Abdominal and Pelvic Radiology Practice Questions

Q: A patient presents with right iliac fossa pain for 48 hours. USG image (shown with Doppler) demonstrates a hyperaemic appendix-region structure with surrounding inflammatory changes. There is no free fluid or evidence of perforation on USG. What is the most appropriate next step?

Contrast-enhanced CT (CECT) of the abdomen and pelvis. ***Contrast-enhanced CT (CECT) of the abdomen and pelvis*** - In adults with equivocal or suggestive USG findings but continuing clinical uncertainty, CECT is the **gold standard diagnostic modality** with superior sensitivity and specificity for acute appendicitis. - It helps rule out **alternative pathology** like regional enteritis, colitis, or malignancies that might mimic appendicitis, ensuring surgical planning is guided by the most accurate diagnosis. *Direct surgical management (emergency appendicectomy)* - Relying solely on USG, which is **operator-dependent** and often limited by bowel gas, leads to a higher rate of negative appendicectomy. - Further imaging is required especially if there is no pathognomonic finding (like a non-compressible appendix >6mm or appendicolith) clearly identified on the initial USG scan. *USG-guided biopsy of the lesion* - Biopsy of the appendix is **never indicated** in the acute setting as it risks **perforation, peritonitis, and seeding infection** or potential malignancy into the peritoneal cavity. - The inflammatory nature of the appendix is suspected based on imaging and clinical history, not requiring histological confirmation before intervention. *USG-guided percutaneous drainage* - Percutaneous drainage is reserved for patients with an **organized appendix mass or abscess** requiring intervention prior to definitive surgery. - Since there is **no free fluid or evidence of perforation** noted on USG, there is no fluid collection to drain.

Q: An elderly female patient presents to the emergency department with acute onset left flank pain radiating to the groin. What is the most appropriate imaging protocol for initial evaluation?

Ultrasound of the abdomen followed by CT if inconclusive. ***Ultrasound of the abdomen followed by CT if inconclusive*** - In pregnant or elderly/frail patients where minimizing radiation is a priority, initial abdominal ultrasound is the preferred modality for detecting hydronephrosis. - If the ultrasound is inconclusive or findings suggest a more complex pathology, a CT scan can then be performed as a second-line investigation to confirm stones. *Direct MRI of the abdomen and pelvis* - MRI is generally not the first-line imaging modality for renal colic because it is expensive, time-consuming, and less sensitive for detecting acute urinary calculi. - It is primarily reserved for patients where radiation must be avoided entirely and ultrasound is insufficient, or when evaluating soft tissue complications of renal obstruction. *Plain X-ray of the abdomen followed by CT urogram* - Plain abdominal radiographs (KUB) have very low sensitivity for small or radiolucent kidney stones and are generally insufficient as an initial screening tool. - While CT urogram is the gold standard for stone detection, routinely using it after an X-ray is inefficient; non-contrast CT (NCCT) is preferred over CT urogram for simple suspected nephrolithiasis. *Non-contrast CT (NCCT) followed by contrast-enhanced CT (CECT)* - While NCCT is the gold standard for diagnosing renal lithiasis in the general population, it exposes the patient to ionizing radiation. - A sequential NCCT followed by CECT is unnecessary for routine renal colic and would result in excessive radiation dose and contrast exposure without clinical benefit.

Q: A 58-year-old male presents with a 3-month history of altered bowel habits, passage of blood mixed with stool, and a 6 kg weight loss. Colonoscopy was incomplete due to a tight stricture in the sigmoid colon. A barium enema is performed and the image is shown in Image 3. Which radiological sign is demonstrated, and with which pathology is it classically associated?

A. Apple-core sign — annular carcinoma of the colon. ***A. Apple-core sign — annular carcinoma of the colon*** - The **apple-core sign** (or napkin-ring sign) represents a **short, circumferential stricture** with overhanging edges and mucosal destruction, characteristic of **annular carcinoma**. - This patient's clinical presentation of **altered bowel habits**, **blood in stool**, and **significant weight loss** is highly suspicious for **colorectal malignancy**. *B. Bird-beak sign — sigmoid volvulus* - The **bird-beak sign** is a feature seen on contrast studies where there is a **smooth, tapered narrowing** at the site of colonic torsion. - It is classically associated with **acute-intestinal obstruction** due to **sigmoid volvulus**, which does not typically present with chronic weight loss. *C. Thumb-printing sign — ischaemic colitis* - **Thumb-printing** indicates **submucosal edema** or hemorrhage, appearing as rounded indentations on the bowel wall during a barium study. - This sign is typically seen in **ischaemic colitis** and presents with **acute-onset abdominal pain** and hematochezia rather than a progressive stricture. *D. Coffee-bean sign — closed-loop large bowel obstruction* - The **coffee-bean sign** is a classic **plain abdominal radiograph** finding representing a massively dilated loop of the sigmoid colon during **volvulus**. - It indicates a **closed-loop obstruction** and is identified by the apposition of the inflamed bowel walls, which is distinct from a **malignant stricture**.

Q: Which of the following radiographic presentations cannot be seen in a patient with intussusception?

Corkscrew sign. **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).

Q: What is this study?

Retrograde Pyelogram. ***Retrograde Pyelogram*** - Shows **contrast injected via ureteral catheter** with **pelvicalyceal system opacification** without nephrogram phase, characteristic of retrograde approach. - **Catheter visible** ascending from below through the ureter, confirming retrograde contrast injection technique. *Ultrasound* - Uses **sound waves** without any contrast material, producing grayscale images of organ structure. - Cannot demonstrate the **detailed pelvicalyceal anatomy** with contrast opacification seen in this study. *X Ray KUB* - Plain radiograph showing **bones and soft tissue shadows** without any contrast enhancement. - Would not show the **opacified collecting system** or ureteral catheter as clearly demonstrated here. *Contrast CT KUB* - Provides **cross-sectional images** in axial, coronal, and sagittal planes with contrast enhancement. - Would show **nephrogram phase** with parenchymal enhancement, unlike this study which shows only collecting system opacification.

Q: Which of the following is NOT an ultrasound finding consistent with the diagnosis of adenomyosis?

Encapsulated hypoechoic lesion. **Explanation:** The correct answer is **D. Encapsulated hypoechoic lesion**. This finding is characteristic of a **uterine leiomyoma (fibroid)**, not adenomyosis. Fibroids are well-circumscribed, encapsulated tumors that displace surrounding myometrium. In contrast, adenomyosis is a diffuse process where endometrial glands and stroma invade the myometrium, leading to an ill-defined, non-encapsulated "shaggy" appearance. **Analysis of Options:** * **Uterine enlargement (Option A):** Adenomyosis typically causes a "globular" enlargement of the uterus, often with an asymmetrical thickening of the posterior wall. * **Subendometrial echogenic linear striations (Option B):** This is a highly specific sign of adenomyosis. It represents the invasion of endometrial tissue into the myometrium, creating "fan-shaped" shadowing or "venetian blind" appearance. * **Thickening of the transitional zone (Option C):** On ultrasound (and more clearly on MRI), a thickened junctional zone (usually >12 mm) is a hallmark diagnostic feature of adenomyosis. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, menorrhagia, and a symmetrically enlarged, "boggy" (soft) uterus. * **Mnemonic for USG findings:** "RAIN" – **R**ay-like shadows (striations), **A**symmetrical wall thickening, **I**sland-like cysts (myometrial cysts), and **N**on-capsulated. * **Gold Standard Diagnosis:** Histopathology (post-hysterectomy); however, **MRI** is the most accurate non-invasive imaging modality. * **Key Distinction:** Unlike fibroids, adenomyotic lesions cannot be easily "shelled out" during surgery because they lack a surgical capsule.

Q: Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?

Intussusception. ### 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 1

A patient presents with right iliac fossa pain for 48 hours. USG image (shown with Doppler)
demonstrates a hyperaemic appendix-region structure with surrounding inflammatory changes.
There is no free fluid or evidence of perforation on USG. What is the most appropriate next step?

Accepted Answer

Contrast-enhanced CT (CECT) of the abdomen and pelvis

Answer

Direct surgical management (emergency appendicectomy)

Answer

USG-guided biopsy of the lesion

Answer

USG-guided percutaneous drainage

Question 2

An elderly female patient presents to the emergency department with acute onset left flank pain
radiating to the groin. What is the most appropriate imaging protocol for initial evaluation?

Accepted Answer

Ultrasound of the abdomen followed by CT if inconclusive

Answer

Direct MRI of the abdomen and pelvis

Answer

Plain X-ray of the abdomen followed by CT urogram

Answer

Non-contrast CT (NCCT) followed by contrast-enhanced CT (CECT)

Question 3

A 58-year-old male presents with a 3-month history of altered bowel habits, passage of blood mixed with stool, and a 6 kg weight loss. Colonoscopy was incomplete due to a tight stricture in the sigmoid colon. A barium enema is performed and the image is shown in Image 3. Which radiological sign is demonstrated, and with which pathology is it classically associated?

Accepted Answer

A. Apple-core sign — annular carcinoma of the colon

Answer

B. Bird-beak sign — sigmoid volvulus

Answer

C. Thumb-printing sign — ischaemic colitis

Answer

D. Coffee-bean sign — closed-loop large bowel obstruction

Question 4

A 65-year-old male presents with a 4-month history of epigastric pain, early satiety, and progressive weight loss. He has a history of Helicobacter pylori infection treated 10 years ago. Haemoglobin is 9.2 g/dL. A barium meal fluoroscopy study is shown in Image 1. Which of the following best describes the radiological sign visible and its significance?

Accepted Answer

Carman meniscus sign — indicates a malignant gastric ulcer with rolled, shelf-like edges that collect barium centrally in a crescent shape

Answer

Hampton's line sign — indicates a benign gastric ulcer with a thin lucent line across the ulcer neck

Answer

Niche sign of Haudek — indicates a benign penetrating ulcer projecting beyond the gastric wall on the lesser curvature

Answer

Leather bottle stomach (linitis plastica) — indicates diffuse submucosal infiltration producing a rigid, narrowed stomach without a focal ulcerating mass

Question 5

Which of the following radiographic presentations cannot be seen in a patient with intussusception?

Accepted Answer

Corkscrew sign

Answer

Target sign

Answer

Crescent sign

Answer

Normal radiograph

Question 6

What is this study?

Accepted Answer

Retrograde Pyelogram

Answer

Ultrasound

Answer

X Ray KUB

Answer

Contrast CT KUB

Question 7

Which of the following conditions typically presents with a 'pseudokidney sign' on ultrasound?

Accepted Answer

Carcinoma of the stomach

Answer

Trichobezoar

Answer

Carcinoma of the kidney

Answer

Polycystic kidney disease

Question 8

Which of the following is NOT an ultrasound finding consistent with the diagnosis of adenomyosis?

Accepted Answer

Encapsulated hypoechoic lesion

Answer

Uterine enlargement

Answer

Subendometrial echogenic linear striations

Answer

Thickening of the transitional zone

Question 9

Which condition is characterized by a 'doughnut' sign and 'coiled spring' appearance on imaging?

Accepted Answer

Intussusception

Answer

Meckel's diverticulum

Answer

Intestinal malrotation

Answer

Volvulus

Question 10

What is the typical CECT finding that suggests the diagnosis of pseudomyxoma peritonei?

Accepted Answer

Scalloping of the visceral surfaces of the liver and spleen

Answer

Ascites with increased HU units

Answer

Peritoneal seedlings

Answer

Pseudokidney sign

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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