Abdominal and Pelvic Radiology — MCQs

An adult male presented with abdominal pain and diarrhea. A Barium meal follow-through revealed a mildly narrowed lumen of a loop with stretched and fixed rigid walls. A CT contrast study showed a stellate-shaped, enhancing mesenteric lesion with adjacent bowel wall thickening. What does this mass lesion represent?

Q127Easy

The double-bubble sign on an abdominal X-ray is typically seen in which of the following conditions?

Q128Easy

Step ladder pattern is characteristic of which of the following conditions?

Q129Easy

A plain radiograph of the chest and abdomen shows findings suggestive of which of the following conditions?

Q130Easy

Bilateral spider leg appearance of kidney in IVP is seen in?

Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs

Question 121: The "coffee bean sign" is characteristically seen in which of the following conditions?

A. Sigmoid volvulus (Correct Answer)
B. Hepatocellular carcinoma
C. Gallstones
D. Paralytic ileus

Explanation: **Explanation:** The **"Coffee Bean Sign"** (also known as the inverted U-loop or Frimann-Dahl’s sign) is a classic radiographic finding in **Sigmoid Volvulus**. It occurs when the sigmoid colon twists on its mesenteric axis, causing a closed-loop obstruction. The loop becomes massively dilated with gas; the two apposed inner walls of the dilated loop form a central dense line (the "cleft" of the bean), while the outer walls form the rounded contour of the bean. The apex of the "bean" typically points toward the right upper quadrant. **Analysis of Incorrect Options:** * **Hepatocellular Carcinoma:** Typically presents as a mass lesion on Ultrasound or a "wash-in/wash-out" pattern on Triphasic CT. It does not cause large bowel dilatation. * **Gallstones:** Characterized by radiopaque shadows in the right hypochondrium (if calcified) or "Mercedes-Benz sign" (gas within stones). * **Paralytic Ileus:** Shows generalized dilatation of both small and large bowel loops with multiple air-fluid levels, but lacks the specific closed-loop configuration of a volvulus. **High-Yield Clinical Pearls for NEET-PG:** * **Bird’s Beak Sign:** Seen on Barium Enema at the site of the twist in sigmoid volvulus. * **Whirl Sign:** The appearance of twisted mesentery and vessels on CT scan. * **Management:** Initial treatment is often sigmoidoscopic detorsion (if no gangrene), followed by elective surgery. * **Cecal Volvulus:** Unlike sigmoid, the "comma sign" is seen, and the apex usually points toward the left upper quadrant.

Question 122: What is the investigation of choice for studying vesico-ureteric reflux?

A. Ascending pyelogram
B. Cystogram
C. Intravenous urogram
D. Micturition cystourethrogram (Correct Answer)

Explanation: **Explanation:** **Micturition Cystourethrogram (MCU/VCUG)** is the gold standard investigation for diagnosing and grading **Vesico-ureteric Reflux (VUR)**. The underlying medical concept relies on the fact that VUR is a dynamic process where urine flows retrograde from the bladder into the ureters. This is most likely to occur during the **voiding (micturition) phase** when intra-vesical pressure is at its highest. MCU allows real-time fluoroscopic visualization of the bladder filling and emptying, enabling the identification of the reflux and its severity (Grades I-V). **Why other options are incorrect:** * **Ascending Pyelogram (Retrograde Pyelogram):** This involves injecting contrast directly into the ureters via cystoscopy. It is used to visualize the ureteric anatomy and site of obstruction, not to assess functional reflux from the bladder. * **Cystogram (Static):** A static cystogram only visualizes the bladder. While it may show gross reflux during the filling phase, it often misses reflux that occurs only during the high-pressure voiding phase. * **Intravenous Urogram (IVU):** This is a functional study of the kidneys and excretion. While it may show secondary signs of chronic reflux (like hydroureteronephrosis or renal scarring), it cannot definitively diagnose or grade active VUR. **Clinical Pearls for NEET-PG:** * **Grading:** VUR is graded using the International System of Radiographic Grading (Grade I: ureter only; Grade V: gross dilatation and tortuosity with loss of papillary impressions). * **Radionuclide Cystogram (RNC):** This is more sensitive than MCU and involves less radiation; it is preferred for **follow-up** of known VUR, though MCU remains the initial choice for anatomical detail. * **Initial Screening:** In a child with the first episode of febrile UTI, **Ultrasound** is the initial screening tool, but MCU is the definitive test for VUR.

Question 123: In a pregnant woman of 28 weeks gestation, intrauterine fetal death (IUD) is earliest demonstrated on X-ray by which sign?

A. Increased flexion
B. Overlapping of cranial bones
C. Spalding's sign
D. Gas in vessels (Correct Answer)

Explanation: **Explanation:** The diagnosis of intrauterine fetal death (IUD) on X-ray is based on specific radiological signs that appear at different time intervals following fetal demise. **1. Why "Gas in vessels" is correct:** The **earliest** radiological sign of IUD is the presence of gas within the fetal heart and large vessels (e.g., aorta), known as **Robert’s Sign**. It can appear as early as **6 to 12 hours** after death. This occurs due to the release of gases (primarily nitrogen) from the decomposition of fetal blood. While X-rays are rarely used today due to the superiority of ultrasound, Robert's sign remains the earliest detectable radiographic feature. **2. Analysis of Incorrect Options:** * **Spalding’s Sign (Overlapping of cranial bones):** This is a classic sign of IUD but typically takes **4 to 7 days** to develop. It occurs due to the liquefaction of the brain and loss of intracranial pressure, leading to the collapse of the skull bones. * **Increased Flexion (Hartley’s Sign):** This refers to an exaggerated curvature of the fetal spine due to the loss of muscular tone. It usually takes several days to become apparent. * **Overlapping of cranial bones:** This is simply the description of Spalding's sign (Option C) and follows the same delayed timeline. **3. Clinical Pearls for NEET-PG:** * **Gold Standard:** Real-time **Ultrasonography** is the investigation of choice for IUD (demonstrating absence of fetal heart activity). * **Robert’s Sign:** Gas in fetal vessels (Earliest X-ray sign, ~12 hours). * **Spalding’s Sign:** Overlapping of skull bones (Most famous X-ray sign, ~4-7 days). * **Deuel’s Halo Sign:** Edema of the fetal scalp causing a "halo" appearance (due to fluid accumulation in subcutaneous tissues). * **Sphenoid Bone Sign:** Flattening of the sphenoid bone.

Question 124: What is the most probable diagnosis on this barium film?

A. Lymphoma
B. Brucellosis
C. Tuberculosis
D. Crohn's disease (Correct Answer)

Explanation: ***Crohn's disease*** - Characteristic **string sign of Kantor** (narrowed terminal ileum) and **skip lesions** with normal bowel segments between diseased areas are pathognomonic on barium studies. - **Cobblestone mucosa** appearance and **rose-thorn ulcers** create a distinctive pattern that differentiates it from other inflammatory conditions. *Lymphoma* - Typically shows **smooth, regular narrowing** without the irregular ulceration and skip pattern seen in Crohn's disease. - **Polypoid masses** or **aneurysmal dilatation** are more characteristic features on barium studies, not the string sign. *Brucellosis* - Rarely causes significant **small bowel involvement** that would be visible on barium studies. - When GI symptoms occur, they are usually **non-specific** without the characteristic radiological findings like skip lesions or string sign. *Tuberculosis* - Shows **concentric narrowing** of the ileocecal region with **shortened cecum** and **gaping ileocecal valve**. - Lacks the **skip lesions** and **cobblestone appearance** characteristic of Crohn's disease on barium studies.

Question 125: What is the most important use of transrectal ultrasonography (TRUS)?

A. Screening for prostate cancer
B. Distinguishing prostate cancer from benign prostatic hyperplasia (BPH)
C. Systematic prostate biopsy in suspected prostate cancer (Correct Answer)
D. Guiding transurethral resection of prostate cancer

Explanation: **Explanation:** **Transrectal Ultrasonography (TRUS)** is a specialized imaging modality that uses a high-frequency probe placed in the rectum to provide high-resolution images of the prostate gland and seminal vesicles. **Why Option C is Correct:** The primary and most important clinical application of TRUS is to provide **real-time image guidance for systematic prostate biopsies**. While TRUS can visualize the anatomy, it cannot reliably differentiate between malignant and benign tissue based on echogenicity alone. Therefore, its role is to ensure that biopsy needles are accurately and systematically placed (usually via a 12-core template) into different zones of the prostate to obtain tissue for histopathological diagnosis, which is the gold standard for confirming cancer. **Why Other Options are Incorrect:** * **Option A:** TRUS is **not a screening tool**. Screening for prostate cancer is primarily done using Digital Rectal Examination (DRE) and Serum Prostate-Specific Antigen (PSA) levels. * **Option B:** TRUS has low specificity for cancer. Many prostate cancers are isoechoic (invisible on USG), and benign conditions like prostatitis or BPH can mimic the hypoechoic appearance of a tumor. * **Option C:** Transurethral resection (TURP) is an endoscopic surgical procedure performed via the urethra; it does not require TRUS guidance. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Appearance:** On TRUS, prostate cancer most commonly appears as a **hypoechoic lesion** in the **peripheral zone**. * **Biopsy Technique:** The standard is the **TRUS-guided 12-core systematic biopsy**. * **Emerging Trend:** Multiparametric MRI (mpMRI) followed by **MRI-TRUS fusion biopsy** is now becoming the preferred method for targeting suspicious lesions more accurately than TRUS alone. * **Other Uses:** TRUS is also excellent for evaluating **male infertility** (detecting ejaculatory duct obstruction or seminal vesicle cysts).

Question 126: An adult male presented with abdominal pain and diarrhea. A Barium meal follow-through revealed a mildly narrowed lumen of a loop with stretched and fixed rigid walls. A CT contrast study showed a stellate-shaped, enhancing mesenteric lesion with adjacent bowel wall thickening. What does this mass lesion represent?

A. Jejunal adenocarcinoma
B. Mesenteric carcinoid tumor (Correct Answer)
C. Lymphoma
D. Liposarcoma

Explanation: ### Explanation The clinical and radiological presentation is classic for a **Mesenteric Carcinoid Tumor**. **1. Why Option B is Correct:** Carcinoid tumors are neuroendocrine neoplasms that frequently secrete serotonin. When these tumors metastasize to the mesentery, they incite a profound **desmoplastic (fibrotic) reaction**. * **CT Findings:** The "stellate" or "spiculated" appearance is pathognomonic, representing a soft-tissue mass with radiating strands of fibrosis that pull on the mesentery. * **Barium Findings:** The serotonin-induced fibrosis causes kinking, tethering, and narrowing of the bowel loops, leading to the "stretched and fixed" appearance described. The enhancement on CT is due to the hypervascular nature of neuroendocrine tumors. **2. Why Other Options are Incorrect:** * **A. Jejunal Adenocarcinoma:** Typically presents as a short-segment, irregular "apple-core" narrowing or a polypoid mass. It does not usually cause a stellate mesenteric mass with extensive desmoplasia. * **C. Lymphoma:** Usually presents as bulky, "sandwich-like" mesenteric lymphadenopathy that encases vessels without causing significant desmoplasia or luminal narrowing. It is typically hypoattenuating and does not show a stellate pattern. * **D. Liposarcoma:** This is a large, fat-containing retroperitoneal mass. While it can displace bowel, it does not produce the specific spiculated, fibrotic mesenteric reaction seen here. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ileum (for midgut carcinoids). * **Carcinoid Syndrome:** Occurs only after liver metastasis (flushing, diarrhea, right-sided heart failure). * **Biomarker:** 24-hour urinary **5-HIAA** (metabolite of serotonin). * **Imaging Sign:** "Spiculated mesenteric mass" = Carcinoid. * **Nuclear Medicine:** **Octreotide scan** (Somatostatin receptor scintigraphy) or Ga-68 DOTATATE PET/CT are the investigations of choice for localization.

Question 127: The double-bubble sign on an abdominal X-ray is typically seen in which of the following conditions?

A. Colon carcinoma
B. Duodenal atresia (Correct Answer)
C. Acute pancreatitis
D. Perforation

Explanation: **Explanation:** The **Double-Bubble Sign** is a classic radiographic finding pathognomonic for **Duodenal Atresia**. It represents two air-filled pockets: the first is the **stomach** (proximal bubble) and the second is the **dilated proximal duodenum** (distal bubble). The "sign" occurs because there is a complete obstruction at the level of the duodenum, preventing gas from passing into the distal small bowel. **Why the other options are incorrect:** * **Colon Carcinoma:** Typically presents with signs of distal large bowel obstruction, such as peripheral bowel loop dilatation or a "bird's beak" sign on a barium enema, rather than proximal gastric/duodenal dilatation. * **Acute Pancreatitis:** May show a "Sentinel Loop" (localized ileus of a jejunal loop) or the "Colon Cut-off Sign," but not a double-bubble. * **Perforation:** Characterized by **Pneumoperitoneum** (free air under the diaphragm), not localized luminal gas bubbles. **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Duodenal atresia is strongly associated with **Down Syndrome (Trisomy 21)** in approximately 30% of cases. * **Antenatal Finding:** It is often suspected on prenatal ultrasound when **polyhydramnios** is present. * **Clinical Presentation:** The neonate typically presents with **bilious vomiting** within the first 24–48 hours of life (as the obstruction is usually distal to the Ampulla of Vater). * **Differential for Double-Bubble:** While Duodenal Atresia is the most common cause, other causes include **Annular Pancreas**, **Malrotation with Midgut Volvulus**, and **Duodenal Web**.

Question 128: Step ladder pattern is characteristic of which of the following conditions?

A. Acute appendicitis
B. Diaphragmatic hernia
C. Intestinal perforation
D. Small bowel obstruction (Correct Answer)

Explanation: **Explanation:** The **Step-ladder pattern** is a classic radiological sign seen on an erect abdominal X-ray in patients with **Small Bowel Obstruction (SBO)**. **1. Why Small Bowel Obstruction is correct:** When the small intestine is obstructed, gas and fluid accumulate proximally. As the bowel loops dilate, they arrange themselves one above the other in a staggered fashion. On an erect film, the fluid settles at the bottom of these loops, creating multiple **air-fluid levels**. Because the small bowel is suspended by a short, slanted mesentery, these loops appear stacked diagonally, resembling the rungs of a step-ladder. **2. Why other options are incorrect:** * **Acute appendicitis:** Typically shows non-specific gas patterns. A specific sign might be a calcified **appendicolith** or localized ileus in the right lower quadrant (sentinel loop), but not a step-ladder pattern. * **Diaphragmatic hernia:** Characterized by the presence of bowel loops or solid organs within the thoracic cavity, often causing a mediastinal shift. * **Intestinal perforation:** The hallmark is **pneumoperitoneum** (free air under the diaphragm on an erect X-ray), not air-fluid levels within the bowel. **3. Clinical Pearls for NEET-PG:** * **Valvulae Conniventes (Plicae Circulares):** These are mucosal folds that cross the *entire width* of the small bowel, giving it a "coiled spring" appearance. * **String of Beads Sign:** Small bubbles of gas trapped between valvulae conniventes in a fluid-filled small bowel; highly specific for SBO. * **Rule of 3/6/9:** Normal diameter limits are <3cm for small bowel, <6cm for colon, and <9cm for cecum. * **Large Bowel Obstruction:** Characterized by peripheral distribution of loops and **Haustrations** (folds that do *not* cross the entire width).

Question 129: A plain radiograph of the chest and abdomen shows findings suggestive of which of the following conditions?

A. Pneumoperitoneum (Correct Answer)
B. Pleural effusion
C. Pneumonia
D. Volvulus

Explanation: ***Pneumoperitoneum*** - **Free air under the diaphragm** on erect chest X-ray is the classic radiological sign of pneumoperitoneum, appearing as a **crescent-shaped lucency**. - Often indicates **bowel perforation** requiring urgent surgical intervention, commonly seen in perforated peptic ulcers or bowel injuries. *Pleural effusion* - Characterized by **blunting of costophrenic angles** and **meniscus sign** on chest X-ray, not free air under diaphragm. - Shows **fluid accumulation** in pleural space, appearing as **homogeneous opacity** in dependent portions of thorax. *Pneumonia* - Presents as **consolidation** or **infiltrates** within lung parenchyma, typically showing **air bronchograms**. - Does not cause **free air under diaphragm**; instead shows **increased opacity** in affected lung segments. *Volvulus* - Shows characteristic **coffee bean sign** or **bird's beak appearance** on abdominal X-ray due to twisted bowel loops. - Associated with **dilated bowel loops** and **air-fluid levels**, but does not produce free air under diaphragm unless perforation occurs.

Question 130: Bilateral spider leg appearance of kidney in IVP is seen in?

A. Hydronephrosis
B. Polycystic kidney (Correct Answer)
C. Medullary sponge kidney
D. Renal cell carcinoma

Explanation: **Explanation:** The **"Spider Leg Appearance"** on Intravenous Pyelogram (IVP) is a classic radiological sign of **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**. This appearance occurs because multiple large, non-communicating cysts within the renal parenchyma exert pressure on the collecting system. This leads to the elongation, thinning, and stretching of the renal calyces, making them resemble the long, spindly legs of a spider. **Analysis of Options:** * **Polycystic Kidney (Correct):** As explained, the mechanical compression by numerous cysts causes the characteristic stretching of the infundibula and calyces. * **Hydronephrosis:** This results in the **"Clubbing of calyces"** due to the dilation of the collecting system from distal obstruction, rather than thinning/stretching. * **Medullary Sponge Kidney:** Characterized by the **"Bouquet of flowers"** or **"Paintbrush"** appearance due to ectasia (dilation) of the collecting tubules in the renal pyramids. * **Renal Cell Carcinoma:** Typically presents as a focal mass causing localized distortion or a "filling defect" in the collecting system, rather than the uniform bilateral stretching seen in ADPKD. **High-Yield Clinical Pearls for NEET-PG:** * **ADPKD:** Associated with Berry aneurysms (Circle of Willis), hepatic cysts, and mitral valve prolapse. * **Swiss Cheese Appearance:** The characteristic appearance of ADPKD on a nephrogram (multiple radiolucent areas). * **Flower Vase Appearance:** Seen in Horseshoe kidney due to the lower poles being fused and the axes of the kidneys being reversed. * **Rim Sign:** Seen in severe hydronephrosis (opacification of the compressed parenchyma).

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