Abdominal and Pelvic Radiology Practice Questions

Q: Among the following, which is the investigation of choice for evaluation of common bile duct (CBD)?

MRCP. ***Correct: MRCP*** - **Magnetic Resonance Cholangiopancreatography (MRCP)** is the investigation of choice for comprehensive CBD evaluation - **Non-invasive technique** with high sensitivity (95%) and specificity (97%) for biliary pathology - **Provides detailed anatomical visualization** of the entire biliary tree without radiation or contrast agents - **Superior for detecting** CBD stones, strictures, and obstructions *Incorrect: CECT Abdomen* - Can visualize the CBD but provides less detailed luminal information compared to MRCP - More useful for assessing surrounding structures, tumor staging, and vascular involvement - Not the primary investigation of choice for biliary tree evaluation *Incorrect: HIDA scan* - Hepatobiliary Iminodiacetic Acid scan is a functional study that assesses gallbladder function and cystic duct patency - Tracks radioactive tracer flow but does not provide detailed anatomical imaging - Cannot visualize the cause of obstruction, making it unsuitable for primary CBD evaluation *Incorrect: Ultrasonography* - Initial screening modality that is readily available and non-invasive - Can detect CBD dilation and some stones but has limited sensitivity - Limited by bowel gas interference and operator dependency - Provides less detail than MRCP, especially for distal CBD segments

Q: Consider the following radiological signs : 1. Claw sign in barium enema 2. Apple core sign in barium enema 3. Multiple fluid levels with absent caecal gas in plain skiagram of abdomen 4. Single large fluid and air level in plain skiagram of abdomen Which of the above signs is/are suggestive of ileocolic intussusception?

1 only. ***1 only*** - The **claw sign** in a barium enema is a classic radiological finding in **ileocolic intussusception**, where the intussusceptum indents the barium column, forming a characteristic claw-like appearance - This sign indicates the presence of the invaginated bowel segment within the larger bowel, as the barium passes around it - It is the most specific radiological sign for intussusception on contrast studies *3 only* - **Multiple fluid levels** with absent caecal gas on plain skiagram are indicative of **small bowel obstruction**, which can be caused by intussusception but is **not specific** to it - This finding does not pinpoint intussusception specifically and can occur with adhesions, hernias, or other causes of obstruction - Alone, this does not diagnose ileocolic intussusception *1 and 2 only* - While the **claw sign** (1) is specific to intussusception, the **apple core sign** (2) is characteristic of a **constricting colonic malignancy**, not intussusception - The apple core sign represents irregular narrowing of the bowel lumen due to an annular carcinoma - Including sign 2 makes this option incorrect for intussusception *1, 2, 3 and 4* - Only the **claw sign** (1) is specifically suggestive of intussusception - The **apple core sign** (2) indicates colonic carcinoma, not intussusception - **Multiple fluid levels with absent caecal gas** (3) indicate bowel obstruction but lack specificity - A **single large fluid and air level** (4) suggests gastric outlet obstruction or closed loop obstruction, not specifically intussusception

Q: 'Double duct' sign is diagnostic of

periampullary carcinoma. ***periampullary carcinoma*** - The **"double duct sign"** refers to the simultaneous dilation of both the **common bile duct** and the **pancreatic duct**. - This sign is highly suggestive of an obstruction at the **ampulla of Vater**, most commonly caused by **periampullary carcinoma**. *hepatocellular carcinoma* - **Hepatocellular carcinoma** primarily affects the liver parenchyma and typically does not cause simultaneous dilation of both the common bile and pancreatic ducts. - It more commonly presents with symptoms related to **liver dysfunction** or a palpable **liver mass**. *gallbladder carcinoma* - **Gallbladder carcinoma** can lead to bile duct obstruction, but it generally causes dilation of the **biliary tree** proximal to the obstruction, not simultaneous dilation of both the bile and pancreatic ducts. - The obstruction is usually located at the **cystic duct** or **common hepatic duct** due to direct tumor extension or nodal involvement. *Klatskin's carcinoma* - **Klatskin's tumor** is a type of **cholangiocarcinoma** located at the **bifurcation of the common hepatic duct**. - While it causes **biliary obstruction** and dilation of the intrahepatic ducts, it does not typically cause dilation of the pancreatic duct.

Q: A 20 years old man had history of pain in the right side of abdomen. His X-ray abdomen AP view shows radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:

Renal Calculus. ***Renal Calculus*** - A **radio-opaque shadow** in the right abdomen, located **behind the vertebral column** on a lateral X-ray, is highly suggestive of a **renal calculus (kidney stone)**. - Renal calculi are located in the **retroperitoneal space**. On a lateral X-ray view, retroperitoneal structures like the kidneys appear to be **superimposed over or behind the vertebral column**, which is the key anatomical landmark for localization. - The clinical presentation of right-sided abdominal pain combined with this radiological finding makes renal calculus the most probable diagnosis. *Gall stone disease* - **Gallstones** are typically located in the **right upper quadrant** of the abdomen on an AP view but would appear **anterior to the vertebral column** on a lateral X-ray, as the gallbladder is an intraperitoneal organ. - Only about 10-20% of gallstones are sufficiently **calcified** to be radio-opaque on plain X-ray. *Phlebolith* - **Phleboliths** are calcified venous thrombi, commonly found in the **pelvis** and would appear within the **vascular structures**, not typically behind the vertebral column in the mid-abdomen in a pattern consistent with a renal calculus. - While they are radio-opaque, their usual anatomical location and characteristic **central lucency** (target sign) help differentiate them. *Calcified mesenteric lymph node* - **Calcified mesenteric lymph nodes** are common incidental findings and would be located within the **mesentery**, appearing **anterior to the vertebral column** on a lateral X-ray. - They often have an irregular or lobulated appearance, distinct from the more discrete and often smoother shape of a renal calculus.

Q: 'Chain of Lakes' appearance due to sacculation with intervening short strictures of pancreatic duct is seen on:

ERCP. ***ERCP*** - **Endoscopic Retrograde Cholangiopancreatography (ERCP)** is an invasive imaging technique that directly visualizes the bile and pancreatic ducts by injecting contrast, allowing for the classic "chain of lakes" appearance (dilatation and stricturing) seen in chronic pancreatitis. - This characteristic appearance on ERCP is a definitive sign of advanced **chronic pancreatitis**, indicating ductal irregularity, strictures, and dilations. *Ultrasonography* - While ultrasonography can show features of chronic pancreatitis like **pancreatic calcifications** and **ductal dilation**, it typically does not provide the detailed luminal view necessary to appreciate the "chain of lakes" pattern. - Its utility in visualizing the pancreatic duct can be limited by **bowel gas** and patient body habitus, making it less sensitive for intricate ductal changes. *CECT abdomen* - **Contrast-Enhanced Computed Tomography (CECT) of the abdomen** can identify pancreatic calcifications, **atrophy**, and **ductal dilation** in chronic pancreatitis but is generally not as precise as ERCP in delineating the intricate "chain of lakes" pattern within the duct itself. - CECT is more effective for assessing parenchymal changes and complications like **pseudocysts** rather than the fine ductal morphology. *Plain X-ray abdomen* - A plain X-ray of the abdomen primarily visualizes **calcifications** within the pancreas, which are a common feature of chronic pancreatitis. - However, it does not provide any information about the **ductal anatomy** or the "chain of lakes" appearance, as it is a 2D image without contrast in the ducts.

Q: Identify the condition shown in the plain abdominal radiograph.

Pancreatic calcification. ***Pancreatic calcification*** - The radiograph displays **multiple, punctate, and amorphous calcifications** clustered in the upper abdomen, characteristic of **chronic pancreatitis**. - These calcifications represent **calcium deposits within the pancreatic ducts and parenchyma**, a hallmark sign of chronic inflammation and damage to the pancreas. *Mesenteric calcification* - **Mesenteric calcifications** are typically more scattered and linear, often following the distribution of blood vessels or lymph nodes within the mesentery, which is not seen here. - They are generally less dense and less granular than the calcifications observed in the image. *Horseshoe kidney* - A **horseshoe kidney** is a congenital anomaly where the kidneys are fused at their lower poles, forming a U-shape, and is typically located lower in the abdomen, often overlying the spine. - This condition presents with the characteristic **renal outlines** and not diffuse calcifications as shown. *Jejunal fecolith* - A **jejunal fecolith** would appear as a singular or a few discrete, dense, and typically rounded or oval radio-opacities within the lumen of the jejunum. - The diffuse, scattered pattern of calcifications displayed in the image is inconsistent with a fecolith, which is usually composed of inspissated fecal material.

Q: A 45-year-old farmer presents with right upper quadrant pain and a history of exposure to livestock. An abdominal ultrasound shows a cystic lesion in the liver with internal floating membranes, described as the "Water lily sign." Based on this finding, what is the most likely Gharbi classification stage of the hydatid cyst?

Gharbi Stage III. ***Gharbi Stage III*** - This stage is characterized by a **cystic lesion with internal floating membranes** (daughter cysts or detached endocyst), which is consistent with the "Water lily sign" described. - The membranes are indicative of a **degenerating or ruptured endocyst** within the main cyst, signifying a more advanced stage than simple cysts. *Gharbi Stage I* - This stage represents a **simple, unilocular cyst** with an anechoic (fluid-filled) lumen, without any internal structures or membranes. - It would appear as a clearly defined, fluid-filled mass with a smooth wall, lacking the internal complexity shown in the image. *Gharbi Stage II* - Gharbi Stage II is characterized by a **cyst with internal septations**, indicating the presence of multiple daughter cysts within the main cyst. - While it involves internal structures, these are typically well-defined septa rather than freely moving, detached membranes. *Gharbi Stage IV* - This stage describes a **heterogeneous, degenerating cyst** with a solid-like appearance, often without a clear cystic lumen. - It reflects a more advanced, often calcified or completely inactivated cyst, which does not match the clear cystic structure with floating membranes seen in the image.

Q: What is the Diagnosis based on the CT Scan given below?

Renal polycystic kidney disease. ***Polycystic kidney disease*** - The CT scan images show **enlarged kidneys** replaced by numerous **cysts of varying sizes**, which is the hallmark appearance of polycystic kidney disease. - The presence of multiple cysts **bilaterally** and diffusely throughout the renal parenchyma is characteristic of this genetic disorder. *Renal cyst* - A single renal cyst is a common benign finding, appearing as a **well-defined, fluid-filled** structure. - The images clearly demonstrate **multiple cysts** affecting both kidneys, ruling out a solitary renal cyst. *Renal tumor* - A renal tumor (e.g., renal cell carcinoma) typically appears as a **solid mass**, often with heterogeneous enhancement after contrast. - The lesions seen in the image are predominantly **cystic** and multifocal, which is inconsistent with a typical renal tumor. *Renal angiomyolipoma* - Renal angiomyolipomas are benign tumors containing **fat, smooth muscle, and blood vessels**, and they characteristically show **macroscopic fat** on CT scans. - While they can be multiple, especially in tuberous sclerosis, the dominant feature in the image is widespread cystic transformation, not fat-containing solid masses.

Q: What condition does the MRCP (Magnetic Resonance Cholangiopancreatography) image indicate?

Choledochal cyst. **Choledochal cyst** - The MRCP image clearly shows a **cystic dilation** of the common bile duct, which is characteristic of a choledochal cyst. - This congenital anomaly involves saccular or fusiform dilation of the bile ducts, as depicted by the **balloon-like structure** in the image. - MRCP is the **gold standard imaging modality** for diagnosing choledochal cysts, providing excellent visualization of the biliary tree anatomy. *Dilated CBD (Common Bile Duct)* - While a choledochal cyst is a type of CBD dilation, simply stating "dilated CBD" is not specific enough, as the image shows a distinct **cystic morphology** beyond just uniform dilation. - Common bile duct dilation can be caused by various factors like stones or strictures, but the **focal, bulbous appearance** points specifically to a cyst. *Acute cholecystitis* - Acute cholecystitis typically presents with signs of gallbladder inflammation, such as **gallbladder wall thickening**, pericholecystic fluid, and gallstones, which are not depicted in this MRCP. - MRCP primarily visualizes the bile ducts and does not typically show the inflammatory changes of the gallbladder wall as clearly as ultrasound or CT. *Cholangiocarcinoma* - Cholangiocarcinoma usually manifests as a **stricture** or **mass** within the bile ducts, causing upstream dilation, rather than the isolated cystic dilation seen in the image. - There is no evidence of an obstructing mass or irregular narrowing within the bile ducts that would suggest a malignancy.

Q: A 30-year-old female presents with sterile pyuria. The radiograph below is provided. What is the most likely diagnosis?

Putty Kidney. ***Putty Kidney*** - The image visible in the question shows a **caseous calcification** of the renal parenchyma, which is characteristic of a "putty kidney," a late manifestation of **renal tuberculosis**. - **Sterile pyuria** is commonly associated with renal tuberculosis, where Mycobacterium tuberculosis infection leads to chronic inflammation and granuloma formation in the kidney, eventually resulting in caseous necrosis and calcification. *Psoas Calcification* - This typically refers to calcification within the **psoas muscle**, which would appear as a linear or amorphous calcification along the path of the muscle, an appearance not consistent with the image. - While psoas abscesses can calcify, they would not manifest as widespread renal parenchymal calcification and are not specifically linked to sterile pyuria in this manner. *Staghorn Calculus* - A **staghorn calculus** is a large, branched kidney stone that fills all or part of the renal pelvis and calyces, resembling the antlers of a stag. - While these stones are composed of mineral salts and would be radiopaque, their morphology is distinctly different from the diffuse, caseous calcification seen in the image. *Nephrocalcinosis* - **Nephrocalcinosis** is a condition characterized by diffuse microcalcifications throughout the renal parenchyma, usually affecting the tubules. - The calcifications in the provided image appear more nodular and clustered, consistent with late-stage tuberculous caseous necrosis, rather than the fine, diffuse pattern of nephrocalcinosis.

Question 1

Among the following, which is the investigation of choice for evaluation of common bile duct (CBD)?

Accepted Answer

MRCP

Answer

CECT Abdomen

Answer

HIDA scan

Answer

Ultrasonography

Question 2

Consider the following radiological signs :

1. Claw sign in barium enema

2. Apple core sign in barium enema

3. Multiple fluid levels with absent caecal gas in plain skiagram of abdomen

4. Single large fluid and air level in plain skiagram of abdomen
Which of the above signs is/are suggestive of ileocolic intussusception?

Accepted Answer

1 only

Answer

3 only

Answer

1 and 2 only

Answer

1, 2, 3 and 4

Question 3

'Double duct' sign is diagnostic of

Accepted Answer

periampullary carcinoma

Answer

hepatocellular carcinoma

Answer

gallbladder carcinoma

Answer

Klatskin's carcinoma

Question 4

A 20 years old man had history of pain in the right side of abdomen. His X-ray abdomen AP view shows radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:

Accepted Answer

Renal Calculus

Answer

Gall stone disease

Answer

Phlebolith

Answer

Calcified mesenteric lymph node

Question 5

'Chain of Lakes' appearance due to sacculation with intervening short strictures of pancreatic duct is seen on:

Accepted Answer

ERCP

Answer

Ultrasonography

Answer

CECT abdomen

Answer

Plain X-ray abdomen

Question 6

Identify the condition shown in the plain abdominal radiograph.

Accepted Answer

Pancreatic calcification

Answer

Mesenteric calcification

Answer

Horseshoe kidney

Answer

Jejunal fecolith

Question 7

A 45-year-old farmer presents with right upper quadrant pain and a history of exposure to livestock. An abdominal ultrasound shows a cystic lesion in the liver with internal floating membranes, described as the "Water lily sign." Based on this finding, what is the most likely Gharbi classification stage of the hydatid cyst?

Accepted Answer

Gharbi Stage III

Answer

Gharbi Stage I

Answer

Gharbi Stage II

Answer

Gharbi Stage IV

Question 8

What is the Diagnosis based on the CT Scan given below?

Accepted Answer

Renal polycystic kidney disease

Answer

Renal cyst

Answer

Renal tumor

Answer

Renal angiomyolipoma

Question 9

What condition does the MRCP (Magnetic Resonance Cholangiopancreatography) image indicate?

Accepted Answer

Choledochal cyst

Answer

Dilated CBD (Common Bile Duct)

Answer

Acute cholecystitis

Answer

Cholangiocarcinoma

Question 10

A 30-year-old female presents with sterile pyuria. The radiograph below is provided. What is the most likely diagnosis?

Accepted Answer

Putty Kidney

Answer

Psoas Calcification

Answer

Staghorn calculus

Answer

Nephrocalcinosis

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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