Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs

Question 131: 'Rim' and 'ball' nephrograms in intravenous urography are seen in which condition?

A. Normal kidneys
B. Acute obstructive nephropathy
C. Chronic obstructive nephropathy (Correct Answer)
D. Chronic renal failure

Explanation: **Explanation:** The correct answer is **Chronic obstructive nephropathy**. This phenomenon occurs during Intravenous Urography (IVU) due to long-standing hydronephrosis. **1. Why Chronic Obstructive Nephropathy is correct:** In chronic obstruction, the renal pelvis and calyces are massively dilated, leading to severe thinning of the renal parenchyma. * **Rim Nephrogram:** This represents the thin shell of remaining functional renal parenchyma (cortex and medulla) being opacified by contrast, surrounding the dilated, non-opacified calyces. * **Ball Nephrogram:** This occurs when the contrast eventually enters the dilated, clubbed calyces, appearing as rounded "balls" of opacification. **2. Why the other options are incorrect:** * **Normal kidneys:** A normal nephrogram is uniform and homogenous, appearing within 1 minute of contrast injection, followed by rapid excretion into the pelvicalyceal system. * **Acute obstructive nephropathy:** This typically presents with an **"Increasingly Dense Nephrogram."** The kidney is swollen, and contrast accumulates in the tubules because of high intratubular pressure, but it is not excreted promptly. * **Chronic renal failure:** In end-stage renal disease, the kidneys are usually small and shrunken with poor contrast uptake, leading to a **faint or absent nephrogram**. **3. Clinical Pearls for NEET-PG:** * **Negative Pyelogram:** In the early phase of IVU in chronic obstruction, the dilated, water-filled calyces appear as lucent areas against the opacified parenchyma. * **Crescent Sign:** A high-yield finding in hydronephrosis where contrast is concentrated in collecting tubules that have been displaced and flattened into a crescent shape by dilated calyces. * **Delayed Films:** In cases of obstruction, delayed films (up to 24 hours) are essential to visualize the site of obstruction.

Question 132: Gasless abdomen on X-ray is found in all except:

A. Annular pancreas
B. Duodenal atresia
C. Pyloric stenosis
D. Meckel's diverticulum (Correct Answer)

Explanation: ### Explanation A **"gasless abdomen"** on a plain X-ray refers to a paucity or complete absence of bowel gas distal to the stomach or duodenum. This occurs when there is a high-grade proximal obstruction or when the stomach contents cannot pass into the distal intestines. **1. Why Meckel’s Diverticulum is the Correct Answer:** Meckel’s diverticulum is a vestigial remnant of the vitellointestinal duct located in the distal ileum. In its uncomplicated state, it does not cause obstruction and has no effect on the distribution of bowel gas. Even if it causes complications like intussusception or volvulus, it typically results in **dilated bowel loops** (distal obstruction) rather than a gasless abdomen. Therefore, it is the "except" in this list. **2. Analysis of Incorrect Options:** * **Annular Pancreas & Duodenal Atresia:** Both conditions cause high intestinal obstruction at the level of the duodenum. If the obstruction is complete and occurs early (or if the infant has vomited all swallowed air), the distal bowel will contain no gas. These typically present with the classic **"Double Bubble" sign**, with a gasless distal abdomen. * **Pyloric Stenosis:** While the classic description is a "distended stomach," severe cases with persistent vomiting can lead to a gasless appearance of the distal intestines because air is unable to pass through the stenosed pyloric canal. **Clinical Pearls for NEET-PG:** * **Double Bubble Sign:** Diagnostic of Duodenal Atresia, Annular Pancreas, or Midgut Volvulus. * **Single Bubble Sign:** Seen in Pyloric Stenosis. * **Triple Bubble Sign:** Seen in Jejunal Atresia. * **Other causes of Gasless Abdomen:** Acute pancreatitis (due to vomiting/ileus), high-grade esophageal atresia (without fistula), and midgut volvulus (early stage).

Question 133: A 64-year-old man develops increasing dysphagia over many months. A barium swallow is performed. What is the most likely cause of his clinical presentation?

A. Carcinoma of the esophagus (Correct Answer)
B. Achalasia
C. Sliding hiatal hernia
D. Paraoesophageal hernia

Explanation: ***Carcinoma of the esophagus*** - Progressive dysphagia in a **64-year-old male** with **irregular narrowing** and **shouldering/apple-core appearance** on barium swallow is characteristic of **esophageal carcinoma**. - The **rat-tail sign** and abrupt transition from normal to narrowed esophagus strongly suggests malignant stricture rather than benign causes. *Achalasia* - Typically presents with **bird-beak appearance** on barium swallow showing smooth, symmetrical tapering at the gastroesophageal junction. - Characterized by **failure of lower esophageal sphincter relaxation** with associated **esophageal dilatation** proximal to the obstruction. *Sliding hiatal hernia* - Shows **gastroesophageal junction displacement** above the diaphragm with a **bell-shaped** or **tulip-shaped** appearance on barium swallow. - Usually causes **gastroesophageal reflux symptoms** rather than progressive mechanical dysphagia seen in this case. *Paraoesophageal hernia* - Demonstrates **herniation of gastric fundus** alongside the esophagus while the **gastroesophageal junction remains below the diaphragm**. - Typically presents with **chest pain** and **early satiety** rather than progressive dysphagia, and shows characteristic **upside-down stomach** appearance.

Question 134: What is the current imaging technique of choice for the diagnosis of hydatidiform mole?

A. Computed tomography
B. Ultrasonography (Correct Answer)
C. Plain X-ray abdomen
D. Magnetic resonance imaging

Explanation: **Explanation:** **Ultrasonography (USG)** is the gold standard and the primary imaging modality for diagnosing hydatidiform mole (molar pregnancy). The diagnosis is based on characteristic sonographic patterns: * **Complete Mole:** Classically presents as a **"Snowstorm appearance"** or "bunch of grapes" appearance. This represents a complex intrauterine echogenic mass with multiple small cystic spaces (hydropic villi) and the absence of fetal parts or an amniotic sac. * **Partial Mole:** May show a thickened placenta with cystic spaces and the presence of identifiable fetal tissues or a gestational sac. **Why other options are incorrect:** * **Computed Tomography (CT):** CT involves significant ionizing radiation, which is contraindicated in suspected pregnancy. While it may be used to stage gestational trophoblastic neoplasia (GTN) for distant metastasis (e.g., lungs or liver), it is not the primary diagnostic tool for the mole itself. * **Plain X-ray Abdomen:** This has no role in modern diagnosis. It cannot visualize soft tissue structures or early pregnancy and exposes the patient to unnecessary radiation. * **Magnetic Resonance Imaging (MRI):** While MRI provides excellent soft-tissue contrast and can help assess myometrial invasion in malignant cases (Choriocarcinoma), it is expensive, time-consuming, and unnecessary for the initial diagnosis when USG is highly sensitive. **High-Yield Clinical Pearls for NEET-PG:** * **Biochemical Marker:** Quantitative **beta-hCG** levels are disproportionately high for the gestational age. * **Theca Lutein Cysts:** Often seen on USG as bilateral, multiloculated ovarian cysts due to high hCG levels. * **Treatment of Choice:** Suction and Evacuation (S&E). * **Follow-up:** Weekly beta-hCG monitoring until three consecutive normal values are obtained to rule out persistent trophoblastic disease.

Question 135: What does a hysterosalpingography (HSG) report typically show in cases of tubal patency issues?

A. Hydro-salpinx (Correct Answer)
B. Uterus didelphys
C. Adenomyosis
D. Endometriosis

Explanation: ### Explanation **Hysterosalpingography (HSG)** is the gold standard initial investigation for evaluating the uterine cavity and fallopian tube patency in cases of infertility. **1. Why Hydrosalpinx is Correct:** Hydrosalpinx refers to a fallopian tube that is distended and filled with fluid, usually due to distal tubal occlusion (often from pelvic inflammatory disease). On HSG, tubal patency is confirmed by the **free spill** of contrast into the peritoneal cavity. In hydrosalpinx, the contrast enters the tube but fails to spill, instead collecting in a dilated, club-shaped ampullary portion. This directly indicates a **tubal patency issue**. **2. Why Other Options are Incorrect:** * **Uterus Didelphys:** This is a congenital Müllerian duct anomaly resulting in a double uterus and double cervix. While HSG can diagnose this, it is a structural uterine anomaly, not a primary "tubal patency" issue. * **Adenomyosis:** This is the presence of endometrial tissue within the myometrium. It is best diagnosed via MRI or Transvaginal Ultrasound (TVUS). HSG may show non-specific findings like "diverticula" extending into the myometrium, but it is not a test for tubal patency. * **Endometriosis:** While endometriosis can cause tubal adhesions, the disease itself is a clinical/laparoscopic diagnosis. HSG cannot visualize endometrial implants on the ovaries or peritoneum. **Clinical Pearls for NEET-PG:** * **Best time for HSG:** Proliferative phase (Day 7 to Day 10 of the menstrual cycle) to ensure the endometrium is thin and the patient is not pregnant. * **Beaded appearance of tubes:** Highly suggestive of **Genital Tuberculosis**. * **Intravasation of contrast:** If contrast enters the uterine venous/lymphatic plexus, it may indicate high injection pressure or recent uterine trauma. * **Therapeutic effect:** HSG can sometimes clear minor tubal blockages (mucus plugs), slightly increasing pregnancy rates immediately following the procedure.

Question 136: A stab wound immediately superior to the pubic symphysis on the anterior pelvic wall would most likely injure which visceral organ first?

A. Small intestine
B. Urinary bladder (Correct Answer)
C. Rectum
D. Sigmoid colon

Explanation: ***Urinary bladder*** - The **urinary bladder** sits directly in the **retropubic space** (space of Retzius), immediately posterior to the pubic symphysis, making it the first organ encountered by a stab wound superior to the symphysis. - When the bladder is **distended with urine**, it rises superiorly above the pubic symphysis, further increasing its vulnerability to anterior penetrating injuries. *Small intestine* - The **small bowel loops** are located more **superiorly** in the abdomen and pelvis, well above the level of the pubic symphysis. - Protected by the **greater omentum** and situated in the **peritoneal cavity**, making it less likely to be the first organ injured by a low anterior stab wound. *Rectum* - The **rectum** is located **posteriorly** in the pelvis, behind the bladder and separated from the anterior pelvic wall by the **rectovesical pouch** in males. - A stab wound from the **anterior approach** would have to traverse the bladder first before reaching the rectum. *Sigmoid colon* - The **sigmoid colon** is positioned **posteriorly and laterally** in the pelvis, typically in the **left iliac fossa**. - Located at a **higher level** than the pubic symphysis and protected by overlying structures, making it an unlikely first target for anterior penetrating trauma.

Question 137: Which of the following is the most sensitive imaging modality for the diagnosis of idiopathic chronic pancreatitis (IOC)?

A. Contrast-enhanced Computed Tomography (CT) (Correct Answer)
B. Ultrasound (USG)
C. Serum lipase level
D. Serum amylase level

Explanation: **Explanation:** **Contrast-enhanced Computed Tomography (CT)** is the investigation of choice and the most sensitive imaging modality for diagnosing chronic pancreatitis among the given options. The diagnosis of chronic pancreatitis relies on identifying structural changes in the pancreatic parenchyma and ductal system. CT is highly effective at detecting the classic triad of chronic pancreatitis: **pancreatic calcifications** (the most specific sign), **ductal dilatation**, and **parenchymal atrophy**. It also helps in identifying complications like pseudocysts, portal vein thrombosis, and arterial pseudoaneurysms. **Why other options are incorrect:** * **Ultrasound (USG):** While often the initial screening tool, USG is operator-dependent and frequently limited by overlying bowel gas. It is less sensitive than CT for detecting subtle calcifications or early parenchymal changes. * **Serum Lipase and Amylase:** These are biochemical markers used for **Acute Pancreatitis**. In chronic pancreatitis, the progressive destruction of acinar tissue often leads to normal or even low levels of these enzymes; therefore, they have no diagnostic value for chronic disease. **High-Yield Clinical Pearls for NEET-PG:** * **Most specific sign of Chronic Pancreatitis:** Pancreatic calcifications. * **Gold Standard for early/subtle changes:** Endoscopic Ultrasound (EUS) or Secretin-enhanced MRCP (though CT remains the practical first-line diagnostic imaging). * **Chain of Lakes appearance:** Refers to the beaded appearance of the main pancreatic duct due to multiple strictures and dilatations, best seen on MRCP or ERCP. * **Most common cause:** Alcohol abuse (Chronic), whereas Gallstones are the most common cause of Acute Pancreatitis.

Question 138: Which of the following is NOT a radiological feature of sigmoid volvulus?

A. Inverted U shaped bowel loop
B. Liver overlap sign
C. Bird of prey sign
D. Cupola sign (Correct Answer)

Explanation: **Explanation:** **Sigmoid Volvulus** is a common cause of large bowel obstruction occurring when the sigmoid colon twists on its mesenteric axis. **Why the Cupola Sign is the Correct Answer:** The **Cupola sign** is a radiological feature of **pneumoperitoneum** (perforated viscus), not volvulus. It refers to an arcuate lucency seen on a supine chest or abdominal radiograph, representing air trapped under the central tendon of the diaphragm. **Analysis of Incorrect Options (Features of Sigmoid Volvulus):** * **Inverted U-shaped loop:** This is the classic appearance of the massively dilated sigmoid colon, which loses its haustrations and rises out of the pelvis, often reaching the diaphragm. * **Liver Overlap Sign:** This occurs when the gas-distended sigmoid loop extends superiorly and overlaps the liver shadow. This helps differentiate sigmoid volvulus from cecal volvulus (where the cecum usually stays to the left and does not overlap the liver). * **Bird of Prey Sign:** Seen on a **Barium Enema**, it represents the tapering of the contrast at the site of the twist, resembling a bird's beak or "ace of spades." **NEET-PG High-Yield Pearls:** * **Coffee Bean Sign:** The most common X-ray sign of sigmoid volvulus (the two walls of the dilated loop form the "cleft" of the bean). * **Frimann-Dahl Sign:** Three dense lines (the walls of the sigmoid) converging toward the site of obstruction in the pelvis. * **Whirl Sign:** The pathognomonic finding on **CT scan**, representing the twisting of the mesentery and vessels. * **Management:** Initial treatment is usually endoscopic detorsion (Rigid Proctosigmoidoscopy) unless gangrene is suspected.

Question 139: Radiography of which of the following renal stones shows opacity, EXCEPT?

A. Oxalate
B. Uric acid (Correct Answer)
C. Cystine
D. Struvite

Explanation: **Explanation:** The visibility of renal stones on a plain X-ray (KUB) depends on their **atomic number** and **density** relative to surrounding tissues. Stones containing calcium are radiopaque, while those lacking heavy elements are radiolucent. **Why Uric Acid is the Correct Answer:** Uric acid stones are composed of organic compounds with low atomic numbers. They do not contain calcium or other heavy minerals, making them **radiolucent** on conventional radiography. They are typically visualized using Ultrasound or Non-Contrast Computed Tomography (NCCT), where they appear hyperdense. **Analysis of Incorrect Options:** * **Oxalate (Calcium Oxalate):** These are the most common renal stones. Due to their high calcium content, they are **highly radiopaque** and easily seen on X-ray. * **Cystine:** These stones contain sulfur atoms. While they are less dense than calcium stones, they are **faintly radiopaque** (often described as having a "ground-glass" appearance). * **Struvite (Triple Phosphate):** Composed of Magnesium Ammonium Phosphate, these often form "staghorn" calculi. They contain enough mineral content to be **radiopaque**, though usually less so than pure calcium oxalate. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Radiolucent Stones (SULI):** **S**ulfonamides, **U**ric acid, **L**euvonir/Indinavir (HIV drugs), **I**ndinavir. * **Gold Standard Investigation:** Non-Contrast CT (NCCT) is the investigation of choice for all renal stones as it can detect almost all types, including radiolucent uric acid stones (except Indinavir stones). * **Pure Matrix stones** are also radiolucent. * **Cystine stones** are unique for being hexagonal on microscopy and faintly opaque on X-ray.

Question 140: Type II Abernethy malformation refers to:

A. Portal shunt of suprahepatic veins (Correct Answer)
B. Portal shunt of portal vein
C. Shunt between renal and hepatic vein
D. Hepatic vein drain into splenic vein

Explanation: **Explanation:** **Abernethy Malformation** is a rare congenital anomaly characterized by a portosystemic shunt, where portal blood bypasses the liver and drains directly into the systemic venous system. It is classified into two main types: 1. **Type I (Complete Shunt):** There is a total absence of the intrahepatic portal vein. Portal blood drains completely into the IVC or renal veins. This is more common in females and often associated with other congenital anomalies (e.g., polysplenia). 2. **Type II (Partial Shunt):** The intrahepatic portal vein is **present** but hypoplastic. A portion of the portal blood is diverted into the systemic circulation via a side-to-side shunt. The most common site for this drainage is into the **suprahepatic veins** or the IVC. Therefore, **Option A** is the correct description of a Type II malformation. **Analysis of Incorrect Options:** * **Option B:** While it involves the portal vein, the term "portal shunt of portal vein" is redundant and does not specify the systemic connection required for Abernethy. * **Option C:** Shunts between renal and hepatic veins are not the defining feature of Abernethy malformation; these are typically seen in acquired conditions like portal hypertension (splenorenal shunts). * **Option D:** Hepatic veins draining into the splenic vein is anatomically incorrect for this malformation; the flow in Abernethy is from the portal system *to* the systemic system. **Clinical Pearls for NEET-PG:** * **Imaging Gold Standard:** CT Angiography or MR Portography. * **Complications:** Hepatic encephalopathy (due to ammonia bypassing the liver) and **Hepatocellular Carcinoma (HCC)** or Hepatoblastoma (due to altered hepatic trophic factors). * **Management:** Type I requires liver transplantation (since no portal vein exists); Type II can often be treated with surgical or radiological closure of the shunt.

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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