Abdominal and Pelvic Radiology Practice Questions

Q: Which of the following findings is not typically seen on imaging of acute pyelonephritis?

Increased vascularity. **Explanation:** Acute pyelonephritis is a clinical diagnosis, but imaging (USG or CT) is often used to assess complications. The hallmark of acute pyelonephritis on imaging is **decreased perfusion**, not increased. **Why "Increased Vascularity" is the correct answer (the finding NOT seen):** In acute pyelonephritis, the inflammatory process leads to interstitial edema and leukocyte infiltration. This causes compression of the small intrarenal vessels and capillaries. Consequently, Doppler ultrasound or contrast-enhanced CT typically shows **decreased/absent vascularity** or "striated nephrograms" in the affected segments. Increased vascularity is more characteristic of tumors or certain chronic inflammatory conditions, but not acute bacterial infection of the renal parenchyma. **Analysis of Incorrect Options:** * **A. Grossly enlarged kidney:** Edema and inflammatory cell infiltration cause the kidney to swell, leading to global or focal reniform enlargement. * **B. Focal areas of hypoechogenicity:** On ultrasound, the edema reduces the echogenicity of the renal parenchyma compared to the normal cortex. * **C. Perinephric edema:** Inflammation often spreads to the surrounding Gerota’s fascia, manifesting as "stranding" on CT or fluid collections/thickening on ultrasound. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Imaging:** Contrast-Enhanced CT (CECT) is the most sensitive modality for diagnosing pyelonephritis and its complications (e.g., abscess). * **Striated Nephrogram:** A classic CT finding characterized by linear bands of delayed enhancement due to tubular obstruction and interstitial edema. * **Emphysematous Pyelonephritis:** A life-threatening necrotizing infection (common in diabetics) characterized by **gas** within the renal parenchyma.

Q: CECT with nodular enhancement is suggestive of:

Hemangioma. **Explanation:** **Hemangioma** is the most common benign tumor of the liver. The characteristic finding on Contrast-Enhanced Computed Tomography (CECT) is **peripheral globular/nodular enhancement** during the arterial phase. This enhancement follows a "centripetal" pattern, meaning it fills in progressively from the periphery toward the center in the venous and delayed phases (the "filling-in" phenomenon). The density of the enhancement typically matches that of the aorta. **Analysis of Incorrect Options:** * **Hepatic Adenoma:** Typically shows early, intense, relatively uniform arterial enhancement (not nodular) and may show "washout" or become isodense on delayed scans. It is often associated with oral contraceptive use. * **Focal Nodular Hyperplasia (FNH):** Characterized by intense, homogeneous arterial enhancement with a pathognomonic **central stellate scar** that shows delayed enhancement. It does not exhibit peripheral nodularity. * **Cholangiocarcinoma:** Usually presents as a hypoattenuating mass with **delayed capsular retraction** and progressive internal enhancement due to its fibrous (desmoplastic) stroma. **High-Yield Pearls for NEET-PG:** * **Hemangioma:** Most common benign liver tumor; "Peripheral nodular puddling" is the buzzword. * **FNH:** Second most common benign tumor; "Spoke-wheel appearance" on angiography; Sulfur colloid uptake on scintigraphy (due to Kupffer cells). * **Hepatocellular Carcinoma (HCC):** Shows "Arterial hyperenhancement" with "Rapid venous washout." * **MRI:** Hemangiomas appear as "Light bulb bright" on T2-weighted images.

Q: Which of the following conditions is typically associated with a feline esophagus appearance on imaging?

Eosinophilic esophagitis. ### Explanation **Correct Answer: A. Eosinophilic esophagitis** The **"Feline Esophagus"** (also known as shires or esophageal rings) refers to the appearance of multiple, fine, concentric mucosal rings on a barium swallow study. This appearance mimics the normal anatomy of a cat’s esophagus. In humans, this is a classic radiological hallmark of **Eosinophilic Esophagitis (EoE)**. The rings are caused by the contraction of the *muscularis mucosae* in response to chronic allergic inflammation. In addition to rings, EoE may present with a "small-caliber esophagus" or linear furrows. **Analysis of Incorrect Options:** * **B. Radiation esophagitis:** Typically presents as long-segment smooth tapering or strictures due to fibrosis, rather than discrete concentric rings. * **C. Gastroesophageal reflux disease (GERD):** While chronic GERD can cause "feline folds" (transient transverse folds), it more commonly presents with distal esophageal strictures, erosions, or a hiatal hernia. The term "Feline Esophagus" is most strongly associated with EoE in modern medical examinations. * **D. Carcinoma of the esophagus:** Usually presents as an irregular, asymmetric filling defect with "apple-core" narrowing or abrupt mucosal destruction. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** EoE is often seen in young males with a history of atopy (asthma, eczema) presenting with **food impaction** or dysphagia. * **Endoscopy:** Shows "stacked rings" (trachealization of the esophagus). * **Histology:** The gold standard for diagnosis is ≥15 eosinophils per high-power field (HPF) on biopsy. * **Management:** First-line treatments include proton pump inhibitors (PPIs), topical steroids (fluticasone/budesonide), and dietary elimination.

Q: "Double bubble" sign with absent distal bowel air shadows on X-ray abdomen is characteristic of?

Duodenal atresia. ### Explanation **1. Why Duodenal Atresia is Correct:** The **"Double Bubble" sign** represents the gaseous distension of the stomach and the first part of the duodenum, separated by the pyloric sphincter. In **Duodenal Atresia**, there is complete failure of recanalization of the duodenum during the 8th–10th week of gestation. Because the obstruction is complete, no air can pass into the distal small or large intestines. Therefore, the classic radiographic presentation is two air-filled bubbles in the upper abdomen with a **gasless distal abdomen**. **2. Why Other Options are Incorrect:** * **Duodenal Webs:** While a duodenal web can cause a double bubble sign, it is often an incomplete obstruction (fenestrated web). This usually allows some air to pass distally, resulting in **distal bowel gas** on X-ray. * **Congenital Hypertrophic Pyloric Stenosis (CHPS):** CHPS typically presents with a **"Single Bubble"** (distended stomach) and a gasless distal abdomen only if the obstruction is total. However, the obstruction is at the pylorus, so the duodenum does not dilate. * **All of the above:** Incorrect because the absence of distal air specifically points toward complete atresia rather than partial stenosis or webs. **3. High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Duodenal atresia is strongly associated with **Down Syndrome (Trisomy 21)** in approximately 30% of cases. * **Antenatal Finding:** Polyhydramnios is common due to the inability of the fetus to swallow and absorb amniotic fluid. * **Vomiting:** Characteristically presents as **bilious vomiting** within the first 24–48 hours of life (as the obstruction is usually distal to the Ampulla of Vater). * **Differential for Double Bubble:** If distal gas is present, consider Malrotation with Midgut Volvulus (a surgical emergency), Duodenal Stenosis, or Annular Pancreas.

Q: Computed Tomography (CT scan) is least accurate for diagnosis of:

1cm size Gall stones. **Explanation:** The correct answer is **D. 1cm size Gall stones**. The primary reason CT is least accurate for gallstones is that approximately **15-25% of gallstones are "isodense" to bile**. Because CT density depends on the attenuation of X-rays, stones composed primarily of pure cholesterol have a similar radiodensity to the surrounding bile, making them invisible on a standard CT scan. In contrast, **Ultrasonography (USG)** is the gold standard for gallstones, as it relies on acoustic impedance rather than density, achieving nearly 95% sensitivity. **Analysis of other options:** * **A. 1cm Hepatic Artery Aneurysm:** With the use of IV contrast (CT Angiography), vascular structures are opacified. A 1cm aneurysm would appear as a bright, contrast-filled out-pouching, making CT highly accurate. * **B. 1cm Para-aortic Lymph node:** CT is the modality of choice for staging and detecting lymphadenopathy. A 1cm node is easily visualized against the low-density retroperitoneal fat. * **C. 1cm Pancreatic Tail Mass:** Multi-detector CT (MDCT) with a dedicated pancreatic protocol is highly sensitive for detecting small focal masses, especially if they cause contour deformity or enhancement changes. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Gallstones:** Transabdominal Ultrasound (USG). * **Most Sensitive for Choledocholithiasis (CBD stones):** MRCP (Magnetic Resonance Cholangiopancreatography) or EUS (Endoscopic Ultrasound). * **CT Appearance:** Only calcified (radiopaque) or mixed stones are consistently seen on CT. Pure cholesterol stones are often missed. * **Rule of Thumb:** If a question asks for the "Investigation of Choice" for the gallbladder, the answer is almost always USG.

Q: All of the following are features of splenic rupture on plain X-ray of the abdomen except?

Obliteration of colonic air bubble. In splenic rupture, the primary radiological findings on a plain X-ray are related to the accumulation of blood (hemoperitoneum) in the left upper quadrant and the resulting mass effect on surrounding structures. ### **Explanation of the Correct Answer** **Option C (Obliteration of colonic air bubble)** is the correct answer because it is **not** a feature of splenic rupture. In fact, the opposite occurs: the **splenic flexure of the colon is typically displaced downwards** by the enlarging perisplenic hematoma. This is known as the "indentation" or "displacement" of the colonic gas shadow, rather than its obliteration. ### **Analysis of Incorrect Options** * **A. Obliteration of psoas shadow:** Hemoperitoneum or retroperitoneal hemorrhage associated with splenic injury causes a "ground-glass" opacity that obscures the sharp margin of the psoas muscle. * **B. Obliteration of splenic outline:** As blood collects around the spleen, the density of the hematoma matches the density of the spleen, causing the distinct anatomical borders of the organ to disappear. * **D. Elevation of left hemidiaphragm:** The accumulation of blood and subphrenic irritation often leads to a reactive elevation of the left diaphragm and may be associated with left-sided pleural effusion or basal atelectasis. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Investigation:** Contrast-Enhanced CT (CECT) is the investigation of choice for hemodynamically stable patients to grade splenic injury. * **FAST Scan:** Focused Assessment with Sonography for Trauma is the initial screening tool in the ER to detect free fluid. * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation from a ruptured spleen. * **Ballance’s Sign:** Fixed dullness to percussion in the left flank and shifting dullness in the right flank.

Q: Which X-ray sign is indicative of pneumoperitoneum?

Rigler's sign. **Explanation:** **Rigler’s Sign (Correct Answer):** Rigler’s sign, also known as the **double-wall sign**, is a classic radiographic indicator of **pneumoperitoneum** (free intraperitoneal air). Under normal conditions, only the inner mucosal surface of the bowel wall is visible because it is outlined by intraluminal gas. When there is a perforation, free air collects in the peritoneal cavity, outlining the outer (serosal) surface of the bowel. When both the inner and outer margins of the bowel wall are clearly visualized on a plain radiograph, it confirms the presence of extraluminal air. **Analysis of Incorrect Options:** * **A. Steeple sign:** Refers to the subglottic narrowing seen on an AP neck X-ray, characteristic of **Laryngotracheobronchitis (Croup)**. * **C. Golden ‘S’ sign:** Seen on a chest X-ray when there is **Right Upper Lobe collapse** caused by a central mass (usually bronchogenic carcinoma). * **D. ‘Bird of prey’ sign:** Also known as the "Bird’s beak" sign, it is seen on a barium swallow in **Achalasia Cardia** or on a contrast enema in **Sigmoid Volvulus**. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Pneumoperitoneum:** The most sensitive plain film is the **Erect Chest X-ray**, which can detect as little as 1–2 ml of free air under the diaphragm. * **Cupola Sign:** Refers to air trapped under the central tendon of the diaphragm on a supine X-ray. * **Football Sign:** Seen in massive pneumoperitoneum (usually in neonates), where the entire abdominal cavity is outlined by air, resembling an American football. * **Tell-tale Sign:** Air outlining the falciform ligament.

Q: A central stellate scar on CT scans is typically seen in which of the following conditions?

All of the above. ### Explanation The presence of a **central stellate (star-shaped) scar** is a classic radiological sign seen in specific benign or slow-growing tumors. This scar typically represents a core of dense fibrous or fibrovascular tissue. **1. Focal Nodular Hyperplasia (FNH):** This is the most common liver tumor associated with a central scar. On CT, the scar is typically hypoattenuating on the arterial phase but shows **delayed enhancement** due to the accumulation of contrast within the fibrous tissue. **2. Renal Oncocytoma:** This is a benign renal neoplasm. A central stellate scar is seen in approximately 33% of cases. Unlike FNH, the scar in oncocytoma often remains **hypovascular** and does not enhance significantly, helping to differentiate it from Renal Cell Carcinoma (RCC). **3. Serous Cystadenoma (SCA) of the Pancreas:** Often referred to as a "sunburst" or "honeycomb" lesion, this benign pancreatic tumor frequently features a central calcified stellate scar. The presence of **central calcification** within the scar is highly suggestive of SCA. #### Why "All of the above" is correct: While FNH is the most frequently tested association, the central stellate scar is a shared morphological feature across all three listed conditions. Recognizing this "triad" is essential for differential diagnosis in abdominal imaging. #### High-Yield Clinical Pearls for NEET-PG: * **FNH:** Look for the "spoke-wheel" appearance on angiography. It is not associated with oral contraceptives (unlike hepatic adenoma). * **Fibrolamellar Carcinoma:** A malignant liver tumor in young adults that *also* has a central scar. However, unlike FNH, the scar in fibrolamellar carcinoma is usually **calcified** and does not enhance. * **Oncocytoma:** Often presents with a "spoke-wheel" vascular pattern on angiography, similar to FNH.

Q: What condition is characterized by 'scalloping' of the edge of the sigmoid colon on barium enema?

Pneumatosis intestinalis. **Explanation:** **Pneumatosis intestinalis** is the correct answer. This condition is characterized by the presence of gas within the wall of the gastrointestinal tract (submucosal or subserosal). On a barium enema, these intramural gas bubbles protrude into the lumen, creating a characteristic **"scalloped"** or "thumbprinting-like" appearance of the colonic margin. Unlike true thumbprinting caused by edema, these radiolucent areas represent gas collections that displace the barium column. **Analysis of Incorrect Options:** * **Diverticulosis:** Characterized by multiple small, flask-shaped outpouchings (diverticula) extending *outside* the colonic lumen, often described as a "saw-tooth" appearance when associated with muscular hypertrophy. * **Ulcerative Colitis:** Early stages show mucosal granularity or "lead-pipe" appearance (loss of haustrations) in chronic stages. It does not typically produce focal scalloping. * **Carcinoma Colon:** Usually presents as a focal, irregular narrowing with overhanging edges, famously known as the **"Apple-core" lesion**. **Clinical Pearls for NEET-PG:** * **Pneumatosis Cystoides Intestinalis:** A primary form where multiple gas-filled cysts form in the subserosa/submucosa; it is often asymptomatic but can lead to benign pneumoperitoneum. * **Secondary Pneumatosis:** Often a surgical emergency, associated with **Necrotizing Enterocolitis (NEC)** in neonates or mesenteric ischemia in adults. * **Radiological Sign:** On a plain X-ray, look for "linear or curvilinear lucencies" parallel to the bowel wall. * **Differential Diagnosis:** Scalloping can also be seen in **pseudomyxoma peritonei**, but this occurs on the *outer* surface of solid organs (like the liver or spleen) rather than the inner colonic lumen.

Question 1

Which of the following MR imaging findings distinguishes vaginal atresia from Mullerian agenesis?

Accepted Answer

Presence of a cervix

Answer

Amount of upper vaginal dilatation

Answer

Length of the atresia

Answer

Hymeneal ring appearance

Question 2

Which of the following findings is not typically seen on imaging of acute pyelonephritis?

Accepted Answer

Increased vascularity

Answer

Grossly enlarged kidney

Answer

Focal areas of hypoechogenicity

Answer

Perinephric edema

Question 3

CECT with nodular enhancement is suggestive of:

Accepted Answer

Hemangioma

Answer

Hepatic adenoma

Answer

Focal Nodular Hyperplasia (FNH)

Answer

Cholangiocarcinoma

Question 4

Which of the following conditions is typically associated with a feline esophagus appearance on imaging?

Accepted Answer

Eosinophilic esophagitis

Answer

Radiation esophagitis

Answer

Gastroesophageal reflux disease (GERD)

Answer

Carcinoma of the esophagus

Question 5

"Double bubble" sign with absent distal bowel air shadows on X-ray abdomen is characteristic of?

Accepted Answer

Duodenal atresia

Answer

Duodenal webs

Answer

Congenital hypertrophic pyloric stenosis (CHPS)

Answer

All of the above

Question 6

Computed Tomography (CT scan) is least accurate for diagnosis of:

Accepted Answer

1cm size Gall stones

Answer

1cm size Aneurysm in the Hepatic Artery

Answer

1cm size Lymph node in the para-aortic region

Answer

1cm size Mass in the tail of pancreas

Question 7

All of the following are features of splenic rupture on plain X-ray of the abdomen except?

Accepted Answer

Obliteration of colonic air bubble

Answer

Obliteration of psoas shadow

Answer

Obliteration of splenic outline

Answer

Elevation of left hemidiaphragm

Question 8

Which X-ray sign is indicative of pneumoperitoneum?

Accepted Answer

Rigler's sign

Answer

Steeple sign

Answer

Golden 'S' sign

Answer

'Bird of prey' sign

Question 9

A central stellate scar on CT scans is typically seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Renal oncocytoma

Answer

Focal Nodular Hyperplasia (FNH)

Answer

Serous cystadenoma of the pancreas

Question 10

What condition is characterized by 'scalloping' of the edge of the sigmoid colon on barium enema?

Accepted Answer

Pneumatosis intestinalis

Answer

Diverticulosis

Answer

Ulcerative colitis

Answer

Carcinoma colon

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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