Abdominal and Pelvic Radiology Practice Questions

Q: What is the characteristic feature of a malignant gastric ulcer seen on a barium meal?

Carman meniscus sign. ### Explanation In barium studies, the differentiation between benign and malignant gastric ulcers is a high-yield topic for NEET-PG. **Correct Answer: B. Carman Meniscus Sign** The **Carman meniscus sign** is a classic radiological feature of a large, necrotic, malignant gastric ulcer (usually adenocarcinoma). It occurs when a lenticular-shaped ulcer sits on a large, elevated mass. When manual compression is applied during a barium meal, the barium is trapped in the ulcer crater, appearing as a **crescent (meniscus)** with its convexity directed toward the gastric wall. The "Kirklin complex" refers to the elevated, nodular neoplastic rim surrounding this meniscus. **Analysis of Incorrect Options:** * **A. Hampton Line:** This is a thin (1 mm), sharp, radiolucent line across the neck of an ulcer crater, representing the undermined mucosal edge. It is a hallmark of a **benign** gastric ulcer. * **C. Ulcer Cap:** This is not a standard radiological term for malignancy. However, a "summit lesion" or "ulcer on a mound" can be seen in both, but the specific morphology of the mound determines the nature. * **D. Ulcer Crater:** This is a general term for the barium-filled niche. In benign ulcers, the crater typically projects **beyond** the predicted gastric contour, whereas in malignant ulcers, the crater lies **within** the contour. **High-Yield Clinical Pearls for NEET-PG:** * **Benign Ulcer Features:** Hampton line, Ulcer collar (edematous rim), and radiating mucosal folds that reach the very edge of the crater. * **Malignant Ulcer Features:** Carman meniscus sign, irregular/nodular base, and mucosal folds that stop short or are clubbed/fused before reaching the crater. * **Location:** Benign ulcers are most common on the lesser curvature; malignant ulcers can occur anywhere but are suspicious if located on the greater curvature.

Q: Renal tuberculosis can be diagnosed earliest by which imaging modality?

Intravenous pyelogram (IVP). **Explanation:** **1. Why Intravenous Pyelogram (IVP) is the Correct Answer:** Renal tuberculosis (TB) is a "disease of the calyces." The earliest pathological changes occur at the renal papillae (papillitis), leading to erosion and ulceration. **Intravenous Pyelogram (IVP)** is the most sensitive modality for detecting these subtle, early mucosal changes. The earliest radiological sign of renal TB on IVP is **"moth-eaten" calyces**, which represents irregular ulceration of the papillary tips. As the disease progresses, IVP can also demonstrate "Phantom Calyx" (infundibular stricture causing non-visualization of a calyx). **2. Why Other Options are Incorrect:** * **CT Scan:** While Contrast-Enhanced CT (CECT) is the "Gold Standard" for staging and assessing the extent of advanced renal TB (showing "Putty Kidney" or calcifications), it lacks the spatial resolution required to detect the very earliest mucosal ulcerations seen on IVP. * **Ultrasonography (USG):** USG is non-specific. It may show hydronephrosis or debris, but it cannot visualize early papillary erosions or subtle calyceal distortions. * **Angiography:** This is an invasive procedure used to assess vascularity. It has no role in the early diagnosis of renal TB and would only show non-specific findings like decreased perfusion in end-stage "autonephrectomy." **3. High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign on IVP:** Moth-eaten calyces. * **Most Common Sign on IVP:** Hydrocalycosis (due to strictures). * **Putty Kidney:** A small, shrunken, non-functioning kidney with autonephrectomy (seen in end-stage TB). * **Thimble Bladder:** A small-capacity, fibrotic bladder resulting from chronic TB cystitis. * **Kerr’s Kink:** A characteristic narrowing at the pelviureteric junction (PUJ) seen in renal TB.

Q: What is the most common cause of 'target lesion' in the stomach?

Melanoma. **Explanation:** The **'Target lesion'** (also known as the **'Bull’s eye' lesion**) on a barium study or CT scan refers to a large, solitary or multiple submucosal nodules with a central crater or umbilication. This central depression is caused by ulceration at the apex of the mass. **1. Why Melanoma is Correct:** Metastatic **Melanoma** is the most common cause of multiple target lesions in the gastrointestinal tract, particularly the stomach. Melanoma has a high predilection for hematogenous spread to the submucosa of the GI tract. As the submucosal nodule grows, it outstrips its blood supply, leading to central necrosis and ulceration, which creates the classic "bull's eye" appearance when barium fills the central crater. **2. Analysis of Incorrect Options:** * **Carcinoid:** While carcinoid tumors are submucosal, they typically present as small, firm, yellowish nodules and rarely ulcerate to form a classic target lesion compared to melanoma. * **Lymphoma:** Gastric lymphoma usually presents with markedly thickened rugal folds or large infiltrating masses. While it can occasionally ulcerate, it is not the "most common" cause of this specific radiological sign. * **Fibroma:** These are rare benign mesenchymal tumors. They are usually smooth and do not typically undergo central umbilication. **3. Clinical Pearls for NEET-PG:** * **Differential Diagnosis of Target Lesions:** Metastatic melanoma (most common), Kaposi sarcoma, Lymphoma, and occasionally GIST (Gastrointestinal Stromal Tumor). * **Ectopic Pancreas:** If a target lesion is seen specifically in the **antrum** of the stomach, an ectopic pancreas (pancreatic rest) is a high-yield differential. * **Key Imaging Sign:** The "Target sign" in **ultrasound** is different; it typically refers to **Intussusception** (concentric rings of bowel). Always distinguish between the "Target lesion" on barium/CT (ulcerated mass) and the "Target sign" on USG.

Q: The Seagull sign is seen in which of the following conditions?

Gallstone ileus. **Explanation:** The **Seagull sign** in abdominal radiology refers to the characteristic appearance of **gas within the biliary tree (pneumobilia)**. In the context of **Gallstone ileus**, this occurs because a large gallstone erodes through the gallbladder wall into the duodenum (cholecystoenteric fistula). This fistula allows air from the bowel to enter the biliary tract, appearing on an X-ray or CT as Y-shaped or branching lucencies in the right upper quadrant, resembling a seagull in flight. Gallstone ileus is classically defined by **Rigler’s Triad** on a plain abdominal radiograph: 1. **Pneumobilia** (Seagull sign) 2. **Small bowel obstruction** (dilated loops) 3. **Ectopic gallstone** (usually in the ileocecal valve) **Analysis of Incorrect Options:** * **Chronic pancreatitis:** Characterized by "Chain of Lakes" appearance (ductal dilatation) or speckled calcifications on X-ray/CT. * **Appendicitis:** Associated with an appendicolith (fecalith) or the "Target sign" on ultrasound/CT, but not pneumobilia. * **Acute cholecystitis:** Typically shows gallbladder wall thickening, pericholecystic fluid, or a positive sonographic Murphy’s sign. **NEET-PG Clinical Pearls:** * **Rigler’s Triad** is a high-yield diagnostic cluster for Gallstone ileus. * The most common site of obstruction in gallstone ileus is the **ileum** (narrowest part of the small bowel). * **Bouveret Syndrome** is a specific variant where the gallstone impacts in the duodenum, causing gastric outlet obstruction. * *Note:* In vascular radiology, the "Seagull sign" can also refer to the celiac trunk and its branches (hepatic and splenic arteries) on CT/US, but in the context of abdominal pathology questions, it almost always refers to pneumobilia.

Q: A multiloculated cystic lesion in the liver is a CT feature of which of the following?

Hydatid cyst. ### Explanation **Correct Answer: A. Hydatid Cyst** Hydatid disease, caused by *Echinococcus granulosus*, typically presents as a well-defined cystic lesion in the liver. The characteristic CT feature is a **multiloculated appearance**, often described as a **"cyst-within-a-cyst."** This occurs due to the formation of **daughter cysts** within a larger mother cyst. Other classic imaging findings include internal septations (honeycomb pattern), a detached germinal membrane (water-lily sign), and curvilinear "eggshell" calcification of the cyst wall. **Why the other options are incorrect:** * **B. Necrotic mass:** While a necrotic tumor can have fluid components, it usually presents as a central area of low attenuation with irregular, thick, and ragged walls, rather than organized internal daughter cysts. * **C. Hepatocellular carcinoma (HCC):** HCC is typically a solid hypervascular lesion. On contrast-enhanced CT, it shows characteristic **"arterial phase enhancement"** with **"venous phase washout."** It is not primarily a multiloculated cystic lesion. * **D. Metastasis:** Most liver metastases are solid. While some (e.g., from cystadenocarcinoma) can be cystic, they typically present as multiple discrete lesions rather than a single multiloculated cyst with internal daughter vesicles. **High-Yield Clinical Pearls for NEET-PG:** * **Gharbi Classification:** Used to stage Hydatid cysts based on ultrasound/CT findings (Type II is the classic multivesicular/multiloculated stage). * **Water-lily sign:** Seen when the endocyst detaches from the pericyst due to rupture or death of the parasite. * **Management:** The **PAIR** technique (Puncture, Aspiration, Injection, Re-aspiration) is a minimally invasive treatment option, though contraindicated in superficial or heavily calcified cysts. * **Serology:** ELISA for echinococcal antibodies is the most common confirmatory laboratory test.

Q: Which type of mesenteric ischemia is best visualized by CECT?

Acute mesenteric venous thrombosis. **Explanation:** **Contrast-Enhanced Computed Tomography (CECT)** is the gold standard for diagnosing **Acute Mesenteric Venous Thrombosis (MVT)**. In MVT, CECT demonstrates a high sensitivity (>90%) by showing a filling defect (hypodensity) within the superior mesenteric vein (SMV), often associated with significant bowel wall thickening, "target sign" enhancement, and mesenteric stranding due to venous congestion. **Why the other options are incorrect:** * **A & B (Embolic Occlusion & Arterial Thrombosis):** While CECT can detect arterial occlusions, **CT Angiography (CTA)** with thin-section arterial phase reconstruction is the preferred modality for arterial causes. Embolic events often occur at the origin of the SMA or distal to the middle colic artery, requiring high-resolution arterial imaging to visualize the "cutoff" sign. * **C (Non-occlusive Mesenteric Ischemia - NOMI):** NOMI is caused by low-flow states (e.g., shock, vasopressors). CECT findings are often non-specific or normal in early stages. **Digital Subtraction Angiography (DSA)** remains the gold standard for NOMI as it allows for both diagnosis (showing "string-of-beads" appearance) and therapeutic infusion of vasodilators like papaverine. **High-Yield Clinical Pearls for NEET-PG:** * **MVT Hallmark:** Look for the **"Target Sign"** or **"Halo Sign"** on CECT, representing submucosal edema. * **Pneumatosis Intestinalis:** Presence of air in the bowel wall on CT indicates advanced ischemia/infarction (poor prognosis). * **SMA vs. SMV:** Arterial ischemia (SMA) usually presents with "paper-thin" bowel walls due to lack of inflow, whereas venous ischemia (SMV) presents with "thickened" walls due to congestion. * **Gold Standard for Arterial Ischemia:** CT Angiography (CTA).

Q: Intravenous pyelogram (IVP) of polycystic kidney disease typically shows which of the following appearances?

Spider leg deformity. **Explanation:** In **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**, the kidneys are bilaterally enlarged due to the presence of multiple cysts of varying sizes within the renal parenchyma. On an **Intravenous Pyelogram (IVP)**, these cysts exert pressure on the renal pelvis and calyces. This leads to the elongation, narrowing, and stretching of the calyces, creating the characteristic **"Spider leg deformity."** **Analysis of Options:** * **Spider leg deformity (Correct):** Caused by the extrinsic compression and stretching of the pelvicalyceal system by multiple parenchymal cysts in ADPKD. * **Cobra head appearance:** This is the classic sign of a **Ureterocele** (specifically the "adult" or orthotopic type), where there is cystic dilatation of the distal intramural ureter surrounded by a radiolucent halo. * **Dropping lily appearance:** Seen in a **Duplex Collecting System** with an obstructed upper pole moiety. The opacified lower pole is displaced downward and outward by the non-visualized, hydronephrotic upper pole. * **Flower base (or Vase) appearance:** This is characteristic of **Horseshoe Kidney**, where the lower poles are fused, causing the axes of the kidneys to be reversed and the lower calyces to point medially. **High-Yield Clinical Pearls for NEET-PG:** * **Swiss Cheese Appearance:** The nephrogram phase of IVP in ADPKD shows multiple radiolucent areas (cysts) against opacified parenchyma. * **Best Initial Investigation:** Ultrasonography (USG) is the screening modality of choice for ADPKD. * **Associated Findings:** Look for liver cysts (most common extra-renal manifestation) and Berry aneurysms (Circle of Willis), which can lead to Subarachnoid Hemorrhage (SAH).

Q: What is the investigation of choice for gall bladder stones?

Ultrasound (USG). **Explanation:** **Ultrasound (USG)** is the investigation of choice (gold standard) for diagnosing gallstones (cholelithiasis). It has a sensitivity and specificity exceeding 95%. The underlying medical concept relies on the fact that stones are dense structures that reflect sound waves, appearing as **hyperechoic** (bright) foci within the anechoic (dark) gallbladder lumen. A hallmark diagnostic feature is the presence of **posterior acoustic shadowing** and movement of the stones with changes in patient positioning. **Analysis of Incorrect Options:** * **X-ray Abdomen:** Only 10-15% of gallstones are radiopaque (contain enough calcium to be seen). Most stones are cholesterol-based and radiolucent, making X-rays unreliable. * **Oral Cholecystography (OCG):** Once the gold standard, it is now obsolete. It required the ingestion of contrast and a functional gallbladder to concentrate it; it is time-consuming and less accurate than USG. * **Intravenous Cholangiogram:** Historically used to visualize the bile ducts, it has been replaced by non-invasive MRCP or therapeutic ERCP. It is not used for primary gallbladder stone screening. **High-Yield Clinical Pearls for NEET-PG:** * **WES Triad:** (Wall-Echo-Shadow) is seen on USG when the gallbladder is completely filled with stones. * **Acute Cholecystitis:** USG is also the initial investigation, but **HIDA scan** (Radionuclide scan) is the most sensitive/conflicting "gold standard" for diagnosis. * **Choledocholithiasis (CBD stones):** **ERCP** is the gold standard (diagnostic + therapeutic), while **MRCP** is the investigation of choice for diagnosis alone.

Q: What is the most sensitive investigation for pancreatic carcinoma?

CT scan. **Explanation:** **CT scan (specifically Multidetector Helical CT or MDCT)** is the investigation of choice and the most sensitive modality for diagnosing and staging pancreatic carcinoma. Its high sensitivity (95–100%) stems from its ability to provide thin-section, multiphasic imaging (pancreatic and portal venous phases). This allows for the detection of small hypoattenuating masses, assessment of vascular invasion (resectability), and identification of distant metastases or lymphadenopathy in a single study. **Why other options are incorrect:** * **Angiography:** Historically used to detect vascular involvement, it is invasive and has been entirely replaced by non-invasive CT angiography. * **ERCP:** While highly sensitive for detecting biliary or pancreatic ductal obstruction (showing the "Double Duct Sign"), it is an invasive procedure. It is now primarily reserved for therapeutic interventions (stenting) rather than primary diagnosis. * **Ultrasound:** Often the initial screening tool for jaundice, but its sensitivity is limited by overlying bowel gas and body habitus. It cannot reliably stage the tumor or detect small lesions in the pancreatic tail. **Clinical Pearls for NEET-PG:** * **Investigation of Choice:** MDCT (Dual-phase CT). * **Most Sensitive for Small Tumors (<2cm):** Endoscopic Ultrasound (EUS) is technically more sensitive than CT for very small lesions and allows for FNA, but CT remains the standard "best" initial investigation for diagnosis and staging. * **Classic Sign:** "Double Duct Sign" (dilatation of both common bile duct and pancreatic duct) on imaging suggests a tumor in the head of the pancreas. * **Tumor Marker:** CA 19-9 (used for monitoring recurrence, not for primary screening).

Question 1

What is the characteristic feature of a malignant gastric ulcer seen on a barium meal?

Accepted Answer

Carman meniscus sign

Answer

Hampton line

Answer

Ulcer cap

Answer

Ulcer crater

Question 2

Renal tuberculosis can be diagnosed earliest by which imaging modality?

Accepted Answer

Intravenous pyelogram (IVP)

Answer

CT scan

Answer

Angiography

Answer

Ultrasonography (USG)

Question 3

A 5-year-old girl, without a past history of UTI, is in the hospital receiving antibiotics for E coli pyelonephritis. She remains febrile after 4 days of appropriate antibiotic treatment. A renal ultrasound shows no abscess, but a focal enlargement of one of the lobes of the right kidney. A CT scan of the abdomen reveals a wedge-shaped area in the right kidney distinct from the normal tissue with minimal contrast enhancement. What is the appropriate management for this patient?

Accepted Answer

Prolonged antibiotic therapy

Answer

Routine treatment with 10 to 14 days of antibiotics for pyelonephritis

Answer

Surgical consultation

Answer

Dimercaptosuccinic acid (DMSA) scan

Question 4

What is the most common cause of 'target lesion' in the stomach?

Accepted Answer

Melanoma

Answer

Carcinoid

Answer

Lymphoma

Answer

Fibroma

Question 5

The Seagull sign is seen in which of the following conditions?

Accepted Answer

Gallstone ileus

Answer

Chronic pancreatitis

Answer

Appendicitis

Answer

Acute cholecystitis

Question 6

A multiloculated cystic lesion in the liver is a CT feature of which of the following?

Accepted Answer

Hydatid cyst

Answer

Necrotic mass

Answer

Hepatocellular carcinoma

Answer

Metastasis

Question 7

Which type of mesenteric ischemia is best visualized by CECT?

Accepted Answer

Acute mesenteric venous thrombosis

Answer

Mesenteric ischemia by embolic occlusion

Answer

Acute mesenteric artery thrombosis

Answer

Non-occlusive mesenteric ischemia

Question 8

Intravenous pyelogram (IVP) of polycystic kidney disease typically shows which of the following appearances?

Accepted Answer

Spider leg deformity

Answer

Cobra head appearance

Answer

Dropping lily appearance

Answer

Flower base appearance

Question 9

What is the investigation of choice for gall bladder stones?

Accepted Answer

Ultrasound (USG)

Answer

X-ray abdomen

Answer

Oral cholecystography (OCG)

Answer

Intravenous cholangiogram

Question 10

What is the most sensitive investigation for pancreatic carcinoma?

Accepted Answer

CT scan

Answer

Angiography

Answer

ERCP

Answer

Ultrasound

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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