Abdominal and Pelvic Radiology Practice Questions

Q: A 75-year-old male with a history of hypertension presents with sudden-onset severe abdominal pain radiating to the back. Which diagnostic tool would be most beneficial in differentiating between a ruptured abdominal aneurysm and acute pancreatitis?

CT angiography. ***CT angiography*** - **CT angiography** is the most beneficial tool for differentiating a **ruptured abdominal aortic aneurysm (AAA)** from acute pancreatitis due to its ability to visualize the aorta and detect active extravasation or hematoma [2]. - It clearly identifies the presence, size, and rupture status of an AAA, which is crucial for immediate surgical planning [1]. *MRI abdomen with contrast* - While MRI can provide detailed soft tissue imaging, it is generally **less rapid** and **more expensive** than CT in emergent situations, especially for suspected rupture [2]. - **Motion artifacts** from abdominal breathing can also degrade image quality, and it may not be as readily available in emergency settings as CT. *Endoscopic ultrasound* - **Endoscopic ultrasound (EUS)** is primarily used for detailed imaging of the pancreas, bile ducts, and upper gastrointestinal tract, but it is **invasive** and not suitable for an acute emergency like a suspected AAA rupture. - EUS would not be effective in assessing the aorta for rupture or dissecting an aneurysm. *CT abdomen with oral contrast* - A standard **CT scan of the abdomen with oral contrast** is useful for evaluating the bowel and other intra-abdominal structures, but **oral contrast does not enhance vascular structures sufficiently** to diagnose an AAA rupture. - It would not provide the clear arterial phase imaging necessary to detect active bleeding or the integrity of the aortic wall as effectively as CT angiography [3].

Q: What does the 'football sign' on an abdominal X-ray indicate?

Pneumoperitoneum. ***Pneumoperitoneum*** - The **"football sign"** is observed on a supine abdominal X-ray and is characterized by the visualization of the entire anterior abdominal wall due to a large amount of **free air** in the peritoneal cavity. - This sign indicates **pneumoperitoneum**, which is often a critical finding suggesting **viscus perforation**. *Ascites* - **Ascites** refers to the accumulation of fluid in the peritoneal cavity, which would typically cause a generalized hazy appearance and sometimes **flank bulging** on X-ray. - It would not result in the distinct outlining of the abdominal wall by air as seen in the **football sign**. *Bowel obstruction* - **Bowel obstruction** is characterized by dilated loops of bowel, often with **air-fluid levels** on erect views, but does not present with free intraperitoneal air. - While it can sometimes lead to perforation and subsequent pneumoperitoneum, the football sign itself directly indicates the presence of **free air**, not the obstruction itself. *Renal stone* - A **renal stone** (nephrolithiasis) would appear as a **radio-opaque density** in the region of the kidney or ureter on an abdominal X-ray. - This finding is unrelated to the distribution of air within the abdominal cavity or the **football sign**.

Q: The Barium Swallow examination shows a filling defect in the esophagus. What is the most probable diagnosis?

Esophageal Carcinoma. ***Esophageal Carcinoma*** - A filling defect on a barium swallow study, especially with irregular borders and luminal narrowing, is highly suggestive of an **esophageal carcinoma**. - The image appears to show an **irregular, obstructing lesion** that displaces the barium column, characteristic of a mass. *Esophageal Ring* - An esophageal ring, such as a **Schatzki ring**, typically presents as a thin, circumferential narrowing of the distal esophagus, forming a smooth, shelf-like indentation, which is not seen here. - Esophageal rings usually cause **intermittent dysphagia** to solids but do not present as a large, irregular filling defect. *Esophageal Tear* - An esophageal tear (e.g., **Mallory-Weiss tear**) is a mucosal laceration that would present with **hematemesis** and would typically appear as a linear defect or streak on a barium swallow if visible, not a filling defect. - A tear is not usually associated with a persistent mass effect or irregular luminal obstruction seen in the image. *Achalasia Cardia* - **Achalasia** is characterized by the failure of the lower esophageal sphincter to relax and **absent peristalsis** in the esophageal body, leading to a classic "bird's beak" or "rat tail" appearance on barium swallow due to distal narrowing and proximal dilation. - While it causes luminal narrowing, it does not typically present as an irregular filling defect within the lumen, but rather as a smooth tapering of the distal esophagus.

Q: Identify the radiological sign of Ischemic colitis from the image provided.

Thumbprinting sign of Ischemic colitis. ***Thumbprinting sign of Ischemic colitis*** - The image displays prominent **indentations (thumbprinting)** along the bowel wall, especially in the descending colon (indicated by arrows). These indentations are caused by **edema** and **hemorrhage** in the submucosal layer due to ischemia. - This characteristic appearance on a barium enema is a classic radiological sign highly suggestive of **ischemic colitis**. *Lead pipe sign* - The lead pipe sign describes a featureless, rigid, and tubular appearance of the colon due to loss of haustral folds, and is classically associated with **ulcerative colitis**. - This image does not show a smooth, rigid, haustra-less colon, but rather focal mucosal indentations characteristic of thumbprinting. *String sign of Kantor* - The string sign of Kantor refers to a thin, string-like narrowing of the terminal ileum seen on barium studies, classically associated with **Crohn disease** due to severe transmural inflammation and fibrosis. - The findings in this image are of the colon with submucosal edematous indentations, inconsistent with the string sign. *Apple core sign* - The apple core sign describes an annular, shouldered, irregular narrowing of the colon resembling the core of an apple, classically associated with **colorectal carcinoma**. - The image does not show an annular constricting lesion with shouldering, but rather diffuse submucosal thumbprinting consistent with ischemic colitis.

Q: A female patient presented with recurrent urinary tract infections. What is the most probable diagnosis based on the imaging findings?

Ureterocele. ***Ureterocele*** - The imaging shows a classic **cobra-head sign**: a smooth, rounded radiolucent filling defect surrounded by a thin radiopaque halo within the **contrast-filled bladder**, which is characteristic of a **ureterocele**. This is often associated with recurrent UTIs due to obstruction and stasis. - A ureterocele is a **congenital dilation** of the terminal part of the ureter as it enters the bladder, causing a cystic protrusion into the bladder lumen. *Congenital megaureter* - A congenital megaureter would appear as a **diffusely dilated ureter** throughout its course, often extending from the renal pelvis, rather than a localized cystic structure within the bladder. - While it can cause recurrent UTIs, the specific bladder filling defect seen here is not typical for an isolated megaureter. *Urinary stones* - Urinary stones would typically appear as **radiopaque foci** of varying size, depending on their composition, within the collecting system or bladder. - They do not typically present as a smooth, rounded filling defect within a contrast-filled bladder. *Ureteral duplication* - Ureteral duplication involves two separate ureters draining a single kidney, which often have their own separate openings into the bladder or meet before entering. - While it can be associated with UTIs (especially with reflux or ectopia), the primary finding on imaging would be the presence of **two distinct ureters**, not an intravesical cystic structure.

Q: Based on the imaging findings, identify the condition associated with the following results.

Imaging shows a bulbar urethral stricture. ***Imaging shows a bulbar urethral stricture*** - The image provided clearly indicates a **stricture** in the **bulbar urethra**, which is a common site for urethral narrowing. The arrow is placed in the bulbar segment, distal to the membranous urethra and proximal to the penile urethra, with the bladder and prostatic urethra visible proximally as anatomical landmarks. - This anatomical location in the **male urethra** is particularly susceptible to trauma and inflammation, often leading to stricture formation. *Imaging shows a penile stricture* - A **penile stricture** would be located in the anterior urethra, specifically within the shaft of the penis, which is not where the stricture is depicted. - While possible, the imaging highlights a narrowing in a region distinct from the main penile urethra. *Imaging shows a prostatic stricture* - A **prostatic stricture** would refer to narrowing within the **prostatic urethra**, located within the prostate gland. - The imaging does not show a stricture in this specific anatomical area. *Imaging shows a membranous stricture* - A **membranous stricture** would be located in the **membranous urethra**, which is a short segment passing through the urogenital diaphragm. - The stricture shown is clearly more anterior (distal) to this region, in the bulbar segment, as confirmed by the arrow placement distal to the bulbomembranous junction.

Q: What radiological sign is depicted in this ultrasound image?

Target sign. ***Target sign*** - The image displays a cross-section of bowel loops concentrically arranged, creating a characteristic "target" or "doughnut" sign, which is pathognomonic for **intussusception** on ultrasound. - This appearance represents the invaginated bowel (intussusceptum) within the receiving bowel (intussuscipiens), with layers of bowel wall and mesentery visible. *Colon carcinoma* - Colon carcinoma would typically appear as a focal, often eccentric, **mural thickening** or a mass lesion, rather than the concentric pattern seen here. - While it can cause bowel obstruction, its primary ultrasound appearance is generally not that of a target sign. *Sigmoid volvulus* - Sigmoid volvulus involves a twisting of the sigmoid colon, leading to a massively dilated sigmoid loop with a characteristic **"coffee bean" sign** on plain radiographs or a **"whirl sign"** on CT, neither of which is present in this ultrasound image. - The dilated loop seen in volvulus would have a different ultrasound appearance, often showing fluid-filled, distended bowel. *Cecal volvulus* - Cecal volvulus is also a twisting of a part of the colon (the cecum and ascending colon), resulting in similar features to sigmoid volvulus, such as significant **bowel distension** and a **"whirl sign"** on cross-sectional imaging due to mesenteric twisting. - The target sign is not characteristic of cecal volvulus, which involves a different mechanism of obstruction.

Q: What does the following radiograph from a double contrast esophagram represent?

Feline esophagus appearance. ***Feline esophagus appearance*** - The radiograph from a **double contrast esophagram** shows distinct, closely spaced, **transverse folds** in the esophagus, which is characteristic of the "feline esophagus" appearance. - This appearance is often associated with conditions like **reflux esophagitis**, suggesting chronic irritation or inflammation. *Congenital esophageal atresia* - This condition involves a **discontinuity of the esophagus**, typically diagnosed in neonates. - It would present as a **blind-ending esophageal pouch** with no distal passage of contrast, which is not seen here. *Acquired esophageal stenosis* - Acquired stenosis would appear as a **focal narrowing or stricture** of the esophageal lumen. - While the esophagus might be inflamed, it typically does not produce the characteristic stacked transverse folds seen in the image. *Tracheoesophageal fistula* - A tracheoesophageal fistula involves an **abnormal connection between the esophagus and the trachea**. - This would be evidenced by the **passage of contrast from the esophagus into the tracheal system**, which is not demonstrated on this esophagram.

Q: A 35-year-old patient with weight loss, sterile pyuria, and a history of pulmonary tuberculosis undergoes a plain abdominal radiograph. It shows irregular, dense calcification conforming to the right renal outline in the renal fossa, consistent with extensive dystrophic calcification of the kidney. What is the most likely diagnosis?

Renal tuberculosis (autonephrectomy/putty kidney). The diagnosis is renal tuberculosis with extensive dystrophic calcification, often termed a putty kidney or tuberculous autonephrectomy. Genitourinary tuberculosis classically causes sterile pyuria and may occur years after pulmonary infection. Chronic caseating granulomatous inflammation destroys the renal parenchyma, which can subsequently undergo irregular, dense calcification conforming to part or all of the renal outline. Medullary nephrocalcinosis is usually bilateral and distributed within the renal pyramids; a calcified uterine leiomyoma is located in the pelvis and often has a coarse popcorn pattern; and a staghorn calculus forms a branching opacity within the renal collecting system rather than calcifying the renal parenchyma.

Q: Which condition is associated with the "Drooping lily sign"?

Duplicated collecting system. ***Duplicated collecting system*** - The "drooping lily sign" is a classic radiographic finding in congenital **duplicated collecting systems** where the lower pole ureter and corresponding renal pelvis are displaced inferiorly and laterally due to an obstructed, dilated, and ectopic upper pole ureter and dilated calyces. - This displacement gives the lower pole calyces the appearance of a **"drooping lily"** on an intravenous pyelogram (IVP) or other imaging studies. *Hydronephrosis* **Hydronephrosis** refers to the swelling of a kidney due to a build-up of urine, typically due to obstruction. - While a duplicated system can cause hydronephrosis in the obstructed upper pole, **hydronephrosis itself doesn't directly present with a "drooping lily sign"** but rather features like dilated renal pelvis and calyces. *Chronic pyelonephritis* - **Chronic pyelonephritis** is an inflammatory condition of the kidney and renal pelvis, often due to recurrent infections. - Imaging typically shows **scarring, cortical thinning, and blunting of calyces**, distinct from the "drooping lily" appearance. *Renal cell carcinoma* - **Renal cell carcinoma (RCC)** is a malignant tumor of the kidney. - Imaging features usually include a **renal mass**, often with calcifications, necrosis, or vascular invasion, which is unrelated to the "drooping lily sign."

Question 1

A 75-year-old male with a history of hypertension presents with sudden-onset severe abdominal pain radiating to the back. Which diagnostic tool would be most beneficial in differentiating between a ruptured abdominal aneurysm and acute pancreatitis?

Accepted Answer

CT angiography

Answer

MRI abdomen with contrast

Answer

Endoscopic ultrasound

Answer

CT abdomen with oral contrast

Question 2

What does the 'football sign' on an abdominal X-ray indicate?

Accepted Answer

Pneumoperitoneum

Answer

Ascites

Answer

Bowel obstruction

Answer

Renal stone

Question 3

The Barium Swallow examination shows a filling defect in the esophagus. What is the most probable diagnosis?

Accepted Answer

Esophageal Carcinoma

Answer

Esophageal Ring

Answer

Esophageal Tear

Answer

Achalasia Cardia

Question 4

Identify the radiological sign of Ischemic colitis from the image provided.

Accepted Answer

Thumbprinting sign of Ischemic colitis

Answer

String sign of Kantor

Answer

Apple core sign

Answer

Lead pipe sign

Question 5

A female patient presented with recurrent urinary tract infections. What is the most probable diagnosis based on the imaging findings?

Accepted Answer

Ureterocele

Answer

Congenital megaureter

Answer

Urinary stones

Answer

Ureteral duplication

Question 6

Based on the imaging findings, identify the condition associated with the following results.

Accepted Answer

Imaging shows a bulbar urethral stricture

Answer

Imaging shows a penile stricture

Answer

Imaging shows a prostatic stricture

Answer

Imaging shows a membranous stricture

Question 7

What radiological sign is depicted in this ultrasound image?

Accepted Answer

Target sign

Answer

Colon carcinoma

Answer

Sigmoid volvulus

Answer

Cecal volvulus

Question 8

What does the following radiograph from a double contrast esophagram represent?

Accepted Answer

Feline esophagus appearance

Answer

Congenital esophageal atresia

Answer

Acquired esophageal stenosis

Answer

Tracheoesophageal fistula

Question 9

A 35-year-old patient with weight loss, sterile pyuria, and a history of pulmonary tuberculosis undergoes a plain abdominal radiograph. It shows irregular, dense calcification conforming to the right renal outline in the renal fossa, consistent with extensive dystrophic calcification of the kidney. What is the most likely diagnosis?

Accepted Answer

Renal tuberculosis (autonephrectomy/putty kidney)

Answer

Medullary nephrocalcinosis

Answer

Calcified uterine leiomyoma

Answer

Staghorn renal calculus

Question 10

Which condition is associated with the "Drooping lily sign"?

Accepted Answer

Duplicated collecting system

Answer

Hydronephrosis

Answer

Chronic pyelonephritis

Answer

Renal cell carcinoma

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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