Abdominal and Pelvic Radiology — MCQs
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Bilateral 'Spider leg sign' on IVP is suggestive of:
What is the gold standard for the diagnosis of echinococcal cyst?
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?
Which of the following is NOT a true feature of ileocecal tuberculosis on a diagnostic barium follow-through examination?
What condition is suggested by the following appearance on a barium enema?
Cobra head appearance is seen in which condition?
An apple core lesion is typically seen in which of the following conditions?
Which of the following conditions is characterized by a "spider leg" appearance?
Gooseneck deformity is seen in which of the following conditions?
What is the earliest detectable congenital malformation by ultrasound?
Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs
Question 471: Bilateral 'Spider leg sign' on IVP is suggestive of:
- A. Renal stone
- B. Polycystic kidney (Correct Answer)
- C. Hypernephroma
- D. Hydronephrosis
Explanation: ### Explanation The **Spider leg sign** is a classic radiological finding on Intravenous Pyelogram (IVP) characteristic of **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**. **1. Why Polycystic Kidney is Correct:** In ADPKD, the renal parenchyma is replaced by multiple large, expanding cysts. These cysts exert pressure on the renal collecting system, causing the renal pelvis and calyces to become **stretched, elongated, and narrowed**. On an IVP, these attenuated calyces resemble the long, thin legs of a spider. The sign is typically **bilateral** because ADPKD is a systemic genetic disorder affecting both kidneys. **2. Why the Other Options are Incorrect:** * **Renal Stone:** Typically presents as a radiopaque shadow (on KUB) or a filling defect (on IVP). It may cause proximal dilatation but does not cause the characteristic elongation of calyces. * **Hypernephroma (RCC):** While a large tumor can distort the calyces (often called the "Dromedary hump" or "claw sign"), the distortion is usually **unilateral** and focal rather than the diffuse, bilateral "spider leg" appearance. * **Hydronephrosis:** This results in the **ballooning or blunting** of the calyces (clubbing) due to obstruction, which is the morphological opposite of the thinned, stretched appearance seen in ADPKD. **3. High-Yield Clinical Pearls for NEET-PG:** * **Swiss Cheese Appearance:** The nephrogram phase of IVP in ADPKD shows multiple radiolucent areas (cysts) against the enhancing parenchyma. * **Flower Vase Pattern:** Seen in **Horseshoe Kidney** due to the anterior and medial displacement of the lower poles. * **Maiden Waist Deformity:** Refers to the inward deviation of ureters, often seen in **Retroperitoneal Fibrosis**. * **ADPKD Associations:** Berry aneurysms (Circle of Willis), hepatic cysts, and mitral valve prolapse (MVP).
Question 472: What is the gold standard for the diagnosis of echinococcal cyst?
- A. X-ray
- B. CT scan
- C. USG
- D. ELISA (Correct Answer)
Explanation: **Explanation:** The diagnosis of **Echinococcal cyst (Hydatid disease)**, caused primarily by *Echinococcus granulosus*, relies on a combination of serology and imaging. **Why ELISA is the Correct Answer:** In the context of establishing a definitive diagnosis, **ELISA (Enzyme-Linked Immunosorbent Assay)** for IgG antibodies is considered the **gold standard** (specifically the screening test of choice with high sensitivity). While imaging identifies the lesion, serological confirmation is required to differentiate it from other cystic lesions (like simple cysts or abscesses) and to confirm the parasitic etiology. A positive ELISA is often followed by Western Blot for 100% specificity. **Analysis of Incorrect Options:** * **USG (Ultrasonography):** This is the **investigation of choice (IOC)** for screening and staging (Gharbi/WHO classification). It is excellent for visualizing daughter cysts and "water lily" signs but cannot provide a definitive serological diagnosis. * **CT Scan:** This is the best modality for detecting **wall calcification** and evaluating complications (rupture/infection) or cysts in extrahepatic locations. It is more sensitive than USG for calcification but is not the diagnostic gold standard. * **X-ray:** This may show incidental curvilinear calcification (eggshell calcification) in the right upper quadrant, but it lacks the sensitivity and specificity for a formal diagnosis. **Clinical Pearls for NEET-PG:** * **Pathognomonic Sign:** "Water lily sign" (detached endocyst membrane) seen on USG/CT. * **Treatment of Choice:** Surgical excision (modified PAIR technique or cystectomy) combined with **Albendazole**. * **Caution:** Diagnostic aspiration (FNA) is generally **contraindicated** due to the risk of anaphylactic shock from spillage of cyst fluid. * **Calcification:** A completely calcified cyst usually indicates a dead/inactive parasite.
Question 473: 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?
- A. Metastatic germ cell tumor (Correct Answer)
- B. Metastatic melanoma
- C. Lymphoma
- D. Metastatic transitional cell tumor
Explanation: **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.
Question 474: Which of the following is NOT a true feature of ileocecal tuberculosis on a diagnostic barium follow-through examination?
- A. Apple core appearance (Correct Answer)
- B. Pulled up or contracted cecum
- C. Widening of the ileocecal angle
- D. Stricture involving the terminal ileum
Explanation: **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).
Question 475: What condition is suggested by the following appearance on a barium enema?
- A. Ulcer
- B. Intussusception (Correct Answer)
- C. Carcinoma
- D. Diverticulum
Explanation: ***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.
Question 476: Cobra head appearance is seen in which condition?
- A. Ureterocele (Correct Answer)
- B. Wilm's Tumor
- C. Horse shoe kidney
- D. Vesicoureteral reflux
Explanation: **Explanation:** The **Cobra head appearance** (also known as the **Adder head sign**) is a classic radiological finding seen on an Intravenous Pyelogram (IVP) or contrast-enhanced CT. It represents a **Ureterocele**, which is a congenital cystic dilatation of the distal-most intramural portion of the ureter. * **Why it occurs:** The "head" of the cobra is formed by the contrast-filled dilated distal ureter protruding into the bladder lumen. This is surrounded by a thin, radiolucent halo (the "hood" of the cobra), which represents the combined thickness of the ureteral wall and the bladder mucosa. **Analysis of Incorrect Options:** * **Wilm’s Tumor:** Typically presents as a large, intrarenal mass that displaces and distorts the pelvicalyceal system (**Claw sign**). * **Horse shoe kidney:** Characterized by the fusion of the lower poles of the kidneys. On IVP, it shows a **Flower-vase appearance** due to the vertical orientation of the renal axes and anteriorly directed calyces. * **Vesicoureteral reflux (VUR):** Diagnosed primarily via Micturating Cystourethrogram (MCU). It shows contrast moving retrograde from the bladder into the ureters; it does not produce a cobra head deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Cobra Head Sign:** Specifically indicates a **simple (orthotopic) ureterocele**. If the radiolucent halo is thick or irregular, one must suspect a bladder malignancy. * **Drooping Lily Sign:** Seen in cases of a duplicated collecting system where an upper pole ureterocele causes mass effect, displacing the lower pole moiety downwards and outwards. * **Key Association:** Ureteroceles are frequently associated with **Weigert-Meyer Law** (upper pole ureter inserts ectopically and prone to ureterocele; lower pole inserts orthotopically and prone to reflux).
Question 477: An apple core lesion is typically seen in which of the following conditions?
- A. Diverticulosis
- B. Diverticulitis
- C. Carcinoma of the colon (Correct Answer)
- D. Intussusception
Explanation: **Explanation:** The **"Apple Core Lesion"** (also known as the napkin-ring sign) is a classic radiologic finding on a barium enema study. It represents a short, circumferential, irregular constriction of the colon lumen with overhanging edges (shouldering). **1. Why Carcinoma of the Colon is Correct:** This sign is most characteristic of **annular constricting adenocarcinoma of the colon**, particularly in the descending and sigmoid colon. The appearance is caused by the tumor infiltrating the bowel wall circumferentially, leading to focal narrowing of the lumen. The "shouldered" margins represent the transition between the normal bowel wall and the abrupt edge of the malignant mass. **2. Analysis of Incorrect Options:** * **Diverticulosis:** Refers to the presence of small outpouchings (herniations) of the colonic mucosa. On barium enema, these appear as "saw-tooth" configurations or small sacs, not circumferential narrowing. * **Diverticulitis:** This is the inflammation of diverticula. While it can cause luminal narrowing due to edema or spasm, the narrowing is usually over a longer segment and lacks the sharp, overhanging "shouldered" margins of a malignancy. * **Intussusception:** This occurs when one segment of the bowel telescopes into another. The classic radiologic signs are the **"Coiled Spring Appearance"** or the **"Target Sign"** on ultrasound/CT, rather than an apple core lesion. **3. Clinical Pearls for NEET-PG:** * **Most common site:** The apple core lesion is most frequently seen in the **left colon** (descending/sigmoid). * **Differential Diagnosis:** While highly suggestive of malignancy, a similar appearance can rarely be seen in focal Crohn’s disease, chronic ulcerative colitis, or ischemic strictures. * **Next Step:** When an apple core lesion is identified on imaging, the gold standard for confirmation is **Colonoscopy with biopsy**.
Question 478: Which of the following conditions is characterized by a "spider leg" appearance?
- A. Polycystic kidney disease (Correct Answer)
- B. Pyelonephritis
- C. Hydronephrosis
- D. Renal artery stenosis
Explanation: ### Explanation **Correct Option: A. Polycystic Kidney Disease (PKD)** The "spider leg" appearance is a classic radiological sign seen on an **Intravenous Urogram (IVU)** in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD). This appearance occurs because multiple, large parenchymal cysts compress, stretch, and elongate the renal calyces and pelvis. The resulting thin, elongated, and attenuated calyces resemble the long, spindly legs of a spider. **Incorrect Options:** * **B. Pyelonephritis:** Acute pyelonephritis usually shows normal imaging or generalized renal swelling. Chronic pyelonephritis is characterized by cortical scarring and "clubbing" of the calyces, not elongation. * **C. Hydronephrosis:** This condition involves the dilation of the renal pelvis and calyces due to obstruction. On IVU, this appears as "ballooning" or blunting of the calyces (e.g., "clubbed calyces"), which is the opposite of the thin stretching seen in PKD. * **D. Renal Artery Stenosis:** This typically presents with a small, shrunken kidney on the affected side. On IVU, it may show delayed excretion of contrast and "spastic" or small-looking collecting systems, but not the spider leg deformity. **High-Yield Clinical Pearls for NEET-PG:** * **ADPKD:** Associated with Berry aneurysms (Circle of Willis), hepatic cysts, and mitral valve prolapse. * **Swiss Cheese Appearance:** Seen on IVU in **Medullary Sponge Kidney** (due to ectatic collecting ducts). * **Flower Vase Appearance:** Seen in **Horseshoe Kidney** (due to the lower poles being fused and the ureters being displaced laterally). * **Rim Sign/Crescent Sign:** Associated with severe hydronephrosis.
Question 479: Gooseneck deformity is seen in which of the following conditions?
- A. Congenital hip and patella syndrome (CHPS)
- B. Ischemic colitis
- C. Ileocecal tuberculosis (Correct Answer)
- D. Crohn's disease
Explanation: **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.
Question 480: What is the earliest detectable congenital malformation by ultrasound?
- A. Spina bifida
- B. Cystic hygroma
- C. Anencephaly (Correct Answer)
- D. Encephalocele
Explanation: **Explanation:** **Anencephaly** is the correct answer because it is the earliest detectable congenital malformation via ultrasound, typically identifiable by the **end of the first trimester (10–14 weeks)**. It results from the failure of the cranial end of the neural tube to close. On ultrasound, the characteristic absence of the calvarium and cerebral hemispheres is seen, often described as the **"Frog-eye appearance"** or "Mickey Mouse sign" in the coronal view. **Analysis of Incorrect Options:** * **Spina Bifida:** While it can be suspected in the late first trimester via indirect signs (like an abnormal intracranial translucency), a definitive diagnosis usually requires a mid-trimester (18–22 weeks) anomaly scan to visualize the vertebral defect and "Lemon" or "Banana" signs. * **Cystic Hygroma:** This is a lymphatic malformation often seen in the first trimester (associated with Turner syndrome), but it is technically a fluid collection/soft tissue abnormality rather than a primary structural skeletal/neural tube malformation like anencephaly. * **Encephalocele:** This involves a midline cranial defect with herniation of brain tissue. While detectable early, it is often smaller and more subtle than the total absence of the vault seen in anencephaly, making anencephaly the most consistently detectable "earliest" lesion. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** The "Acrania-Anencephaly Sequence" begins with acrania; once the unprotected brain tissue degenerates due to exposure to amniotic fluid, it becomes anencephaly. * **Biochemical Marker:** Maternal Serum Alpha-Fetoprotein (MSAFP) is significantly **elevated** in open neural tube defects. * **Prevention:** Folic acid supplementation (400 mcg/day for low risk; 4 mg/day for high risk) started pre-conceptionally reduces the risk by 70%.
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