Abdominal and Pelvic Radiology

Abdominal and Pelvic Radiology Indian Medical PG Question 1: A 30 year old female comes with hypovolemic shock after blunt trauma of the abdomen. An emergency USG of abdomen shows splenic tear. Which of the following is to be done -

• A. Monitor patient to assess for progression
• B. CECT of the abdomen
• C. Immediate surgery (Correct Answer)
• D. Diagnostic lavage of peritoneal cavity before proceeding

Abdominal and Pelvic Radiology Explanation: ***Immediate surgery*** - A patient in **hypovolemic shock** after a **blunt abdominal trauma** with a confirmed **splenic tear** on ultrasound (FAST scan) indicates active hemorrhage and hemodynamic instability. - In such a critical state, **immediate surgical intervention** (laparotomy) is necessary to control bleeding and stabilize the patient's condition, as non-operative management is contraindicated. *Monitor patient to assess for progression* - This approach is suitable for **hemodynamically stable** patients with splenic injuries, where observation and serial examinations can be considered. - Given the patient's **hypovolemic shock**, monitoring alone risks critical delays in hemorrhage control, leading to further decompensation. *CECT of the abdomen* - An abdominal **CT scan with contrast** (CECT) is the gold standard for detailed assessment of abdominal injuries but requires the patient to be **hemodynamically stable**. - Performing a CECT on a patient in **hypovolemic shock** would delay life-saving intervention and is not appropriate for this unstable condition. *Diagnostic lavage of peritoneal cavity before proceeding* - **Diagnostic peritoneal lavage (DPL)** is an older, invasive diagnostic test used to detect intra-abdominal bleeding, but it has largely been replaced by **FAST scans** and **CT scans**. - In this case, the **FAST scan already confirms a splenic tear**, and the patient's **hypovolemic shock** necessitates immediate definitive treatment rather than an additional diagnostic step.

Abdominal and Pelvic Radiology Indian Medical PG Question 2: Which of the following statements regarding a patient of liver trauma are correct? 1. Liver is the most common organ injured following abdominal trauma. 2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST. 3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients. 4. Blunt injuries have a higher mortality as compared to penetrating injuries.

• A. 1. Liver is the most common organ injured following abdominal trauma.
• B. 2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST.
• C. 4. Blunt injuries have a higher mortality as compared to penetrating injuries.
• D. 3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients. (Correct Answer)

Abdominal and Pelvic Radiology Explanation: ***3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients.*** - A **contrast-enhanced CT abdomen** is the diagnostic study of choice for **hemodynamically stable patients** with suspected liver trauma, as it accurately quantifies injury and guides management. - It helps in grading the liver injury, identifying active extravasation, and detecting associated injuries, thus determining the need for operative versus non-operative management. *1. Liver is the most common organ injured following abdominal trauma.* - While the liver is frequently injured in abdominal trauma, the **spleen** is actually the most commonly injured solid organ in cases of **blunt abdominal trauma**. - The liver is the second most commonly injured solid organ, but its large size and fragile nature make it highly susceptible to injury. *2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST.* - **Hemodynamically unstable patients** with suspected abdominal trauma often require **surgical exploration (laparotomy)**, but the presence of **free intraperitoneal fluid on FAST** alone does not automatically necessitate laparotomy in stable patients. - Free fluid on FAST in a stable patient can represent blood or other fluid, and further imaging like CT is needed to assess the source and extent of injury before surgical intervention. *4. Blunt injuries have a higher mortality as compared to penetrating injuries.* - **Penetrating injuries** (e.g., stab wounds, gunshot wounds) generally have a **higher mortality rate** than blunt injuries due to the direct damage to vital structures and risk of massive hemorrhage and infection. - While blunt injuries can be severe, they often lead to less direct and immediate damage to major vessels and organs compared to penetrating trauma.

Abdominal and Pelvic Radiology Indian Medical PG Question 3: The imaging modality primarily used in FAST (Focused Assessment with Sonography for Trauma) exam is:

• A. X-ray
• B. CT
• C. MRI
• D. USG (Correct Answer)

Abdominal and Pelvic Radiology Explanation: **USG** - **Focused Assessment with Sonography for Trauma (FAST)** exam specifically uses **ultrasound (USG)** to rapidly detect free fluid (blood) in pericardial, perihepatic, perisplenic, and pelvic spaces. - Its quick, non-invasive nature and portability make it ideal for **point-of-care assessment** in trauma settings. *X-ray* - While X-rays are useful in trauma for detecting **fractures** and some pneumothoraces, they are not the primary modality for detecting free fluid in the peritoneal or pericardial cavities during a FAST exam. - X-rays do not provide real-time, dynamic imaging of soft tissues and fluid accumulation as effectively as ultrasound. *CT* - **Computed Tomography (CT)** is a highly detailed imaging modality used in trauma for comprehensive assessment of injuries to organs, bones, and vessels. - However, it involves **radiation exposure**, takes longer to perform, and is typically reserved for hemodynamically stable patients after initial resuscitation and FAST exam. *MRI* - **Magnetic Resonance Imaging (MRI)** provides excellent soft tissue contrast, but its use in acute trauma is very limited due to its **long scan times**, high cost, and incompatibility with many metallic medical devices. - MRI is not suitable for rapid assessment of free fluid in hemodynamically unstable trauma patients.

Abdominal and Pelvic Radiology Indian Medical PG Question 4: Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?

• A. Green
• B. Yellow (Correct Answer)
• C. Blue
• D. Black

Abdominal and Pelvic Radiology Explanation: ***Yellow*** - Patients in the **yellow category** are those who require **significant medical attention** and intervention, such as surgery, but whose condition is stable enough to withstand a delay of a few hours up to 24 hours without immediate threat to life or limb. - This category indicates a **delayed but urgent need** for treatment, distinguishing them from immediate (red) or minor (green) cases. *Blue* - The color **blue** is generally **not a standard triage category** in most commonly used disaster protocols (e.g., START, JumpSTART). - Triage systems typically use red, yellow, green, and black to prioritize patients based on immediate medical need and prognosis. *Green* - The **green category** is for patients with **minor injuries** who are considered "walking wounded" and can often wait for treatment for several hours, sometimes up to a few days. - These individuals are **stable** and do not require immediate intervention to preserve life or limb. *Black* - The **black category** is reserved for individuals who are **deceased** or have injuries so severe that survival is unlikely given the available resources, often implying **palliative care** rather than active life-saving interventions in a mass casualty event. - This category signifies that resources would be better allocated to patients with a higher chance of survival.

Abdominal and Pelvic Radiology Indian Medical PG Question 5: Which of the following is the correct management of abdominal compartment syndrome?

• A. Antihypertensives
• B. Urgent Fasciotomy
• C. Wait and monitor for 24 hours
• D. Urgent decompressive laparotomy (Correct Answer)

Abdominal and Pelvic Radiology Explanation: ***Urgent decompressive laparotomy*** - The definitive treatment for abdominal compartment syndrome (ACS) is **urgent surgical decompression** via **decompressive laparotomy**. - This involves opening the abdominal fascia to immediately **reduce intra-abdominal pressure (IAP)**, typically indicated when IAP >20 mmHg with new organ dysfunction. - Decompression is crucial to prevent irreversible organ damage, restore perfusion to compressed organs, and improve ventilation. - The abdomen is often left open temporarily with negative pressure wound therapy until the patient stabilizes. *Antihypertensives* - Antihypertensives may manage systemic hypertension but do not address the **elevated intra-abdominal pressure** that is the primary pathology in ACS. - This approach is insufficient and could worsen **organ perfusion** by reducing the perfusion pressure gradient (MAP - IAP) to already compressed abdominal organs. - ACS requires mechanical decompression, not pharmacological blood pressure management. *Urgent Fasciotomy* - Fasciotomy is the correct treatment for **extremity compartment syndrome** (e.g., leg, forearm), where it relieves pressure within muscle compartments. - It is anatomically inappropriate for **abdominal compartment syndrome**, which requires opening the abdominal cavity, not limb fascial compartments. - This represents a fundamental misunderstanding of the anatomical site requiring decompression. *Wait and monitor for 24 hours* - ACS is a **surgical emergency** that can rapidly progress to multiorgan failure, acute kidney injury, respiratory failure, and cardiovascular collapse. - Delaying intervention by 24 hours would likely result in **irreversible organ damage** and significantly increased mortality. - Once diagnosed (IAP >20 mmHg with organ dysfunction), urgent decompression is mandatory.

Abdominal and Pelvic Radiology Indian Medical PG Question 6: Rigler's sign is suggestive of?

• A. Pneumothorax
• B. Pneumoperitoneum (Correct Answer)
• C. Peritonitis
• D. Hemothorax

Abdominal and Pelvic Radiology Explanation: ***Correct: Pneumoperitoneum*** - **Rigler's sign** (double wall sign) is the visualization of both the **inner (mucosal) and outer (serosal) surfaces** of the bowel wall on an abdominal X-ray. - This occurs when **free intraperitoneal air** outlines both sides of the bowel wall, making it a **pathognomonic sign of pneumoperitoneum**. - Commonly seen in **bowel perforation** from causes like peptic ulcer, trauma, or iatrogenic injury. *Incorrect: Pneumothorax* - Refers to air in the **pleural space** (thoracic cavity), not the peritoneal cavity. - Diagnosed on chest X-ray by the **visceral pleural line** with absent lung markings peripherally. - Completely different anatomical compartment from where Rigler's sign is observed. *Incorrect: Peritonitis* - Represents **inflammation of the peritoneum**, which is a clinical and pathological diagnosis. - While pneumoperitoneum from perforation can **lead to peritonitis**, Rigler's sign specifically indicates the **presence of free air**, not inflammation itself. - Peritonitis has no specific pathognomonic radiological sign like Rigler's. *Incorrect: Hemothorax* - Refers to **blood in the pleural cavity** (thoracic, not abdominal). - Appears as a **pleural effusion** with meniscus sign on chest X-ray. - Unrelated to abdominal radiological findings or free air.

Abdominal and Pelvic Radiology Indian Medical PG Question 7: What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?

• A. USG (Correct Answer)
• B. CT Scan
• C. X-ray
• D. MRI

Abdominal and Pelvic Radiology Explanation: ***USG*** - An **ultrasound (USG)** is the preferred initial imaging modality in pediatric acute abdomen due to its **lack of ionizing radiation**, ease of use, and ability to visualize common causes like appendicitis and intussusception. - It is particularly useful for assessing **fluid collections**, inflammation, and obstruction in a non-invasive manner suitable for children. *CT Scan* - While it offers detailed anatomical views, **CT scans** involve significant **ionizing radiation**, which is a concern in children due to increased lifetime cancer risk. - It is typically reserved for cases where **USG is inconclusive** or if there is a high suspicion of conditions not well visualized by ultrasound. *X-ray* - **X-rays** provide limited information for soft tissue pathologies and are primarily useful for detecting **bowel obstruction (air-fluid levels)** or **free air** (perforation). - They lack the resolution to diagnose many common causes of acute abdomen in children, such as appendicitis or intussusception. *MRI* - **MRI** provides excellent soft tissue contrast without ionizing radiation but often requires **sedation** in young children due to the long scan times and need for stillness. - It is less readily available and more expensive than USG, making it a less practical first-line investigation for an acute presentation.

Abdominal and Pelvic Radiology Indian Medical PG Question 8: Which of the following statements about CT imaging is the MOST accurate?

• A. Water has a Hounsfield unit (HU) of zero. (Correct Answer)
• B. CT head dose remains constant regardless of the protocol used.
• C. CT cannot detect gallstones under any circumstances.
• D. CT uses unfiltered x-ray beams.

Abdominal and Pelvic Radiology Explanation: ***Water has a Hounsfield unit (HU) of zero.*** - The **Hounsfield unit (HU)** scale is a quantitative scale used to describe radiodensity in CT scans, where **water is defined as 0 HU**. - This establishes a crucial reference point for measuring the attenuation of other tissues, which can range from approximately **-1000 HU for air** to **+1000 HU or more for dense bone**. *CT head dose remains constant regardless of the protocol used.* - The **radiation dose** in CT scans is highly variable and depends significantly on the **protocol used**, including factors like mA, kVp, pitch, and scan length. - **Dose optimization techniques** and protocol adjustments are routinely employed to minimize patient exposure while maintaining diagnostic image quality. *CT cannot detect gallstones under any circumstances.* - While **ultrasound (US)** is the primary modality for detecting gallstones, CT can visualize them, especially if they are **calcified** or of mixed composition. - **Non-calcified gallstones** may be more challenging to detect on CT, but they are not impossible to see, particularly with current generation scanners and appropriate windowing. *CT uses unfiltered x-ray beams.* - CT scanners use **filtered x-ray beams** to provide higher quality images and reduce patient dose. - **Filtration (e.g., aluminum or copper)** removes low-energy x-rays, which would otherwise be absorbed by the patient without contributing to image formation.

Abdominal and Pelvic Radiology Indian Medical PG Question 9: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?

• A. Contrast enhanced computed tomography (Correct Answer)
• B. Retrograde urogram
• C. Intravenous urogram
• D. Ultrasonography of abdomen

Abdominal and Pelvic Radiology Explanation: ***Contrast enhanced computed tomography (CECT)*** - **CECT** is the **investigation of choice** for evaluating solid organ injuries, including renal trauma, in hemodynamically stable patients with blunt abdominal trauma and hematuria. - It provides detailed imaging of the kidneys, urinary tract, and surrounding structures, allowing for the classification of injury severity and identification of associated injuries. *Retrograde urogram* - A retrograde urogram is primarily used to evaluate the **lower urinary tract** (urethra and bladder) for strictures or injuries, specifically when there is a suspicion of urethral injury. - It is not the primary imaging modality for assessing renal parenchymal or collecting system injuries from blunt trauma. *Intravenous urogram (IVU)* - While an IVU can assess the upper urinary tract, it has largely been replaced by **CECT** in the acute trauma setting due to CECT's superior resolution and ability to evaluate renal parenchyma and other abdominal organs. - IVU exposes the patient to radiation and requires contrast administration, and it may not adequately visualize subtle renal injuries or hematomas as effectively as CECT. *Ultrasonography of abdomen* - **Ultrasound** is useful for rapidly detecting free fluid (suggesting hemorrhage) or gross hydronephrosis in trauma, but it has limited sensitivity for diagnosing specific renal parenchymal injuries or urinary extravasation. - Its role in blunt abdominal trauma with hematuria is often as an initial screening tool, but it is not sufficient for definitive diagnosis or grading of renal injuries.

Abdominal and Pelvic Radiology Indian Medical PG Question 10: A 28-year-old male patient presents with colicky abdominal pain along with vomiting. X-ray abdomen shows:

• A. Pseudo-obstruction
• B. Cancer colon
• C. Small bowel obstruction (Correct Answer)
• D. Paralytic ileus

Abdominal and Pelvic Radiology Explanation: ***Small bowel obstruction*** - The X-ray image shows multiple **dilated loops of small bowel** with **air-fluid levels** and prominent **valvulae conniventes** (herringbone pattern), which are classic signs of small bowel obstruction. - The clinical presentation of **colicky abdominal pain** and **vomiting** is highly consistent with a small bowel obstruction. *Pseudo-obstruction* - Pseudo-obstruction, or Ogilvie's syndrome, primarily affects the **large bowel**, leading to colonic dilation without a mechanical obstruction. - While it can cause abdominal pain and vomiting, the X-ray findings would typically show marked dilation of the colon rather than predominantly small bowel loops. *Cancer colon* - Colon cancer, if it causes obstruction, typically presents as a **large bowel obstruction**, with colonic dilation proximal to the tumor. - While severe cases could lead to cecal dilation and subsequent small bowel obstruction, the primary radiographic findings would focus on the colon. *Paralytic ileus* - Paralytic ileus, or adynamic ileus, involves generalized bowel dilation (both small and large bowel) due to **impaired peristalsis**, without mechanical obstruction. - Although it causes abdominal pain and vomiting, it usually presents with more continuous, less colicky pain, and the X-ray often shows gas in the colon, which is typically absent or minimal in a complete small bowel obstruction.

Abdominal and Pelvic Radiology Flashcard 1 of 10

Question: What is the best investigation for pneumoperitoneum?

Answer: CT scan

Abdominal and Pelvic Radiology Flashcard 2 of 10

Question: Acute _____ shows a dense persistent nephrogram.

Answer: urinary obstruction

Abdominal and Pelvic Radiology Flashcard 3 of 10

Question: _____ sign in Acute Pancreatitis is seen due to edema around the kidney due to the involvement of paranephric fat

Answer: Renal halo

Abdominal and Pelvic Radiology Flashcard 4 of 10

Question: Air is seen on both sides of the bowel wall, called _____ sign, seen in pneumoperitoneum

Answer: Rigler's

Abdominal and Pelvic Radiology Flashcard 5 of 10

Question: _____ is the initial modality of choice for diagnosing a case of suspected chronic pancreatitis.

Answer: Abdominal CT scan

Abdominal and Pelvic Radiology Flashcard 6 of 10

Question: Investigation of choice in acute pancreatitis is _____.

Answer: CECT

Abdominal and Pelvic Radiology Flashcard 7 of 10

Question: The _____ Index (CTSI) has a maximum of 10 points, and it is the sum of the Balthazar grade points and pancreatic necrosis grade points.

Answer: Computed Tomography Severity

Abdominal and Pelvic Radiology Flashcard 8 of 10

Question: The given image shows the presence of a _____ in lower end of esophagus.

Answer: Schatzki’s ring

Abdominal and Pelvic Radiology Flashcard 9 of 10

Question: The given Retrograde ureterogram showing dilated clubbed calyces with stricture of the left ureteropelvic junction is suggestive of _____

Answer: Hydronephrosis

Abdominal and Pelvic Radiology Flashcard 10 of 10

Question: In _____ sign or double wall sign, inner mucosal and outer serosal layers of bowel are enhanced in pneumoperitoneum

Answer: Rigler's