Abdominal and Pelvic Radiology Practice Questions

Q: A plain radiograph of a patient with chronic abdominal pain is provided. What is the probable diagnosis based on the image?

Pancreatitis. ***Pancreatitis*** - **Pancreatic calcifications** on plain abdominal X-ray are pathognomonic for chronic pancreatitis, appearing as rim-like or stippled densities in the epigastric region. - Chronic abdominal pain with **radiographic calcifications** strongly indicates chronic pancreatitis due to ductal obstruction and parenchymal fibrosis. *Pneumoperitoneum* - Characterized by **free gas under the diaphragm** (Rigler's sign) on upright chest or abdominal X-rays, not calcifications. - Typically presents with **acute onset** severe abdominal pain following bowel perforation, not chronic pain. *Hemoperitoneum* - Manifests as **loss of psoas shadow** and generalized **haziness** or ground-glass appearance on plain films. - Associated with **acute trauma** or **ruptured viscus**, presenting with hemodynamic instability rather than chronic pain. *Acute Appendicitis* - May show **appendicolith** (calcified deposit) in the **right iliac fossa** or localized gas pattern, not epigastric calcifications. - Presents with **acute onset** right lower quadrant pain with **McBurney's point tenderness**, not chronic abdominal pain.

Q: A patient presents with right hypochondrium pain. Which of the following investigations should be done?

USG. **Explanation:** **1. Why USG is the Correct Answer:** Ultrasonography (USG) is the **initial investigation of choice** for any patient presenting with right hypochondrium (RHC) pain. The most common causes of pain in this region are hepatobiliary in origin, such as gallstones (cholelithiasis), acute cholecystitis, or liver abscesses. USG is highly sensitive (up to 95-98%) for detecting gallstones, is non-invasive, cost-effective, radiation-free, and allows for real-time assessment (e.g., eliciting the **Sonographic Murphy’s sign**). **2. Why Other Options are Incorrect:** * **CT (Computed Tomography):** While excellent for complications (like perforation or gangrenous cholecystitis) and evaluating the pancreas, it is not the first-line tool. CT is less sensitive than USG for detecting cholesterol gallstones and involves ionizing radiation. * **MRI (MRCP):** Magnetic Resonance Cholangiopancreatography is the gold standard for visualizing the biliary tree and detecting common bile duct (CBD) stones (choledocholithiasis), but it is expensive, time-consuming, and reserved for complex cases or when USG is inconclusive. * **Cholecystogram:** This is an obsolete historical investigation. It has been entirely replaced by USG and HIDA scans in modern clinical practice. **Clinical Pearls for NEET-PG:** * **Investigation of Choice (IOC) for Gallstones:** USG. * **Gold Standard for Acute Cholecystitis:** Radionuclide scan (HIDA scan). * **IOC for Choledocholithiasis:** MRCP (Non-invasive) or ERCP (Invasive/Therapeutic). * **IOC for CBD stones in a patient with jaundice:** USG (Initial), then MRCP. * **Sonographic Murphy’s Sign:** Maximal tenderness over the gallbladder when compressed by the USG probe; a hallmark of acute cholecystitis.

Q: The 'apple core' sign observed in a barium enema is typically associated with which of the following conditions?

Carcinoma of the colon. ### Explanation The **'apple core' sign** (also known as a napkin-ring sign) is a classic radiologic finding on a barium enema, pathognomonic for **annular, constricting carcinoma of the colon** (most commonly the sigmoid colon). **1. Why the Correct Answer is Right:** In colorectal carcinoma, the tumor grows circumferentially around the bowel wall. This leads to a short, irregular, and eccentric narrowing of the bowel lumen with "overhanging edges" or "shouldering" at the proximal and distal ends. On a barium study, the contrast fills the narrow central channel and the areas around the overhanging margins, resembling the core of an apple after the surrounding fruit has been eaten. **2. Analysis of Incorrect Options:** * **Ileocecal Tuberculosis:** Typically presents with the **'Stierlin sign'** (rapid emptying of the inflamed cecum) or the **'Goose neck deformity'** (shrunken, conical cecum with a wide-open ileocecal valve). * **Carcinoma of the Esophagus:** While it can cause irregular narrowing, the term 'apple core' is specific to the colon. Esophageal malignancy often shows an irregular "rat-tail" appearance or eccentric filling defects. * **Achalasia Cardia:** Characterized by a smooth, symmetric, tapered narrowing of the distal esophagus, known as the **'Bird’s beak'** or **'Rat-tail'** appearance. **3. Clinical Pearls for NEET-PG:** * **Most common site:** The sigmoid colon is the most frequent site for these annular lesions. * **Clinical presentation:** Left-sided colonic cancers (where apple core signs are common) typically present with **altered bowel habits** and intestinal obstruction, whereas right-sided cancers often present with iron deficiency anemia. * **Differential Diagnosis:** Chronic diverticulitis or Crohn's disease can occasionally mimic this sign, but they usually involve longer segments and lack the sharp "shouldering" of malignancy.

Q: Calcific hepatic metastases are most commonly seen in which of the following primary tumors?

Adenocarcinoma of the colon. **Explanation:** **Calcific hepatic metastases** are a specific radiological finding that can narrow the differential diagnosis in abdominal imaging. **1. Why Adenocarcinoma of the Colon is correct:** Mucinous adenocarcinomas, particularly those originating from the **colon and rectum**, are the most common cause of calcified liver metastases. The underlying mechanism is the production of **mucin** by the tumor cells; this mucin undergoes dystrophic calcification. On CT scans, these appear as fine, punctate, or granular calcifications within the metastatic lesions. **2. Analysis of Incorrect Options:** * **Carcinoid Tumors:** While these can occasionally calcify, they are more characteristically known for being **hypervascular** (enhancing brightly in the arterial phase) rather than primarily calcific. * **Renal Cell Carcinoma (RCC):** Metastases from RCC are typically hypervascular and prone to hemorrhage, but primary calcification is less common than in mucinous GI malignancies. * **Lymphoma:** Hepatic involvement in lymphoma usually presents as hepatomegaly or discrete non-calcified nodules. Calcification in lymphoma is rare and typically occurs only **after treatment** (post-chemotherapy). **3. NEET-PG High-Yield Pearls:** * **Mnemonic for Calcified Liver Metastases:** "Old Men Can Play" (**O**varian cystadenocarcinoma, **M**ucinous adenocarcinoma of colon, **C**arcinoid, **P**ancreatic islet cell tumors). * **Hypervascular Metastases:** Remember "MR. T" (**M**elanoma, **R**CC, **T**hyroid/Islet cell/Carcinoid). * **Hypovascular Metastases:** Lung, Breast, and non-mucinous GI cancers. * **Imaging Choice:** CT is the most sensitive modality for detecting these calcifications compared to Ultrasound or MRI.

Q: Which investigation is useful for detecting extraadrenal pheochromocytoma?

Contrast-enhanced computed tomography (CCT). **Explanation:** **1. Why CECT is the Correct Answer:** Contrast-Enhanced Computed Tomography (CECT) is the **initial imaging modality of choice** for localizing pheochromocytomas, including extra-adrenal ones (paragangliomas). It offers excellent spatial resolution and high sensitivity (90–100%). Extra-adrenal pheochromocytomas are most commonly found in the **Organ of Zuckerkandl** (near the origin of the inferior mesenteric artery). On CECT, these tumors typically appear as well-defined, hypervascular masses with significant enhancement (>110 HU) and delayed washout. **2. Analysis of Other Options:** * **Ultrasound (USG):** While safe, it has low sensitivity for retroperitoneal structures and small extra-adrenal masses due to interference from bowel gas. * **MRI (T2-weighted):** MRI is highly sensitive and classically shows a **"Light Bulb Sign"** (hyperintensity) on T2W images. It is the preferred modality in children, pregnant women, or patients with contrast allergies. However, CECT remains the standard first-line investigation for localization in general adults. * **MIBG Scan:** This is a **functional/nuclear imaging** technique. While highly specific for confirming the diagnosis and detecting metastatic or multiple sites, it is not the primary investigation for initial localization due to lower spatial resolution compared to CT. **3. NEET-PG High-Yield Pearls:** * **Rule of 10s:** 10% are extra-adrenal, 10% bilateral, 10% malignant, and 10% pediatric. * **Biochemical Confirmation First:** Always perform 24-hour urinary metanephrines or plasma free metanephrines *before* imaging to avoid incidentaloma confusion. * **Pre-op Management:** Always start **Alpha-blockers** (e.g., Phenoxybenzamine) before Beta-blockers to prevent a hypertensive crisis. * **Extra-adrenal sites:** Most common is the Organ of Zuckerkandl; other sites include the bladder wall and carotid body.

Q: What is the term for the appearance of diverticulosis on a barium enema as depicted in the image?

Saw tooth appearance. ***Saw tooth appearance*** - Diverticulosis on **barium enema** creates a characteristic **saw tooth pattern** due to **circular muscle hypertrophy** and **spasm** between diverticular outpouchings. - The alternating **indentations** and **bulges** along the colonic wall resemble the teeth of a saw, making this the classic radiological sign. *Cork screw appearance* - This describes the radiological appearance of **diffuse esophageal spasm** on barium swallow, not colonic diverticulosis. - Characterized by **tertiary contractions** creating a **corkscrew pattern** in the esophagus during swallowing. *Bird of prey appearance* - This sign is associated with **sigmoid volvulus** on plain abdominal X-ray, showing a **coffee bean sign**. - The **twisted sigmoid colon** creates a configuration resembling a **bird's beak** or **bird of prey**, not related to diverticulosis. *Claw sign* - This radiological sign is seen in **renal cysts** on IVP or in **intussusception** on contrast enemas. - Represents **mass effect** or **invagination** creating **claw-like indentations**, unrelated to diverticular disease.

Q: Tear drop bladder is seen in which of the following conditions?

All of the above. **Explanation:** The **"Tear drop bladder"** (or pear-shaped bladder) is a classic radiological sign where the urinary bladder is compressed from both sides, causing it to lose its normal rounded shape and appear elongated and narrow. **1. Underlying Medical Concept:** The bladder is a highly compliant organ located in the extraperitoneal space of the pelvis. Any process that causes **extrinsic compression** or symmetric accumulation of fluid, fat, or blood in the perivesical space (specifically the space of Retzius) will squeeze the bladder medially and superiorly, resulting in this characteristic shape. **2. Analysis of Options:** * **Pelvic Lipomatosis (Option B):** This is the most classic association. It is a benign condition characterized by the overgrowth of unencapsulated fat in the perivesical and perirectal spaces, which "squeezes" the bladder into a teardrop shape. * **Pelvic Abscess (Option A):** Large, bilateral, or diffuse pelvic collections (pus) can exert enough mass effect to compress the bladder. * **Bladder Rupture / Pelvic Hematoma (Option C):** In the context of trauma, a large **pelvic hematoma** (often associated with pelvic fractures) or extravasation of urine/blood into the perivesical space causes rapid compression, leading to the teardrop appearance. Since all three conditions involve extrinsic compression of the bladder, **Option D (All of the above)** is correct. **High-Yield Clinical Pearls for NEET-PG:** * **Other causes:** Inferior vena cava (IVC) obstruction, bilateral lymphadenopathy, and massive iliac artery aneurysms. * **Pelvic Lipomatosis association:** Often associated with **cystitis glandularis** and increased risk of bladder carcinoma. * **Imaging Modality:** Best visualized on **IVP (Intravenous Pyelogram)** or Contrast-enhanced CT. * **Differential Diagnosis:** Do not confuse with "Christmas tree bladder," which is seen in neurogenic bladder (detrusor-sphincter dyssynergia).

Q: An incidental finding on ultrasound abdomen is suggestive of which of the following?

Adenomyomatosis. ***Adenomyomatosis*** - Characteristic **comet-tail artifacts** on ultrasound due to **Rokitansky-Aschoff sinuses** filled with cholesterol crystals, making it a classic incidental finding. - Shows **focal or diffuse gallbladder wall thickening** with **hyperechoic foci** that create the pathognomonic comet-tail appearance on ultrasound. *Gallbladder stone* - Presents as **mobile hyperechoic structures** with **posterior acoustic shadowing**, not as wall thickening with comet-tail artifacts. - Typically **symptomatic** with biliary colic rather than being an incidental finding, and moves with patient positioning. *Gallbladder polyp* - Appears as **fixed hyperechoic lesions** attached to the gallbladder wall **without posterior shadowing**. - Does not demonstrate the characteristic **comet-tail artifacts** or **Rokitansky-Aschoff sinuses** seen in adenomyomatosis. *Xanthogranulomatous cholecystitis* - Shows **irregular wall thickening** with **hypoechoic intramural nodules** and loss of normal wall layering on ultrasound. - Usually presents with **severe symptoms** and **pericholecystic fluid**, making it less likely to be an incidental finding.

Q: A 45-year-old male shows calcification on the right side of his abdomen in an AP view. In the lateral view, the calcification is seen to overlie the spine. What is the most likely diagnosis?

Renal stones. ### Explanation The key to solving this question lies in understanding the **retroperitoneal vs. intraperitoneal** anatomy as visualized on a lateral abdominal radiograph. **1. Why Renal Stones are Correct:** The kidneys are **retroperitoneal** structures located in the paravertebral gutters. On a lateral X-ray, retroperitoneal structures (like the kidneys and ureters) project **posteriorly**, often overlying or appearing just posterior to the anterior border of the vertebral bodies. Therefore, a calcification that overlies the spine on a lateral view is classically diagnostic of a renal or ureteric calculus. **2. Analysis of Incorrect Options:** * **Gallstones (A):** The gallbladder is an **intraperitoneal** organ located anteriorly. On a lateral view, gallstones appear **anterior to the spine**, usually in the space between the abdominal wall and the vertebral column. * **Calcified Mesenteric Nodes (B):** These are associated with the mesentery of the small bowel. They are highly mobile and typically appear **anterior to the spine** on a lateral view. They often have a characteristic "popcorn" appearance. * **Calcified Rib (D):** While ribs are posterior, a calcified costal cartilage or rib tip would typically follow the anatomical contour of the rib cage and would not specifically be described as "overlying the spine" in a way that mimics a visceral stone. **3. NEET-PG High-Yield Pearls:** * **Lateral View Rule:** * **Overlying/Posterior to spine:** Renal stones, Abdominal Aortic Aneurysm (calcified wall). * **Anterior to spine:** Gallstones, Pancreatic calcifications, Mesenteric lymph nodes. * **Phleboliths:** These are small calcifications in pelvic veins. They often have a **lucent center**, which helps distinguish them from ureteric stones (which are usually solid). * **Staghorn Calculi:** Most commonly composed of **Struvite** (Magnesium Ammonium Phosphate) and associated with Proteus infections.

Question 1

Which of the following is true regarding the principles of MRCP?

Accepted Answer

Use of heavily T2-weighted images without contrast.

Answer

Use of IV Gadolinium contrast agent is used to enhance the biliary radicals and the pancreatic duct.

Answer

Contrast agent is instilled percutaneously into the biliary radicals first, and then MRI is done.

Answer

Intraluminal dye is used to create a three-dimensional view of the biliary radicals and the pancreatic duct.

Question 2

A plain radiograph of a patient with chronic abdominal pain is provided. What is the probable diagnosis based on the image?

Accepted Answer

Pancreatitis

Answer

Pneumoperitoneum

Answer

Hemoperitoneum

Answer

Acute Appendicitis

Question 3

A patient presents with right hypochondrium pain. Which of the following investigations should be done?

Accepted Answer

USG

Answer

CT

Answer

MRI

Answer

Cholecystogram

Question 4

The 'apple core' sign observed in a barium enema is typically associated with which of the following conditions?

Accepted Answer

Carcinoma of the colon

Answer

Ileocecal tuberculosis

Answer

Carcinoma of the esophagus

Answer

Achalasia of the cardia

Question 5

Calcific hepatic metastases are most commonly seen in which of the following primary tumors?

Accepted Answer

Adenocarcinoma of the colon

Answer

Carcinoid tumors

Answer

Renal cell carcinoma

Answer

Lymphoma

Question 6

Which investigation is useful for detecting extraadrenal pheochromocytoma?

Accepted Answer

Contrast-enhanced computed tomography (CCT)

Answer

Ultrasound (USG)

Answer

T2-weighted MRI with gadolinium contrast

Answer

MIBG scan

Question 7

What is the term for the appearance of diverticulosis on a barium enema as depicted in the image?

Accepted Answer

Saw tooth appearance

Answer

Cork screw appearance

Answer

Bird of prey appearance

Answer

Claw sign

Question 8

Tear drop bladder is seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Pelvic abscess

Answer

Pelvic lipomatosis

Answer

Bladder rupture

Question 9

An incidental finding on ultrasound abdomen is suggestive of which of the following?

Accepted Answer

Adenomyomatosis

Answer

Gallbladder stone

Answer

Gallbladder polyp

Answer

Xanthogranulomatous cholecystitis

Question 10

A 45-year-old male shows calcification on the right side of his abdomen in an AP view. In the lateral view, the calcification is seen to overlie the spine. What is the most likely diagnosis?

Accepted Answer

Renal stones

Answer

Gallstones

Answer

Calcified mesenteric nodes

Answer

Calcified rib

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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