Abdominal and Pelvic Radiology Practice Questions

Q: Air in the biliary tract is seen in all of the following conditions except:

Sclerosing cholangitis. **Explanation:** The presence of air in the biliary tree is known as **pneumobilia**. It occurs when there is an abnormal communication between the biliary system and the gastrointestinal tract or a loss of sphincter integrity. **Why Sclerosing Cholangitis is the correct answer:** Primary Sclerosing Cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation, fibrosis, and strictures of the bile ducts. While it causes "beading" of the ducts on imaging (MRCP/ERCP), it does **not** typically involve the formation of a fistula or the reflux of air from the bowel. Therefore, pneumobilia is not a feature of this condition. **Analysis of Incorrect Options:** * **Gallstone Ileus:** This occurs when a large gallstone erodes through the gallbladder wall into the duodenum (cholecystoenteric fistula). Air travels from the gut into the biliary tree, forming part of **Rigler’s Triad** (Pneumobilia, Small bowel obstruction, Ectopic gallstone). * **Carcinoma of the Gallbladder:** Advanced malignancy can cause local invasion and necrosis, leading to a fistula between the gallbladder and adjacent bowel loops (duodenum or colon), resulting in pneumobilia. * **Endoscopic Papillotomy:** During ERCP, the Sphincter of Oddi is often cut (sphincterotomy). This destroys the natural valve mechanism, allowing enteric air to reflux freely into the common bile duct. **NEET-PG High-Yield Pearls:** * **Rigler’s Triad:** Pathognomonic for Gallstone Ileus (Pneumobilia + SBO + Gallstone in iliac fossa). * **Differential Diagnosis of Pneumobilia:** Recent ERCP/Sphincterotomy (most common), Cholecystoenteric fistula, Emphysematous cholecystitis, and Incompetent Sphincter of Oddi. * **Imaging:** On Ultrasound, pneumobilia appears as bright echogenic foci with "dirty" posterior shadowing within the bile ducts. On CT, air is seen in the dependent (anterior) portion of the left lobe of the liver.

Q: Which radiological method is best for staging cervical carcinoma?

PET-CT. **Explanation:** The staging of cervical carcinoma has evolved significantly. While the FIGO staging was traditionally clinical, the 2018 revision now allows the use of advanced imaging to assign the stage. **Why PET-CT is the Correct Answer:** PET-CT (Positron Emission Tomography-Computed Tomography) is considered the superior modality for **staging**, particularly for detecting **extrapelvic disease and lymph node metastasis** (para-aortic and distant nodes). While MRI is excellent for evaluating the local extent of the primary tumor (size and parametrial invasion), PET-CT provides a whole-body assessment, which is crucial for accurate staging and planning radiotherapy or surgery. It has higher sensitivity and specificity than CT or MRI for identifying nodal involvement. **Analysis of Incorrect Options:** * **MRI:** This is the best modality for evaluating **local tumor extent** (T-staging), such as tumor size, vaginal involvement, and parametrial invasion, due to its superior soft-tissue contrast. However, for overall staging (including distant nodes), PET-CT is preferred. * **Sonosalpingography:** This is a specialized ultrasound technique used to evaluate the patency of fallopian tubes in infertility workups; it has no role in cancer staging. * **Doppler USG:** While it can assess vascularity within a mass, it lacks the anatomical detail and systemic reach required for staging cervical malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Best for Local Staging (Parametrial invasion):** MRI. * **Best for Nodal and Distant Metastasis:** PET-CT. * **FIGO 2018 Update:** Imaging (MRI/CT/PET-CT) is now formally incorporated into the staging system. * **Most common histological type:** Squamous cell carcinoma. * **Primary screening tool:** Pap smear (Cytology) or HPV DNA testing.

Q: Carman's meniscus sign is diagnostic of –

Carcinoma of the stomach. **Explanation:** **Carman’s meniscus sign** is a classic radiological finding seen during a barium meal study, specifically diagnostic of a **large, malignant gastric ulcer** (Carcinoma of the stomach). The sign occurs when a large ulcer sits on a flat, infiltrated surface. When manual compression is applied during the barium study, the edges of the ulcer (the tumor mass) project into the lumen, while the ulcer crater itself remains filled with barium. This creates a **crescent or meniscus shape**, with the concavity facing the gastric lumen. This is distinct from a benign ulcer, which typically projects beyond the gastric wall. **Analysis of Options:** * **A. Peptic Ulcer:** Benign peptic ulcers typically show the "Hampton’s line" or "Ulcer niche" projecting *outside* the normal contour of the stomach. They do not exhibit the meniscus sign. * **B. Cholecystitis:** This is an inflammatory condition of the gallbladder, usually diagnosed via Ultrasound (showing wall thickening/pericholecystic fluid), not barium studies. * **D. Meconium Ileus:** This is a neonatal intestinal obstruction (often associated with Cystic Fibrosis). Radiologically, it presents with a "soap bubble" appearance (Neuhauser sign) in the right iliac fossa. **High-Yield Clinical Pearls for NEET-PG:** * **Kirklin Complex:** This refers to the "bright rim" or radiolucent zone surrounding the Carman’s meniscus, representing the elevated malignant margin. * **Benign vs. Malignant:** Benign ulcers have smooth margins and radiating mucosal folds that reach the edge of the crater. Malignant ulcers have irregular margins and folds that stop short of the crater. * **Linitis Plastica:** Another presentation of gastric cancer ("Leather bottle stomach") characterized by a rigid, non-distensible stomach on barium swallow.

Q: The 'diamond sign' is radiographically observed in which of the following conditions?

Congenital pyloric stenosis. **Explanation:** **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is characterized by the hypertrophy of the circular muscle fibers of the pylorus, leading to gastric outlet obstruction. The **'Diamond Sign'** is a specific radiographic finding seen during a Barium swallow/Upper GI series. It represents a transient, diamond-shaped mucosal hypertrophy or a small amount of barium trapped between the thickened muscle folds at the proximal end of the pyloric canal. **Analysis of Options:** * **A. Congenital Pyloric Stenosis (Correct):** In addition to the Diamond sign, other classic radiological signs include the **String sign** (narrowed pyloric canal), **Beak sign** (tapered entrance to the canal), and **Double track sign** (barium trapped between mucosal folds). * **B. Esophageal Atresia:** Characterized by a "blind pouch" on X-ray (with a feeding tube coiled in the neck). If a tracheoesophageal fistula is present, gas will be seen in the abdomen. * **C. Intestinal Obstruction:** Typically presents with dilated bowel loops and multiple air-fluid levels on an erect abdominal X-ray. Specific signs include the "Double Bubble" sign (Duodenal atresia) or "Coffee bean" sign (Sigmoid volvulus). * **D. Colon Cancer:** Classically associated with the **"Apple Core" lesion** (annular constriction) on a Barium enema, particularly in the descending or sigmoid colon. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Non-bilious, projectile vomiting in a 3–6 week old infant. * **Physical Exam:** Palpable "olive-shaped" mass in the epigastrium and visible gastric peristalsis. * **Metabolic Abnormality:** Hypochloremic, hypokalemic metabolic alkalosis (Paradoxical aciduria). * **Investigation of Choice:** Ultrasonography (Criteria: Pyloric muscle thickness >3-4 mm or canal length >14-16 mm). * **Treatment:** Ramstedt’s Pyloromyotomy.

Q: A patient with a history of choledocholithiasis presents with elevated conjugated bilirubin. Ultrasound reveals a dilated biliary system up to the terminal pancreas. In case of suspicion of an ampullary obstructive calculus, which of the following investigations would be most sensitive?

Endoscopic Ultrasound (EUS). ### Explanation **Correct Answer: D. Endoscopic Ultrasound (EUS)** #### Why EUS is the Correct Choice: In the context of suspected **choledocholithiasis** or **ampullary obstruction**, EUS is currently considered the most sensitive diagnostic modality. Because the EUS probe is placed in the immediate proximity of the duodenum (periampullary region), it provides high-resolution images of the distal common bile duct (CBD) and the ampulla of Vater. It is particularly superior to MRCP for detecting **small stones (<5 mm)** and microlithiasis, which are often missed by other imaging techniques. #### Analysis of Incorrect Options: * **A. Percutaneous Transhepatic Cholangiography (PTC):** This is an invasive procedure typically reserved for dilated intrahepatic ducts when ERCP is not feasible. It is not the first-line investigation for distal CBD stones. * **B. Magnetic Resonance Cholangiopancreatography (MRCP):** While MRCP is highly sensitive (approx. 90-95%) and non-invasive, it has a lower sensitivity than EUS for very small stones or sludge at the terminal end of the CBD. * **C. X-ray Abdomen:** Most gallstones (80-85%) are radiolucent (cholesterol stones). Only about 15% are radio-opaque, making X-ray a very poor screening tool for biliary obstruction. #### NEET-PG High-Yield Pearls: * **Gold Standard (Diagnostic + Therapeutic):** ERCP (Endoscopic Retrograde Cholangiopancreatography). However, due to the risk of pancreatitis, it is not the first-line *diagnostic* test. * **Most Sensitive Diagnostic Test:** EUS (especially for distal CBD/ampullary pathology). * **Best Non-invasive Screening Test:** MRCP. * **Initial Investigation of Choice:** Transabdominal Ultrasound (USG) is always the first step for suspected biliary pathology, though it often fails to visualize the distal CBD due to overlying bowel gas.

Q: A barium swallow shows which of the following findings?

Carcinoma esophagus. ***Carcinoma esophagus*** - Shows classic **irregular filling defect** with **shouldering** and **rat-tail** or **apple-core appearance** on barium swallow. - Demonstrates **abrupt luminal narrowing** with **mucosal irregularities** and **asymmetric wall thickening**. *Achalasia cardia* - Presents with characteristic **bird-beak appearance** showing smooth tapering at the gastroesophageal junction. - Associated with **dilated esophageal body** above the narrowed lower esophageal sphincter, unlike the irregular stricture seen in carcinoma. *Nut cracker esophagus* - Primarily a **manometric diagnosis** based on high-amplitude peristaltic contractions (>180 mmHg). - Barium swallow typically appears **normal** or may show mild tertiary contractions, not the filling defect pattern described. *Oesophageal stricture* - Shows **smooth, symmetrical tapering** with regular mucosal outline on barium studies. - Lacks the **irregular shouldering** and **asymmetric narrowing** characteristic of malignant lesions.

Q: Endometriomas on ultrasound typically appear as?

Cystic with diffuse internal low-level echoes.. **Explanation:** **1. Why Option C is Correct:** Endometriomas (also known as "chocolate cysts") are localized forms of endometriosis within the ovary. On ultrasound, the classic appearance is a **well-defined cystic mass** containing **diffuse, homogeneous, low-level internal echoes**. This appearance is often described as a **"ground-glass"** pattern. These echoes represent the hemorrhagic debris and old blood (hemosiderin) that accumulate within the cyst over multiple menstrual cycles. **2. Why Other Options are Incorrect:** * **Options A & B (Solid):** Endometriomas are fluid-filled (blood) structures, not solid tumors. While the echoes can sometimes be dense, they demonstrate **posterior acoustic enhancement**, confirming their cystic nature. * **Option D (Focal hyperechoic internal echoes):** This description is more characteristic of a **Mature Cystic Teratoma (Dermoid cyst)**, which often contains focal hyperechoic components like hair or sebum (Rokitansky nodules), rather than the uniform, diffuse echoes seen in endometriomas. **3. High-Yield Clinical Pearls for NEET-PG:** * **Ground-glass appearance:** The pathognomonic sonographic descriptor for endometrioma. * **Doppler:** Endometriomas typically show **no internal vascularity** on color Doppler (unlike malignant ovarian tumors). * **MRI Appearance:** Shows **"T2 shading"** (high signal on T1 due to blood, and low signal on T2 due to high iron/protein concentration). This is a classic board-exam favorite. * **Differential Diagnosis:** Hemorrhagic corpus luteum cysts can mimic endometriomas but usually resolve over 1–2 menstrual cycles, whereas endometriomas persist.

Q: In a pregnant woman of 28 weeks gestation, intrauterine fetal death (IUD) is earliest demonstrated on X-ray by which sign?

Gas in vessels. **Explanation:** The diagnosis of intrauterine fetal death (IUD) on X-ray is based on specific radiological signs that appear at different time intervals following fetal demise. **1. Why "Gas in vessels" is correct:** The **earliest** radiological sign of IUD is the presence of gas within the fetal heart and large vessels (e.g., aorta), known as **Robert’s Sign**. It can appear as early as **6 to 12 hours** after death. This occurs due to the release of gases (primarily nitrogen) from the decomposition of fetal blood. While X-rays are rarely used today due to the superiority of ultrasound, Robert's sign remains the earliest detectable radiographic feature. **2. Analysis of Incorrect Options:** * **Spalding’s Sign (Overlapping of cranial bones):** This is a classic sign of IUD but typically takes **4 to 7 days** to develop. It occurs due to the liquefaction of the brain and loss of intracranial pressure, leading to the collapse of the skull bones. * **Increased Flexion (Hartley’s Sign):** This refers to an exaggerated curvature of the fetal spine due to the loss of muscular tone. It usually takes several days to become apparent. * **Overlapping of cranial bones:** This is simply the description of Spalding's sign (Option C) and follows the same delayed timeline. **3. Clinical Pearls for NEET-PG:** * **Gold Standard:** Real-time **Ultrasonography** is the investigation of choice for IUD (demonstrating absence of fetal heart activity). * **Robert’s Sign:** Gas in fetal vessels (Earliest X-ray sign, ~12 hours). * **Spalding’s Sign:** Overlapping of skull bones (Most famous X-ray sign, ~4-7 days). * **Deuel’s Halo Sign:** Edema of the fetal scalp causing a "halo" appearance (due to fluid accumulation in subcutaneous tissues). * **Sphenoid Bone Sign:** Flattening of the sphenoid bone.

Q: What is the most probable diagnosis on this barium film?

Crohn's disease. ***Crohn's disease*** - Characteristic **string sign of Kantor** (narrowed terminal ileum) and **skip lesions** with normal bowel segments between diseased areas are pathognomonic on barium studies. - **Cobblestone mucosa** appearance and **rose-thorn ulcers** create a distinctive pattern that differentiates it from other inflammatory conditions. *Lymphoma* - Typically shows **smooth, regular narrowing** without the irregular ulceration and skip pattern seen in Crohn's disease. - **Polypoid masses** or **aneurysmal dilatation** are more characteristic features on barium studies, not the string sign. *Brucellosis* - Rarely causes significant **small bowel involvement** that would be visible on barium studies. - When GI symptoms occur, they are usually **non-specific** without the characteristic radiological findings like skip lesions or string sign. *Tuberculosis* - Shows **concentric narrowing** of the ileocecal region with **shortened cecum** and **gaping ileocecal valve**. - Lacks the **skip lesions** and **cobblestone appearance** characteristic of Crohn's disease on barium studies.

Question 1

Air in the biliary tract is seen in all of the following conditions except:

Accepted Answer

Sclerosing cholangitis

Answer

Gall stone ileus

Answer

Carcinoma of the gallbladder

Answer

Endoscopic papillotomy

Question 2

Which radiological method is best for staging cervical carcinoma?

Accepted Answer

PET-CT

Answer

MRI

Answer

Sonosalpingography

Answer

Doppler USG

Question 3

Carman's meniscus sign is diagnostic of –

Accepted Answer

Carcinoma of the stomach

Answer

Peptic ulcer

Answer

Cholecystitis

Answer

Meconium ileus

Question 4

The 'diamond sign' is radiographically observed in which of the following conditions?

Accepted Answer

Congenital pyloric stenosis

Answer

Esophageal atresia

Answer

Intestinal obstruction

Answer

Colon cancer

Question 5

A patient with a history of choledocholithiasis presents with elevated conjugated bilirubin. Ultrasound reveals a dilated biliary system up to the terminal pancreas. In case of suspicion of an ampullary obstructive calculus, which of the following investigations would be most sensitive?

Accepted Answer

Endoscopic Ultrasound (EUS)

Answer

Percutaneous Transhepatic Cholangiography (PTC)

Answer

Magnetic Resonance Cholangiopancreatography (MRCP)

Answer

X-ray abdomen

Question 6

A barium swallow shows which of the following findings?

Accepted Answer

Carcinoma esophagus

Answer

Achalasia cardia

Answer

Nut cracker esophagus

Answer

Oesophageal stricture

Question 7

Endometriomas on ultrasound typically appear as?

Accepted Answer

Cystic with diffuse internal low-level echoes.

Answer

Solid with diffuse internal low-level echoes.

Answer

Solid with focal internal low-level echoes.

Answer

Cystic with focal hyperechoic internal echoes.

Question 8

In a pregnant woman of 28 weeks gestation, intrauterine fetal death (IUD) is earliest demonstrated on X-ray by which sign?

Accepted Answer

Gas in vessels

Answer

Increased flexion

Answer

Overlapping of cranial bones

Answer

Spalding's sign

Question 9

What is the most probable diagnosis on this barium film?

Accepted Answer

Crohn's disease

Answer

Lymphoma

Answer

Brucellosis

Answer

Tuberculosis

Question 10

What is the most important use of transrectal ultrasonography (TRUS)?

Accepted Answer

Systematic prostate biopsy in suspected prostate cancer

Answer

Screening for prostate cancer

Answer

Distinguishing prostate cancer from benign prostatic hyperplasia (BPH)

Answer

Guiding transurethral resection of prostate cancer

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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