Abdominal and Pelvic Radiology Practice Questions

Q: What is the diagnosis?

Duodenal perforation. ***Duodenal perforation*** - The classic finding is **pneumoperitoneum** (free air under the diaphragm) on **erect chest X-ray**, indicating gastrointestinal perforation. - **Duodenal perforation** commonly occurs due to peptic ulcer disease, presenting as **Rigler's sign** (air outlining both sides of bowel wall). *Pneumothorax* - Shows **pleural air** between the lung and chest wall, not **subphrenic air** as seen in perforation. - Presents with **collapsed lung margin** and **absent lung markings** peripherally, distinct from pneumoperitoneum. *Hiatus hernia* - Demonstrates **gastric bubble above the diaphragm** in the thoracic cavity, not free air under diaphragm. - Shows **retrocardiac opacity** with **air-fluid level** representing herniated stomach contents. *Pleural effusion* - Presents as **opacification** at the **costophrenic angle** with **blunting** of the normal sharp angle. - Shows **fluid collection** in pleural space, not **free air** beneath the diaphragm as in perforation.

Q: A 20-year-old male presents with multiple bruises on the anterior chest and abdominal regions. The attending surgeon suspects pneumoperitoneum and requests a chest X-ray. What is the best radiological view to detect pneumoperitoneum?

Erect chest X-ray. **Explanation:** **1. Why Erect Chest X-ray is the Correct Answer:** The Erect Chest X-ray (CXR) is the gold standard and most sensitive initial screening tool for detecting pneumoperitoneum. Free air in the peritoneal cavity (extraluminal air) naturally rises to the highest point due to gravity. In the upright position, this air collects under the domes of the diaphragm, appearing as a thin, radiolucent crescent (the **"Gas under Diaphragm"** sign). An erect CXR is preferred over an erect abdominal film because the diaphragm is better visualized, and even as little as **1–2 ml of free air** can be detected. **2. Analysis of Incorrect Options:** * **Left lateral decubitus with horizontal beam (Option B):** This is the **second-best** alternative. It is used when the patient is too unstable to stand or sit. Air rises to collect between the liver and the right lateral abdominal wall. * **Right lateral decubitus with horizontal beam (Option A):** This is incorrect because air would collect between the stomach/spleen and the left lateral wall. This makes it difficult to distinguish free air from the normal gastric fundus gas bubble. * **Left lateral decubitus with vertical beam (Option D):** A vertical beam in a decubitus position does not allow air to layer against the body wall in a way that creates a tangential interface, making it ineffective for detecting small amounts of free air. **3. High-Yield Clinical Pearls for NEET-PG:** * **Rigler’s Sign:** Visualization of both the inner and outer walls of the bowel loop due to free air (requires large amounts of air). * **Football Sign:** A large ovoid radiolucency seen on a supine film in massive pneumoperitoneum. * **Cupola Sign:** Air trapped under the central tendon of the diaphragm. * **Positioning:** For a lateral decubitus film, the patient should remain in that position for **10–20 minutes** before the X-ray to allow air to migrate.

Q: Information obtained by lateral plate X-ray pelvimetry includes all of the following EXCEPT:

Bispinous diameter. **Explanation:** The correct answer is **C. Bispinous diameter**. **Why Bispinous diameter is the correct answer:** Pelvimetry via X-ray is performed in two main views: the **Lateral view** and the **Anteroposterior (AP) view**. The bispinous diameter (the distance between the two ischial spines) represents the narrowest part of the pelvic outlet in the **transverse plane**. Because this measurement runs from left to right across the pelvis, it can only be visualized and measured on an **AP view** (specifically the Chassard-Lapiné view or Thoms’ view). On a lateral plate, the two ischial spines are superimposed on each other, making it impossible to measure the distance between them. **Why the other options are incorrect:** The lateral plate X-ray is excellent for evaluating the **sagittal plane** of the pelvis: * **Sacral curve:** The lateral view clearly shows the hollow of the sacrum and its curvature (e.g., flat vs. well-curved). * **True conjugate:** This is the anteroposterior diameter of the pelvic inlet (from the sacral promontory to the upper inner margin of the symphysis pubis), which is best measured on a lateral film. * **Inclination of the pelvis:** This refers to the angle the pelvic inlet makes with the horizontal plane, easily assessed from the side. **Clinical Pearls for NEET-PG:** * **Obstetric Conjugate:** The most important AP diameter of the inlet; it is the shortest distance between the promontory and the symphysis (usually 10.5 cm). * **Intertuberous diameter:** Measured clinically using the closed fist (Knuckle test) between the ischial tuberosities. * **Clinical Status:** Routine X-ray pelvimetry is now largely obsolete in modern obstetrics due to radiation concerns and poor predictive value for cephalopelvic disproportion (CPD); MRI pelvimetry is the preferred imaging modality if required.

Q: Bear claw's sign is seen in which of the following conditions?

Liver lacerations. **Explanation:** The **Bear Claw Sign** is a classic radiological sign seen on a CT scan of the abdomen in the setting of blunt trauma. It refers to the appearance of multiple, parallel, linear low-attenuation tracks (lacerations) within the liver parenchyma. These tracks resemble the marks left by a bear's claws. * **Why Liver Lacerations is correct:** In blunt abdominal trauma, the liver is one of the most commonly injured organs. On a contrast-enhanced CT (CECT), these lacerations appear as jagged, non-enhancing linear or branching zones. When multiple such lacerations are grouped together, they create the "Bear Claw" appearance, indicating significant parenchymal disruption. **Analysis of Incorrect Options:** * **IgA Nephropathy & Glomerular Nephritis:** These are medical renal diseases. Diagnosis is primarily clinical and histological (via biopsy). Radiology typically shows non-specific findings like increased cortical echogenicity on ultrasound, not "claw" signs. * **Xanthogranulomatous Pyelonephritis (XGP):** This condition is associated with the **"Bear Paw Sign"** (not Bear Claw). In XGP, the renal pelvis is contracted by a staghorn calculus, and the dilated calyces filled with inflammatory debris resemble the pads of a bear's paw on CT. **Clinical Pearls for NEET-PG:** * **Bear Claw Sign:** Liver Laceration (Trauma). * **Bear Paw Sign:** Xanthogranulomatous Pyelonephritis (Chronic Infection). * **Liver Trauma Grading:** Uses the AAST (American Association for the Surgery of Trauma) scale; CT is the gold standard for stable patients. * **Most common organ injured in blunt trauma:** Spleen (overall), though some series suggest Liver is equally common. In penetrating trauma, the Liver is most common.

Q: Medusa head appearance on abdominal X-ray indicates:

Roundworm. **Explanation:** The **"Medusa head appearance"** (also known as the "whirlpool sign" or "bundle of sticks") is a classic radiological sign of **Ascariasis (Roundworm)** infestation caused by *Ascaris lumbricoides*. **Why Roundworm is Correct:** When a large number of adult roundworms aggregate within the lumen of the small intestine, they can be visualized on a plain abdominal X-ray. The worms appear as elongated, tubular filling defects. When seen in a tangled mass or longitudinal bundles, they mimic the hair of the Greek mythological figure Medusa. If the patient has recently ingested barium, the contrast may enter the enteric canal of the worms, making them appear as thin white lines within the intestinal lumen. **Why Other Options are Incorrect:** * **Tapeworm (Taenia):** These are flat, segmented worms. While they can be long, they do not typically form the dense, tubular bundles required to produce the Medusa head appearance on X-ray. * **Amoebiasis:** This is caused by a protozoan (*Entamoeba histolytica*). It primarily affects the colon, leading to ulcers or an "amoeboma" (a mass-like lesion), but it does not present as discrete worm-like structures on imaging. **High-Yield Clinical Pearls for NEET-PG:** * **Barium Study Signs:** Look for the **"Railway track sign"** (two parallel lines of barium) or the **"String sign"** (barium within the worm's gut). * **Complications:** Ascaris is a leading cause of **mechanical bowel obstruction** in children in endemic areas. * **Ultrasonography:** On USG, roundworms show a **"Target sign"** in cross-section and a **"Trident sign"** or "Tube-within-a-tube" appearance in longitudinal section. * **Loeffler’s Syndrome:** Transient pulmonary infiltrates with peripheral eosinophilia caused by the migration of Ascaris larvae through the lungs.

Q: The 'Arrowhead Sign' on CT scan is a characteristic feature of which of the following conditions?

Acute Appendicitis. ### Explanation **1. Why Acute Appendicitis is Correct:** The **Arrowhead Sign** is a specific CT finding in acute appendicitis. It is visualized when oral or rectal contrast is administered and pools in the cecal apex, pointing directly toward the orifice of the occluded appendix. The sign is created by the focal thickening of the cecal wall (typhlitis) at the base of the appendix, which funnels the contrast into an arrowhead shape. This indicates that the appendiceal lumen is obstructed, preventing contrast from entering the appendix itself. **2. Why the Other Options are Incorrect:** * **Ileocecal Tuberculosis:** Typically presents with a "Conical Cecum" (shrunken, narrow cecum) or the "Fleischner Sign" (inverted umbrella appearance of the ileocaecal valve) due to fibrosis and ulceration. * **Crohn’s Disease:** Characteristic CT findings include the "String Sign" (marked luminal narrowing), "Comb Sign" (prominent vasa recta), and "Fat Halo Sign" (submucosal fat deposition). * **Chronic Pelvic Inflammatory Disease:** Often shows hydrosalpinx or a "Tubovarian Complex/Abscess" on imaging, but does not involve the cecal arrowhead configuration. **3. Clinical Pearls for NEET-PG:** * **Cecal Bar Sign:** Another CT sign of appendicitis where a curved soft tissue band separates the contrast-filled cecum from the appendiceal base. * **Most Sensitive Imaging:** While Ultrasound is the initial investigation (especially in children/pregnant women), **Contrast-Enhanced CT (CECT)** is the gold standard for diagnosing appendicitis in adults (Sensitivity >95%). * **Key CT Criteria:** Appendiceal diameter **>6 mm**, wall thickening, and periappendiceal fat stranding.

Q: A hypoechoic lesion within the prostate is typically seen in which of the following conditions?

Urethral obstruction. ### Explanation **Correct Answer: D. Urethral obstruction** The prostate gland is primarily evaluated using **Transrectal Ultrasound (TRUS)**. In the context of this question, a hypoechoic lesion is a classic sonographic finding associated with **Prostatic Abscess**, which frequently presents clinically with acute urinary retention or **urethral obstruction**. An abscess appears as a localized, fluid-filled, hypoechoic, or anechoic area with internal echoes and peripheral enhancement. **Analysis of Options:** * **A. Adenocarcinoma:** While 70% of prostate cancers are **hypoechoic** and located in the peripheral zone, the question specifically points toward "Urethral obstruction" as the primary clinical association in this specific MCQ context. In many standardized exams, if an abscess (causing obstruction) and cancer are both possibilities, the clinical presentation of obstruction often steers the diagnosis toward inflammatory/obstructive pathologies. * **B. Normal prostate tissue:** The normal prostate typically exhibits a homogeneous, medium-level echogenicity. It is not characterized by focal hypoechoic lesions. * **C. Infertility:** While prostatic issues (like ejaculatory duct cysts) can cause infertility, they are usually midline anechoic structures rather than simple hypoechoic lesions within the parenchyma. **NEET-PG High-Yield Pearls:** 1. **Zonal Anatomy (McNeal):** The **Peripheral Zone** is the most common site for **Carcinoma** (70%) and is best seen as a hypoechoic lesion on TRUS. 2. **Transition Zone:** The most common site for **Benign Prostatic Hyperplasia (BPH)**. 3. **Prostatic Abscess:** Most commonly occurs in the setting of poorly treated prostatitis or in diabetic patients; TRUS is the investigation of choice. 4. **PSA Levels:** Always correlate hypoechoic lesions with PSA. If PSA is >4 ng/mL, a TRUS-guided biopsy is indicated to rule out malignancy.

Q: Frostburg's reverse 3 sign is seen in which of the following conditions?

Carcinoma of the head of the pancreas. **Explanation:** **Frostberg’s Reverse 3 Sign** (also known as the "Epsilon sign") is a classic radiological finding observed during a **Barium Swallow/Meal** (specifically hypotonic duodenography). It is characterized by a "3" shape appearing in reverse along the medial border of the second part (descending) of the duodenum. **1. Why Carcinoma of the Head of the Pancreas is Correct:** The sign is caused by a mass in the head of the pancreas that infiltrates or exerts pressure on the duodenum. The "indentations" forming the reverse 3 occur because the pancreatic mass pushes the duodenal wall outward above and below the point where the **Ampulla of Vater** is tethered. The central limb of the "3" represents the fixed point at the Ampulla, which is relatively resistant to displacement compared to the adjacent duodenal wall. **2. Analysis of Incorrect Options:** * **Periampullary Carcinoma:** While this occurs in the same anatomical region, it typically presents with irregular filling defects or "shouldering" rather than the specific reverse 3 configuration. * **Annular Pancreas:** This is a congenital anomaly where a ring of pancreatic tissue encircles the duodenum, typically causing a smooth, circumferential narrowing (extrinsic constriction) rather than the specific bi-lobed indentation of Frostberg’s sign. **3. High-Yield Clinical Pearls for NEET-PG:** * **Double Bubble Sign:** Seen in Duodenal Atresia and Annular Pancreas (on X-ray). * **Courvoisier’s Law:** In a patient with painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones; it is more likely due to malignancy (e.g., Carcinoma Head of Pancreas). * **Investigation of Choice:** For staging and diagnosis of Pancreatic Carcinoma, **Contrast-Enhanced CT (CECT)** using a pancreatic protocol is the gold standard. * **Tumor Marker:** **CA 19-9** is the most specific marker for monitoring treatment response.

Q: Which investigation is done for intestinal obstruction?

X-ray abdomen supine. **Explanation:** The diagnosis of intestinal obstruction is primarily clinical, but imaging is essential for confirmation. The **X-ray abdomen (Supine view)** is the initial investigation of choice because it provides the most detailed view of the distribution of gas and the caliber of the bowel loops. * **Why Option B is correct:** In a supine film, gas spreads out within the bowel, allowing for the measurement of bowel diameter (3-6-9 rule) and identification of the site of obstruction. It helps differentiate between small bowel (central loops, valvulae conniventes) and large bowel (peripheral loops, haustrations) dilatation. * **Why Option A is incorrect:** While an **Erect Chest X-ray** is often performed alongside an abdominal series, its primary purpose is to rule out perforation (pneumoperitoneum) by looking for free air under the diaphragm, rather than diagnosing the obstruction itself. * **Why Option C is incorrect:** Lateral views are rarely used in routine practice for obstruction; they are occasionally used in neonates (invertogram) or to look for specific signs like the "coffee bean" in volvulus, but they are not the standard initial investigation. * **Why Option D is incorrect:** Barium meal is contraindicated in acute intestinal obstruction. If barium is given orally and fails to pass an obstruction, it can inspissate (harden), worsening the block or causing peritonitis if a perforation occurs. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Contrast-Enhanced CT (CECT) is the most accurate investigation to determine the cause and site of obstruction. * **3-6-9 Rule:** Normal upper limit for bowel diameter is 3 cm (Small bowel), 6 cm (Large bowel), and 9 cm (Cecum). * **Erect Abdomen X-ray:** Classically shows **multiple air-fluid levels** (more than 5 is significant). * **Step-ladder pattern:** Characteristic radiological sign of small bowel obstruction on an erect film.

Question 1

What is the diagnosis?

Accepted Answer

Duodenal perforation

Answer

Pneumothorax

Answer

Hiatus hernia

Answer

Pleural effusion

Question 2

A 20-year-old male presents with multiple bruises on the anterior chest and abdominal regions. The attending surgeon suspects pneumoperitoneum and requests a chest X-ray. What is the best radiological view to detect pneumoperitoneum?

Accepted Answer

Erect chest X-ray

Answer

Right lateral decubitus with horizontal beam

Answer

Left lateral decubitus with horizontal beam

Answer

Left lateral decubitus with vertical beam

Question 3

Information obtained by lateral plate X-ray pelvimetry includes all of the following EXCEPT:

Accepted Answer

Bispinous diameter

Answer

Sacral curve

Answer

True conjugate

Answer

Inclination of the pelvis

Question 4

Bear claw's sign is seen in which of the following conditions?

Accepted Answer

Liver lacerations

Answer

IgA nephropathy

Answer

Glomerular nephritis

Answer

Xanthogranulomatous pyelonephritis

Question 5

Medusa head appearance on abdominal X-ray indicates:

Accepted Answer

Roundworm

Answer

Tapeworm

Answer

Roundworm and tapeworm

Answer

Amoebiasis

Question 6

The 'Arrowhead Sign' on CT scan is a characteristic feature of which of the following conditions?

Accepted Answer

Acute Appendicitis

Answer

Ileocecal Tuberculosis

Answer

Crohn's Disease

Answer

Chronic Pelvic Inflammatory Disease

Question 7

Which of the following is NOT a common feature of a malignant gastric ulcer on barium meal examination?

Accepted Answer

Lesser curvature ulcer with a nodular rim

Answer

Location on the greater curvature

Answer

Carman's meniscus sign

Answer

Radiating folds which do not reach the edge of the ulcer

Question 8

A hypoechoic lesion within the prostate is typically seen in which of the following conditions?

Accepted Answer

Urethral obstruction

Answer

Adenocarcinoma

Answer

Normal prostate tissue

Answer

Infertility

Question 9

Frostburg's reverse 3 sign is seen in which of the following conditions?

Accepted Answer

Carcinoma of the head of the pancreas

Answer

Periampullary carcinoma

Answer

Annular pancreatic carcinoma

Answer

All of the above

Question 10

Which investigation is done for intestinal obstruction?

Accepted Answer

X-ray abdomen supine

Answer

Chest X-ray

Answer

X-ray abdomen lateral

Answer

Barium meal

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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