Ultrasound — MCQs

Ultrasound Indian Medical PG Practice Questions and MCQs

Question 211: 'Triphasic waveform' on colour Doppler is of

A. Portal vein
B. Hepatic artery
C. Hepatic vein (Correct Answer)
D. All of the options

Explanation: ***Hepatic vein*** - A normal hepatic vein Doppler waveform is **triphasic**, showing two antegrade (towards the heart) waves corresponding to **ventricular systole (S wave)** and **diastole (D wave)**, and one small retrograde (away from the heart) wave corresponding to **atrial contraction (a wave)**. - This triphasic pattern reflects the cyclic pressure changes in the right atrium and is crucial for assessing **right heart function** and conditions affecting hepatic venous outflow. *Portal vein* - The portal vein typically exhibits a **monophasic waveform** with continuous, low-velocity, hepatopetal (towards the liver) flow, often with slight undulations due to respiration. - The absence of a triphasic pattern differentiates it from the hepatic veins, as its flow is driven by pressure differences from the mesenteric circulation, not directly by cardiac cycles. *Hepatic artery* - The hepatic artery demonstrates a **high-resistive, biphasic waveform** with a sharp systolic peak and continuous diastolic flow, reflecting its essential role in supplying oxygenated blood to the liver parenchyma. - It does not show a triphasic pattern, which is characteristic of venous structures influenced by right atrial pressures. *All of the options* - This option is incorrect because only the **hepatic veins** typically display a triphasic waveform; the portal vein and hepatic artery have distinct, different waveform patterns. - Each vessel's unique flow pattern is indicative of its specific physiological role and anatomical connection to the cardiac cycle.

Question 212: Causes of thickened gallbladder wall on ultrasound examination are all except:

A. Congestive cardiac failure
B. Postprandial state
C. Cholecystitis
D. Kawasaki disease (Correct Answer)

Explanation: ***Kawasaki disease*** (Correct - NOT a typical cause of gallbladder wall thickening) * Although **Kawasaki disease** can cause systemic inflammation and **gallbladder hydrops** (distension) in children, it typically does NOT present with primary gallbladder wall thickening as a diagnostic finding. * The gallbladder manifestation in Kawasaki disease is **hydrops** (distension without stones), which is distinct from wall thickening. * Other hallmark features include **coronary artery aneurysms**, mucocutaneous manifestations, rash, and lymphadenopathy. * Gallbladder wall thickening is **not a recognized criterion** or common ultrasound finding in Kawasaki disease. --- *Congestive cardiac failure* (Incorrect - DOES cause thickening) * **Right-sided heart failure** leads to systemic venous congestion, causing **edema** in the gallbladder wall and subsequent thickening on ultrasound. * The thickening results from increased **hydrostatic pressure** and fluid accumulation in the wall. * This is a well-recognized cause of gallbladder wall thickening in the setting of hepatic congestion and ascites. *Postprandial state* (Incorrect - DOES cause thickening) * After a meal, especially one rich in fats, the gallbladder **contracts physiologically** to expel bile into the duodenum. * The contracted gallbladder wall appears **thickened** due to muscular contraction and reduced luminal volume. * This is a **normal physiological response**, not pathology; the thickening is *transient*, *symmetric*, and resolves on follow-up imaging after fasting. *Cholecystitis* (Incorrect - DOES cause thickening) * **Acute cholecystitis** involves inflammation of the gallbladder, directly causing **edema** and cellular infiltration of the gallbladder wall. * Wall thickening (>3 mm) is a **primary ultrasound diagnostic criterion** for acute cholecystitis. * Often accompanied by *pericholecystic fluid*, gallstones, and positive **sonographic Murphy's sign**.

Question 213: A patient with right lower quadrant pain shows target sign on ultrasound. Diagnosis?

A. Intussusception (Correct Answer)
B. Diverticulitis
C. Mesenteric cyst
D. Appendicitis

Explanation: ***Intussusception*** - The **target sign** on ultrasound is a classic radiological finding in **intussusception**, indicating a segment of bowel telescoping into an adjacent segment. - This condition is a common cause of **acute abdominal pain** and bowel obstruction, particularly in young children, though it can occur in adults. *Diverticulitis* - Diverticulitis presents with **inflammation of diverticula**, often in the left lower quadrant, but can occur in the right. - Ultrasound findings typically include **thickened bowel wall**, pericolic fat stranding, and sometimes abscesses, not a target sign. *Mesenteric cyst* - A mesenteric cyst is a **fluid-filled mass** located within the mesentery and would appear as a well-defined, anechoic (fluid-filled) structure on ultrasound. - It would not exhibit the characteristic concentric layers of the target sign. *Appendicitis* - Acute appendicitis is characterized by a **dilated, non-compressible appendix** with a thickened wall and surrounding inflammation on ultrasound. - While it causes right lower quadrant pain, the specific **target sign** is not typical for appendicitis.

Question 214: True about hypertrophic pyloric stenosis on ultrasound

A. Target sign appearance on ultrasound
B. Pyloric channel length greater than 15mm on ultrasound
C. Muscle thickness greater than 4mm on ultrasound (Correct Answer)
D. Muscle thickness less than 3mm on ultrasound

Explanation: ***Muscle thickness greater than 4mm on ultrasound*** - A **pyloric muscle thickness of 4 mm or more** is the **primary quantitative diagnostic criterion** for hypertrophic pyloric stenosis on ultrasound. - This measurement provides **objective, reproducible** assessment and is the most reliable parameter for diagnosis. - Increased muscle thickness leads to luminal narrowing and gastric outlet obstruction. *Target sign appearance on ultrasound* - The "target sign" or "donut sign" **is indeed seen** in hypertrophic pyloric stenosis and represents the **concentric layers** of thickened pyloric muscle and mucosa on transverse view. - However, it is a **qualitative, descriptive finding** rather than a specific diagnostic measurement. - While characteristic, it is **less specific** than quantitative measurements and can occasionally be seen in other conditions with pyloric wall thickening. - The target sign indicates presence of pyloric abnormality but requires **measurement confirmation** for definitive diagnosis. *Pyloric channel length greater than 15mm on ultrasound* - A **pyloric channel length of 16-17 mm or more** is the accepted diagnostic criterion for hypertrophic pyloric stenosis. - A measurement of **15mm is borderline** and falls just below the diagnostic threshold, making it insufficient for definitive diagnosis. - While length is increased in HPS, this specific cutoff is not diagnostic. *Muscle thickness less than 3mm on ultrasound* - A pyloric muscle thickness **less than 3mm** is considered within the **normal range** for infants and effectively rules out hypertrophic pyloric stenosis. - HPS is characterized by significant **muscle hypertrophy** (≥3-4mm), making this option clearly incorrect.

Question 215: The most appropriate screening modality for hepatocellular carcinoma

A. CT abdomen
B. MRI abdomen
C. Ultrasound (Correct Answer)
D. PET scan

Explanation: ***Ultrasound*** - **Ultrasound** is the recommended first-line screening modality for hepatocellular carcinoma (HCC) due to its high sensitivity, non-invasiveness, and cost-effectiveness. - It allows for the detection of **hepatic nodules** in patients with risk factors, such as cirrhosis, facilitating early intervention. *CT abdomen* - While **CT scans** are excellent for characterizing liver lesions and staging HCC, they are generally not used for routine screening due to radiation exposure and higher cost. - CT is typically employed as a **diagnostic follow-up** after an abnormal ultrasound finding. *MRI abdomen* - **MRI** provides superior soft tissue contrast and is often used for definitive diagnosis and characterization of liver lesions, especially when ultrasound or CT findings are equivocal. - However, its high cost and longer acquisition time make it unsuitable for **routine screening purposes**. *PET scan* - **PET scans** are primarily used in oncology for evaluating metastatic disease and assessing treatment response, rather than for primary screening of HCC. - HCC is often not highly **fluorodeoxyglucose (FDG)-avid**, limiting the utility of routine PET scanning for initial detection.

Question 216: A 45-year-old female presents with a 2 cm thyroid nodule. Which TIRADS category has >95% risk of malignancy?

A. TIRADS 4
B. TIRADS 2
C. TIRADS 5 (Correct Answer)
D. TIRADS 3

Explanation: ***TIRADS 5*** - A **TIRADS 5** classification indicates a **highly suspicious** nodule with features strongly suggestive of **malignancy**. - This category corresponds to a **>95% risk of malignancy**, necessitating further investigation such as fine-needle aspiration (FNA). *TIRADS 4* - **TIRADS 4** nodules are classified as **moderately suspicious** for malignancy, with a risk ranging from **5% to 50%**. - While requiring follow-up and often FNA, the risk is significantly lower than for TIRADS 5. *TIRADS 2* - **TIRADS 2** nodules are considered **benign**, with a **0% risk of malignancy** (or extremely low). - These nodules typically have features like **spongiform appearance** or purely cystic composition. *TIRADS 3* - **TIRADS 3** nodules are classified as **mildly suspicious**, with a malignancy risk between **0% and 5%**. - They often have some indeterminate features but are predominantly considered to be low risk.

Question 217: Characteristic of venous blood flow of lower limb in duplex Doppler is?

A. Biphasic (Correct Answer)
B. Non phasic
C. Monophasic
D. Triphasic

Explanation: ***Biphasic*** - Normal venous blood flow in the **major lower limb veins** (femoral, popliteal) on duplex Doppler is characteristically **biphasic**, showing variations with respiration. - This biphasic pattern reflects the influence of the **thoracoabdominal pump**, where inspiration decreases intrathoracic pressure and increases intra-abdominal pressure, thus impeding venous return, and expiration reverses this action. - The two phases correspond to **acceleration during expiration** and **deceleration during inspiration**. *Non phasic* - **Non-phasic** (continuous) flow usually indicates a **proximal obstruction** such as deep vein thrombosis (DVT). - This pattern means the respiratory variations are absent due to the blockage preventing normal pressure changes from affecting venous return. - Loss of phasicity is an important sign of venous pathology. *Monophasic* - **Monophasic** flow shows only one phase (forward flow) without clear respiratory variation. - While monophasic flow can be **normal in smaller peripheral veins** (e.g., calf veins), in major lower limb veins it may suggest **partial obstruction** or poor respiratory effort. - It lacks the distinct respiratory modulation seen with biphasic flow. *Triphasic* - **Triphasic** flow is characteristic of **arterial waveforms** in peripheral arteries, showing rapid antegrade flow, brief reversal during early diastole, and slower forward flow during late diastole. - This is not a normal finding for venous blood flow and represents arterial rather than venous physiology.

Question 218: Which finding on echocardiography suggests 'constrictive pericarditis'?

A. Pericardial thickening and septal bounce (Correct Answer)
B. Increased wall thickness
C. Global hypokinesis
D. Pericardial effusion

Explanation: ***Pericardial thickening and septal bounce*** - **Pericardial thickening** is a direct anatomical feature of constrictive pericarditis, indicating the fibrotic and inflamed state of the pericardium. - **Septal bounce**, or interventricular septal motion variation with respiration, is a highly specific sign of constriction, due to exaggerated ventricular interdependence. *Increased wall thickness* - This finding is more characteristic of **hypertrophic cardiomyopathy** or **hypertensive heart disease**, where the myocardial muscle itself thickens. - While it can impair diastolic function, it doesn't indicate a primary pericardial issue. *Global hypokinesis* - **Global hypokinesis** refers to reduced overall contractility of the heart muscle, typically seen in conditions like **dilated cardiomyopathy** or significant **ischemic heart disease**. - This indicates systolic dysfunction, whereas constrictive pericarditis primarily affects diastolic filling. *Pericardial effusion* - A **pericardial effusion** is an accumulation of fluid around the heart, which can cause **cardiac tamponade** if severe. - While effusions can sometimes precede or coexist with constrictive pericarditis, the fluid itself is not the hallmark of constriction, which is defined by a thickened, rigid pericardium.

Question 219: How does 'hepatic vein thrombosis' present on Doppler ultrasound?

A. Absent or reversed flow (Correct Answer)
B. Anechoic appearance
C. Increased flow
D. Normal triphasic flow

Explanation: ***Absent or reversed flow*** - **Hepatic vein thrombosis** directly obstructs blood flow, leading to either an absence of detectable flow or, in some cases, reversal of flow due to high downstream pressure and collateral formation. - This finding on **Doppler ultrasound** is a key indicator of **Budd-Chiari syndrome**, caused by the obstruction of hepatic venous outflow. *Anechoic appearance* - An **anechoic appearance** on ultrasound typically refers to a fluid-filled structure, such as a cyst or gallbladder, which allows sound waves to pass through without reflection. - While thrombosis can affect the lumen of a vessel, the thrombus itself often has some echogenicity, and the primary Doppler finding relates to flow dynamics, not simply the anechoic nature of the vessel. *Increased flow* - **Increased flow** in the hepatic veins would suggest a hyperdynamic state or shunting, which is not characteristic of venous thrombosis. - Thrombosis causes obstruction, leading to a reduction or cessation of flow, not an increase. *Normal triphasic flow* - **Normal triphasic flow** in the hepatic veins is characterized by three distinct phases corresponding to cardiac cycles: antegrade flow during systole and diastole, and a brief period of reversed flow during atrial contraction. - The presence of thrombosis would disrupt this normal pattern, making it an unlikely finding in **hepatic vein thrombosis**.

Question 220: The 'onion skin' appearance of a liver lesion on ultrasound is suggestive of which diagnosis?

A. Hepatocellular carcinoma
B. Focal nodular hyperplasia
C. Hepatic abscess
D. Hydatid cyst (Correct Answer)

Explanation: ***Hydatid cyst*** - The classic "**onion skin**" or "water lily" sign on ultrasound is characteristic of a **hydatid cyst**, representing detached endocyst membranes floating within the cyst. - This appearance is due to the degeneration and separation of the inner germinal layer from the outer fibrous layer, often seen in **Echinococcus granulosus** infection. *Hepatocellular carcinoma* - **Hepatocellular carcinoma** (HCC) typically appears as a heterogeneous mass on ultrasound, often with a **mosaic pattern** and sometimes a **capsule**, rather than an "onion skin" appearance. - Features like **portal vein thrombosis** and **washout** on contrast-enhanced imaging are more characteristic of HCC. *Focal nodular hyperplasia* - **Focal nodular hyperplasia** (FNH) is a benign lesion characterized by a central scar and spokewheel vascular pattern on imaging, not an "onion skin" appearance. - It usually appears as a **well-circumscribed mass** that is iso- or slightly hyperechoic on ultrasound. *Hepatic abscess* - A **hepatic abscess** typically presents as a hypoechoic, ill-defined mass with internal debris and sometimes gas on ultrasound. - It often has an **irregular wall** and can show **posterior acoustic enhancement**, but not the "onion skin" layering.

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Ultrasound — MCQs

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