Abdominal and Pelvic Radiology — MCQs
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A pseudo gestational sac is seen on ultrasonography in which of the following conditions?
Which of the following radiographic presentations cannot be seen in a patient with intussusception?
Which of the following conditions typically presents with a 'pseudokidney sign' on ultrasound?
What condition is indicated by the thumb print sign on an abdominal radiograph?
Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?
What is the characteristic 'scrambled egg' appearance seen in?
What is the typical CECT finding that suggests the diagnosis of pseudomyxoma peritonei?
The Graham Cole test refers to which of the following investigations?
"Lemon sign" and "Banana sign" are seen in which condition?
Non-visualization of the gallbladder is a feature seen in acute cholecystitis in which of the following investigations?
Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs
Question 1: A pseudo gestational sac is seen on ultrasonography in which of the following conditions?
- A. Missed abortion
- B. Ectopic gestation (Correct Answer)
- C. Complete abortion
- D. Hematometra
Explanation: **Explanation:** In **Ectopic Gestation**, a **pseudo gestational sac** is a common sonographic pitfall. It represents an intra-uterine fluid collection (blood or secretions) surrounded by a single layer of decidua, mimicking an early pregnancy. Unlike a true gestational sac, it is **centrally located** within the endometrial cavity and lacks the "Double Decidual Sign" (the two concentric rings representing the decidua capsularis and decidua parietalis). **Analysis of Options:** * **Ectopic Gestation (Correct):** Hormonal changes in ectopic pregnancy cause the endometrium to undergo a decidual reaction. Fluid or blood trapped within this decidualized endometrium creates the pseudo-sac appearance. * **Missed Abortion:** This involves a non-viable **true** gestational sac (often with a fetal pole but no cardiac activity) that remains within the uterus. It is not a "pseudo" sac. * **Complete Abortion:** On ultrasound, this typically shows an empty uterus with a thin, regular endometrial stripe. No sac-like structures (true or pseudo) should be visible if the products of conception are entirely expelled. * **Hematometra:** This is a collection of blood within the uterine cavity, usually due to an imperforate hymen or cervical stenosis. While it is a fluid collection, it lacks the specific decidualized rim and clinical context of a pregnancy-related sac. **High-Yield Clinical Pearls for NEET-PG:** * **Double Decidual Sign:** The hallmark of a **true** intrauterine pregnancy (IUP) on USG. * **Yolk Sac:** Its presence is the first definitive sign of an IUP (visible at ~5.5 weeks). * **Intrauterine Fluid + Empty Adnexa:** In a patient with positive β-hCG, always differentiate between a very early IUP and a pseudo-sac of ectopic pregnancy. * **Location:** True sacs are usually **eccentric** (embedded in the decidua); pseudo-sacs are **central**.
Question 2: Which of the following radiographic presentations cannot be seen in a patient with intussusception?
- A. Target sign
- B. Corkscrew sign (Correct Answer)
- C. Crescent sign
- D. Normal radiograph
Explanation: **Explanation:** Intussusception occurs when a proximal segment of the bowel (intussusceptum) invaginates into a distal segment (intussuscipiens). **Why Corkscrew Sign is the Correct Answer:** The **Corkscrew sign** is a classic radiological finding seen on a barium swallow or follow-through in cases of **Midgut Volvulus** (associated with malrotation). It represents the spiral appearance of the distal duodenum and jejunum as they wrap around the superior mesenteric artery (SMA). It is not a feature of intussusception. **Analysis of Incorrect Options:** * **Target Sign (or Bull’s eye sign):** This is a hallmark of intussusception. On a plain radiograph or CT, it represents the layers of the intussusceptum and intussuscipiens seen in cross-section. On ultrasound, it is often called the "Doughnut sign." * **Crescent Sign (Meniscus sign):** This occurs when the leading edge of the intussusceptum protrudes into a gas-filled pocket in the distal bowel, creating a crescent-shaped lucency. It is a highly specific sign for intussusception on plain X-rays. * **Normal Radiograph:** In the early stages of intussusception, up to **25% of plain abdominal radiographs can appear completely normal**. A normal X-ray does not rule out the diagnosis, which is why ultrasound is the gold standard for screening. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Ultrasound (look for the "Pseudokidney" or "Target" sign). * **Classic Triad:** Colicky abdominal pain, palpable sausage-shaped mass, and "red currant jelly" stools (though the full triad is seen in <40% of cases). * **Treatment:** Non-operative reduction using **Hydrostatic (saline/barium)** or **Pneumatic (air) enema** is the first-line treatment in stable patients. * **Lead Point:** In children, it is usually idiopathic (hypertrophied Peyer’s patches); in adults, it is usually due to a pathological lead point (e.g., malignancy or Meckel’s diverticulum).
Question 3: Which of the following conditions typically presents with a 'pseudokidney sign' on ultrasound?
- A. Trichobezoar
- B. Carcinoma of the stomach (Correct Answer)
- C. Carcinoma of the kidney
- D. Polycystic kidney disease
Explanation: ### Explanation The **'Pseudokidney sign'** is a classic ultrasonographic finding characterized by a hypoechoic (dark) peripheral rim and a central hyperechoic (bright) core. This appearance mimics the normal anatomy of a kidney (where the cortex is hypoechoic and the renal sinus is hyperechoic). **1. Why Carcinoma of the Stomach is Correct:** The sign occurs when there is significant **concentric or eccentric thickening of the gastrointestinal wall**. In gastric carcinoma, the thickened, infiltrated wall of the stomach represents the hypoechoic rim, while the narrowed lumen containing air, mucus, or debris represents the hyperechoic center. While most commonly associated with **intussusception**, it is a hallmark of **gastrointestinal malignancies** (stomach or colon) and inflammatory conditions like Crohn’s disease. **2. Analysis of Incorrect Options:** * **Trichobezoar (A):** Typically presents as a highly echogenic arcuate line with dense posterior acoustic shadowing (the "Stomach Wall-Gas-Interface" or "Shell" sign) rather than a kidney-like structure. * **Carcinoma of the Kidney (C):** This would present as a solid mass arising *from* the kidney, often distorting the normal renal architecture, rather than "mimicking" a kidney. * **Polycystic Kidney Disease (D):** This presents as bilateral, massively enlarged kidneys replaced by multiple thin-walled, anechoic cysts. It does not produce the specific "target" or "pseudokidney" morphology. **3. NEET-PG High-Yield Pearls:** * **Pseudokidney Sign:** Also known as the **"Target sign"** or **"Donut sign"** on transverse ultrasound/CT sections. * **Differential Diagnosis:** Intussusception (most common cause in children), Gastric/Colonic Adenocarcinoma (most common cause in elderly), Crohn’s disease, and Volvulus. * **Clinical Context:** If you see this sign in an elderly patient with weight loss, think **Malignancy**; in a child with red currant jelly stools, think **Intussusception**.
Question 4: What condition is indicated by the thumb print sign on an abdominal radiograph?
- A. Ischemic colitis
- B. Crohn's disease
- C. Pseudomembranous colitis
- D. All the above (Correct Answer)
Explanation: **Explanation:** The **"Thumbprinting sign"** is a classic radiologic finding on a plain abdominal X-ray that represents **focal thickening of the colonic wall** due to submucosal edema and hemorrhage. On a radiograph, the haustral folds appear thickened and blunted, resembling the impression of a thumb pressed into the bowel wall. **Why "All of the above" is correct:** Thumbprinting is a non-specific sign of **severe colonic wall inflammation**. It occurs when any pathological process causes significant submucosal fluid accumulation: * **Ischemic Colitis (Option A):** This is the most common association. Reduced blood flow leads to submucosal hemorrhage and edema. * **Crohn’s Disease (Option B):** Transmural inflammation during an acute flare-up can cause significant wall thickening and edema. * **Pseudomembranous Colitis (Option C):** Severe *Clostridioides difficile* infection causes profound mucosal edema and "shaggy" wall thickening, often presenting with prominent thumbprinting. **Clinical Pearls for NEET-PG:** 1. **Differential Diagnosis:** Beyond the options provided, thumbprinting can also be seen in **Ulcerative Colitis**, **Amoebic Colitis**, and **Lymphoma**. 2. **Clinical Correlation:** While the sign is non-specific, the clinical context is key. Sudden onset abdominal pain in an elderly patient with thumbprinting highly suggests **Ischemic Colitis**. 3. **Next Step:** If thumbprinting is seen on a plain film, the next gold-standard imaging is usually a **CT scan with IV contrast** to better visualize bowel wall enhancement and mesenteric vessels. 4. **Lead Pipe Appearance:** Contrast this with the "Lead Pipe" colon (loss of haustrations), which is characteristic of chronic Ulcerative Colitis.
Question 5: Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?
- A. Intussusception (Correct Answer)
- B. Meckel's diverticulum
- C. Intestinal malrotation
- D. Volvulus
Explanation: ### Explanation **Correct Answer: A. Intussusception** Intussusception occurs when a proximal segment of the bowel (intussusceptum) invaginates into a distal segment (intussuscipiens). This creates characteristic imaging patterns: * **Doughnut/Target Sign:** On **ultrasound** (transverse view), the concentric layers of the bowel walls appear as a hypoechoic outer ring and a hyperechoic center. * **Coiled Spring Appearance:** On a **barium or air enema**, the contrast trickles into the narrow space between the intussusceptum and the intussuscipiens, resembling a coiled spring. * **Pseudokidney Sign:** On longitudinal ultrasound, the layered bowel resembles a kidney. **Why the other options are incorrect:** * **B. Meckel’s Diverticulum:** Typically diagnosed via a **Technetium-99m pertechnetate scan** (Meckel’s scan), which identifies ectopic gastric mucosa. It does not produce concentric ring signs. * **C. Intestinal Malrotation:** Characterized by the **Whirlpool sign** (SMV twisting around the SMA) on ultrasound/CT and a "corkscrew" appearance of the duodenum on upper GI contrast studies. * **D. Volvulus:** Sigmoid volvulus classically shows a **"Coffee Bean" sign** or "Omega" sign on X-ray and a "Bird’s Beak" appearance on contrast enema. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Intermittent abdominal pain, palpable "sausage-shaped" mass, and **"Red currant jelly" stools**. * **Lead Point:** In children, it is usually idiopathic (preceded by viral URTI/hypertrophied Peyer’s patches); in adults, it is often due to a malignancy. * **Treatment:** Non-operative reduction using **hydrostatic (saline) or pneumatic (air) enema** is the first-line treatment in stable pediatric cases.
Question 6: What is the characteristic 'scrambled egg' appearance seen in?
- A. Carcinoma of the stomach
- B. Carcinoma of the gallbladder
- C. Pancreatic carcinoma (Correct Answer)
- D. Renal carcinoma
Explanation: **Explanation:** The **'scrambled egg' appearance** is a classic radiological sign seen on **Barium meal** studies in cases of **Pancreatic carcinoma**, specifically when the tumor involves the head of the pancreas. As the pancreatic head enlarges due to malignancy, it causes extrinsic compression, displacement, and infiltration of the adjacent C-loop of the duodenum. This results in a combination of mucosal destruction, irregular filling defects, and tethering of the duodenal folds. On a barium study, this disorganized, mottled, and irregular appearance of the duodenal mucosa resembles scrambled eggs. **Analysis of Options:** * **Carcinoma of the stomach (A):** Typically presents with signs like the 'Leather bottle stomach' (Linitis Plastica) or 'Carman’s meniscus sign' for malignant ulcers. * **Carcinoma of the gallbladder (B):** Usually diagnosed via USG or CT showing a mass replacing the gallbladder or focal wall thickening; it does not produce this specific barium sign. * **Renal carcinoma (D):** Being a retroperitoneal organ, it may displace the bowel but does not typically cause the intrinsic mucosal destruction pattern described. **High-Yield Clinical Pearls for NEET-PG:** * **Frostberg’s Inverted '3' Sign:** Another classic barium sign for pancreatic head carcinoma caused by the fixation of the duodenal mucosa at the Ampulla of Vater. * **Widening of the Duodenal C-loop:** A common radiological finding in pancreatic head masses. * **Double Duct Sign:** Seen on ERCP/MRCP, representing simultaneous dilatation of the Common Bile Duct (CBD) and the Pancreatic Duct. * **Courvoisier’s Law:** In a patient with painless jaundice and a palpable gallbladder, the cause is unlikely to be gallstones (usually pancreatic head malignancy).
Question 7: What is the typical CECT finding that suggests the diagnosis of pseudomyxoma peritonei?
- A. Scalloping of the visceral surfaces of the liver and spleen (Correct Answer)
- B. Ascites with increased HU units
- C. Peritoneal seedlings
- D. Pseudokidney sign
Explanation: ### **Explanation** **Pseudomyxoma Peritonei (PMP)** is a clinical syndrome characterized by the accumulation of abundant mucinous (gelatinous) ascites within the peritoneal cavity, most commonly secondary to a ruptured mucinous cystadenoma or cystadenocarcinoma of the appendix. **1. Why Option A is Correct:** The hallmark CECT finding of PMP is the **scalloping of the visceral surfaces** of solid organs, particularly the **liver and spleen**. Unlike simple serous ascites, which exerts uniform pressure, the dense, gelatinous nature of the mucinous implants exerts focal extrinsic pressure on the capsules of these organs, creating a characteristic "indented" or scalloped appearance. This is a high-yield diagnostic feature that distinguishes PMP from other causes of ascites. **2. Why Other Options are Incorrect:** * **Option B:** While PMP involves fluid accumulation, "increased HU units" (high-density ascites) is non-specific and can be seen in hemoperitoneum or chylous ascites. * **Option C:** Peritoneal seedlings (carcinomatosis) typically appear as nodular or plaque-like enhancements. While PMP involves peritoneal spread, "scalloping" is the more specific and "classic" radiological descriptor for this condition. * **Option D:** The **Pseudokidney sign** is a classic USG/CT finding for **Intussusception** or gastrointestinal tumors (like lymphoma), where the bowel wall thickening resembles a kidney. **3. NEET-PG High-Yield Pearls:** * **Primary Source:** Most commonly the **Appendix** (look for a dilated, mucocele-filled appendix on CT). * **Redistribution Phenomenon:** Mucinous fluid follows the flow of peritoneal fluid but tends to accumulate in stagnant areas (e.g., pelvis, paracolic gutters, and Morison’s pouch) while sparing the mobile small bowel loops. * **Treatment:** The gold standard is **Cytoreductive Surgery (CRS)** combined with **Hyperthermic Intraperitoneal Chemotherapy (HIPEC)**, often referred to as the "Sugarbaker Procedure."
Question 8: The Graham Cole test refers to which of the following investigations?
- A. Oral cholecystography (Correct Answer)
- B. Intravenous cholangiography
- C. Pre-operative cholangiography
- D. Post-operative cholangiography
Explanation: **Explanation:** The **Graham Cole test** is the historical eponym for **Oral Cholecystography (OCG)**. Introduced by Evarts Graham and Warren Cole in 1924, it was the first non-invasive method to visualize the gallbladder and revolutionized the diagnosis of gallstones before the advent of ultrasonography. **1. Why Oral Cholecystography is correct:** The test involves the oral administration of an iodinated contrast agent (e.g., iopanoic acid). The contrast is absorbed in the small intestine, conjugated in the liver, and excreted into the bile. It then concentrates in the gallbladder. A functioning gallbladder will opacify on X-ray, while a non-opacified gallbladder (the "negative" Graham Cole test) suggests cystic duct obstruction or chronic cholecystitis. **2. Why other options are incorrect:** * **Intravenous cholangiography (IVC):** Uses IV contrast (e.g., iodipamide) to visualize the bile ducts directly. It is faster but carries a higher risk of anaphylaxis. * **Pre-operative/Post-operative cholangiography:** These involve injecting contrast directly into the biliary tree during surgery (to check for stones) or via a T-tube after surgery (to ensure ductal patency). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Currently, **Ultrasonography** is the first-line investigation for gallstones. * **HIDA Scan:** The most sensitive test for **Acute Cholecystitis**. * **The "Double Dose" Test:** If the gallbladder fails to opacify after the first dose of OCG, a second dose is given; persistent non-visualization is diagnostic of gallbladder disease. * **Prerequisite:** For OCG to work, the patient must have a serum bilirubin **< 2 mg/dL**; otherwise, the liver cannot excrete the contrast.
Question 9: "Lemon sign" and "Banana sign" are seen in which condition?
- A. Down syndrome
- B. Spina bifida (Correct Answer)
- C. Turner syndrome
- D. Periventricular leukomalacia
Explanation: **Explanation:** The **"Lemon sign"** and **"Banana sign"** are classic sonographic markers of **Open Neural Tube Defects (ONTDs)**, specifically **Spina bifida**. These signs result from the **Arnold-Chiari Malformation Type II**, where the downward displacement of the hindbrain occurs due to low cerebrospinal fluid (CSF) pressure. 1. **Lemon Sign:** This refers to the scalloping or indentation of the frontal bones of the fetal skull. It occurs because the downward pull on the brain causes a decrease in intraspinal pressure, leading to the collapse of the frontal bones. 2. **Banana Sign:** This refers to the cerebellum being pulled downward into the foramen magnum, causing it to lose its typical dumbbell shape and appear curved like a banana. This is often associated with the obliteration of the **cisterna magna**. **Analysis of Incorrect Options:** * **Down Syndrome (Trisomy 21):** Associated with markers like increased nuchal translucency, absent nasal bone, and "double bubble" sign (duodenal atresia), but not cranial contour changes. * **Turner Syndrome (45, XO):** Characterized by cystic hygroma, increased nuchal translucency, and coarctation of the aorta. * **Periventricular Leukomalacia (PVL):** A form of white-matter brain injury typically seen in premature infants, appearing as echogenic areas or cysts near the lateral ventricles on ultrasound. **NEET-PG High-Yield Pearls:** * The **Lemon sign** is most sensitive in the second trimester (18–24 weeks) but may disappear later as the skull ossifies. * The **Banana sign** is more specific for spina bifida than the lemon sign and often persists into the third trimester. * **Maternal Serum Alpha-Fetoprotein (MSAFP):** Elevated levels are the primary biochemical screening tool for open spina bifida.
Question 10: Non-visualization of the gallbladder is a feature seen in acute cholecystitis in which of the following investigations?
- A. HIDA scan (Correct Answer)
- B. USG abdomen
- C. CECT abdomen
- D. MRCP
Explanation: **Explanation:** The correct answer is **A. HIDA scan** (Hepatobiliary Iminodiacetic Acid scan), also known as Cholescintigraphy. **Why HIDA scan is the correct answer:** The hallmark of acute cholecystitis is the **obstruction of the Cystic Duct**, usually by a gallstone. In a HIDA scan, a radioactive tracer (Technetium-99m labeled iminodiacetic acid) is injected intravenously, taken up by hepatocytes, and excreted into the bile. In a healthy individual, the tracer fills the gallbladder within 30–60 minutes. In acute cholecystitis, the cystic duct is blocked; therefore, the tracer enters the common bile duct and duodenum but **fails to enter (visualize) the gallbladder**, even on delayed images (up to 4 hours). This "non-visualization" is the diagnostic criterion. **Why other options are incorrect:** * **B. USG Abdomen:** This is the **investigation of choice (screening)** for acute cholecystitis. Findings include gallbladder wall thickening (>4mm), pericholecystic fluid, and a positive sonographic Murphy’s sign. The gallbladder is usually well-visualized and distended. * **C. CECT Abdomen:** Used primarily to detect complications like gangrene or perforation. It shows wall enhancement and fat stranding but does not rely on "non-visualization" for diagnosis. * **D. MRCP:** Excellent for visualizing biliary anatomy and detecting stones in the CBD (choledocholithiasis), but it is not the standard functional test for acute cholecystitis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard (Most Sensitive):** HIDA scan is the most sensitive imaging modality for diagnosing acute cholecystitis. * **False Positives in HIDA:** Can occur in prolonged fasting (TPN), severe liver disease, or chronic cholecystitis. * **Rim Sign:** Increased tracer uptake in the liver parenchyma adjacent to the gallbladder fossa on HIDA scan, suggesting gangrenous cholecystitis. * **Morphine Augmentation:** Administering low-dose morphine during a HIDA scan constricts the Sphincter of Oddi, increasing biliary pressure to force tracer into the gallbladder, shortening the study time.
Practice by Chapter
Imaging of Liver
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Biliary Tract Imaging
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Pancreatic Imaging
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Spleen and Lymphatic System
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Gastrointestinal Tract Imaging
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Renal and Urinary Tract Imaging
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Adrenal Imaging
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Female Pelvic Imaging
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Male Pelvic Imaging
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Abdominal Trauma Imaging
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Acute Abdomen Imaging
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Imaging of Peritoneal Cavity and Retroperitoneum
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