Abdominal and Pelvic Radiology Practice Questions

Q: Identify the type of investigation shown in the image below.

Myelography. ***Correct: Myelography*** - The image displays **contrast agent within the spinal canal**, outlining the spinal cord and nerve roots against the bony structures of the cervical spine - This technique is used to visualize **nerve impingement, disc herniation, or spinal cord compression** - Characteristic finding: contrast delineating the thecal sac and nerve root sleeves *Incorrect: Angiography* - Angiography involves injecting contrast into **blood vessels** to visualize vascular structures, detect blockages, or aneurysms - The image shows the **spinal canal** rather than the vascular tree *Incorrect: Neurography* - Neurography (MR neurography) is a specialized **MRI technique** to visualize peripheral nerves themselves - Does not involve injection of contrast into the spinal canal as shown in the image *Incorrect: Fluoroscopy* - Fluoroscopy is a **real-time X-ray imaging technique** used for dynamic assessment or procedure guidance - While fluoroscopy may be used **during** myelography to guide needle placement, the specific technique of contrast visualization in the spinal canal defines this as myelography

Q: What type of gallstones are shown in the image from a patient with history of acute cholecystitis?

Cholesterol stones. ***Cholesterol stones*** - The image distinctly shows multiple, **yellowish, translucent stones** within the gallbladder, which are characteristic macroscopic features of **cholesterol gallstones**. - These stones are formed due to an imbalance in bile composition, specifically **supersaturation of cholesterol**, and are the most common type of gallstone associated with acute cholecystitis. *Black pigment stones* - These stones are typically **small, rigid, and dark** (black to dark brown) in color, often resembling gravel. - They are composed primarily of **unconjugated bilirubin polymer** and calcium salts, and are commonly seen in conditions like **hemolytic anemias** or cirrhosis. *Strawberry gallbladder* - This is a condition called **cholesterolosis**, where cholesterol deposits accumulate within the gallbladder mucosa, giving it a **strawberry-like appearance** due to prominent yellow flecks against a red background. - While it involves cholesterol, it refers to the mucosal changes, not the presence of discrete, large stones in the lumen. *Brown pigmented stones* - Brown pigment stones are soft, greasy, and tend to be **laminated**. They are primarily composed of **calcium bilirubinate** and fatty acid calcium salts. - They are typically associated with **biliary tract infections** and stasis, and are often seen in the bile ducts rather than solely in the gallbladder.

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: Pneumobilia can be seen in

gallstone ileus. ***gallstone ileus*** - **Gallstone ileus** is a mechanical small bowel obstruction caused by a large gallstone that has eroded through the gallbladder wall into the small intestine, forming a **cholecystoenteric fistula**. - The presence of the fistula allows **gas from the bowel to enter the biliary tree**, resulting in pneumobilia, which is a classic radiographic finding in this condition. *acute pancreatitis* - **Acute pancreatitis** is inflammation of the pancreas, often caused by gallstones or alcohol, but it does **not typically involve communication between the bowel and the biliary tree**. - While gallstones can cause pancreatitis, the condition itself does **not lead to gas in the biliary system**. *Mirizzi's syndrome* - **Mirizzi's syndrome** involves obstruction of the common hepatic duct due to extrinsic compression by a stone impacted in the cystic duct or gallbladder neck, and it **does not typically create a fistula with the bowel**. - Although inflammation can be severe, it usually **does not lead to pneumobilia** unless a rare fistulous connection to the bowel also occurs separately. *carcinoma gallbladder* - **Gallbladder carcinoma** is a malignancy that can obstruct the biliary system, but it **does not inherently cause a direct communication between the gastrointestinal tract and the biliary tree** to allow for gas entry. - While advanced cancer can cause fistulas, **pneumobilia is not a typical or early sign** of gallbladder carcinoma itself.

Q: An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Achalasia cardia. ***Achalasia cardia*** - The classic radiographic features of achalasia on a barium swallow include a **dilated esophagus** with proximal food retention (leading to an **air-fluid level**) and a characteristic narrowing at the gastroesophageal junction, creating a **"bird-beak" appearance**. - This appearance is due to the failure of the lower esophageal sphincter to relax during swallowing, combined with absent esophageal peristalsis. *Carcinoma oesophagus* - Oesophageal carcinoma typically presents as an **irregular, constricting lesion** or a **filling defect** on barium swallow, often with mucosal irregularity or shelf-like margins, rather than a smooth "bird beak." - While it can cause dysphagia and possibly proximal dilation, the specific "bird beak" morphology is not characteristic of cancer. *Barrett's oesophagus* - Barrett's esophagus is a histological diagnosis involving **metaplastic changes** in the esophageal lining, usually due to chronic GERD. - It does not have a distinct radiographic appearance on barium swallow, though it might be associated with reflux changes or **ulcerations**, but not a "bird beak" sign. *Hiatus hernia* - Hiatus hernias are characterized by the **protrusion of a portion of the stomach into the chest cavity** through the esophageal hiatus of the diaphragm. - On a barium swallow, this appears as an **accumulation of barium above the diaphragm**, often with a wide opening at the esophagogastric junction, which is distinct from the narrowed "bird beak" of achalasia.

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: 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: 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.

Question 1

Identify the type of investigation shown in the image below.

Accepted Answer

Myelography

Answer

Angiography

Answer

Neurography

Answer

Fluoroscopy

Question 2

What type of gallstones are shown in the image from a patient with history of acute cholecystitis?

Accepted Answer

Cholesterol stones

Answer

Black pigment stones

Answer

Strawberry gallbladder

Answer

Brown pigmented stones

Question 3

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 4

'Double duct' sign is diagnostic of

Accepted Answer

periampullary carcinoma

Answer

hepatocellular carcinoma

Answer

gallbladder carcinoma

Answer

Klatskin's carcinoma

Question 5

Pneumobilia can be seen in

Accepted Answer

gallstone ileus

Answer

acute pancreatitis

Answer

Mirizzi's syndrome

Answer

carcinoma gallbladder

Question 6

An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Accepted Answer

Achalasia cardia

Answer

Carcinoma oesophagus

Answer

Barrett's oesophagus

Answer

Hiatus hernia

Question 7

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 8

Identify the condition shown in the plain abdominal radiograph.

Accepted Answer

Pancreatic calcification

Answer

Mesenteric calcification

Answer

Horseshoe kidney

Answer

Jejunal fecolith

Question 9

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 10

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

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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