Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology Indian Medical PG Practice Questions and MCQs

Question 591: The initial imaging investigation for suspected intestinal obstruction is?

A. Ultrasound
B. CT scan
C. Barium study
D. X-ray abdomen (Correct Answer)

Explanation: ***Correct: X-ray abdomen*** - An **X-ray of the abdomen** is usually the **initial imaging investigation** due to its widespread availability, low cost, and ability to quickly identify signs of obstruction like **dilated bowel loops** and **air-fluid levels**. - While not as sensitive or specific as a CT scan, it serves as a crucial **first-line diagnostic tool** to determine the presence of an obstruction and guide further workup. *Incorrect: Ultrasound* - Ultrasound can be useful, especially in specific scenarios like suspected **intussusception** in children or **pyloric stenosis**. - However, its diagnostic accuracy for general intestinal obstruction in adults is often limited by **bowel gas** and operator dependence, making it less ideal as the initial test compared to X-ray. *Incorrect: CT scan* - A **CT scan with intravenous and oral contrast** is considered the **gold standard** for diagnosing intestinal obstruction, precisely localizing the obstruction, and identifying its cause. - It is typically performed **after an initial X-ray** has confirmed suspicion or as a primary investigation if an X-ray is inconclusive or complex pathology is suspected from the outset. *Incorrect: Barium study* - **Barium studies** (e.g., small bowel follow-through) involve administering contrast orally or rectally to visualize the bowel lumen. - While historically used, they are generally **avoided in suspected acute obstruction** due to the risk of barium impaction proximal to the obstruction or peritonitis if a perforation is present.

Question 592: A 70-year-old male presents with a pulsatile abdominal mass. Which diagnostic study is most appropriate to confirm the presence of an abdominal aortic aneurysm?

A. MRI
B. Plain X-ray
C. CT angiography
D. Abdominal ultrasound (Correct Answer)

Explanation: ***Abdominal ultrasound*** - An abdominal ultrasound is the **initial and most appropriate diagnostic study** due to its non-invasive nature, accessibility, and high accuracy in visualizing the **aorta's diameter** and presence of a pulsatile mass. - It can effectively **measure the size of the aneurysm**, detect its presence, and monitor its progression over time. *CT angiography* - While **CT angiography** provides detailed anatomical information, it involves **ionizing radiation** and **contrast dye**, making it a less preferred initial diagnostic tool compared to ultrasound for screening or initial confirmation. - It is typically reserved for **surgical planning** or in cases where ultrasound findings are inconclusive, or more detailed vascular mapping is required. *MRI* - **MRI** is an excellent imaging modality for soft tissue and vascular structures but is generally **more expensive and time-consuming** than ultrasound, and less readily available, making it less suitable as a first-line diagnostic test for AAA. - Its use is often limited to patients who cannot undergo CT due to **renal insufficiency** or **contrast allergy**. *Plain X-ray* - A **plain X-ray** of the abdomen is **not sensitive** or specific enough to accurately diagnose or rule out an abdominal aortic aneurysm. - It may incidentally show **aortic calcification**, but it cannot reliably measure the aortic diameter or confirm an aneurysm.

Question 593: Which imaging technique is essential for evaluating a suspected perforation of the gastrointestinal tract?

A. Abdominal ultrasound
B. X-ray using oral contrast
C. CT scan with IV contrast (Correct Answer)
D. MRI of the abdomen

Explanation: ***CT scan with IV contrast*** - A **CT scan with intravenous (IV) contrast** is the most sensitive and specific imaging modality for detecting **gastrointestinal (GI) perforation**. - It can visualize **free air**, fluid collections, and the site of perforation, providing crucial information for surgical planning. *Abdominal ultrasound* - While useful for detecting **free fluid** or abscesses, **abdominal ultrasound** is less sensitive for identifying **free air** in the abdomen, which is a hallmark of perforation. - Its diagnostic accuracy depends heavily on the operator's skill and patient body habitus. *X-ray using oral contrast* - An **X-ray using oral contrast** (e.g., gastrografin) can demonstrate a leak if the contrast extravasates, but it is less sensitive for small perforations and can be time-consuming. - Oral contrast is contraindicated if there's a risk of aspiration in an unstable patient, or if there is a known large perforation where the contrast could enter the peritoneal cavity and cause peritonitis. *MRI of the abdomen* - **MRI of the abdomen** is generally not the first-line imaging technique for acute GI perforation due to its longer acquisition times and higher cost. - Although it can detect **free fluid** and inflammation, it is not as readily available or as rapid as a CT scan, which is critical in an emergency setting.

Question 594: A patient with fever, back pain, and difficulty walking is diagnosed with a psoas abscess. Which imaging modality is the most effective for confirming the diagnosis?

A. CT scan (Correct Answer)
B. Ultrasound
C. X-ray
D. MRI

Explanation: ***CT scan*** - **CT scan** is the **most effective** imaging modality for diagnosing a psoas abscess due to its superior ability to visualize deep soft tissue structures and precisely delineate the abscess. - It clearly shows the **inflammation**, fluid collection, and extension of the abscess, guiding potential drainage. *Ultrasound* - While useful for superficial collections, **ultrasound** has limited penetration and is often obscured by bowel gas, making it less effective for deep structures like the psoas muscle. - It may be used as a **bedside tool** for initial assessment or guided aspiration if the abscess is readily accessible. *X-ray* - **X-rays** have very limited utility in diagnosing psoas abscesses as they primarily visualize bony structures and cannot effectively delineate soft tissue collections. - They might show indirect signs like **loss of the psoas shadow**, but this is non-specific and insensitive. *MRI* - **MRI** provides excellent soft tissue contrast and is highly sensitive for detecting abscesses, but it is typically reserved for cases where CT is inconclusive or when there is a need to rule out spinal involvement. - It is **more expensive** and less readily available than CT, making it a secondary option for initial diagnosis.

Question 595: A 60-year-old male with a history of smoking presents with severe abdominal pain and a pulsatile abdominal mass. What is the most appropriate next step in managing this patient?

A. Immediate surgery
B. CT angiography (Correct Answer)
C. Ultrasound of the abdomen
D. Observation

Explanation: ***CT angiography*** - **CT angiography** is the most appropriate next step for a **hemodynamically stable** patient with suspected **abdominal aortic aneurysm (AAA)**, as suggested by severe abdominal pain and a pulsatile abdominal mass in a smoker. - **CT angiography** is the gold standard for delineating the size, extent, anatomical relationships, and most importantly, the **rupture status** of an AAA, providing critical information for surgical planning. - This imaging is essential for determining the appropriate surgical approach (open repair vs. endovascular repair/EVAR) and identifying contained ruptures that may not be immediately life-threatening but require urgent intervention. - The patient presentation suggests a **symptomatic or contained rupture**, and assuming hemodynamic stability, imaging should precede surgery. *Immediate surgery* - Immediate surgery **without imaging** is indicated only when the patient is **hemodynamically unstable** (hypotension, shock) or in frank rupture with peritoneal signs, where delays for imaging would be fatal. - In a **stable** patient, proceeding directly to surgery without CT angiography increases operative risks due to lack of precise anatomical information about aneurysm size, location, proximal/distal extent, and involvement of renal or iliac arteries. - The question scenario, while concerning, does not explicitly indicate hemodynamic instability, making imaging the preferred next step. *Ultrasound of the abdomen* - **Ultrasound** is excellent for screening and confirming the presence of AAA, measuring aortic diameter, but it has significant limitations in acute settings. - **Ultrasound cannot reliably detect rupture** or provide the detailed anatomical information necessary for surgical planning (proximal/distal extent, branch vessel involvement). - In this acute presentation with suspected rupture, ultrasound would be insufficient and would delay definitive diagnosis, making **CT angiography** superior. *Observation* - **Observation** is absolutely contraindicated in a patient with severe abdominal pain and a pulsatile abdominal mass, as this presentation strongly suggests **symptomatic or ruptured AAA**. - AAA rupture carries mortality rates of 50-80% even with treatment, and any delay in diagnosis and intervention significantly increases mortality. - The combination of symptoms (severe pain) with a pulsatile mass in a high-risk patient (elderly male smoker) mandates immediate diagnostic workup, not observation.

Question 596: What does the 'football sign' on an abdominal X-ray indicate?

A. Ascites
B. Pneumoperitoneum (Correct Answer)
C. Bowel obstruction
D. Renal stone

Explanation: ***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**.

Question 597: Identify the radiological sign of Ischemic colitis from the image provided.

A. Diverticulitis
B. Appendicitis
C. Thumbprinting sign of Ischemic colitis (Correct Answer)
D. None of the options

Explanation: ***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 or CT scan is a classic radiological sign highly suggestive of **ischemic colitis**. *Diverticulitis* - Diverticulitis typically presents with **saccular outpouchings** (diverticula) that become inflamed, potentially showing wall thickening or **pericolonic fat stranding**. - This image does not show typical diverticula or signs of severe inflammation associated with diverticulitis, but rather diffuse mucosal changes. *Appendicitis* - Appendicitis is characterized by inflammation of the **vermiform appendix**, typically seen as a **dilated**, non-compressible appendix with surrounding fat stranding in the right lower quadrant. - The radiological findings in the image are of the colon, not the appendix, and are inconsistent with acute appendicitis. *None of the options* - The image presents a clear and characteristic radiological sign that points to a specific diagnosis, making this option incorrect. - The presence of **thumbprinting** is a well-established indicator for ischemic colitis.

Question 598: Chain of lakes appearance is seen in?

A. Chronic pancreatitis (Correct Answer)
B. Gallstone ileus
C. Sub-acute intestinal obstruction
D. Acute pancreatitis

Explanation: ***Chronic pancreatitis*** - The **"chain of lakes" appearance** refers to the characteristic imaging finding of **multiple dilated pancreatic ducts** with intervening strictures, indicative of chronic inflammation and fibrosis. - This morphology is a hallmark of advanced chronic pancreatitis on **ERCP or MRCP**, reflecting irreversible damage to the pancreatic ductal system. *Gallstone ileus* - Characterized by **mechanical obstruction of the small intestine** by a gallstone that has entered the bowel lumen through a cholecystoenteric fistula. - Imaging shows signs of small bowel obstruction, pneumobilia, and ectopic gallstone, not pancreatic ductal abnormalities. *Sub-acute intestinal obstruction* - Refers to partial or intermittent bowel obstruction with features like abdominal pain, distension, vomiting, and altered bowel habits. - Imaging findings relate to dilated bowel loops proximal to the obstruction, not pancreatic duct changes. *Acute pancreatitis* - While acute pancreatitis can involve ductal inflammation and occasionally transient dilation, it does not present with the **permanent "chain of lakes" morphology** seen in chronic disease. - Acute pancreatitis shows peripancreatic inflammation, fluid collections, or necrosis rather than chronic ductal strictures and dilatations.

Question 599: Which condition is associated with the "Drooping lily sign"?

A. Hydronephrosis
B. Duplicated collecting system (Correct Answer)
C. Chronic pyelonephritis
D. Renal cell carcinoma

Explanation: ***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 600: The most appropriate first-line investigation to be performed in suspected cases of gastric cancer is:

A. Endoscopy (Correct Answer)
B. Plain radiography
C. CT Scan
D. Double contrast radiography

Explanation: ***Endoscopy*** - **Endoscopy with biopsy** is the most definitive first-line investigation for suspected gastric cancer as it allows direct visualization of the gastric mucosa and tissue sampling for histological confirmation. - It is crucial for early detection, staging, and guiding subsequent management strategies in patients suspected of having gastric malignancy. *Double contrast radiography* - **Double contrast radiography** (barium swallow) can reveal suspicious mucosal abnormalities but is less sensitive and specific than endoscopy for detecting and characterizing early gastric lesions. - It does not allow for **biopsy**, which is essential for definitive diagnosis of cancer. *Plain radiography* - **Plain radiography** (X-ray) has very limited utility in diagnosing gastric cancer as it cannot visualize mucosal lesions or provide detailed information about the gastric wall. - It is primarily used for detecting complications like **perforation** or **obstruction**, rather than primary diagnosis. *CT Scan* - A **CT scan** is valuable for staging gastric cancer after diagnosis, assessing local invasion, lymph node involvement, and distant metastases. - However, it is not the first-line diagnostic modality because it cannot directly visualize early mucosal lesions or provide **histological confirmation** via biopsy.

Practice by Chapter

Imaging of Liver

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Biliary Tract Imaging

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Pancreatic Imaging

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Spleen and Lymphatic System

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Gastrointestinal Tract Imaging

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Renal and Urinary Tract Imaging

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Adrenal Imaging

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Female Pelvic Imaging

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Male Pelvic Imaging

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Abdominal Trauma Imaging

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Acute Abdomen Imaging

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Imaging of Peritoneal Cavity and Retroperitoneum

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