Abdominal Trauma Imaging — MCQs

10 questions

A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?

Investigation of choice for diagnosis of splenic rupture –

Investigation of choice in an unstable patient with suspected intra-abdominal injury is -

Which structure can be palpated through the anterior wall of the rectum, directly in front of the rectum in the midline, during a rectal examination of a 27-year-old woman?

Gold standard investigation for hemodynamically stable blunt abdominal trauma is:

Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?

A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

A 60-year-old male with a history of smoking presents with severe abdominal pain and a pulsatile abdominal mass. What is the most appropriate next step in managing this patient?

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

Q10

"String of beads" appearance on horizontal abdominal view X-ray is suggestive of:

Abdominal Trauma Imaging Indian Medical PG Practice Questions and MCQs

Question 1: A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?

A. Hemothorax
B. Hollow viscus perforation (Correct Answer)
C. Pneumothorax
D. Intestinal obstruction

Explanation: ***Hollow viscus perforation*** - The chest X-ray clearly shows **free air under the diaphragm** (pneumoperitoneum), which is a hallmark sign of a perforated hollow viscus in the abdomen. - The history of **bull gore to the abdomen** and subsequent abdominal pain and obstipation further supports a traumatic perforation of a stomach or intestinal segment. *Hemothorax* - Hemothorax would present as **fluid in the pleural space**, typically seen as blunting of the costophrenic angles or an effusion on X-ray, which is not evident here. - While trauma can cause hemothorax, the prominent finding on this X-ray is intra-abdominal air, not intrathoracic fluid. *Pneumothorax* - Pneumothorax is characterized by the presence of **air in the pleural space**, leading to lung collapse and absence of lung markings in the affected area, which is not observed on this X-ray. - The air seen is clearly **below the diaphragm**, indicating intra-abdominal free air, not air in the chest cavity surrounding the lung. *Intestinal obstruction* - Intestinal obstruction typically presents with **dilated bowel loops** and **air-fluid levels** on an abdominal X-ray, along with abdominal pain and obstipation. - While the patient has obstipation, the primary X-ray finding is free air under the diaphragm, which is not characteristic of an uncomplicated intestinal obstruction.

Question 2: Investigation of choice for diagnosis of splenic rupture –

A. MRI
B. Peritoneal lavage
C. Ultrasound
D. CT scan (Correct Answer)

Explanation: **CT scan** - A **CT scan** with intravenous contrast is the investigation of choice for splenic rupture due to its high sensitivity and specificity in detecting **splenic injury**, **hematomas**, and **free intraperitoneal fluid**. - It provides detailed anatomical information, crucial for grading the injury and guiding management decisions, especially in hemodynamically stable patients. *MRI* - **MRI** offers excellent soft tissue contrast, but it is **time-consuming** and often **not readily available** in emergency settings for acute trauma. - It is typically reserved for more chronic or complex cases where detailed soft tissue characterization is not immediately needed in acute trauma. *Peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less specific than imaging for diagnosing splenic rupture. - It detects the presence of **intraperitoneal bleeding** but does not localize the injury or provide information about the extent of organ damage. *Ultrasound* - **Ultrasound (FAST exam)** is a rapid, non-invasive tool for detecting **free fluid** in the abdomen but has limited sensitivity for directly visualizing the spleen or accurately grading splenic injuries. - While useful for rapid assessment of **hemodynamically unstable** patients, a **negative FAST exam does not rule out splenic injury**, especially in stable patients.

Question 3: Investigation of choice in an unstable patient with suspected intra-abdominal injury is -

A. USG (FAST) (Correct Answer)
B. CT scan
C. X-ray abdomen
D. DPL

Explanation: ***USG*** - **Focused assessment with sonography for trauma (FAST) exam** is the investigation of choice in an **unstable patient** due to its rapid, non-invasive nature and ability to detect free fluid (blood) in the peritoneal, pericardial, and pleural spaces. - It can be performed at the **bedside** without moving the patient, making it ideal for hemodynamically unstable individuals with suspected intra-abdominal injury. *CT scan* - While a **CT scan** provides detailed anatomical information, it requires the patient to be stable enough for transport to a radiology suite and prolonged scanning time. - It is often difficult to obtain in **unstable patients** who may require continuous resuscitation and monitoring. *X-ray abdomen* - An **X-ray abdomen** has limited utility for detecting intra-abdominal injuries and primarily identifies issues like free air under the diaphragm (suggesting hollow organ perforation) or foreign bodies. - It is **not sensitive** for detecting free fluid (hemoperitoneum) or solid organ injuries, which are critical in trauma. *DPL* - **Diagnostic peritoneal lavage (DPL)** is an invasive procedure that involves inserting a catheter into the peritoneal cavity to detect blood or other fluid. - While sensitive, it is **invasive**, can complicate subsequent imaging, and has largely been replaced by the FAST exam due to the latter's non-invasive nature and comparable diagnostic accuracy for free fluid.

Question 4: Which structure can be palpated through the anterior wall of the rectum, directly in front of the rectum in the midline, during a rectal examination of a 27-year-old woman?

A. Bladder
B. Body of uterus
C. Cervix of uterus (Correct Answer)
D. Pubic symphysis

Explanation: Cervix of uterus - The cervix is located posterior to the bladder and inferior to the body of the uterus, making it palpable through the anterior rectal wall via the rectovaginal septum [2]. - Its firm, rounded structure can be felt as a distinct nodule directly anterior to the rectum in the midline during a digital rectal examination. - This is a standard clinical finding in pelvic examination. Bladder - The bladder is anterior to the uterus and cervix; an empty bladder is usually not palpable through the anterior rectal wall. - A distended bladder would be palpable, but it would be a soft, fluctuating mass, not a firm structure like the cervix. Body of uterus - The body of the uterus is superior to the cervix and in the typical anteverted position (normal in ~80% of women), it is angled anteriorly and superiorly, generally beyond the reach of a digital rectal exam for direct palpation through the anterior rectal wall [1]. - In the less common retroverted uterus, the body may be palpable through the posterior fornix of the vagina or through the rectum, but this is not the typical anatomical relationship. Pubic symphysis - The pubic symphysis is a bony joint located at the very anterior aspect of the pelvis, far too anterior and superior to be palpable through the anterior wall of the rectum. - It forms the anterior boundary of the bony pelvis, while the rectum is situated posteriorly within the pelvic cavity.

Question 5: Gold standard investigation for hemodynamically stable blunt abdominal trauma is:

A. DPL
B. FAST scan
C. Plain X-ray
D. CT with contrast (Correct Answer)

Explanation: ***CT with contrast*** - **Computed tomography (CT) with intravenous contrast** is considered the **gold standard** for evaluating hemodynamically stable patients with blunt abdominal trauma due to its high sensitivity and specificity in detecting solid organ injuries, free fluid, and active extravasation. - It provides detailed anatomical information, helping to grade injuries and guide management decisions. *DPL* - **Diagnostic peritoneal lavage (DPL)** is an invasive procedure primarily used in hemodynamically unstable patients to rapidly detect intra-abdominal hemorrhage. - It has a high false-positive rate and is less specific for identifying the exact source or extent of injury compared to CT. *FAST scan* - The **Focused Assessment with Sonography for Trauma (FAST) scan** is a rapid, non-invasive imaging modality used to detect free fluid (usually blood) in the peritoneum, pericardium, and pleural spaces. - While useful for initial screening and in hemodynamically unstable patients, it is operator-dependent and cannot reliably detect retroperitoneal injuries or solid organ damage not associated with significant free fluid. *Plain X-ray* - **Plain X-rays** (e.g., abdominal X-rays) have very limited utility in assessing blunt abdominal trauma as they poorly visualize soft tissues and cannot detect hemorrhage or solid organ injury. - They are primarily used to evaluate for skeletal injuries or free air suggesting a ruptured viscus, which are not the primary concerns in comprehensive abdominal trauma assessment.

Question 6: Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?

A. CT Scan
B. Diagnostic peritoneal lavage
C. FAST (Correct Answer)
D. Standing X ray Abdomen

Explanation: ***FAST*** - For a **hemodynamically unstable** patient with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST)** is the quickest and most appropriate initial investigation to detect **free fluid** (indicating hemorrhage) in the abdomen or pericardium. - Its **rapidity and non-invasiveness** make it ideal for immediate decision-making regarding surgical intervention. *CT Scan* - **CT scans** provide detailed anatomical information but require the patient to be **hemodynamically stable** and are time-consuming for an emergency assessment. - Moving an unstable patient to radiology for a CT scan can significantly **delay definitive treatment**. *Diagnostic peritoneal lavage* - While historically used, **diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less commonly performed now due to the availability of FAST. - It has a high rate of **false positives** and potential complications, making it less favorable as a first-line investigation. *Standing X ray Abdomen* - A **standing X-ray of the abdomen** is primarily useful for detecting **free air under the diaphragm** (indicating bowel perforation) or major bony injuries. - It is **poor at detecting free fluid** or organ injury, which is the primary concern in suspected liver trauma in an unstable patient.

Question 7: A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

A. Diagnostic peritoneal lavage
B. Laparotomy
C. CECT (Correct Answer)
D. Laparoscopy

Explanation: ***CECT*** - A **Contrast-Enhanced Computed Tomography (CECT)** scan is the preferred initial diagnostic step for a hemodynamically stable patient with a stab wound to the flank. - It effectively assesses the **depth of penetration** and identifies potential internal organ injuries in the abdomen or retroperitoneum, guiding further management. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is less commonly used for stab wounds in hemodynamically stable patients due to its **invasiveness** and lower specificity compared to CT scans. - While it can detect peritoneal penetration or significant hemorrhage, it often leads to **unnecessary laparotomies** and is not as precise in identifying specific organ injuries. *Laparotomy* - **Laparotomy** (surgical exploration) is indicated for **hemodynamically unstable** patients or those with definitive signs of peritonitis or evisceration. - Since the patient has **stable vitals**, immediate laparotomy is not the next step, as diagnostic imaging is needed first. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure that can be used diagnostically or therapeutically in stable patients. - However, in the initial assessment of a flank stab wound, a **CECT scan** is typically performed first to get a comprehensive view of potential organ damage before considering a more invasive procedure like laparoscopy.

Question 8: A 60-year-old male with a history of smoking presents with severe abdominal pain and a pulsatile abdominal mass. What is the most appropriate next step in managing this patient?

A. Immediate surgery
B. CT angiography (Correct Answer)
C. Ultrasound of the abdomen
D. Observation

Explanation: ***CT angiography*** - **CT angiography** is the most appropriate next step for a **hemodynamically stable** patient with suspected **abdominal aortic aneurysm (AAA)**, as suggested by severe abdominal pain and a pulsatile abdominal mass in a smoker. - **CT angiography** is the gold standard for delineating the size, extent, anatomical relationships, and most importantly, the **rupture status** of an AAA, providing critical information for surgical planning. - This imaging is essential for determining the appropriate surgical approach (open repair vs. endovascular repair/EVAR) and identifying contained ruptures that may not be immediately life-threatening but require urgent intervention. - The patient presentation suggests a **symptomatic or contained rupture**, and assuming hemodynamic stability, imaging should precede surgery. *Immediate surgery* - Immediate surgery **without imaging** is indicated only when the patient is **hemodynamically unstable** (hypotension, shock) or in frank rupture with peritoneal signs, where delays for imaging would be fatal. - In a **stable** patient, proceeding directly to surgery without CT angiography increases operative risks due to lack of precise anatomical information about aneurysm size, location, proximal/distal extent, and involvement of renal or iliac arteries. - The question scenario, while concerning, does not explicitly indicate hemodynamic instability, making imaging the preferred next step. *Ultrasound of the abdomen* - **Ultrasound** is excellent for screening and confirming the presence of AAA, measuring aortic diameter, but it has significant limitations in acute settings. - **Ultrasound cannot reliably detect rupture** or provide the detailed anatomical information necessary for surgical planning (proximal/distal extent, branch vessel involvement). - In this acute presentation with suspected rupture, ultrasound would be insufficient and would delay definitive diagnosis, making **CT angiography** superior. *Observation* - **Observation** is absolutely contraindicated in a patient with severe abdominal pain and a pulsatile abdominal mass, as this presentation strongly suggests **symptomatic or ruptured AAA**. - AAA rupture carries mortality rates of 50-80% even with treatment, and any delay in diagnosis and intervention significantly increases mortality. - The combination of symptoms (severe pain) with a pulsatile mass in a high-risk patient (elderly male smoker) mandates immediate diagnostic workup, not observation.

Question 9: Gas absent from intestine (gasless abdomen) on x-ray is seen in which condition?

A. Ulcerative colitis
B. Intussusception
C. Acute pancreatitis (Correct Answer)
D. Necrotizing enterocolitis

Explanation: ***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**.

Question 10: "String of beads" appearance on horizontal abdominal view X-ray is suggestive of:

A. Intussusception
B. Sigmoid volvulus
C. Small bowel obstruction (Correct Answer)
D. Large bowel obstruction

Explanation: ***Small bowel obstruction*** - A "string of beads" appearance on a horizontal abdominal view X-ray refers to small gas bubbles trapped between the valvulae conniventes in a dilated small bowel loop. - This finding is highly suggestive of **complete small bowel obstruction**, particularly when accompanied by multiple air-fluid levels and dilated bowel loops. *Intussusception* - While it causes obstruction, intussusception usually appears as a **target sign** (doughnut sign) on ultrasound or a **meniscus sign** on barium enema, not a string of beads on plain X-ray. - Plain X-rays may show signs of **bowel obstruction**, but the string of beads is not characteristic. *Sigmoid volvulus* - Sigmoid volvulus is characterized by a **dilated loop of colon** forming an inverted U-shape, often described as a **coffee bean sign** or **omega sign**, on plain X-ray. - This involves the large bowel, and the "string of beads" specifically relates to gas in the small bowel. *Large bowel obstruction* - Large bowel obstruction typically presents with a **dilated colon** proximal to the obstruction and a collapsed distal colon, often with absent or minimal gas in the rectum and sigmoid. - While air-fluid levels can be present, the "string of beads" is a specific sign of gas within dilated small bowel loops, distinguishing it from most large bowel obstructions.

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