Abdominal and Pelvic Radiology Practice Questions

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

Stent. ***Stent*** - The image clearly shows **bilateral coiled structures** (pigtails) at the proximal and distal ends within the renal pelvis and bladder, which are characteristic features of **double J stents (ureteral stents)**. - These devices are used to maintain patency in the **ureters**, often to bypass obstructions or facilitate urine drainage. *Surgical clips* - **Surgical clips** are typically small, dense, metallic objects used to ligate vessels or tissue, appearing as tiny, bright specks on X-rays. - The structures seen in the image are long, tubular, and coiled, which is inconsistent with the appearance of surgical clips. *Foley catheter* - A **Foley catheter** is a flexible tube inserted into the bladder to drain urine, sometimes with a balloon tip. - It would typically be seen entirely within the **bladder**, and its path would not extend bilaterally into the renal pelvis as shown. *Intravesical wire* - An **intravesical wire** (a wire entirely within the bladder) would appear as a coiled or linear structure confined to the bladder itself. - The structures in the image extend from the renal region down into the bladder, traversing the **ureters**, which is not typical for an intravesical wire.

Q: On CT scan, gastric volvulus typically shows which of the following findings?

Enlarged twisted stomach. ***Enlarged twisted stomach*** - In gastric volvulus, the stomach **twists on its mesentery**, leading to outflow obstruction and subsequent **gastric distension** or enlargement. - CT scans typically show a **dilated stomach** that appears abnormally oriented or twisted, with **obstructed transition points** and possible twisting of the associated mesenteric or vascular pedicle. *Gastric outlet obstruction with normal gastric orientation* - Gastric outlet obstruction alone (e.g., from peptic ulcer disease or malignancy) may cause gastric distension, but the stomach retains its **normal anatomical orientation** without the characteristic twisting seen in volvulus. - The absence of abnormal gastric orientation and transition points distinguishes this from gastric volvulus on CT. *Small-bowel volvulus with mesenteric twisting* - Small-bowel volvulus involves twisting of the small intestine and its mesentery, not the stomach. - While mesenteric twisting may be seen in both conditions, the **location and organ involved** differ, and the stomach would not appear abnormally oriented or distended in isolated small-bowel volvulus. *None of the options* - This option is incorrect because the finding of an **enlarged twisted stomach** with abnormal orientation and obstructed transition points is a hallmark of gastric volvulus on imaging. - CT scans play a crucial role in identifying the **degree of distension** and the characteristic twisting pattern in this condition.

Q: In a patient with a tender and rigid abdomen, what is the expected finding on X-ray?

Air under the diaphragm. ***Air under the diaphragm*** - The presence of **free air** (pneumoperitoneum) beneath the diaphragm on an upright abdominal X-ray is a classic sign of **visceral perforation**. - A **tender and rigid abdomen** (peritoneal signs) indicates irritation of the peritoneum, most commonly due to a ruptured hollow viscus. *Blood under the diaphragm* - While blood can accumulate under the diaphragm (e.g., from **trauma** or a ruptured ectopic pregnancy), it typically manifests as a **hemoperitoneum** on imaging. - Blood is **fluid** and would appear as a fluid collection, not free air, on X-ray. *Hazy lung fields* - **Hazy lung fields** suggest conditions like **pulmonary edema**, pneumonia, or acute respiratory distress syndrome (ARDS). - These findings are primarily associated with pulmonary pathology and are not directly indicative of an acute abdominal emergency like perforation. *Prominent vascular markings* - **Prominent vascular markings** often indicate increased blood flow to the lungs or **pulmonary hypertension**. - This finding is unrelated to acute abdominal pain or peritoneal irritation.

Q: Which of the following X-ray findings is associated with Chilaiditi syndrome?

Pseudopneumoperitoneum. ***Pseudopneumoperitoneum*** - Chilaiditi syndrome is characterized by the **interposition of a loop of colon (usually transverse colon) or, less commonly, small intestine** between the liver and the right hemidiaphragm. - This anatomical variation can mimic **free air under the diaphragm** on an X-ray, leading to the misdiagnosis of pneumoperitoneum. *Pseudopneumothorax* - This term describes the appearance of **air in the pleural space** that is not actually present, which is not associated with Chilaiditi syndrome. - While Chilaiditi syndrome involves misinterpretation of air, it specifically relates to the **abdominal cavity**, not the thoracic cavity. *Pneumothorax* - A **true pneumothorax** is the presence of air in the pleural cavity causing partial or complete lung collapse, which is a significant medical emergency. - It is distinct from Chilaiditi syndrome, which involves **abdominal content displacement** mimicking abdominal free air. *Hydropneumothorax* - This condition involves the presence of both **fluid and air in the pleural cavity**. - It is a pathology of the thoracic cavity and has **no direct association** with the abdominal interposition of bowel loops seen in Chilaiditi syndrome.

Q: Cobra head appearance on excretory urography is suggestive of?

Ureterocele. ***Ureterocele*** - A **cobra head appearance** on excretory urography is a classic sign of a **ureterocele**, which is a cystic dilation of the distal ureter that protrudes into the bladder. - This appearance is due to the dilated ureter appearing like an oval or round filling defect within the bladder lumen, surrounded by a thin radiolucent halo created by the ureteral wall and urine. *Horseshoe kidney* - A horseshoe kidney is characterized by the fusion of the lower poles of the kidneys, causing a **"U" shape** across the midline, often identified by the isthmus. - It does not present with a cobra head appearance but rather a typical anatomical variation of renal position and fusion. *Duplication of renal pelvis* - Duplication of the renal pelvis involves two separate collecting systems draining one kidney, which can be seen as two distinct pelvicalyceal systems. - This condition does not create a cobra head appearance; instead, it shows an abnormal number of collecting systems within a single kidney. *Simple cyst of kidney* - A simple renal cyst typically appears as a **well-defined, anechoic (on ultrasound) or hypodense (on CT) mass** within the kidney parenchyma. - It does not involve the ureter or bladder and thus does not produce a cobra head appearance on urograms.

Q: Rigler's sign is suggestive of?

Pneumoperitoneum. ***Correct: Pneumoperitoneum*** - **Rigler's sign** (double wall sign) is the visualization of both the **inner (mucosal) and outer (serosal) surfaces** of the bowel wall on an abdominal X-ray. - This occurs when **free intraperitoneal air** outlines both sides of the bowel wall, making it a **pathognomonic sign of pneumoperitoneum**. - Commonly seen in **bowel perforation** from causes like peptic ulcer, trauma, or iatrogenic injury. *Incorrect: Pneumothorax* - Refers to air in the **pleural space** (thoracic cavity), not the peritoneal cavity. - Diagnosed on chest X-ray by the **visceral pleural line** with absent lung markings peripherally. - Completely different anatomical compartment from where Rigler's sign is observed. *Incorrect: Peritonitis* - Represents **inflammation of the peritoneum**, which is a clinical and pathological diagnosis. - While pneumoperitoneum from perforation can **lead to peritonitis**, Rigler's sign specifically indicates the **presence of free air**, not inflammation itself. - Peritonitis has no specific pathognomonic radiological sign like Rigler's. *Incorrect: Hemothorax* - Refers to **blood in the pleural cavity** (thoracic, not abdominal). - Appears as a **pleural effusion** with meniscus sign on chest X-ray. - Unrelated to abdominal radiological findings or free air.

Q: What is the best investigation for diagnosis and staging of renal cell carcinoma with thrombus extending into the IVC?

CT scan. ***CT scan*** - **CT scan** with contrast is the gold standard for diagnosing renal cell carcinoma and evaluating the extent of tumor thrombus into the **IVC**. - It provides detailed anatomical information on the tumor, staging, and involvement of adjacent structures. *Angiography* - **Angiography** is an invasive procedure primarily used for mapping the vascular supply of the tumor preoperatively or for embolization, not as a primary diagnostic tool. - It carries risks associated with contrast agents and catheterization and provides less comprehensive detail on tumor extension compared to CT. *Colour doppler imaging* - While useful for detecting blood flow and confirming the presence of a thrombus, **color Doppler imaging** (ultrasound) has limitations in accurately assessing the cranial extent of an IVC thrombus. - Its diagnostic accuracy is highly operator-dependent and less reliable for deep structures like the IVC compared to CT. *IVP* - **Intravenous Pyelogram (IVP)** assesses the urinary tract's structure and function but has limited utility in detecting soft tissue masses like renal cell carcinoma or IVC thrombus. - It involves radiation exposure and contrast material, and has largely been replaced by more advanced imaging techniques like CT and MRI for renal masses.

Q: Which of the following imaging modalities is most appropriate for initial evaluation of suspected acute appendicitis in a young adult patient?

Ultrasound. ***Ultrasound*** - **First-line imaging modality** for suspected acute appendicitis in young adults, especially in children, pregnant women, and young females - **Advantages:** No ionizing radiation, readily available, cost-effective, can be performed at bedside - **High specificity** (>90%) when positive findings are present - **Graded compression technique** helps visualize the appendix and assess for periappendiceal inflammation - **Limitations:** Operator-dependent, may be difficult in obese patients or with overlying bowel gas *CT scan (Contrast-enhanced)* - **Most sensitive imaging modality** (sensitivity >95%) for acute appendicitis - Considered when ultrasound is inconclusive or technically difficult - **Gold standard** in adults, especially in obese patients - Provides excellent visualization of the appendix and complications (perforation, abscess) - However, involves **ionizing radiation**, making it less ideal as first-line in young patients *MRI* - **Preferred in pregnant women** when ultrasound is inconclusive - No ionizing radiation exposure - High accuracy but **limited availability**, longer scan time, and higher cost - Not typically used as first-line imaging in non-pregnant young adults *Plain radiography (X-ray)* - **Limited role** in diagnosing acute appendicitis - Non-specific findings; may show fecalith, loss of psoas shadow, or signs of perforation - Cannot reliably visualize the appendix - **Not recommended** as initial imaging for suspected appendicitis

Q: "String of beads" appearance on horizontal abdominal view X-ray is suggestive of:

Small bowel obstruction. ***Small bowel obstruction*** - A "string of beads" appearance on a horizontal abdominal view X-ray refers to small gas bubbles trapped between the valvulae conniventes in a dilated small bowel loop. - This finding is highly suggestive of **complete small bowel obstruction**, particularly when accompanied by multiple air-fluid levels and dilated bowel loops. *Intussusception* - While it causes obstruction, intussusception usually appears as a **target sign** (doughnut sign) on ultrasound or a **meniscus sign** on barium enema, not a string of beads on plain X-ray. - Plain X-rays may show signs of **bowel obstruction**, but the string of beads is not characteristic. *Sigmoid volvulus* - Sigmoid volvulus is characterized by a **dilated loop of colon** forming an inverted U-shape, often described as a **coffee bean sign** or **omega sign**, on plain X-ray. - This involves the large bowel, and the "string of beads" specifically relates to gas in the small bowel. *Large bowel obstruction* - Large bowel obstruction typically presents with a **dilated colon** proximal to the obstruction and a collapsed distal colon, often with absent or minimal gas in the rectum and sigmoid. - While air-fluid levels can be present, the "string of beads" is a specific sign of gas within dilated small bowel loops, distinguishing it from most large bowel obstructions.

Question 1

What is the structure seen in the X-ray?

Accepted Answer

Stent

Answer

Surgical clips

Answer

Foley catheter

Answer

Intravesical wire

Question 2

On CT scan, gastric volvulus typically shows which of the following findings?

Accepted Answer

Enlarged twisted stomach

Answer

None of the options

Answer

Gastric outlet obstruction with normal gastric orientation

Answer

Small-bowel volvulus with mesenteric twisting

Question 3

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

Accepted Answer

Uterine Leiomyoma

Answer

Bladder rupture

Answer

Bladder stone

Answer

Transitional Cell Carcinoma of the Bladder

Question 4

In a patient with a tender and rigid abdomen, what is the expected finding on X-ray?

Accepted Answer

Air under the diaphragm

Answer

Blood under the diaphragm

Answer

Hazy lung fields

Answer

Prominent vascular markings

Question 5

Which of the following X-ray findings is associated with Chilaiditi syndrome?

Accepted Answer

Pseudopneumoperitoneum

Answer

Pseudopneumothorax

Answer

Pneumothorax

Answer

Hydropneumothorax

Question 6

Cobra head appearance on excretory urography is suggestive of?

Accepted Answer

Ureterocele

Answer

Horseshoe kidney

Answer

Duplication of renal pelvis

Answer

Simple cyst of kidney

Question 7

Rigler's sign is suggestive of?

Accepted Answer

Pneumoperitoneum

Answer

Pneumothorax

Answer

Peritonitis

Answer

Hemothorax

Question 8

What is the best investigation for diagnosis and staging of renal cell carcinoma with thrombus extending into the IVC?

Accepted Answer

CT scan

Answer

Angiography

Answer

Colour doppler imaging

Answer

IVP

Question 9

Which of the following imaging modalities is most appropriate for initial evaluation of suspected acute appendicitis in a young adult patient?

Accepted Answer

Ultrasound

Answer

CT scan (Contrast-enhanced)

Answer

Plain radiography (X-ray)

Answer

MRI

Question 10

"String of beads" appearance on horizontal abdominal view X-ray is suggestive of:

Accepted Answer

Small bowel obstruction

Answer

Intussusception

Answer

Sigmoid volvulus

Answer

Large bowel obstruction

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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