Abdominal and Pelvic Radiology Practice Questions

Q: The best investigation for air in the peritoneal cavity is:

X-ray. ***X-ray*** - An **X-ray**, particularly an erect chest X-ray or an erect abdominal X-ray, is the **most sensitive and readily available investigation** to detect **free air under the diaphragm** (pneumoperitoneum). - This free air, indicating a perforated viscus, appears as a **Crescent-shaped lucency** shadowing the diaphragm. *USG* - While ultrasound can sometimes detect free air, it is **less sensitive and specific** than X-ray for this purpose, especially in early or small perforations. - Its utility is more in detecting other intra-abdominal pathologies like fluid collections or organomegaly. *Laparoscopy* - **Laparoscopy** is a **surgical procedure** that allows direct visualization of the peritoneal cavity. - While it can definitively identify free air and its source, it is an **invasive procedure** and not the primary diagnostic investigation for suspected pneumoperitoneum. *Laparotomy* - **Laparotomy** is an **open surgical procedure** involving a large incision to access the abdominal cavity. - It is used for definitive diagnosis and treatment, but it is **highly invasive** and not a diagnostic investigation in the initial workup for air in the peritoneal cavity.

Q: In which of the following conditions is the lead pipe appearance of the colon seen on a barium enema?

Ulcerative colitis. **Ulcerative colitis** - The **"lead pipe" appearance** on a barium enema is indicative of **loss of haustra**, foreshortening, and rigidity of the colon due to chronic inflammation and fibrosis, which are characteristic features of extensive ulcerative colitis. - This appearance reflects a smooth, tube-like colon without the normal sacculations, resulting from **mucosal damage** and subsequent scarring. *Amoebiasis* - While amoebiasis can cause colonic inflammation, it typically presents with **flask-shaped ulcers** and sometimes strictures on barium enema, not a diffuse loss of haustra leading to a "lead pipe" appearance. - The disease is more commonly associated with changes like **filling defects** or **segmental narrowing** rather than overall colonic rigidity. *Tuberculosis of the colon* - Tuberculosis of the colon often causes **strictures**, ulcerations, and sometimes **hypertrophic lesions**, particularly affecting the ileocecal region. - It does not typically result in the widespread mucosal damage and loss of haustra seen in the "lead pipe" appearance of ulcerative colitis, but rather **focal deformities**. *Crohn's involvement of the colon* - Crohn's disease is characterized by a **"cobblestoned" appearance** due to deep ulcerations and transmural inflammation, skip lesions, and **fistulae**. - While it can cause strictures and bowel wall thickening, the diffuse loss of haustra leading to the "lead pipe" sign is more specific to **ulcerative colitis**, which primarily affects the mucosa.

Q: X-ray given below suggestive of:

Gas mimicking peritoneal presence (Pseudopneumoperitoneum). * ***Gas mimicking peritoneal presence (Pseudopneumoperitoneum)*** * The X-ray shows **Chilaiditi's sign**, where the **colon is interposed between the liver and diaphragm**. * This interposition of bowel gas can mimic **free intraperitoneal gas** (pneumoperitoneum) creating a false appearance. * *Gas mimicking mediastinal presence (Pseudopneumomediastinum)* * This term refers to **gas in a location that looks like the mediastinum** but is not truly there, which is not depicted in this image. * The radiological findings are specifically related to the **subdiaphragmatic region**. * *Free gas in the mediastinum (Pneumomediastinum)* * **Pneumomediastinum** is characterized by air within the mediastinal structures, often seen outlining the **aorta or heart borders**. * The provided X-ray demonstrates gas below the diaphragm, not within the mediastinum. * *Free gas in the peritoneal cavity (Pneumoperitoneum)* * **Pneumoperitoneum** is the presence of free air in the peritoneal cavity, typically indicated by **air under the diaphragm** (e.g., **"football sign"** in upright films). * While there is gas under the diaphragm, it is **intraluminal bowel gas** rather than free intraperitoneal gas, which is the key distinction for pseudopneumoperitoneum.

Q: Which of the following liver metastases appear hypoechoic on ultrasound?

Breast cancer. **Breast cancer** - Liver metastases from **breast cancer** frequently present as **hypoechoic lesions** on ultrasound, due to the tumor's cellular composition and vascularity. - This appearance helps differentiate them from other more commonly echogenic or mixed metastatic patterns. *RCC* - **Renal cell carcinoma (RCC)** metastases to the liver often appear **hyperechoic** or **mixed echogenicity** on ultrasound due to their rich vascularity. - This is a distinct characteristic, different from the predominantly hypoechoic nature seen with breast cancer metastases. *Colon cancer* - Liver metastases from **colon cancer** are typically **echogenic** or **mixed echogenicity** on ultrasound, sometimes with a hypoechoic rim ("target sign"). - Their presentation is generally not purely hypoechoic, making them distinguishable from breast cancer metastases. *Mucinous adenocarcinoma* - Liver metastases from **mucinous adenocarcinoma** can be quite variable, but they often appear **complex**, possibly with **cystic components** or mixed echogenicity, rather than uniformly hypoechoic. - The mucin content can create a distinct internal architecture on ultrasound that differs from solid hypoechoic lesions.

Q: What is the diagnosis based on the following X-ray?

Bladder stone. ***Bladder stone*** - A large, **radiopaque opacity** positioned centrally within the **pelvis**, overlying the anticipated location of the **urinary bladder**, is highly suggestive of a bladder stone. - The **smooth, calcified appearance** on X-ray is characteristic of many types of bladder calculi. *Renal Tuberculosis* - Renal tuberculosis typically presents with **calcifications in the kidneys** themselves, or shows signs of **hydronephrosis** or **ureteral strictures**. - It does not usually manifest as a single, large, well-defined calcification within the bladder lumen on a plain X-ray. *Uterine Fibroid* - Calcified uterine fibroids (leiomyomas) would appear as **speckled, popcorn-like calcifications** in the **pelvis**, often superior to the bladder, and not as a single, large, well-defined stone-like opacity within the bladder region. - Their location is also often distinct from the central bladder space. *Bladder Carcinoma* - Bladder carcinoma is rarely visible as a **dense, central calcification** on a plain X-ray. - While some tumors can calcify, they typically present as **filling defects**, **wall thickening**, or **irregular soft tissue masses**, which are best visualized with contrast studies or cross-sectional imaging, not a single large stone-like opacity.

Q: Focal and diffuse thickening of gallbladder wall with high amplitude reflections and 'comet tail' artifacts on USG suggest the diagnosis of –

Adenomyomatosis. ***Adenomyomatosis*** - This condition is characterized by **hyperplasia of the muscular layer** and **outpouchings of the mucosa** through the muscular wall (Rokitansky-Aschoff sinuses). - The thickened wall with **Rokitansky-Aschoff sinuses** containing bile or cholesterol crystals causes **high-amplitude reflections** and **comet tail artifacts** on ultrasound. *Carcinoma of gall bladder* - While carcinoma can also cause focal or diffuse thickening of the gallbladder wall, it typically appears as a **mass lesion** and **does not usually demonstrate comet-tail artifacts**. - **Comet-tail artifacts** are pathognomonic for **adenomyomatosis**, indicating gas, cholesterol crystals, or inspissated bile within Rokitansky-Aschoff sinuses. *Cholesterolosis* - This condition, also known as **strawberry gallbladder**, involves the deposition of **cholesterol esters in the lamina propria** of the gallbladder wall. - It usually presents as **multiple small polyps** on ultrasound, without the diffuse wall thickening or classic "comet tail" artifact seen with adenomyomatosis. *Xanthogranulomatous cholecystitis* - This is a rare, severe form of chronic cholecystitis characterized by **lipid-laden macrophages** and significant **fibrosis** in the gallbladder wall. - It causes **marked, diffuse mural thickening** or **nodular lesions** which can mimic carcinoma, but it typically **lacks the specific acoustic shadowing and comet tail artifacts** associated with adenomyomatosis.

Q: All are sonological features of Budd Chiari syndrome, EXCEPT:

Diffusely dilated hepatic veins. ***Diffusely dilated hepatic veins*** - **Diffusely dilated hepatic veins** are *not* a sonological feature of **Budd-Chiari syndrome**, as the primary pathology is **hepatic venous obstruction**, which leads to *narrowing, stenosis, or absence of flow* rather than generalized dilatation. - In Budd-Chiari syndrome, hepatic veins are typically **compressed, thrombosed, or stenotic**, not uniformly dilated throughout their course. - While **focal proximal dilatation** can occur upstream of a stenotic segment (see option below), **diffuse dilatation** of all hepatic veins is not characteristic of this condition. *Intraluminal echogenicity of hepatic vein* - **Intraluminal echogenicity** within the hepatic veins indicates the presence of **thrombus** or **fibrin**, which is a direct cause of **Budd-Chiari syndrome**. - This finding is crucial for diagnosing **acute hepatic venous thrombosis** and is a classic sonographic feature. *Stenosis and proximal dilatation of the hepatic veins* - **Stenosis** (narrowing) of the hepatic veins is a hallmark finding due to **thrombus formation**, **webs**, or **fibrosis** causing obstruction. - **Proximal dilatation** refers to localized dilation of the vein segment *upstream* from the point of obstruction as blood backs up, which is a classic sign of venous outflow obstruction. - This combination of focal stenosis with proximal dilatation is characteristic and different from diffuse dilatation of all veins. *Thickened walls of hepatic vein* - **Thickened walls** of the hepatic veins can be seen in **chronic Budd-Chiari syndrome** due to **inflammation** and **fibrosis** resulting from long-standing venous congestion and remodeling. - This finding suggests a more established or advanced stage of the disease.

Q: What is the structure seen in the given X-ray below?

Stent. ***Stent*** - The image likely shows a **tubular structure** placed within a lumen, consistent with the appearance of a medical stent on X-ray. - Medical stents, often made of **radiopaque materials**, are used to maintain patency of vessels or ducts. *Foley catheter* - A Foley catheter is typically a **flexible tube** with an inflatable balloon at its tip, inserted into the bladder for urine drainage. - While it has a radiopaque tip, its overall appearance and typical placement *within the bladder* would differ from the structure shown. *Intravesical wire* - An intravesical wire suggests a wire placed **within the bladder**, which is not a standard long-term therapeutic device and would have a distinct, finer appearance than the displayed structure. - There is no common medical device referred to as an "intravesical wire" as a distinct structure, and any wire would appear as a **thin, linear density**. *Surgical clips* - Surgical clips are **small, metallic fasteners** used to ligate vessels or mark tissue during surgery. - They appear as distinct, small, and often multiple **bright densities** on X-ray, not as a continuous tubular structure.

Q: All are important ultrasound findings of amebic liver abscess, EXCEPT:

Located in the left hepatic lobe. ***Located in the left hepatic lobe*** - While amebic liver abscesses can occur in the left lobe, they are **much more common in the right hepatic lobe** due to the preferential blood flow from the portal vein's superior mesenteric branch. - Therefore, location in the left lobe is not an *expected* or typical finding for an amebic liver abscess. *Round or oval in shape* - **Amebic liver abscesses typically present as round or oval lesions** on ultrasound due to their expanding nature within the liver parenchyma. - This morphology is a common characteristic used for their sonographic identification. *Single lesion* - **Amebic liver abscesses are usually solitary**; multiple abscesses are less common. - This characteristic helps differentiate them from other liver pathologies, such as pyogenic abscesses, which are often multiple. *Hypoechoic with irregular ill defined margins initially* - In their early stages, amebic liver abscesses are **hypoechoic (darker) on ultrasound** because of the initial inflammatory response and presence of necrotic material. - They also tend to have **ill-defined and irregular margins** initially as the infection is spreading through the liver tissue.

Q: The "Target sign" ultrasonographically means:

Intussusception. ***Intussusception*** - The **"target sign"** (also known as the **"donut sign"** or **"pseudokidney sign"**) on ultrasound is a classic finding for **intussusception**. - It represents concentric layers of bowel telescoping into an adjacent segment, creating a central hyperechoic core surrounded by hypoechoic rings. *Liver metastasis* - Liver metastases often appear as **hypoechoic, hyperechoic, or mixed echogenicity lesions** on ultrasound, and vary widely in appearance. - While some can have a "target-like" appearance with a hyperechoic rim, it's not the primary or most specific sign for liver metastasis and is less distinct than in intussusception. *Ectopic kidney* - An ectopic kidney is an anatomical variant where the kidney is located outside its normal position, most commonly in the **pelvis**. - On ultrasound, it would appear as a normally formed kidney in an atypical location, without the distinct concentric layers seen in the "target sign." *Ovarian carcinoma* - Ovarian carcinomas present with **complex masses** that can be solid, cystic, or mixed, often with septations, papillary projections, and areas of necrosis. - Their ultrasound appearance is highly variable but does not typically manifest as a "target sign" with concentric rings.

Question 1

The best investigation for air in the peritoneal cavity is:

Accepted Answer

X-ray

Answer

USG

Answer

Laparoscopy

Answer

Laparotomy

Question 2

In which of the following conditions is the lead pipe appearance of the colon seen on a barium enema?

Accepted Answer

Ulcerative colitis

Answer

Amoebiasis

Answer

Tuberculosis of the colon

Answer

Crohn's involvement of the colon

Question 3

X-ray given below suggestive of:

Accepted Answer

Gas mimicking peritoneal presence (Pseudopneumoperitoneum)

Answer

Gas mimicking mediastinal presence (Pseudopneumomediastinum)

Answer

Free gas in the mediastinum (Pneumomediastinum)

Answer

Free gas in the peritoneal cavity (Pneumoperitoneum)

Question 4

Which of the following liver metastases appear hypoechoic on ultrasound?

Accepted Answer

Breast cancer

Answer

RCC

Answer

Colon cancer

Answer

Mucinous adenocarcinoma

Question 5

What is the diagnosis based on the following X-ray?

Accepted Answer

Bladder stone

Answer

Renal Tuberculosis

Answer

Uterine Fibroid

Answer

Bladder Carcinoma

Question 6

Focal and diffuse thickening of gallbladder wall with high amplitude reflections and 'comet tail' artifacts on USG suggest the diagnosis of –

Accepted Answer

Adenomyomatosis

Answer

Carcinoma of gall bladder

Answer

Cholesterolosis

Answer

Xanthogranulomatous cholecystitis

Question 7

All are sonological features of Budd Chiari syndrome, EXCEPT:

Accepted Answer

Diffusely dilated hepatic veins

Answer

Intraluminal echogenicity of hepatic vein

Answer

Stenosis and proximal dilatation of the hepatic veins

Answer

Thickened walls of hepatic vein

Question 8

What is the structure seen in the given X-ray below?

Accepted Answer

Stent

Answer

Foley catheter

Answer

Intravesical wire

Answer

Surgical clips

Question 9

All are important ultrasound findings of amebic liver abscess, EXCEPT:

Accepted Answer

Located in the left hepatic lobe

Answer

Round or oval in shape

Answer

Single lesion

Answer

Hypoechoic with irregular ill defined margins initially

Question 10

The "Target sign" ultrasonographically means:

Accepted Answer

Intussusception

Answer

Liver metastasis

Answer

Ectopic kidney

Answer

Ovarian carcinoma

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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