Contrast and Radiological Procedures Practice Questions

Q: The following image shows:

ERCP showing smooth filling defect. ***ERCP showing smooth filling defect*** - The image displays a **retrograde filling** of the biliary tree with contrast, characteristic of an **Endoscopic Retrograde Cholangiopancreatography (ERCP)**. - The arrow points to a smooth, crescent-shaped defect within the common bile duct, consistent with a **gallstone (choledocholithiasis)** causing a filling defect. *PTC showing smooth filling defect* - **Percutaneous Transhepatic Cholangiography (PTC)** involves an antegrade injection of contrast directly into the intrahepatic bile ducts through the skin, which is not what is seen here. - While PTC can show filling defects, the **retrograde cannulation** of the common bile duct from the duodenum is clearly visible, ruling out PTC. *Oral cholecystogram showing stricture* - An **oral cholecystogram** assesses gallbladder function and stones, not the common bile duct as clearly visualized here. - There is no evidence of a **stricture**, which would appear as a focal narrowing with upstream dilation, instead, a filling defect is central to the finding. *HIDA scan showing cystic duct agenesis* - A **HIDA scan (Hepatobiliary Iminodiacetic Acid scan)** is a nuclear medicine study that assesses gallbladder function and bile flow, not anatomical details of the biliary tree in the same way as a contrast study. - **Cystic duct agenesis** would manifest as the absence of gallbladder visualization, which cannot be determined from this image.

Q: The flow of Barium across the mucosal surface is highly irregular and is seen in which of the following conditions?

Candida esophagitis. ***Candida esophagitis*** - **Candida esophagitis** often presents with a characteristic imaging finding called a "**shaggy esophagus**" on barium swallow studies. - This "shaggy" appearance is due to the irregular adherence of barium to the **candidal plaques and pseudomembranes** on the esophageal mucosa, leading to an irregular flow pattern. *Esophageal cancer* - Esophageal cancer typically appears as a **filling defect**, stricture, or focal irregularity with **shouldering** or mucosal nodularity on barium studies. - The barium flow would be obstructed or narrowed, but usually not described as "highly irregular" across the entire mucosal surface in the same diffuse manner as Candida. *Esophageal varices* - Esophageal varices appear as **snake-like** or **serpiginous filling defects** that are typically longitudinal and alter with respiration, giving a "rosary bead" appearance. - While they cause irregularities, the description of "highly irregular flow across the mucosal surface" is not the primary way varices are characterized on barium studies. *Reflux esophagitis* - Reflux esophagitis can show mild mucosal irregularities, thickening of folds, or strictures, especially in chronic cases. - However, the irregular barium flow from diffuse mucosal plaque adherence characteristic of Candida is not a typical finding in reflux esophagitis.

Q: The following image shows:

Orthopantomogram. ***Orthopantomogram*** - The image displays a panoramic view of the upper and lower jaws, including all teeth, the temporomandibular joints, and surrounding bone structures, which is characteristic of an **Orthopantomogram (OPG)** or panoramic radiograph. - This type of radiograph is commonly used in dentistry to assess the overall dental status, detect **impacted teeth**, and evaluate **bone pathology** across the entire oral cavity. *Water's view* - A **Water's view** (occipitomental view) is a radiographic projection typically used to visualize the maxilla, sinuses (especially the maxillary sinuses), and orbits. - It does not provide a panoramic view of the entire dental arches as seen in the image. *Invertogram* - An **invertogram** is a specialized lateral radiographic view of the abdomen and pelvis, particularly positioned to show the anus and rectum. - It is primarily used to assess **anorectal malformations** in infants and has no relation to dental imaging. *Gynogram* - The term **gynogram** is not a standard or recognized medical imaging technique. - Imaging studies related to gynecological conditions typically involve ultrasound, MRI, or CT scans of the pelvis, not a specific "gynogram" X-ray.

Q: Identify the type of investigation shown in the image below.

Myelography. ***Correct: Myelography*** - The image displays **contrast agent within the spinal canal**, outlining the spinal cord and nerve roots against the bony structures of the cervical spine - This technique is used to visualize **nerve impingement, disc herniation, or spinal cord compression** - Characteristic finding: contrast delineating the thecal sac and nerve root sleeves *Incorrect: Angiography* - Angiography involves injecting contrast into **blood vessels** to visualize vascular structures, detect blockages, or aneurysms - The image shows the **spinal canal** rather than the vascular tree *Incorrect: Neurography* - Neurography (MR neurography) is a specialized **MRI technique** to visualize peripheral nerves themselves - Does not involve injection of contrast into the spinal canal as shown in the image *Incorrect: Fluoroscopy* - Fluoroscopy is a **real-time X-ray imaging technique** used for dynamic assessment or procedure guidance - While fluoroscopy may be used **during** myelography to guide needle placement, the specific technique of contrast visualization in the spinal canal defines this as myelography

Q: Identify the investigation being carried out in the image.

Barium Swallow. ***Barium Swallow*** - The image shows a contrast material, characteristic of **barium**, flowing through the esophagus, captured as a sequence of X-ray images, which is the definition of a barium swallow study. - This **dynamic imaging** allows for evaluation of swallowing function and esophageal motility. *Fluoroscopy* - While a barium swallow uses **fluoroscopy** to visualize the movement of barium, fluoroscopy itself is the technique, not the specific investigation being performed. The image depicts the result of a specific type of fluoroscopic examination. - Fluoroscopy is a general term for real-time X-ray imaging, whereas "Barium Swallow" specifies the type of study being done on the upper GI tract. *X-ray after alkali ingestion* - This scenario would typically involve viewing the effects of **corrosive injury** to the esophagus, which would appear as mucosal damage, narrowing, or perforation. The image does not show these features; instead, it shows smooth passage of contrast. - There is no visible evidence of an acute or chronic injury pattern consistent with **alkali ingestion**, which often leads to severe burns or strictures. *X-ray after acid ingestion* - Similar to alkali ingestion, acid ingestion also causes **corrosive injury**, typically affecting the stomach more severely than the esophagus. The image does not demonstrate these pathological changes. - The smooth, unobstructed flow of contrast in multiple frames is indicative of normal esophageal function rather than the sequelae of corrosive ingestion.

Q: What is the modality of the test shown in the image?

Hysterosalpingography. ***Hysterosalpingography*** - The image shows a **contrast-filled uterus and fallopian tubes**, characteristic of a **hysterosalpingogram (HSG)**. - An HSG uses **X-rays** and **radiopaque contrast media** to visualize the uterine cavity and assess fallopian tube patency. *Hysteroscopy* - **Hysteroscopy** involves direct visualization of the uterine cavity using a **fiber optic endoscope** inserted through the cervix. - It does not produce an X-ray image with contrast filling the fallopian tubes. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure that involves inserting a **laparoscope** through an incision in the abdominal wall to view pelvic organs externally. - This image clearly depicts an internal view of the uterus and tubes through contrast, not an external, endoscopic view. *Saline infusion sonography* - **Saline infusion sonography (SIS)**, also known as sonohysterography, uses **ultrasound** imaging during the infusion of saline into the uterus. - While it assesses the uterine cavity, it is an ultrasound-based technique and does not involve X-ray contrast passing through the fallopian tubes, as seen in the image.

Q: A 71-year-old man is brought to the emergency department because of severe, progressive left leg pain and tingling for 8 hours. The symptoms began while he was watching television. For several months, the patient has noticed calf cramping when going for long walks, as well as occasional foot tingling and numbness, but did not seek medical attention. He has no history of recent injuries. He has poorly-controlled hypertension, hyperlipidemia, type 2 diabetes mellitus, and osteoarthritis. He smoked one pack of cigarettes daily for 35 years but quit 15 years ago. He drinks three beers every night. Current medications include lisinopril, metoprolol succinate, atorvastatin, metformin, and ibuprofen. He appears to be in severe pain and is clutching his left leg. His temperature is 37.4°C (99.3°F), pulse is 110/min, respirations are 18/min, and blood pressure is 163/94 mm Hg. The lungs are clear to auscultation. There is a harsh II/VI systolic ejection murmur best heard at the right upper sternal border. The abdomen is soft and nontender. The left leg is cool to the touch with decreased popliteal, posterior tibial, and dorsalis pedis pulses. There is 5/5 strength on left hip, knee, and ankle testing. The left hip, knee, and ankle show no gross effusion, erythema, or tenderness to palpation. The remainder of the examination shows no abnormalities. Which of the following is most likely to confirm the diagnosis?

Ankle-brachial index. ***Ankle-brachial index*** - An **ankle-brachial index (ABI)** compares blood pressure in the ankles to blood pressure in the arms and is a primary diagnostic tool for **peripheral artery disease (PAD)**, which is strongly suggested by the patient's symptoms of acute limb ischemia superimposed on chronic claudication, risk factors, and physical exam findings. - A low ABI (<0.9) would confirm the presence of **occlusive arterial disease**, explaining the acute pain, coolness, and diminished pulses in the left leg. *Fibrin degradation products* - **Fibrin degradation products (FDPs)**, including **D-dimer**, are markers of **fibrinolysis** and are primarily used to diagnose or rule out **thrombotic events** like deep vein thrombosis (DVT) or pulmonary embolism (PE). - While an arterial occlusion might involve thrombosis, FDPs are not the most direct or specific test for confirming the diagnosis of **acute limb ischemia** caused by PAD. *Creatine kinase concentration* - **Creatine kinase (CK)** levels are elevated in cases of **muscle damage** or **rhabdomyolysis**, which can occur secondary to severe and prolonged acute limb ischemia, but it is not a diagnostic test for the underlying vascular condition itself. - An elevated CK would indicate **tissue necrosis**, which is a consequence of severe ischemia, rather than a diagnostic tool for confirming the presence of **arterial occlusion**. *Compartment pressures* - Measuring **compartment pressures** is indicated to diagnose **acute compartment syndrome**, a condition where increased pressure within a confined fascial space compromises circulation and nerve function. - Although severe ischemia can lead to muscle swelling and potentially compartment syndrome, the primary problem here is the **arterial occlusion itself**, and direct measurement of compartment pressures is not the initial or most appropriate test to confirm the underlying diagnosis of acute limb ischemia in this context.

Q: The dye used for OCG is:

Iopanoic acid. ***Iopanoic acid*** - **Iopanoic acid** is a common oral contrast agent used for **oral cholecystography (OCG)**. - It is an **iodinated organic acid** that is absorbed from the GI tract, concentrated in the liver, and excreted into the bile, allowing visualization of the gallbladder. *Sodium diatrozite* - **Sodium diatrizoate** is primarily used as an **intravenous contrast agent** for studies like excretory urography or CT scans. - It is not typically administered orally for OCG as it is not effectively absorbed and concentrated for gallbladder visualization. *Biligraffin* - **Biligrafin** (also known as sodium iodipamide) is an **intravenous cholangiographic agent**. - While it visualizes bile ducts, it is not an oral agent for direct gallbladder opacification as performed in OCG. *Meglumine iodothalamate* - **Meglumine iodothalamate** is an **intravenous ionic contrast agent** used for various angiographic and urographic procedures. - It is not suitable for oral administration in OCG due to its pharmacological properties and route of excretion.

Q: Second swallowing in barium meal studies is found in-

Pharyngeal pouch. ***Pharyngeal pouch*** - A pharyngeal pouch, specifically a **Zenker's diverticulum**, can lead to food or barium pooling within the pouch. - This pooling can cause a sensation of retained material, prompting a **second swallow** to clear the pharynx and esophagus. *Scleroderma* - Leads to **esophageal dysmotility** due to smooth muscle atrophy and fibrosis, primarily affecting the lower two-thirds of the esophagus. - This manifests as difficulty moving food down the esophagus, but not typically as the need for a second swallow to clear a pouch. *Reflux esophagitis* - Characterized by **inflammation of the esophagus** due to gastric acid reflux. - Symptoms include heartburn and dysphagia, but it does not cause the pooling of barium requiring a second swallow as seen with a pharyngeal pouch. *Achalasia cardia* - Involves the **failure of the lower esophageal sphincter to relax** and loss of peristalsis in the esophageal body. - This results in significant delayed emptying and a "bird's beak" appearance on barium swallow, but not the specific finding of a second swallow to clear a localized pouch.

Q: CECT is least useful as a diagnostic tool for:

Subclavian steal syndrome. ***Correct: Subclavian steal syndrome*** - **Doppler ultrasound** is the primary and most effective diagnostic method for real-time assessment of blood flow velocity and direction in the vertebral and subclavian arteries, directly demonstrating the **"steal" phenomenon** - While **Computed tomography angiography (CTA)** with contrast can visualize the subclavian artery anatomy, it is **not optimal** for evaluating the hemodynamic flow dynamics that define this condition - The diagnosis relies on demonstrating **reversed vertebral artery flow**, which is best assessed with duplex Doppler ultrasound *Incorrect: Glomus jugulare* - **CECT is highly useful** for identifying the characteristic **vascular nature** and **bone erosion** associated with glomus jugulare tumors in the temporal bone - CECT allows for detailed visualization of tumor extent, particularly its relationship to surrounding structures and bony labyrinth - Shows intense enhancement due to the highly vascular nature of this paraganglioma *Incorrect: Carotid body tumor* - **CECT is highly effective** in diagnosing carotid body tumors, which are paragangliomas with **hypervascularity** leading to intense contrast enhancement - Provides excellent anatomical detail, showing the characteristic **splaying of the carotid bifurcation** (Lyre sign) - Clearly demonstrates tumor vascularity and relationship to great vessels *Incorrect: Juvenile angiofibroma* - **CECT is crucial** for diagnosing and staging juvenile angiofibromas, which are **highly vascular tumors** of the nasopharynx that show avid contrast enhancement - Helps delineate the tumor's extent, including involvement of the pterygopalatine fossa, sphenoid sinus, and potential intracranial extension - Essential for pre-operative planning due to the tumor's vascularity

Question 1

The following image shows:

Accepted Answer

ERCP showing smooth filling defect

Answer

PTC showing smooth filling defect

Answer

Oral cholecystogram showing stricture

Answer

HIDA scan showing cystic duct agenesis

Question 2

The flow of Barium across the mucosal surface is highly irregular and is seen in which of the following conditions?

Accepted Answer

Candida esophagitis

Answer

Esophageal cancer

Answer

Esophageal varices

Answer

Reflux esophagitis

Question 3

The following image shows:

Accepted Answer

Orthopantomogram

Answer

Water's view

Answer

Invertogram

Answer

Gynogram

Question 4

Identify the type of investigation shown in the image below.

Accepted Answer

Myelography

Answer

Angiography

Answer

Neurography

Answer

Fluoroscopy

Question 5

Identify the investigation being carried out in the image.

Accepted Answer

Barium Swallow

Answer

Fluoroscopy

Answer

X-ray after alkali ingestion

Answer

X-ray after acid ingestion

Question 6

What is the modality of the test shown in the image?

Accepted Answer

Hysterosalpingography

Answer

Hysteroscopy

Answer

Laparoscopy

Answer

Saline infusion sonography

Question 7

A 71-year-old man is brought to the emergency department because of severe, progressive left leg pain and tingling for 8 hours. The symptoms began while he was watching television. For several months, the patient has noticed calf cramping when going for long walks, as well as occasional foot tingling and numbness, but did not seek medical attention. He has no history of recent injuries. He has poorly-controlled hypertension, hyperlipidemia, type 2 diabetes mellitus, and osteoarthritis. He smoked one pack of cigarettes daily for 35 years but quit 15 years ago. He drinks three beers every night. Current medications include lisinopril, metoprolol succinate, atorvastatin, metformin, and ibuprofen. He appears to be in severe pain and is clutching his left leg. His temperature is 37.4°C (99.3°F), pulse is 110/min, respirations are 18/min, and blood pressure is 163/94 mm Hg. The lungs are clear to auscultation. There is a harsh II/VI systolic ejection murmur best heard at the right upper sternal border. The abdomen is soft and nontender. The left leg is cool to the touch with decreased popliteal, posterior tibial, and dorsalis pedis pulses. There is 5/5 strength on left hip, knee, and ankle testing. The left hip, knee, and ankle show no gross effusion, erythema, or tenderness to palpation. The remainder of the examination shows no abnormalities. Which of the following is most likely to confirm the diagnosis?

Accepted Answer

Ankle-brachial index

Answer

Fibrin degradation products

Answer

Creatine kinase concentration

Answer

Compartment pressures

Question 8

The dye used for OCG is:

Accepted Answer

Iopanoic acid

Answer

Sodium diatrizoate

Answer

Biligraffin

Answer

Meglumine iodothalamate

Question 9

Second swallowing in barium meal studies is found in-

Accepted Answer

Pharyngeal pouch

Answer

Scleroderma

Answer

Reflux esophagitis

Answer

Achalasia cardia

Question 10

CECT is least useful as a diagnostic tool for:

Accepted Answer

Subclavian steal syndrome

Answer

Glomus jugulare

Answer

Carotid body tumor

Answer

Juvenile angiofibroma

Contrast and Radiological Procedures — MCQs

Contrast and Radiological Procedures — MCQs

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