Abdominal and Pelvic Radiology Practice Questions

Q: A 24-year-old man presented with a retroperitoneal, necrotic, heterogeneously enhancing mass on CT near the hilum of the left kidney. What is the most probable diagnosis?

Metastatic germ cell tumor. **Explanation:** The correct answer is **Metastatic germ cell tumor (GCT)**. In a young male (20–40 years), a retroperitoneal mass near the renal hilum is a classic presentation of metastatic spread from a primary testicular tumor. The lymphatic drainage of the testes follows the gonadal veins, leading directly to the **para-aortic and inter-aortocaval lymph nodes** (near the renal hilum). Radiologically, metastatic GCTs (especially non-seminomatous types) are characterized by large, bulky nodes that frequently undergo **central necrosis**, appearing as heterogeneous enhancement on CT. **Analysis of Incorrect Options:** * **Metastatic melanoma:** While melanoma can metastasize to the retroperitoneum, it is less common than GCT in this age group and typically presents with a known primary cutaneous lesion. * **Lymphoma:** This is a common cause of retroperitoneal lymphadenopathy; however, lymphoma typically presents as a "sandwich sign" (encasing vessels) and is usually **homogeneous** and non-necrotic. Necrosis in lymphoma is rare unless post-treatment. * **Metastatic transitional cell tumor:** This usually occurs in older patients and is associated with primary bladder or ureteral malignancies. **NEET-PG High-Yield Pearls:** * **Left Testis Drainage:** Drains to the left para-aortic nodes near the left renal vein. * **Right Testis Drainage:** Drains to the inter-aortocaval nodes. * **Scrotal Skin Drainage:** Drains to the **superficial inguinal lymph nodes** (not para-aortic). * **Imaging Hallmark:** A bulky, necrotic retroperitoneal mass in a young male should always prompt a physical examination of the testes and an ultrasound of the scrotum to rule out an occult primary tumor.

Q: A hysterosalpingogram was performed for infertility evaluation and revealed the appearance shown here. What is the diagnosis?

Bicornuate uterus. ***Bicornuate uterus*** - HSG shows **wide fundal cleft (>1 cm)** with **diverging uterine horns** creating a characteristic **intercornual angle >105°**. - The **external fundal contour is concave**, distinguishing it from other uterine anomalies and confirming complete lack of fusion during embryogenesis. *Septate uterus* - HSG would show a **normal external uterine contour** with an **internal septum** dividing the uterine cavity. - The **intercornual angle is typically <75°** and fundal cleft is **<1 cm**, unlike the wide separation seen in bicornuate uterus. *Unicornuate uterus* - HSG demonstrates a **single, banana-shaped uterine horn** with **no contralateral horn** visible. - Often associated with **ipsilateral renal agenesis** and represents the most severe form of Müllerian duct abnormality. *Arcuate uterus* - HSG shows **minimal fundal indentation ( 105°** but without the pronounced separation of bicornuate uterus.

Q: Which of the following is NOT a true feature of ileocecal tuberculosis on a diagnostic barium follow-through examination?

Apple core appearance. **Explanation:** The correct answer is **A. Apple core appearance**. This is a classic radiological sign of **Colorectal Carcinoma** (specifically the annular type), caused by a circumferential, short-segment narrowing with overhanging edges (shouldering). While tuberculosis can cause narrowing, it typically presents with different morphological features. **Why the other options are features of Ileocecal TB:** * **Pulled up or contracted cecum (Stierlin’s Sign):** Chronic inflammation and fibrosis lead to the contraction of the cecum, which appears shrunken and pulled out of the iliac fossa toward the subhepatic region. * **Widening of the ileocecal angle:** Fibrosis and shortening of the terminal ileum, combined with cecal contraction, cause the normally acute ileocecal angle to become obtuse or "wide." * **Stricture involving the terminal ileum:** TB is a common cause of "hourglass" or "napkin ring" strictures in the small bowel. When the terminal ileum is involved, it may appear as a rigid, narrowed segment (the **"String Sign"**). **High-Yield Clinical Pearls for NEET-PG:** * **Fleischner Sign:** A gaping, incompetent ileocecal valve caused by thickening of the lips of the valve. * **Stierlin Sign:** Rapid emptying of a diseased segment of the ileum/cecum due to irritability, where barium flows directly into the colon without opacifying the inflamed area. * **Conical Cecum:** A shrunken, cone-shaped cecum due to extensive fibrosis. * **Gold Standard Diagnosis:** Colonoscopy with biopsy (showing caseating granulomas).

Q: What condition is suggested by the following appearance on a barium enema?

Intussusception. ***Intussusception*** - Classic **coiled spring sign** or **claw sign** on barium enema due to the telescoping of bowel segments creating a characteristic appearance. - **Meniscus sign** may also be present, representing the leading edge of the intussuscepted bowel outlined by contrast. *Ulcer* - Presents as a **crater-like defect** with contrast collection in the ulcer base, not a telescoping appearance. - Usually shows **mucosal irregularity** and inflammation around the defect rather than the smooth, rounded contours of intussusception. *Carcinoma* - Appears as an **irregular filling defect** with **apple core sign** showing luminal narrowing and shouldering. - Demonstrates **mucosal destruction** and rigid bowel walls, contrasting with the smooth, mobile appearance of intussusception. *Diverticulum* - Shows as **outpouchings** or **sac-like projections** extending beyond the normal bowel contour. - Appears as **contrast-filled pouches** communicating with the bowel lumen, completely different from the telescoping pattern of intussusception.

Q: Gooseneck deformity is seen in which of the following conditions?

Ileocecal tuberculosis. **Explanation:** **Gooseneck deformity** is a classic radiological sign seen in **Ileocecal Tuberculosis**. It occurs due to the contraction and shortening of the terminal ileum, which then enters the cecum at a right angle rather than its usual oblique angle. This anatomical distortion, often accompanied by a shrunken, conical cecum, gives the appearance of a "goose's neck" on a barium meal follow-through (BMFT) or contrast study. **Analysis of Options:** * **Ileocecal Tuberculosis (Correct):** Chronic inflammation leads to fibrosis and cicatrization. Key radiological signs include the **Gooseneck deformity**, **Stierlin’s sign** (rapid emptying of the inflamed segment), and **Fleischner’s sign** (inverted umbrella appearance of the ileocecal valve). * **Ischemic Colitis:** Characterized by **"Thumbprinting"** on X-ray or CT, representing submucosal edema and hemorrhage. * **Crohn’s Disease:** Typically presents with the **"String sign of Kantor"** (marked narrowing of the terminal ileum) and a "cobblestone" mucosal appearance. Unlike TB, Crohn's usually involves a more longitudinal, asymmetrical involvement. * **Congenital Hip and Patella Syndrome (Nail-Patella Syndrome):** Associated with **Fong’s sign** (bilateral iliac horns), not gooseneck deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Stierlin’s Sign:** Seen in Ileocecal TB (and sometimes Crohn's); it refers to the lack of barium retention in the inflamed ileocecal segment due to irritability. * **Conical Cecum:** A hallmark of TB where the cecum becomes shrunken and rigid due to fibrosis. * **Differential Diagnosis:** In the Indian context, always differentiate TB from Crohn’s. TB favors the ileocecal valve and presents with transverse ulcers, whereas Crohn's presents with longitudinal ulcers and skip lesions.

Q: Which one of the following organs is enlarged?

Stomach. ***Stomach*** - The enlarged organ shows characteristic **gastric rugae** and **air-fluid levels** consistent with **gastric distension**. - Located in the **left upper quadrant** with typical **J-shaped** configuration extending across the **epigastric** and **left hypochondriac** regions. *Colon* - Colonic distension would show **haustra** (sacculations) and a more **peripheral location** along the abdominal wall. - The **ascending**, **transverse**, and **descending** segments would be more clearly demarcated in colonic enlargement. *Ovary* - Ovarian enlargement appears as a **pelvic mass** in the **adnexa**, separate from the gastric shadow. - Would be located in the **pelvis** rather than the upper abdomen, with characteristic **cystic** or **solid** echogenicity. *Spleen* - Splenic enlargement (splenomegaly) extends **inferiorly and medially** from the **left costal margin**. - Shows a **homogeneous density** without air-fluid levels and maintains its characteristic **crescentic shape**.

Q: What is the investigation of choice to visualize gallbladder pathologies?

USG. **Explanation:** **Ultrasonography (USG)** is the investigation of choice (IOC) for gallbladder (GB) pathologies due to its high sensitivity and specificity, particularly for detecting gallstones (cholelithiasis) and acute cholecystitis. The underlying medical concept relies on the fact that the GB is a superficial, fluid-filled structure; bile provides an excellent acoustic window, allowing USG to detect stones as small as 1–2 mm with characteristic posterior acoustic shadowing. It is non-invasive, radiation-free, cost-effective, and allows for the assessment of the **Sonographic Murphy’s Sign**. **Why other options are incorrect:** * **CT Scan:** While excellent for detecting complications (like perforation or gangrenous cholecystitis) and staging GB carcinoma, it is less sensitive than USG for detecting radiolucent gallstones and involves ionizing radiation. * **Plain X-Ray:** Only about 10–15% of gallstones are radiopaque (contain enough calcium to be seen). It is no longer a standard screening tool for GB disease. * **MRCP:** This is the gold standard for visualizing the biliary tree and detecting **Choledocholithiasis** (stones in the CBD), but it is too expensive and time-consuming for primary GB evaluation. **High-Yield Clinical Pearls for NEET-PG:** * **IOC for Gallstones/Acute Cholecystitis:** USG. * **Gold Standard for Acute Cholecystitis:** HIDA Scan (Radionuclide scan). * **Gold Standard for Choledocholithiasis:** MRCP (Diagnostic) / ERCP (Therapeutic). * **WES Triad (Wall-Echo-Shadow):** A classic USG finding indicating a gallbladder packed with stones. * **Porcelain Gallbladder:** Intramural calcification of the GB wall; seen on X-ray/CT and associated with an increased risk of GB carcinoma.

Q: On barium swallow, what characteristic appearance is shown by a leiomyoma?

Oval mass lined by barium. **Explanation:** **Leiomyoma** is the most common benign mesenchymal tumor of the esophagus. It typically arises from the smooth muscle of the muscularis propria. On a barium swallow, it presents as a **smooth, oval, or crescent-shaped intramural filling defect**. Because the tumor is located within the wall but outside the mucosa, the overlying mucosa remains intact. This results in the characteristic appearance of an **oval mass lined by barium**, often forming sharp, right-angled, or slightly obtuse borders with the esophageal wall (the "abrupt shelf" sign). **Analysis of Incorrect Options:** * **A. Rat tail appearance (Bird-beak):** This is the classic sign of **Achalasia Cardia**, caused by the failure of the Lower Esophageal Sphincter (LES) to relax. It can also be seen in esophageal carcinoma (pseudoachalasia). * **B. Corkscrew appearance:** This indicates **Diffuse Esophageal Spasm (DES)**, resulting from tertiary, non-peristaltic contractions. * **D. String sign:** This is characteristic of **Hypertrophic Pyloric Stenosis** (in infants) or **Crohn’s disease** (terminal ileum), representing a severely narrowed luminal segment. **Clinical Pearls for NEET-PG:** * **Location:** Leiomyomas are most commonly found in the distal two-thirds of the esophagus. * **Management:** They are usually asymptomatic unless they exceed 5 cm. Surgical enucleation is the treatment of choice; biopsy is generally avoided during endoscopy to prevent scarring, which makes future enucleation difficult. * **Key Sign:** Look for the **"Splitting Sign"** on CT—the tumor splits the esophageal wall layers.

Question 1

An asymptomatic male presented for ultrasonography of the abdomen for medical fitness. A focal lesion was found in his liver on ultrasound. The patient was informed that this is the most common benign hepatic tumor. Which of the following is a false statement about this lesion?

Accepted Answer

The most sensitive and specific investigation is a triphasic contrast-enhanced CT scan.

Answer

Most of these lesions are asymptomatic.

Answer

Characteristic centripetal fill-in enhancement is seen on postcontrast imaging.

Answer

Angiography shows a characteristic 'cotton-wool' appearance.

Question 2

A 24-year-old man presented with a retroperitoneal, necrotic, heterogeneously enhancing mass on CT near the hilum of the left kidney. What is the most probable diagnosis?

Accepted Answer

Metastatic germ cell tumor

Answer

Metastatic melanoma

Answer

Lymphoma

Answer

Metastatic transitional cell tumor

Question 3

A hysterosalpingogram was performed for infertility evaluation and revealed the appearance shown here. What is the diagnosis?

Accepted Answer

Bicornuate uterus

Answer

Septate uterus

Answer

Unicornuate uterus

Answer

Arcuate uterus

Question 4

Which of the following is NOT a true feature of ileocecal tuberculosis on a diagnostic barium follow-through examination?

Accepted Answer

Apple core appearance

Answer

Pulled up or contracted cecum

Answer

Widening of the ileocecal angle

Answer

Stricture involving the terminal ileum

Question 5

What condition is suggested by the following appearance on a barium enema?

Accepted Answer

Intussusception

Answer

Ulcer

Answer

Carcinoma

Answer

Diverticulum

Question 6

Gooseneck deformity is seen in which of the following conditions?

Accepted Answer

Ileocecal tuberculosis

Answer

Congenital hip and patella syndrome (CHPS)

Answer

Ischemic colitis

Answer

Crohn's disease

Question 7

Which one of the following organs is enlarged?

Accepted Answer

Stomach

Answer

Colon

Answer

Ovary

Answer

Spleen

Question 8

What is the investigation of choice to visualize gallbladder pathologies?

Accepted Answer

USG

Answer

CT

Answer

Plain X-Ray

Answer

MRCP

Question 9

Which of the following is the best view for visualizing minimal pneumoperitoneum?

Accepted Answer

Left lateral decubitus with horizontal beam

Answer

X-ray abdomen-erect view

Answer

X-ray abdomen-supine view

Answer

Left lateral view with vertical beam

Question 10

On barium swallow, what characteristic appearance is shown by a leiomyoma?

Accepted Answer

Oval mass lined by barium

Answer

Rat tail appearance

Answer

Corkscrew appearance

Answer

String sign

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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