passage of contrast. - The contrast medium remains within the renal parenchyma for a prolonged period due to the blockage, leading to a dense and persistent nephrogram and delayed excretion.

Q: A patient with right lower quadrant pain shows target sign on ultrasound. Diagnosis?

Intussusception. ***Intussusception*** - The **target sign** on ultrasound is a classic radiological finding in **intussusception**, indicating a segment of bowel telescoping into an adjacent segment. - This condition is a common cause of **acute abdominal pain** and bowel obstruction, particularly in young children, though it can occur in adults. *Diverticulitis* - Diverticulitis presents with **inflammation of diverticula**, often in the left lower quadrant, but can occur in the right. - Ultrasound findings typically include **thickened bowel wall**, pericolic fat stranding, and sometimes abscesses, not a target sign. *Mesenteric cyst* - A mesenteric cyst is a **fluid-filled mass** located within the mesentery and would appear as a well-defined, anechoic (fluid-filled) structure on ultrasound. - It would not exhibit the characteristic concentric layers of the target sign. *Appendicitis* - Acute appendicitis is characterized by a **dilated, non-compressible appendix** with a thickened wall and surrounding inflammation on ultrasound. - While it causes right lower quadrant pain, the specific **target sign** is not typical for appendicitis.

Q: What is the characteristic feature of hepatocellular carcinoma on triphasic CT?

Arterial enhancement with washout. ***Arterial enhancement with washout*** - **Hepatocellular carcinoma (HCC)** classically demonstrates **hyperenhancement** in the arterial phase due to its unique blood supply primarily from the **hepatic artery**. - This is followed by a characteristic **rapid "washout"** of contrast in the portal venous or delayed phases, as the tumor lacks normal portal venous supply and functional bile ducts. *No enhancement* - Lack of enhancement would suggest a **necrotic lesion** or a **benign cyst** rather than a primary malignant tumor like HCC. - This feature is not typical for a viable HCC on a triphasic CT scan. *Delayed enhancement* - **Delayed enhancement** is more typical of **fibrotic lesions** or some benign hepatic masses like **hemangiomas**, which continue to fill in with contrast over time. - It does not show the typical rapid arterial hyperenhancement and washout pattern of HCC. *Progressive enhancement* - **Progressive enhancement** is characteristic of entities like **hepatic hemangiomas**, which show gradual, often nodular, enhancement that follows the blood pool on delayed phases. - This pattern is distinct from the rapid arterial enhancement and subsequent washout seen in HCC.

Question 1

Double decidual sac sign is indicative of?

Accepted Answer

Intrauterine pregnancy

Answer

Ectopic pregnancy

Answer

H. mole

Answer

Twin pregnancy

Question 2

In which of the following conditions is air under both sides of diaphragm visualized -

Accepted Answer

Perforation of duodenal ulcer

Answer

Uterine rupture following illegal abortion

Answer

All of the options

Answer

Perforated Meckel's diverticulum

Question 3

Claw sign seen in?

Accepted Answer

Intussusception

Answer

Malrotation

Answer

Volvulus

Answer

Both

Question 4

USG findings of focal anechoic lesion with floating membranes indicate which liver pathology?

Accepted Answer

Hydatid cyst

Answer

Pyogenic abscess

Answer

Hemangioma

Answer

Amoebic abscess

Question 5

X-Ray appearance of CBD stone on cholangiography is:

Accepted Answer

Meniscus appearance

Answer

Sudden cut off

Answer

Eccentric occlusion

Answer

Smooth tapering

Question 6

Gas absent from intestine (gasless abdomen) on x-ray is seen in which condition?

Accepted Answer

Acute pancreatitis

Answer

Ulcerative colitis

Answer

Intussusception

Answer

Necrotizing enterocolitis

Question 7

Causes of thickened gallbladder wall on ultrasound examination are all except:

Accepted Answer

Kawasaki disease

Answer

Congestive cardiac failure

Answer

Postprandial state

Answer

Cholecystitis

Question 8

A dense persistent nephrogram may be seen in all of the following except:

Accepted Answer

Systemic hypertension

Answer

Severe hydronephrosis

Answer

Dehydration

Answer

Acute ureteral obstruction

Question 9

A patient with right lower quadrant pain shows target sign on ultrasound. Diagnosis?

Accepted Answer

Intussusception

Answer

Diverticulitis

Answer

Mesenteric cyst

Answer

Appendicitis

Question 10

What is the characteristic feature of hepatocellular carcinoma on triphasic CT?

Accepted Answer

Arterial enhancement with washout

Answer

No enhancement

Answer

Delayed enhancement

Answer

Progressive enhancement

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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