Abdominal and Pelvic Radiology Practice Questions

Q: Identify the condition shown in the figure:

Pneumoperitoneum. ***Pneumoperitoneum*** - The image clearly demonstrates **free air** (dark, lucent areas) within the abdominal cavity, particularly seen under the **diaphragm** and anteriorly, which is characteristic of pneumoperitoneum. - The arrow specifically points to a bright, calcific density, which could represent a **gallstone** but the primary and most striking finding is the free air, consistent with perforation. *Calculous cholecystitis* - This condition is characterized by **gallstones** (which may or may not be seen in the image, although a calcification is pointed to) accompanied by gallbladder wall thickening and pericholecystic fluid, which are not the predominant findings here. - While a stone is visible near the gallbladder, the presence of diffuse free air throughout the abdomen makes calculous cholecystitis an unlikely primary diagnosis unless it has led to **perforation**. *Acute pancreatitis* - Acute pancreatitis typically presents with **pancreatic enlargement**, inflammation, and often peripancreatic fluid collections or necrosis. - These findings are not primarily depicted, and there is no evidence of the characteristic inflammation surrounding the pancreas in the given image. *Liver abscess* - A liver abscess would appear as a **hypodense (darker) lesion** within the liver parenchyma, often with a rim of enhancement, indicating a collection of pus. - Such a focal lesion within the liver is not the main finding, and the presence of widespread free air points to a different pathology.

Q: A 30-year-old male presents with acute abdomen. What is the diagnosis based on the CT abdomen given below?

Pneumoperitoneum. ***Pneumoperitoneum*** - The CT image clearly shows **free air (darker areas) within the abdominal cavity** above the liver and bowel loops, which is indicative of pneumoperitoneum. - This finding is consistent with **gas outside the bowel lumen** in the peritoneal space, often resulting from a perforated hollow viscus. *Toxic megacolon* - Toxic megacolon is characterized by **colonic dilation** (typically >6 cm) with signs of systemic toxicity, which is not primarily observed or highlighted here. - While it's a severe condition, the most striking feature in this CT image is the presence of **free intraperitoneal gas**, not diffuse colonic distension. *Perforation peritonitis* - **Perforation peritonitis** is a clinical diagnosis characterized by inflammation of the peritoneum due to a perforation. - While pneumoperitoneum often **causes perforation peritonitis**, the image itself directly depicts the presence of free air and not necessarily the inflammatory response or clinical state of peritonitis. The image solely focuses on the presence of gas. *Bowel obstruction* - Bowel obstruction would typically show **dilated bowel loops proximal to an obstruction point** and collapse beyond it, often with air-fluid levels. - This CT scan does not predominantly display dilated bowel loops or a clear transition point characteristic of a bowel obstruction; instead, the most prominent feature is **extraluminal air**.

Q: Identify the lesion shown in the figure:

Rectus sheath hematoma. ***Rectus sheath hematoma*** - The abdominal X-ray (left image) shows a **large soft tissue mass** in the upper abdomen causing displacement of bowel loops. The CT scan (right image) demonstrates a **well-defined, high-attenuation lesion within the rectus sheath**, indicated by the arrow, consistent with a hematoma. - The appearance of a **fluid collection with high attenuation** on CT in the rectus sheath area, along with the mass effect seen on the plain film, is characteristic of a rectus sheath hematoma. *Small intestinal obstruction* - Small bowel obstruction typically presents with **dilated small bowel loops** and **air-fluid levels** on plain radiographs, which are not the primary finding here. - While there is some bowel gas displacement, the prominent finding is a soft tissue mass rather than classic obstructive patterns. *Large intestinal obstruction* - Large bowel obstruction involves **dilated large bowel loops**, often with **haustral folds**, and may present with a collapsed small bowel distal to the obstruction point. - The images do not show a pattern typical of dilated colon or specific features of large bowel obstruction. *Pneumoperitoneum* - Pneumoperitoneum refers to **free air in the peritoneal cavity**, often visible as air under the diaphragm on an upright chest X-ray or as free air outlining abdominal structures on supine films. - The provided images do not show evidence of free intraperitoneal air; instead, they demonstrate a contained soft tissue mass.

Q: What is the radiological sign demonstrated in the image provided?

Gas under diaphragm. ***Correct Option: Gas under diaphragm*** - The image clearly shows a crescent-shaped lucency (gas) beneath the diaphragm, indicated by the red arrow, which is characteristic of **pneumoperitoneum**. - This finding is a critical sign of a **perforated viscus** within the abdomen, such as a perforated peptic ulcer, perforated diverticulitis, or other hollow viscus perforation. - **Free air under the diaphragm** is best seen on an erect chest X-ray or erect abdominal film and is a surgical emergency. *Incorrect Option: Bat wing sign* - The **"bat wing"** or **"butterfly" sign** refers to bilateral perihilar infiltrates seen in conditions like **pulmonary edema** due to congestive heart failure or acute respiratory distress syndrome (ARDS). - This pattern is not present in the provided image; the lung fields appear relatively clear except for the presence of gas under the diaphragm. *Incorrect Option: Situs inversus* - **Situs inversus** is a congenital condition where the major visceral organs are reversed or mirrored from their normal positions, manifesting as the **heart shadow** on the right side and liver on the left side. - The image shows the heart on the normal left side, and there is no evidence of reversed organ positioning. *Incorrect Option: Money bag appearance* - The **"money bag appearance"** is a recognized radiological sign seen in conditions like **hydronephrosis** on intravenous pyelogram (IVP) or in **hiatal hernia** where the gastric fundus appears as a rounded sac above the diaphragm. - This finding is not demonstrated in the provided image, which clearly shows free gas beneath the diaphragm rather than a soft tissue mass or fluid-filled structure.

Q: Which of these is best for imaging a lesion in the kidney of a 60-year-old man?

Helical CT with contrast. ***Helical CT with contrast*** - **Helical CT with contrast** provides detailed anatomical imaging and information about vascularity, which is crucial for characterizing solid renal masses and distinguishing between benign and malignant lesions. - Given the patient's age and the appearance of the lesion (likely a solid mass based on context, potentially a renal cell carcinoma), contrast enhancement helps assess tumor extent, invasion, and metastatic disease. *USG* - **Ultrasound (USG)** is often the initial imaging modality for renal lesions due to its accessibility and lack of radiation. - However, it has limitations in fully characterizing solid masses and determining their exact nature or extent compared to CT or MRI. *Helical CT* - **Helical CT without contrast** is useful for identifying renal masses and detecting calcifications. - It lacks the ability to assess the vascularity of the lesion, which is vital for differentiating benign cysts from solid tumors, or characterizing the nature of a solid tumor. *MRI* - **MRI** is an excellent alternative to CT, especially in patients with renal insufficiency or contrast allergies. - While highly effective for characterizing renal masses, it is generally considered a second-line imaging option to CT with contrast for initial workup in most cases, or if CT findings are inconclusive.

Q: Comment on the diagnosis of the image shown below.

Coffee bean appearance. ***Coffee bean appearance*** - The image depicts a **dilated loop of colon**, characteristic of a **sigmoid volvulus**, which often resembles a coffee bean on plain abdominal radiographs. - This appearance is due to the **mesentery twisting around the bowel**, causing the dilated loop to fold upon itself. *Apple core appearance* - This describes a **constricting lesion** in the bowel, typically seen in **colorectal cancer**, where the lumen is severely narrowed with overhanging edges. - It denotes an **irregular, circumferential narrowing**, which is not seen in the provided image. *Claw sign* - The **"claw sign"** in the context of imaging refers to the way normal kidney tissue appears to "clasp" or surround an adjacent mass. - This sign is used to distinguish between intrarenal and extrarenal masses, which is irrelevant to the bowel pathology shown. *String sign of Kantor* - The **Kantor's string sign** is a radiologic finding in which the lumen of the terminal ileum is markedly narrowed, appearing as a thin, continuous string of barium. - This is classically associated with **Crohn's disease**, signifying severe inflammation and fibrosis, and is not seen in this image.

Q: A 32-year-old lady presents with history of first trimester miscarriage and underwent HSG. The diagnosis is: (Recent NEET Pattern 2018-19)

Unicornuate uterus. ***Unicornuate uterus*** - A **unicornuate uterus** develops from one **Müllerian duct**, resulting in a single functional uterine horn with a characteristic **banana-shaped** or crescent-shaped cavity. - On **HSG**, it appears as a single, elongated cavity that **deviates to one side** and is typically smaller than normal, associated with increased risk of **first trimester miscarriage**. *Bicornuate uterus* - Would show **two distinct uterine horns** separated by a deep fundal cleft, with the uterus appearing **heart-shaped** externally. - HSG would demonstrate **bifurcation** of the uterine cavity into two separate horns at the fundal level with an **intercornual angle >105 degrees**. *Uterus didelphys* - Complete duplication with **two separate uterine bodies**, cervices, and often vaginas resulting from total failure of **Müllerian duct fusion**. - HSG would show **two completely separate uterine cavities** with no communication, not consistent with the single cavity shown. *Arcuate uterus* - Mildest form of **Müllerian anomaly** with only a slight **fundal indentation** and essentially normal uterine cavity size. - HSG shows a **broad, smooth, mild concave contour** of the fundus, not consistent with the elongated, deviated cavity shown.

Q: What does the given chest X-ray show?

Pneumoperitoneum. ***Pneumoperitoneum*** - The chest X-ray shows **free air under the diaphragm**, visible as a lucent (dark) crescent between the liver/spleen and the diaphragm (indicated by the arrow on the right side of the patient). - This finding is diagnostic of **pneumoperitoneum**, which is often caused by a perforated abdominal viscus like a peptic ulcer or bowel perforation. *Emphysema* - **Emphysema** is a lung condition characterized by over-inflated alveoli and air trapping within the lungs, leading to hyperlucency of the lung fields and flattened diaphragms. - It does not present as free air below the diaphragm but rather as changes within the lung parenchyma. *Diaphragmatic hernia* - A **diaphragmatic hernia** involves the protrusion of abdominal organs into the chest cavity through a defect in the diaphragm. - This would typically show abdominal contents (e.g., bowel loops or stomach) above the diaphragm in the thoracic cavity, not free air below it. *Diaphragmatic eventration* - **Diaphragmatic eventration** is an abnormal elevation of part or all of an intact hemidiaphragm due to thinning and weakness of the diaphragmatic muscle. - It causes an elevated diaphragm but does not involve free air in the peritoneal cavity.

Q: The first imaging modality of choice for a 35-year-old lady, presenting to surgical emergency with complaints of colicky pain in right lower quadrant of abdomen and vomiting since last 2 days is:

Ultrasound abdomen. ***Ultrasound abdomen*** - Ultrasound is the **first-line imaging modality** for evaluating acute right lower quadrant pain in women of reproductive age due to its **safety (no ionizing radiation)**, availability, and cost-effectiveness. - It effectively visualizes the **appendix**, ovaries, uterus, and can detect **appendicitis**, ovarian pathology (e.g., cysts, torsion, ectopic pregnancy), and other causes of acute abdominal pain. - Follows the **ALARA principle** (As Low As Reasonably Achievable) for radiation exposure in young women. *Plain X-ray abdomen erect view* - Plain X-ray has **limited utility** for acute right lower quadrant pain as it cannot visualize soft tissue structures like the appendix or ovaries. - Primarily useful for detecting **bowel obstruction** (air-fluid levels) or **pneumoperitoneum** (free air under diaphragm), which are not suggested by this clinical presentation. *Contrast CT abdomen* - While highly sensitive for appendicitis and intra-abdominal pathologies, contrast CT involves **ionizing radiation** and **IV contrast administration**. - Should be **minimized in women of reproductive age** due to radiation risks (including potential pregnancy). - Reserved for cases where ultrasound is **inconclusive** or when detailed anatomical assessment is required. *Non-contrast CT abdomen* - Non-contrast CT exposes the patient to **ionizing radiation** without the diagnostic advantage of contrast enhancement. - **Less effective** than contrast-enhanced CT for detecting inflammatory processes and appendiceal pathology. - Not preferred as first-line imaging when ultrasound is available and appropriate.

Q: The 'claw sign' in barium enema study favours the diagnosis of :

Intussusception. ***Intussusception*** - The **"claw sign"**, or sometimes called the **"crescent sign"** or **"meniscus sign,"** on a barium enema is indicative of intussusception, where the contrast material fills the space between the intussusceptum and intussuscipiens, creating a claw-like appearance. - This sign represents the barium outlining the leading edge of the **intussusceptum** as it telescopes into the more distal bowel. *Sigmoid volvulus* - Sigmoid volvulus typically presents with a **"coffee bean sign"** or **"omega loop sign"** on plain abdominal radiographs due to the massively dilated, air-filled sigmoid colon. - Barium enema in sigmoid volvulus would show a **"bird's beak"** or **"ace of spades"** appearance at the site of the twist, representing the tapered narrowing. *Crohn's disease* - Crohn's disease is characterized by various findings on barium studies, such as **"skip lesions,"** **cobblestoning**, and **ulcerations**, but not a claw sign. - Strictures, fistulas, and thickened bowel walls are also common in Crohn's disease, creating different radiological patterns. *Gastro colic fistula* - A gastrocolic fistula is an abnormal connection between the stomach and the colon, most commonly seen in advanced gastric carcinoma or Crohn's disease. - On barium enema or upper GI series, it would be identified by the direct visualization of contrast flowing from the colon into the stomach or vice versa, not by a claw sign.

Question 1

Identify the condition shown in the figure:

Accepted Answer

Pneumoperitoneum

Answer

Calculous cholecystitis

Answer

Acute pancreatitis

Answer

Liver abscess

Question 2

A 30-year-old male presents with acute abdomen. What is the diagnosis based on the CT abdomen given below?

Accepted Answer

Pneumoperitoneum

Answer

Toxic megacolon

Answer

Perforation peritonitis

Answer

Bowel obstruction

Question 3

Identify the lesion shown in the figure:

Accepted Answer

Rectus sheath hematoma

Answer

Small intestinal obstruction

Answer

Large intestinal obstruction

Answer

Pneumoperitoneum

Question 4

What is the radiological sign demonstrated in the image provided?

Accepted Answer

Gas under diaphragm

Answer

Bat wing sign

Answer

Situs inversus

Answer

Money bag appearance

Question 5

Which of these is best for imaging a lesion in the kidney of a 60-year-old man?

Accepted Answer

Helical CT with contrast

Answer

USG

Answer

Helical CT

Answer

MRI

Question 6

Comment on the diagnosis of the image shown below.

Accepted Answer

Coffee bean appearance

Answer

Apple core appearance

Answer

Claw sign

Answer

String sign of Kantor

Question 7

A 32-year-old lady presents with history of first trimester miscarriage and underwent HSG. The diagnosis is: (Recent NEET Pattern 2018-19)

Accepted Answer

Unicornuate uterus

Answer

Uterus didelphys

Answer

Arcuate uterus

Answer

Bicornuate uterus

Question 8

What does the given chest X-ray show?

Accepted Answer

Pneumoperitoneum

Answer

Emphysema

Answer

Diaphragmatic hernia

Answer

Diaphragmatic eventration

Question 9

The first imaging modality of choice for a 35-year-old lady, presenting to surgical emergency with complaints of colicky pain in right lower quadrant of abdomen and vomiting since last 2 days is:

Accepted Answer

Ultrasound abdomen

Answer

Plain X-ray abdomen erect view

Answer

Contrast CT abdomen

Answer

Non-contrast CT abdomen

Question 10

The 'claw sign' in barium enema study favours the diagnosis of :

Accepted Answer

Intussusception

Answer

Sigmoid volvulus

Answer

Crohn's disease

Answer

Gastro colic fistula

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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