Abdominal and Pelvic Radiology Practice Questions

Q: A previously healthy 61-year-old woman presents with a 3-week history of altered bowel habit and rectal bleeding. She refuses to undergo colonoscopy. Which of the following is the next best investigation?

CT colonography. **Explanation:** The clinical presentation of altered bowel habits and rectal bleeding in a 61-year-old is highly suspicious for **Colorectal Carcinoma (CRC)**. While colonoscopy is the gold standard for diagnosis and biopsy, **CT Colonography (CTC)**, also known as "Virtual Colonoscopy," is the preferred alternative when a patient refuses or cannot tolerate conventional colonoscopy. **Why CT Colonography is the Correct Choice:** * **High Sensitivity:** CTC uses thin-slice CT data and 3D reconstruction to detect polyps and masses >10mm with sensitivity comparable to optical colonoscopy. * **Non-Invasive:** It does not require sedation and carries a much lower risk of perforation compared to traditional colonoscopy. * **Staging Capability:** Unlike barium studies, CTC can simultaneously evaluate the bowel wall, extraluminal extension, and distant metastases (TNM staging). **Analysis of Incorrect Options:** * **B. CT Abdomen and Pelvis:** A standard contrast-enhanced CT without specific colonic distension (air/CO2) has poor sensitivity for detecting small mucosal lesions or early-stage tumors. * **C. Barium Enema:** Historically used, but now largely replaced by CTC. It has lower sensitivity for small polyps and cannot provide information regarding extraluminal spread or lymphadenopathy. * **D. Barium Meal Follow-Through:** This is used to evaluate the **small intestine** (e.g., Crohn’s disease). It is not an appropriate investigation for suspected rectal or colonic pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Apple Core Sign:** The classic radiological appearance of annular constricting colorectal carcinoma on barium studies. * **Screening:** In average-risk individuals, screening for CRC should begin at age 45. * **Contraindication:** CTC is contraindicated in patients with acute diverticulitis or recent bowel surgery due to the risk of perforation during insufflation.

Q: A 40-year-old male complains of recurrent urinary tract infections. An X-ray KUB shows a radio-opaque shadow. What is the most likely diagnosis?

Ureteric pathology. ### Explanation **Correct Option: A. Ureteric pathology** The presence of a **radio-opaque shadow** on an X-ray KUB (Kidney, Ureter, Bladder) in a patient with recurrent urinary tract infections (UTIs) most commonly signifies a **urinary calculus**. Since the ureter lies within the anatomical field of a KUB film, a stone lodged in the ureter (ureterolithiasis) will appear as an opacity. Recurrent UTIs are a frequent complication of urolithiasis due to urinary stasis and nidus formation for bacteria. **Why other options are incorrect:** * **B. Prostate pathology:** While prostatic calculi exist, they are usually small, multiple, and located behind the symphysis pubis. Most common prostate pathologies (like BPH or Cancer) are soft-tissue changes not visible as distinct radio-opaque shadows on a standard X-ray. * **C. Testicular pathology:** The testes are located in the scrotum, which is generally outside the primary field of a standard KUB. Testicular pathologies (like tumors or torsion) are evaluated via Ultrasound/Doppler, not X-ray. * **D. Stricture urethra:** A stricture is a narrowing of the urethral lumen. It is a soft-tissue abnormality and is **radiolucent**. It requires a Retrograde Urethrogram (RGU) for visualization, not a plain X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **90% of urinary stones** are radio-opaque (Calcium oxalate > Calcium phosphate > Magnesium ammonium phosphate/Struvite). * **Pure Uric Acid, Xanthine, and Indinavir stones** are radiolucent (not seen on X-ray). * **Phleboliths** (calcified pelvic veins) are the most common mimics of ureteric stones; they often have a "lucent center." * **Investigation of Choice:** Non-contrast CT (NCCT) KUB is the gold standard for detecting all types of urinary stones.

Q: Bilateral spider leg appearance of the kidney in IVP is characteristic of which condition?

Polycystic kidney disease. **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, fluid-filled cysts within the renal parenchyma exert pressure on the collecting system. This causes the renal pelvis and calyces to become elongated, stretched, narrowed, and attenuated, mimicking the thin, spindly legs of a spider. **Analysis of Options:** * **Polycystic Kidney Disease (Correct):** As explained, the bilateral enlargement of the kidney by numerous cysts distorts the calyces into elongated, thin structures. * **Hydronephrosis:** This condition presents with **dilatation** of the renal pelvis and calyces (clubbing of calyces), rather than the stretching/thinning seen in ADPKD. * **Medullary Sponge Kidney:** Characterized by the **"Paintbrush appearance"** or "Bouquet of flowers" due to ectasia (dilatation) of the collecting ducts in the renal pyramids. * **Renal Cell Carcinoma:** While it can cause stretching of calyces, it is typically **unilateral** and presents as a localized mass effect rather than the diffuse, bilateral "spider leg" deformity. **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. * **Pancake Kidney:** A fusion anomaly where both kidneys are fused into a single mass in the pelvis. * **Rim Sign:** Seen in severe hydronephrosis on IVP.

Q: A middle-aged male, a diagnosed case of chronic ulcerative colitis, presents to the emergency department with fever and diarrhea for one week, and acute onset abdominal pain for six hours. An erect abdominal X-ray was taken as shown. What is the likely diagnosis?

Toxic megacolon. ***Toxic megacolon*** - A patient with **chronic ulcerative colitis** presenting with fever, diarrhea, and acute abdominal pain strongly suggests **toxic megacolon**, a life-threatening complication. - The erect abdominal X-ray would show **colonic dilatation >6 cm** with **loss of haustral markings**, pathognomonic features of this condition. *Pseudomembranous colitis* - Typically caused by **Clostridioides difficile** infection, often following antibiotic therapy, which is not mentioned in this case. - While it can cause fever and diarrhea, it rarely presents with the **severe colonic dilatation** seen on imaging in toxic megacolon. *Adenocarcinoma of the colon* - Usually presents with **gradual onset** symptoms like weight loss, changes in bowel habits, and occult bleeding over months. - Would not cause the **acute severe dilatation** and systemic toxicity seen in this emergency presentation. *Pneumatosis intestinalis* - Characterized by **gas within the bowel wall** creating a linear lucency pattern on X-ray, not colonic dilatation. - Typically associated with **ischemic bowel disease** or severe inflammation, but doesn't match the clinical presentation of toxic megacolon.

Q: The "string sign" on imaging is suggestive of which of the following conditions?

Hypertrophic Pyloric Stenosis (HPS). ### Explanation **Correct Answer: B. Hypertrophic Pyloric Stenosis (HPS)** The **"String Sign"** is a classic radiological finding in Hypertrophic Pyloric Stenosis (HPS). It is seen on a Barium swallow study when the contrast passes through a severely narrowed and elongated pyloric canal. The hypertrophy of the circular muscle of the pylorus causes luminal constriction, leaving only a thin "string" of contrast visible. **Analysis of Incorrect Options:** * **A. Toxic Megacolon:** Characterized by massive colonic dilation (usually >6 cm) and loss of haustral markings. The classic sign is a "distended, air-filled colon" on a plain X-ray, not a string sign. * **C. Ulcerative Colitis:** Chronic inflammation leads to the loss of haustral folds and shortening of the colon, resulting in the **"Lead Pipe"** appearance. (Note: A "String Sign" can be seen in **Crohn’s Disease** due to terminal ileum narrowing, but it is not a feature of Ulcerative Colitis). * **D. Irritable Bowel Syndrome (IBS):** This is a functional disorder; imaging is typically normal and does not show structural narrowing or the string sign. **High-Yield Clinical Pearls for NEET-PG:** * **HPS Presentation:** Typically occurs in first-born males (3–6 weeks old) with **non-bilious, projectile vomiting**. * **Physical Exam:** A palpable, firm, mobile mass in the epigastrium known as the **"Olive sign."** * **Metabolic Profile:** Hypochloremic, hypokalemic metabolic alkalosis (due to loss of HCl from vomiting). * **Other HPS Signs:** * **Beak Sign:** Contrast entering the proximal end of the narrowed canal. * **Shoulder Sign:** Bulging of the pyloric muscle into the antrum. * **Double Track Sign:** Two thin streaks of barium separated by a radiolucent mucosal fold. * **Investigation of Choice:** Ultrasound (Criteria: Pyloric muscle thickness >3-4 mm or length >14-16 mm).

Q: A middle-aged patient presents with a complaint of right hypochondrial pain. An X-ray shows an elevated right hemidiaphragm. Which of the following is NOT a possible diagnosis?

Acute cholecystitis. **Explanation:** The elevation of a hemidiaphragm on a chest or abdominal X-ray is typically caused by either **phrenic nerve palsy**, **intrathoracic volume loss** (e.g., collapse), or **intra-abdominal pathology** that exerts upward pressure or causes reactive irritation of the diaphragmatic muscle. **Why Acute Cholecystitis is the Correct Answer:** In **Acute Cholecystitis**, the inflammation is localized to the gallbladder, which is situated on the inferior surface of the liver, well away from the diaphragmatic pleura. While it causes significant right hypochondrial pain and tenderness (Murphy’s sign), it typically does not involve the superior surface of the liver or the subphrenic space. Therefore, it does not cause the mass effect or diaphragmatic irritation required to elevate the hemidiaphragm. **Analysis of Incorrect Options:** * **Subphrenic Abscess (Option A):** An accumulation of infected fluid between the liver and the diaphragm directly pushes the diaphragm upward and causes reactive paralysis/splinting. * **Pyogenic & Amoebic Liver Abscesses (Options C & D):** Large abscesses, especially those located in the superior segments of the right lobe of the liver, cause hepatomegaly and localized inflammatory changes that frequently result in an elevated right hemidiaphragm and occasionally a reactive pleural effusion. **NEET-PG High-Yield Pearls:** * **Eventration of Diaphragm:** A congenital condition where the diaphragm is thin/weak (muscular aplasia), leading to permanent elevation. * **Phrenic Nerve Palsy:** Most common cause of a newly elevated hemidiaphragm; confirmed by the **Sniff Test** (paradoxical upward movement of the paralyzed side during inspiration under fluoroscopy). * **Amoebic Liver Abscess:** Classically presents with "anchovy sauce" pus; elevation of the right hemidiaphragm is a classic radiological sign.

Question 1

What type of CT scan is used to characterize the chemical composition of kidney stones?

Accepted Answer

Dual-source CT

Answer

Spiral CT

Answer

Multidetector CT

Answer

HRCT

Question 2

What is the investigation of choice for retroperitoneal soft tissue sarcomas?

Accepted Answer

CT Scan

Answer

MRI

Answer

USG

Answer

PET scan

Question 3

A previously healthy 61-year-old woman presents with a 3-week history of altered bowel habit and rectal bleeding. She refuses to undergo colonoscopy. Which of the following is the next best investigation?

Accepted Answer

CT colonography

Answer

CT abdomen and pelvis

Answer

Barium enema

Answer

Barium meal follow-through

Question 4

A 40-year-old male complains of recurrent urinary tract infections. An X-ray KUB shows a radio-opaque shadow. What is the most likely diagnosis?

Accepted Answer

Ureteric pathology

Answer

Prostate pathology

Answer

Testicular pathology

Answer

Stricture urethra

Question 5

What is true regarding the barium study of ileocecal tuberculosis?

Accepted Answer

String sign

Answer

Goose neck sign

Answer

Right-sided obstruction

Answer

Pulled up cecum

Question 6

Bilateral spider leg appearance of the kidney in IVP is characteristic of which condition?

Accepted Answer

Polycystic kidney disease

Answer

Hydronephrosis

Answer

Medullary sponge kidney

Answer

Renal cell carcinoma

Question 7

A middle-aged male, a diagnosed case of chronic ulcerative colitis, presents to the emergency department with fever and diarrhea for one week, and acute onset abdominal pain for six hours. An erect abdominal X-ray was taken as shown. What is the likely diagnosis?

Accepted Answer

Toxic megacolon

Answer

Pseudomembranous colitis

Answer

Adenocarcinoma of the colon

Answer

Pneumatosis intestinalis

Question 8

All are true about the radiological features of intestinal obstruction except?

Accepted Answer

Volvulus and mesenteric ischemia have characteristic signs on abdominal films.

Answer

The small intestines are said to be dilated if the loops of bowel have a diameter of > 3 cm.

Answer

The large bowel is said to be dilated if it is > 5 cm for distal bowel and > 9 cm for proximal bowel.

Answer

The absence of air-fluid levels on plain supine radiographs does not rule out the presence of an obstruction.

Question 9

The "string sign" on imaging is suggestive of which of the following conditions?

Accepted Answer

Hypertrophic Pyloric Stenosis (HPS)

Answer

Toxic Megacolon

Answer

Ulcerative Colitis

Answer

Irritable Bowel Syndrome (IBS)

Question 10

A middle-aged patient presents with a complaint of right hypochondrial pain. An X-ray shows an elevated right hemidiaphragm. Which of the following is NOT a possible diagnosis?

Accepted Answer

Acute cholecystitis

Answer

Subphrenic abscess

Answer

Pyogenic liver abscess

Answer

Amoebic liver abscess in the right lobe

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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