Abdominal and Pelvic Radiology Practice Questions

Q: Which of the following may be detected on the plain abdominal film and is a premalignant condition?

Porcelain gallbladder. ***Porcelain gallbladder*** - This condition is characterized by **calcification of the gallbladder wall**, appearing as a curvilinear or speckled calcification on a plain abdominal film. - It is considered a **premalignant condition** due to an increased risk of developing gallbladder carcinoma. *Limy bile* - **Limy bile** (or milk of calcium bile) is a thick, pasty, calcium-containing bile that can be seen within the gallbladder lumen on imaging but does not represent calcification of the gallbladder wall itself. - While it indicates chronic inflammation and potential biliary stasis, it is **not considered a premalignant condition** like porcelain gallbladder. *Adenomyosis of gallbladder* - This is a benign condition involving **hyperplasia of the muscularis propria** and **outpouchings of the mucosa** (Rokitansky-Aschoff sinuses) into the muscular layer. - It is typically diagnosed with ultrasound or MRI and is **not reliably detected on a plain abdominal film**, nor is it premalignant. *Cholesterosis* - Also known as **"strawberry gallbladder,"** cholesterosis is a benign condition where **cholesterol esters accumulate in the gallbladder mucosa**. - It is usually **not detectable on plain abdominal films** and is not considered a premalignant condition.

Q: Which HSG finding is most characteristic of genital Koch's disease?

Golf club appearance of fallopian tubes. ***Golf club appearance of fallopian tubes*** - This finding on **hysterosalpingogram (HSG)** is the **most characteristic** sign of **genital tuberculosis (Koch's disease)**, particularly when the fimbrial end of the fallopian tube is dilated and club-shaped. - The **"golf club"** or **"tobacco pipe"** appearance results from fibrotic strictures and scarring at the ampullary-isthmic junction with distal fimbrial dilatation, often leading to **hydrosalpinx** or tubal occlusion—a common cause of infertility in tuberculosis. - This is considered **pathognomonic** when present. *Beaded tubes* - **Beading** or **"rosary bead"** appearance of the fallopian tubes, showing multiple constrictions and dilatations, is also a **classic HSG finding in genital tuberculosis**. - While highly suggestive of TB, it is **less specific** than the golf club appearance as beading can occasionally be seen in other chronic inflammatory conditions. - Both findings may coexist in the same patient. *Honeycomb uterus* - A **"honeycomb" appearance** of the uterus is typically associated with conditions like **adenomyosis**, where endometrial glands and stroma are found within the myometrium. - It is **not a characteristic finding** for genital tuberculosis on HSG. *None of the options* - This option is incorrect because the **golf club appearance** is indeed the most recognized and characteristic HSG finding associated with genital Koch's disease.

Q: All are radioopaque except one.

Uric acid. ***Correct: Uric acid*** - **Uric acid stones** are the only common type of kidney stone that is **radiolucent** (NOT radiopaque) - They are composed of uric acid, which has a lower density than calcium or cystine and thus **does not absorb X-rays effectively** - This low X-ray absorption makes them **invisible or very difficult to visualize** on standard **abdominal radiographs (KUB)** - However, they **can be detected on CT scans** or ultrasound - Account for **5-10% of all kidney stones** *Incorrect: Calcium oxalate* - **Calcium oxalate stones** are the **most common type** of kidney stone (~75% of cases) and are **highly radiopaque** - Their high calcium content causes them to absorb X-rays readily, making them **easily visible on plain radiographs** - Appear as dense white shadows on KUB X-ray *Incorrect: Cystine stones* - **Cystine stones** are formed due to a genetic disorder called **cystinuria** and are **faintly to moderately radiopaque** - While not as dense as calcium stones, they are generally **visible on plain radiographs** due to their sulfur content - Often appear with a characteristic **"ground-glass" texture** on imaging - Account for only **1-2% of kidney stones** *Incorrect: Mixed stones* - **Mixed stones** usually contain components that include a **calcium salt**, making them inherently **radiopaque** - Their visibility on imaging depends on the proportion and type of **calcium-containing components** within the stone - Most commonly contain calcium oxalate mixed with calcium phosphate

Q: Which X-ray finding is more suggestive of ulcerative colitis than Crohn's disease?

Loss of haustrations. ***Loss of haustrations*** - **Loss of haustrations**, also known as "lead pipe" appearance, is a classic X-ray finding in **ulcerative colitis**. - This indicates chronic inflammation leading to fibrosis and shortening of the colon, which obliterates the normal haustral markings. *Rectal sparing* - **Rectal sparing** is more characteristic of **Crohn's disease**, as ulcerative colitis typically involves the rectum and extends proximally. - While rare, some cases of ulcerative colitis can spare the rectum, but it is not the typical presentation seen on imaging. *Tracking of contrast within the bowel wall* - **Tracking of contrast within the bowel wall** (e.g., fistulas, sinus tracts) is a hallmark feature of **Crohn's disease**. - This indicates **transmural inflammation**, which is characteristic of Crohn's disease but not usually seen in ulcerative colitis. *Discontinuous lesions* - **Discontinuous lesions**, also known as "skip lesions," are a classic feature of **Crohn's disease**. - **Ulcerative colitis** is characterized by **continuous inflammation** that starts in the rectum and extends proximally without skipped areas.

Q: Investigation of choice in small renal calculi is:

Low dose non enhanced CT. ***Low dose non enhanced CT*** - **Low dose non-enhanced CT (LD-NCCT)** is the investigation of choice for suspected renal calculi, including **small stones as small as 1-2 mm**, due to its **high sensitivity (95-100%) and specificity (94-96%)** for detecting stones. - **Non-contrast** is preferred because contrast material can obscure small stones, and stones themselves are intrinsically dense enough to be visualized without it. - Low-dose protocols reduce radiation exposure by **50-75%** compared to standard CT while maintaining excellent diagnostic accuracy for stone detection. *High dose non enhanced CT* - A **high dose non-enhanced CT** is unnecessary as the diagnostic accuracy for renal calculi is already excellent with a low-dose protocol. - Using a high dose would lead to **increased radiation exposure** to the patient without providing additional diagnostic benefits for stone detection. - Modern low-dose protocols achieve similar image quality for stone identification. *Low dose enhanced CT* - **Enhanced CT** involves the administration of intravenous contrast, which is generally not required for the detection of renal calculi. - Contrast can potentially **obscure small stones** by making them less conspicuous against the enhanced renal parenchyma and collecting system. - It adds risks associated with contrast administration, such as allergic reactions or contrast-induced nephropathy, without improving stone detection. *High dose enhanced CT* - **High dose enhanced CT** combines the disadvantages of both high radiation exposure and contrast material. - This approach is not indicated for renal calculi and would expose the patient to **unnecessary risks and radiation** without improving diagnostic yield for stones. - Contrast is reserved for evaluating complications or alternative diagnoses, not primary stone detection.

Q: Which of the following is typically seen on ultrasound in acute pyelonephritis?

Enlarged kidney with diffuse swelling. ***Enlarged kidney with diffuse swelling*** - In **acute pyelonephritis**, the **most consistent ultrasound finding** is **renal enlargement** with **diffuse swelling** of the affected kidney. - This occurs due to **inflammatory edema** and increased fluid content within the renal parenchyma, representing the body's inflammatory response to infection. - **Diffuse enlargement** is present in the majority of cases and is often the **earliest sonographic manifestation**, making it the most typical finding. *Localized hypoechogenic areas in the kidney* - **Focal or multifocal hypoechoic areas** are indeed **highly characteristic** of acute pyelonephritis and represent zones of **parenchymal edema and inflammation**. - These are seen in approximately **20-80% of cases** and are considered a hallmark feature. - However, they may not be present in all cases, particularly in early or mild disease, whereas **renal enlargement is more consistently present**. - When visible, these areas have high specificity for the diagnosis. *Fluid collection around the kidney* - **Perinephric fluid collections** or abscesses indicate **complicated pyelonephritis** with extension of infection beyond the renal capsule. - These are **not typical findings in uncomplicated acute pyelonephritis** and suggest more severe or advanced infection requiring aggressive management. *Decreased vascularity* - Acute pyelonephritis typically shows **increased vascularity** on color Doppler due to **hyperemia and inflammatory vasodilation**. - **Decreased vascularity** is associated with **renal infarction**, severe ischemia, or chronic scarring—not acute bacterial infection.

Q: Non-visualization of the kidney in an excretory urogram is seen in.

Renal agenesis. ***Renal agenesis*** - **Renal agenesis** is the complete congenital absence of a kidney, which results in **absolute non-visualization** on excretory urogram. - Since there is **no renal tissue present**, there can be no concentration or excretion of contrast material, making this the classic cause of complete non-visualization. - This is a well-established radiological finding and a primary differential diagnosis when a kidney fails to appear on IVU. *Renal vein thrombosis* - **Renal vein thrombosis** typically causes a **delayed or persistent nephrogram**, not complete non-visualization. - The kidney remains perfused via the arterial supply and can still excrete contrast, though it may be delayed and the kidney appears enlarged. - The characteristic finding is a **prolonged nephrogram phase** with poor excretion into the collecting system, but the kidney parenchyma itself visualizes. *Hydronephrosis* - **Hydronephrosis** shows dilation of the renal pelvis and calyces due to obstruction, but the kidney **does visualize** on IVU. - The typical appearance includes a dilated collecting system with delayed contrast washout, not non-visualization. - The nephrogram phase is usually normal, followed by characteristic pelvicalyceal dilation. *Hypoplasia* - **Renal hypoplasia** refers to a congenitally small but otherwise normal kidney that **will visualize** on excretory urogram. - Though smaller than normal, the hypoplastic kidney maintains function and excretes contrast appropriately. - It appears as a small but normally functioning kidney, not as complete non-visualization.

Q: Pine-tree bladder is a sign of.

Bilharziasis. ***Bilharziasis*** - The "pine-tree bladder" appearance on a retrograde cystogram is characteristic of **chronic bilharzial cystitis**, also known as **schistosomiasis of the bladder**. - This appearance results from **fibrosis**, **granulomas**, and **calcification** of the bladder wall leading to multiple irregular diverticula and trabeculations, which resemble pine-tree branches. *Pelvic abscess* - A pelvic abscess causes an **extrinsic compression** on the bladder, leading to mass effect or displacement, rather than intrinsic wall changes. - It would typically present with symptoms of infection, such as fever and localized pain, and imaging would show a fluid collection. *Intraperitoneal bladder rupture* - An intraperitoneal bladder rupture would lead to extravasation of urine into the peritoneal cavity, which would be visible on imaging as **free fluid** around abdominal organs. - The bladder itself would appear flaccid and potentially collapsed, without the characteristic "pine-tree" appearance. *Neurogenic bladder* - Neurogenic bladder is characterized by **detrusor-sphincter dyssynergia** or loss of bladder sensation, leading to features like **trabeculation**, cellules, and diverticula due to high intravesical pressure. - While it can cause some bladder wall changes, the specific "pine-tree" pattern is not its hallmark, and it is usually associated with neurological deficits.

Q: A 22-year-old man presents with a solitary 2 cm space-occupying lesion of mixed echogenicity in the right lobe of the liver on ultrasound examination. The rest of the liver is normal. Which of the following tests should be done next?

Contrast-enhanced CT scan of the liver. ***Contrast-enhanced CT scan of the liver*** - A **contrast-enhanced CT scan** offers superior anatomical detail and lesion characterization compared to ultrasound, which is crucial for evaluating a newly discovered **space-occupying liver lesion**. - It can help differentiate between benign and malignant lesions, provide information on vascularity, and guide further management or **biopsy planning**. *Ultrasound-guided biopsy of the lesion* - While a biopsy might eventually be needed, it is generally performed **after further imaging** has better characterized the lesion. - Biopsy can be invasive and carries risks; a CT scan can often narrow down the differential diagnosis and determine if a biopsy is truly necessary. *Hepatic scintigraphy* - **Hepatic scintigraphy** (e.g., Tc-99m sulfur colloid scan) is primarily used for evaluating diffuse liver disease, bile duct obstruction, or specific entities like **focal nodular hyperplasia** (FNH) with certain tracers. - It is not the most appropriate initial imaging test for general characterization of a solitary, unspecific liver lesion. *Hepatic angiography* - **Hepatic angiography** is an invasive procedure typically reserved for detailed assessment of liver vascularity, embolization, or pre-surgical planning for highly vascular tumors. - It is not a first-line diagnostic test for an unexplained solitary liver mass after an initial ultrasound.

Q: What is the best investigation to diagnose a hydatid cyst in the liver?

Ultrasound. ***Ultrasound*** - It is often the **initial imaging modality** of choice due to its non-invasiveness, accessibility, and high sensitivity for detecting the characteristic features of **hydatid cysts**, such as the **double-wall sign**, **daughter cysts**, and **hydatid sand**. - Ultrasound can effectively visualize the **cystic nature** of the lesion and its internal architecture, crucial for differentiating it from other liver lesions. *MRI* - While MRI provides excellent soft tissue contrast, it is typically reserved for cases where **ultrasound findings are equivocal** or for better defining the anatomical relationship of the cyst to surrounding structures, especially if surgical intervention is planned. - It can identify complex cyst features but is not usually the **first-line diagnostic tool** due to its higher cost and longer scan time compared to ultrasound. *MRCP* - **Magnetic Resonance Cholangiopancreatography (MRCP)** is specifically designed to visualize the **biliary and pancreatic ducts**. - It is not the primary investigation for diagnosing hydatid cysts themselves, although it may be used if there is suspicion of **biliary tree involvement** or rupture into the bile ducts. *CT scan* - A **CT scan** is also a highly effective imaging modality for identifying hydatid cysts, especially for showing calcifications in the cyst wall and providing a comprehensive view of the abdominal organs. - However, for initial diagnosis, **ultrasound is preferred** due to its lower cost, lack of radiation exposure, and comparable diagnostic accuracy for typical cyst appearances.

Question 1

Which of the following may be detected on the plain abdominal film and is a premalignant condition?

Accepted Answer

Porcelain gallbladder

Answer

Limy bile

Answer

Adenomyosis of gallbladder

Answer

Cholesterosis

Question 2

Which HSG finding is most characteristic of genital Koch's disease?

Accepted Answer

Golf club appearance of fallopian tubes

Answer

None of the options

Answer

Beaded tubes

Answer

Honeycomb uterus

Question 3

All are radioopaque except one.

Accepted Answer

Uric acid

Answer

Calcium oxalate

Answer

Cystine stones

Answer

Mixed stones

Question 4

Which X-ray finding is more suggestive of ulcerative colitis than Crohn's disease?

Accepted Answer

Loss of haustrations

Answer

Rectal sparing

Answer

Tracking of contrast within the bowel wall

Answer

Discontinuous lesions

Question 5

Investigation of choice in small renal calculi is:

Accepted Answer

Low dose non enhanced CT

Answer

High dose non enhanced CT

Answer

Low dose enhanced CT

Answer

High dose enhanced CT

Question 6

Which of the following is typically seen on ultrasound in acute pyelonephritis?

Accepted Answer

Enlarged kidney with diffuse swelling

Answer

Decreased vascularity

Answer

Localized hypoechogenic areas in the kidney

Answer

Fluid collection around the kidney

Question 7

Non-visualization of the kidney in an excretory urogram is seen in.

Accepted Answer

Renal agenesis

Answer

Renal vein thrombosis

Answer

Hydronephrosis

Answer

Hypoplasia

Question 8

Pine-tree bladder is a sign of.

Accepted Answer

Bilharziasis

Answer

Pelvic abscess

Answer

Intraperitoneal bladder rupture

Answer

Neurogenic bladder

Question 9

A 22-year-old man presents with a solitary 2 cm space-occupying lesion of mixed echogenicity in the right lobe of the liver on ultrasound examination. The rest of the liver is normal. Which of the following tests should be done next?

Accepted Answer

Contrast-enhanced CT scan of the liver

Answer

Ultrasound-guided biopsy of the lesion

Answer

Hepatic scintigraphy

Answer

Hepatic angiography

Question 10

What is the best investigation to diagnose a hydatid cyst in the liver?

Accepted Answer

Ultrasound

Answer

MRI

Answer

MRCP

Answer

CT scan

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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