Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs

Question 211: Delayed centripetal contrast enhancement pattern is seen in which of the following conditions?

A. Hemangioma (Correct Answer)
B. Hepatocellular carcinoma (HCC)
C. Metastasis
D. Hepatic cysts

Explanation: **Explanation:** The hallmark of **Cavernous Hemangioma**, the most common benign liver tumor, is its characteristic vascular enhancement pattern on dynamic contrast-enhanced CT or MRI. 1. **Why Hemangioma is correct:** Hemangiomas consist of large, blood-filled endothelial-lined spaces (caverns) with slow internal flow. On dynamic imaging, they exhibit **peripheral globular enhancement** during the arterial phase. In the venous and delayed phases, the contrast gradually moves inward to fill the lesion. This is known as **delayed centripetal filling** or the "filling-in" phenomenon. Eventually, the lesion becomes isodense or hyperdense relative to the liver parenchyma. 2. **Why the other options are incorrect:** * **Hepatocellular Carcinoma (HCC):** Characterized by **"Arterial Bright, Venous Washout."** It shows intense enhancement in the arterial phase followed by rapid washout in the portal venous/delayed phases, often with a pseudocapsule. * **Metastasis:** Most metastases (especially from the GI tract) are hypovascular and show **peripheral "rim" enhancement** (target sign), but they do not typically show centripetal filling. Hypervascular metastases (e.g., RCC, thyroid) enhance early but also show washout. * **Hepatic Cysts:** These are fluid-filled structures and show **no enhancement** across any phase of the study. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** MRI is the most sensitive modality for diagnosing hemangiomas (shows "light bulb" appearance on T2W images). * **Giant Hemangioma:** Defined as a lesion >4–5 cm; these may show incomplete central filling due to internal fibrosis or thrombosis. * **Key Buzzword:** "Peripheral globular enhancement" followed by "centripetal fill-in."

Question 212: What is the investigation of choice for hydronephrosis?

A. Excretory Urography
B. USG (Correct Answer)
C. MRI
D. Cystourethrography

Explanation: **Explanation:** **Ultrasonography (USG)** is the investigation of choice (IOC) and the initial screening modality for hydronephrosis. Its primary advantages include high sensitivity for detecting collecting system dilatation, lack of ionizing radiation, and non-invasiveness. It effectively differentiates obstructive uropathy from medical renal disease and can often identify the level of obstruction (e.g., PUJ obstruction or bladder outlet obstruction). **Analysis of Options:** * **Excretory Urography (IVP):** Historically used to visualize the anatomy of the urinary tract, it is no longer the first-line investigation due to the risk of contrast-induced nephropathy and radiation exposure. It is contraindicated in patients with renal failure. * **MRI:** While highly sensitive (MR Urography), it is expensive, time-consuming, and not readily available. It is reserved for complex cases or when CT/USG are inconclusive, particularly in pregnant patients. * **Cystourethrography (MCU/RGU):** These are specialized fluoroscopic studies used to evaluate the urethra and bladder (e.g., VUR or urethral strictures). They do not directly evaluate the renal parenchyma or proximal collecting system. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Urolithiasis:** Non-Contrast CT (NCCT) KUB is the gold standard for detecting renal and ureteric stones. * **Grading:** Hydronephrosis is graded from I to IV based on the degree of calyceal dilatation and cortical thinning. * **False Positives on USG:** A full bladder or a "distended" pelvis (overhydration) can mimic hydronephrosis; always ask the patient to void and re-scan if in doubt. * **Functional Assessment:** If obstruction is confirmed on USG, a **DTPA or MAG3 Renogram** is the investigation of choice to assess the functional significance of the obstruction.

Question 213: A "saw-tooth" appearance of the colon on barium enema is typically seen with which of the following conditions?

A. Colonic diverticulosis (Correct Answer)
B. Colonic volvulus
C. Colonic carcinoma
D. Ulcerative colitis

Explanation: **Explanation:** The **"saw-tooth" appearance** is a classic radiological sign of **Colonic Diverticulosis**, most commonly observed in the sigmoid colon. This appearance is not caused by the diverticula (outpouchings) themselves, but rather by the **circular muscle hypertrophy** and shortening of the taeniae coli that often accompany the condition. This leads to a series of sharp, serrated indentations along the colonic wall, resembling the teeth of a saw. **Analysis of Options:** * **Colonic Diverticulosis (Correct):** Muscle thickening and spasm create the characteristic serrated or "saw-tooth" contour on barium enema. * **Colonic Volvulus:** Typically presents with a **"bird-beak"** sign (at the site of twist) or a **"coffee bean"** sign (on plain X-ray) in sigmoid volvulus. * **Colonic Carcinoma:** Classically presents with an **"apple-core"** lesion or a "napkin-ring" sign, representing a short-segment, irregular circumferential narrowing with overhanging edges. * **Ulcerative Colitis:** In the chronic stage, it presents with a **"lead-pipe"** appearance due to the loss of haustral folds and shortening of the colon. In acute phases, "collar-stud" ulcers may be seen. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for diverticula:** Sigmoid colon (due to high intraluminal pressure). * **Diverticulitis:** Barium enema is generally **avoided** in the acute phase due to the risk of perforation; **CECT** is the investigation of choice. * **True vs. False Diverticula:** Colonic diverticula are "false" diverticula (pseudodiverticula) because they consist only of mucosa and submucosa herniating through the muscularis layer.

Question 214: The "apple core" sign is seen in which of the following conditions?

A. Carcinoma of the descending colon (Correct Answer)
B. Ulcerative colitis
C. Tuberculosis
D. Diverticulitis

Explanation: ### Explanation **1. Why the Correct Answer is Right:** The **"apple core" sign** (also known as the napkin-ring sign) is a classic radiologic finding on a barium enema. It represents a short, circumferential, and irregular narrowing of the colonic lumen with overhanging edges (shouldering). This appearance is caused by an **annular constricting adenocarcinoma**, most commonly found in the **descending and sigmoid colon**. The "core" represents the narrowed lumen due to the tumor mass, while the "shoulders" represent the abrupt transition from normal tissue to the malignant growth. **2. Why the Incorrect Options are Wrong:** * **Ulcerative Colitis:** Characterized by the **"lead pipe" appearance** in chronic stages, which is a featureless, shortened, and narrowed colon due to the loss of haustral folds, rather than a localized annular mass. * **Tuberculosis:** Typically involves the ileocecal region. Common signs include the **"Stierlin sign"** (rapid emptying of the inflamed cecum) or the **"Goose neck deformity"** (shrunken, conical cecum). * **Diverticulitis:** While it can cause luminal narrowing due to inflammation or muscular hypertrophy (saw-tooth appearance), it typically involves a longer segment of the colon with preserved mucosal patterns and associated diverticula, lacking the sharp "shouldering" of malignancy. **3. Clinical Pearls for NEET-PG:** * **Most common site:** The apple core sign is most frequently associated with **left-sided colonic lesions** (descending/sigmoid) because these tumors tend to be scirrhous and circumferential. * **Clinical presentation:** Left-sided lesions often present early with **altered bowel habits** or intestinal obstruction, whereas right-sided lesions (caecum) are usually fungating and present with **iron deficiency anemia**. * **Differential Diagnosis:** While highly suggestive of malignancy, a "pseudo-apple core" sign can rarely be seen in focal Crohn’s disease, lymphoma, or chronic ischemia.

Question 215: Which of the following is NOT a radiological finding of papillary necrosis on excretory urography?

A. Tracks and horns from calyces
B. Ring shadow
C. Increased dense nephrogram (Correct Answer)
D. Egg in cup appearance

Explanation: **Explanation:** **Renal Papillary Necrosis (RPN)** is a clinicopathologic entity characterized by ischemic necrosis of the renal papillae. On excretory urography (IVP), the findings depend on the stage of the disease (medullary vs. papillary) and the degree of sloughing. **Why "Increased dense nephrogram" is the correct answer:** An **increased dense (persistent) nephrogram** is a hallmark of **Acute Tubular Necrosis (ATN)**, acute ureteric obstruction, or renal vein thrombosis. It is not a feature of papillary necrosis. In RPN, the primary pathology involves the destruction of the papilla and the formation of cavities that communicate with the collecting system, rather than a generalized delay in contrast excretion. **Analysis of Incorrect Options:** * **Tracks and horns:** These represent the early "medullary" type of necrosis where contrast tracks into the necrotic papilla from the fornices, creating a "lobster claw" or "horn" appearance. * **Ring shadow:** This occurs when a necrotic papilla sloughs off entirely and is surrounded by contrast medium within the calyx. * **Egg in cup appearance:** This refers to the "papillary" type of necrosis where the entire central portion of the papilla sloughs off, leaving a hollowed-out, clubbed calyx (the "cup") containing the necrotic debris (the "egg"). **Clinical Pearls for NEET-PG:** * **Mnemonic for Causes (POSTCARDS):** **P**yelonephritis, **O**bstruction, **S**ickle cell disease, **T**uberculosis, **C**irrhosis, **A**nalgesic abuse (most common), **R**enal vein thrombosis, **D**iabetes mellitus, **S**ystemic lupus erythematosus. * **Ball-on-tee appearance:** Another classic description of RPN where contrast fills a central cavity in the papilla. * **Differential Diagnosis:** RPN can mimic **Renal Tuberculosis**, but TB usually presents with more extensive strictures and "putty kidney" (autonephrectomy).

Question 216: A 32-year-old man presents with fever and pain in the right upper quadrant after food intake. What is the investigation of choice?

A. CECT
B. Ultrasound (Correct Answer)
C. MRI
D. HRCT

Explanation: **Explanation:** The clinical presentation of fever and right upper quadrant (RUQ) pain triggered by food intake (post-prandial) is highly suggestive of **Acute Cholecystitis** or symptomatic cholelithiasis. **Why Ultrasound is the Correct Answer:** Ultrasound (USG) is the **initial investigation of choice** for any patient presenting with RUQ pain. It is highly sensitive (up to 95%) and specific for detecting gallstones and gallbladder wall thickening. It is non-invasive, cost-effective, lacks ionizing radiation, and allows for the assessment of the **Sonographic Murphy’s Sign** (maximal tenderness over the gallbladder when compressed by the transducer), which has a high predictive value for acute cholecystitis. **Why Other Options are Incorrect:** * **CECT (Contrast-Enhanced CT):** While excellent for identifying complications (like perforation or gangrene) or alternative diagnoses (like pancreatitis), it is less sensitive than USG for detecting gallstones and involves radiation. * **MRI/MRCP:** These are highly accurate but are generally reserved for suspected common bile duct (CBD) stones (choledocholithiasis) or when USG results are equivocal. They are too time-consuming and expensive for initial screening. * **HRCT (High-Resolution CT):** This is a specialized imaging modality for lung parenchyma (interstitial lung diseases) and has no role in evaluating abdominal pain. **Clinical Pearls for NEET-PG:** * **Gold Standard for Acute Cholecystitis:** HIDA Scan (Cholescintigraphy) is the most accurate test if USG is inconclusive. * **Investigation of Choice for Choledocholithiasis:** MRCP (Non-invasive) or ERCP (if therapeutic intervention is needed). * **USG Findings in Acute Cholecystitis:** Gallstones, GB wall thickening (>3mm), pericholecystic fluid, and a positive Sonographic Murphy’s Sign.

Question 217: Hand joining sign is characteristic of?

A. Pelvic duplication
B. Ureterocele
C. Ureteral duplication
D. Horseshoe kidney (Correct Answer)

Explanation: **Explanation:** The **Hand joining sign** is a classic radiological sign seen in a **Horseshoe kidney**. This sign is observed on an intravenous pyelogram (IVP) or CT scan. It refers to the appearance of the lower poles of the kidneys as they curve medially and fuse across the midline, typically anterior to the aorta and IVC. This fusion creates a visual effect resembling two hands joined together at the fingers or palms. **Why the correct answer is right:** In a horseshoe kidney, the fusion most commonly occurs at the **lower poles** (90% of cases). Because the kidneys are trapped by the **inferior mesenteric artery (IMA)** during their embryonic ascent, they remain lower in the pelvis and are rotated medially. This anatomical configuration results in the characteristic "Hand joining" appearance on imaging. **Why the incorrect options are wrong:** * **Pelvic duplication & Ureteral duplication:** These refer to anomalies of the collecting system (e.g., duplex kidney). While they may show a "drooping lily" sign (in cases of obstructed upper poles), they do not involve the fusion of renal parenchymal poles across the midline. * **Ureterocele:** This is a cystic dilatation of the distal intramural portion of the ureter. On IVP, it presents with the **"Cobra head"** or "Adder head" sign, not the hand joining sign. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of fusion:** Lower poles. * **Vascular constraint:** Ascent is arrested by the **Inferior Mesenteric Artery (IMA)** at the level of L3-L4. * **Associated Complications:** Increased risk of nephrolithiasis (due to stasis), hydronephrosis (UPJ obstruction), and a higher incidence of **Wilms tumor** and **Renal Cell Carcinoma**. * **Other Signs:** "Flower vase" appearance (due to the orientation of the axes of the calyces).

Question 218: Widening of the C-loop of the duodenum is diagnostic of which of the following conditions?

A. Chronic pancreatitis
B. Carcinoma of the head of the pancreas (Correct Answer)
C. Periampullary carcinoma
D. Calculi in the ampulla of Vater

Explanation: **Explanation:** The **C-loop of the duodenum** is the anatomical space formed by the first, second, and third parts of the duodenum, which snugly cradles the **head of the pancreas**. **Why Option B is Correct:** In **Carcinoma of the head of the pancreas**, the tumor mass causes a significant focal enlargement of the pancreatic head. As the mass expands, it exerts outward pressure on the inner curvature of the descending (2nd) and horizontal (3rd) parts of the duodenum. This results in the classic radiological sign known as **"Widening of the C-loop."** On a Barium swallow/meal, this may also be associated with the **"Frostberg’s inverted 3 sign,"** caused by the tumor fixing the ampulla while the rest of the duodenum is pushed outward. **Why Other Options are Incorrect:** * **Chronic Pancreatitis (A):** While it can cause some contour changes due to fibrosis or pseudocysts, it typically leads to a shrunken, atrophic pancreas rather than a massive expansion that widens the C-loop. * **Periampullary Carcinoma (C):** These tumors arise near the ampulla of Vater. While they cause early biliary obstruction (jaundice), they are usually small at the time of presentation and do not typically reach a size sufficient to displace the entire duodenal sweep. * **Calculi in the Ampulla (D):** Stones cause ductal obstruction and pain but do not create a space-occupying mass effect. **NEET-PG High-Yield Pearls:** * **Rose-Thorn Appearance:** Seen in the duodenum in cases of Crohn’s disease. * **Double Bubble Sign:** Classic for Duodenal Atresia. * **Coiled Spring Appearance:** Seen in intramural duodenal hematoma. * **Pad Sign:** Indentation on the antrum of the stomach or duodenum due to a pancreatic mass.

Question 219: Plain abdominal X-ray is useful in which of the following conditions?

A. Acute pancreatitis
B. Cholesterol stones
C. Caecum cancer
D. Sigmoid volvulus (Correct Answer)

Explanation: ### Explanation **Sigmoid Volvulus (Correct Answer)** Sigmoid volvulus is a surgical emergency where the sigmoid colon twists on its mesenteric axis. A plain abdominal X-ray is the **initial investigation of choice** and is often diagnostic. The characteristic finding is a massively dilated, air-filled loop of sigmoid colon rising out of the pelvis, known as the **"Coffee Bean sign"** or **"Omega sign."** The absence of haustral markings and the presence of two fluid levels within the loop are classic radiographic features. **Why other options are incorrect:** * **Acute Pancreatitis:** While X-rays may show non-specific signs like a "sentinel loop" (localized ileus) or the "colon cut-off sign," they are not diagnostic. **Contrast-Enhanced CT (CECT)** is the gold standard for diagnosing complications and assessing severity. * **Cholesterol Stones:** Approximately 80-85% of gallstones are radiolucent (cholesterol-rich) and cannot be seen on a plain X-ray. **Ultrasonography (USG)** is the investigation of choice for cholelithiasis. * **Caecum Cancer:** Plain X-rays lack the soft-tissue resolution to identify colonic masses. Diagnosis requires **Colonoscopy** (for biopsy) or **CT Colonography**. X-rays would only be useful if the cancer caused a secondary bowel obstruction. **High-Yield Clinical Pearls for NEET-PG:** 1. **Sigmoid Volvulus:** Look for the "Coffee Bean sign." On Gastrografin enema, it shows a **"Bird’s Beak"** or **"Ace of Spades"** appearance. 2. **Cecal Volvulus:** Shows a "fetal lamb" or "comma-shaped" air shadow; unlike sigmoid volvulus, the apex usually points toward the left upper quadrant. 3. **Pneumoperitoneum:** The most sensitive plain X-ray sign for hollow viscus perforation is free air under the right diaphragm on an **erect chest X-ray**. 4. **Rigler’s Sign:** Seeing both sides of the bowel wall on an X-ray, indicating pneumoperitoneum.

Question 220: What diagnosis is suggested by this barium swallow?

A. Ingested foreign body
B. Esophageal diverticula
C. Diffuse esophageal spasm (Correct Answer)
D. Gastric linitis plastica

Explanation: ***Diffuse esophageal spasm*** - Shows characteristic **corkscrew** or **rosary bead** appearance on barium swallow due to simultaneous contractions of the esophageal smooth muscle. - Causes **chest pain** and **dysphagia** with non-peristaltic contractions, creating the distinctive radiographic pattern. *Ingested foreign body* - Would appear as a **radiopaque object** with a defined shape and clear borders on barium swallow. - Typically causes **sudden onset dysphagia** and may show **obstruction** or **filling defect** rather than spastic contractions. *Esophageal diverticula* - Appears as **outpouching** or **sac-like projections** from the esophageal wall on barium studies. - Shows **retained barium** in the diverticular pouches, not the undulating pattern seen in spasm. *Gastric linitis plastica* - Presents as **leather bottle stomach** with rigid, non-distensible gastric walls on barium study. - Affects the **stomach**, not the esophagus, and shows **loss of gastric rugae** with decreased capacity.

Practice by Chapter

Imaging of Liver

Practice Questions

Biliary Tract Imaging

Practice Questions

Pancreatic Imaging

Practice Questions

Spleen and Lymphatic System

Practice Questions

Gastrointestinal Tract Imaging

Practice Questions

Renal and Urinary Tract Imaging

Practice Questions

Adrenal Imaging

Practice Questions

Female Pelvic Imaging

Practice Questions

Male Pelvic Imaging

Practice Questions

Abdominal Trauma Imaging

Practice Questions

Acute Abdomen Imaging

Practice Questions

Imaging of Peritoneal Cavity and Retroperitoneum

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free