Pediatric Ultrasonography — MCQs

10 questions

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

All of the following are true regarding congenital dislocation of the hip except which of the following?

Abdominal Ultrasonography in a 3 year old boy shows a solid circumscribed hypoechoic renal mass. Most likely diagnosis is-

The "Target sign" ultrasonographically means:

A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?

True about hypertrophic pyloric stenosis on ultrasound

In a child, non-functioning kidney is best diagnosed by

What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?

Transrectal ultrasonography in carcinoma prostate is most useful for –

Q10

Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:

Pediatric Ultrasonography Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: All of the following are true regarding congenital dislocation of the hip except which of the following?

A. It is always bilateral (Correct Answer)
B. Asymmetric thigh folds may be seen
C. Galeazzi sign and Ortolani's test may be positive
D. Oligohydramnios is a known risk factor for congenital dislocation of the hip

Explanation: ***It is always bilateral*** - **Congenital dislocation of the hip (CDH)** is more commonly **unilateral**, with a predilection for the left hip. - While it can be bilateral, stating it is *always* bilateral is incorrect. - **Bilateral CDH** occurs in only about 20% of cases. *Asymmetric thigh folds may be seen* - **Asymmetric thigh folds** are a common soft sign of **developmental dysplasia of the hip (DDH)**, though they can also be seen in normal infants. - This asymmetry is due to the femoral head's abnormal position, leading to unequal skin fold distribution on the affected side. *Galeazzi sign and Ortolani's test may be positive* - The **Galeazzi sign** (also known as the Allis sign) indicates limb length discrepancy, often seen in unilateral hip dislocation when the knees are flexed. - **Ortolani's test** is a specific maneuver used to reduce a dislocated hip, producing a characteristic *clunk* as the femoral head re-enters the acetabulum. *Oligohydramnios is a known risk factor for congenital dislocation of the hip* - **Oligohydramnios** (decreased amniotic fluid) is a well-established risk factor for CDH due to restricted fetal movement and abnormal intrauterine positioning. - Other risk factors include **breech presentation**, **female sex**, **firstborn child**, and **family history**. - **Polyhydramnios** (excess amniotic fluid) is NOT associated with increased risk of CDH.

Question 3: Abdominal Ultrasonography in a 3 year old boy shows a solid circumscribed hypoechoic renal mass. Most likely diagnosis is-

A. Mesoblastic nephroma
B. Wilms tumor (Correct Answer)
C. Renal cell carcinoma
D. Oncocytoma

Explanation: ***Wilms tumor*** - **Wilms tumor** is the most common renal malignancy in children aged 2-5 years, often presenting as a **palpable abdominal mass** or an incidental finding on imaging. - The ultrasound finding of a **solid, circumscribed, hypoechoic renal mass** in a 3-year-old boy is highly characteristic of Wilms tumor. *Mesoblastic nephroma* - This is typically diagnosed in infants, usually before **6 months of age**, making it less likely in a 3-year-old. - While it is a solid renal mass, its incidence is significantly lower than Wilms tumor in this age group. *Renal cell carcinoma* - **Renal cell carcinoma (RCC)** is extremely rare in young children, predominantly affecting adults. - While RCC can present as a solid renal mass, the age of the patient (3 years old) makes this diagnosis highly improbable. *Oncocytoma* - **Renal oncocytoma** is a benign renal tumor that is almost exclusively seen in adults, typically older than 50 years. - Its occurrence in a 3-year-old child is virtually unheard of.

Question 4: The "Target sign" ultrasonographically means:

A. Liver metastasis
B. Ectopic kidney
C. Intussusception (Correct Answer)
D. Ovarian carcinoma

Explanation: ***Intussusception*** - The **"target sign"** (also known as the **"donut sign"** or **"pseudokidney sign"**) on ultrasound is a classic finding for **intussusception**. - It represents concentric layers of bowel telescoping into an adjacent segment, creating a central hyperechoic core surrounded by hypoechoic rings. *Liver metastasis* - Liver metastases often appear as **hypoechoic, hyperechoic, or mixed echogenicity lesions** on ultrasound, and vary widely in appearance. - While some can have a "target-like" appearance with a hyperechoic rim, it's not the primary or most specific sign for liver metastasis and is less distinct than in intussusception. *Ectopic kidney* - An ectopic kidney is an anatomical variant where the kidney is located outside its normal position, most commonly in the **pelvis**. - On ultrasound, it would appear as a normally formed kidney in an atypical location, without the distinct concentric layers seen in the "target sign." *Ovarian carcinoma* - Ovarian carcinomas present with **complex masses** that can be solid, cystic, or mixed, often with septations, papillary projections, and areas of necrosis. - Their ultrasound appearance is highly variable but does not typically manifest as a "target sign" with concentric rings.

Question 5: A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?

A. Hypertrophic pyloric stenosis
B. Acute appendicitis
C. Jejunal atresia
D. Malrotation with volvulus (Correct Answer)

Explanation: ***Malrotation with volvulus*** - The acute onset of **bilious vomiting** in a 1-week-old infant is a **surgical emergency** and highly suggestive of intestinal obstruction, with malrotation with volvulus being a critical consideration. - The barium enema image (B) shows the **ligament of Treitz** located to the right of the midline, indicating **intestinal malrotation** and a **corkscrew pattern** of the duodenum, which is pathognomonic for **midgut volvulus**. *Hypertrophic pyloric stenosis* - Typically presents with **non-bilious projectile vomiting** and palpable **pyloric olive mass**, usually appearing between 3 to 6 weeks of age, not at 1 week with bilious vomiting. - Imaging would reveal an **elongated, narrowed pyloric channel** (string sign) and thickened pyloric muscle, not the findings seen in the barium study. *Acute appendicitis* - This is an **extremely rare diagnosis** in a 1-week-old infant and typically presents with localized pain, fever, and leukocytosis, which are not the primary symptoms described. - Acute appendicitis would not explain the **bilious vomiting** or the specific findings on the barium study related to intestinal rotation. *Jejunal atresia* - Presents with bilious vomiting and abdominal distension, often diagnosed prenatally or shortly after birth due to proximal dilation and distal collapse of the bowel. - While it causes obstruction, the barium study in jejunal atresia would show a **blind-ending jejunum** and not the distinct malrotation and volvulus features (e.g., corkscrew sign, abnormal Treitz location).

Question 6: 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 7: In a child, non-functioning kidney is best diagnosed by

A. Creatinine clearance
B. Ultrasonography
C. IVU
D. DTPA renogram (Correct Answer)

Explanation: ***DTPA renogram*** - A **DTPA renogram** (diethylene triamine pentaacetic acid scan) is a nuclear medicine study that assesses **renal blood flow** and **glomerular filtration rate (GFR)**. - It is highly effective in determining if a kidney is non-functioning because it directly measures the **uptake and excretion of a radiotracer** by the kidney, providing quantitative data on its functional capacity. *Creatinine clearance* - **Creatinine clearance** is a measure of overall kidney function, reflecting the GFR of **both kidneys combined**. - It cannot specifically identify a non-functioning individual kidney, as the other kidney might compensate for the non-functioning one, leading to a near-normal overall creatinine clearance. *Ultrasonography* - **Ultrasonography** is excellent for evaluating **renal anatomy**, such as size, shape, and presence of cysts, hydronephrosis, or stones. - While it can show structural abnormalities, it provides limited direct information about the **functional status** of the kidney, and a structurally normal kidney can still be non-functional. *IVU (Intravenous Urography)* - **Intravenous Urography (IVU)** uses contrast dye injected intravenously to visualize the kidneys, ureters, and bladder, assessing both anatomy and some aspects of function. - If a kidney is non-functioning, it would show **no uptake or excretion of the contrast dye**, but IVU involves radiation exposure and nephrotoxic contrast, making DTPA renogram often preferred in children for functional assessment.

Question 8: What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?

A. USG (Correct Answer)
B. CT Scan
C. X-ray
D. MRI

Explanation: ***USG*** - An **ultrasound (USG)** is the preferred initial imaging modality in pediatric acute abdomen due to its **lack of ionizing radiation**, ease of use, and ability to visualize common causes like appendicitis and intussusception. - It is particularly useful for assessing **fluid collections**, inflammation, and obstruction in a non-invasive manner suitable for children. *CT Scan* - While it offers detailed anatomical views, **CT scans** involve significant **ionizing radiation**, which is a concern in children due to increased lifetime cancer risk. - It is typically reserved for cases where **USG is inconclusive** or if there is a high suspicion of conditions not well visualized by ultrasound. *X-ray* - **X-rays** provide limited information for soft tissue pathologies and are primarily useful for detecting **bowel obstruction (air-fluid levels)** or **free air** (perforation). - They lack the resolution to diagnose many common causes of acute abdomen in children, such as appendicitis or intussusception. *MRI* - **MRI** provides excellent soft tissue contrast without ionizing radiation but often requires **sedation** in young children due to the long scan times and need for stillness. - It is less readily available and more expensive than USG, making it a less practical first-line investigation for an acute presentation.

Question 9: Transrectal ultrasonography in carcinoma prostate is most useful for –

A. To detect hypoechoic area
B. Seminal vesicle involvement
C. Measurement of prostatic volume
D. Guided prostatic biopsies (Correct Answer)

Explanation: ***Guided prostatic biopsies*** - **Transrectal ultrasonography (TRUS)** provides real-time visualization of the prostate, allowing for precise guidance during **prostatic biopsies**. - This guidance ensures that tissue samples are taken from suspicious areas, increasing the diagnostic yield for **prostate cancer**. *To detect hypoechoic area* - While TRUS can identify **hypoechoic areas** in the prostate, which may suggest malignancy, these are **not specific** to cancer and can be caused by other conditions like inflammation. - The primary utility of TRUS in prostate cancer is not merely detection of these areas, but rather using this information for targeted sampling. *Seminal vesicle involvement* - TRUS can visualize the seminal vesicles, but its accuracy in definitively determining **seminal vesicle invasion** is limited compared to more advanced imaging like **MRI**. - **MRI** is generally preferred for assessing extraprostatic extension and seminal vesicle involvement due to its superior soft tissue contrast. *Measurement of prostatic volume* - TRUS is used to measure **prostatic volume**, which is important for calculating **PSA density** and for treatment planning in benign prostatic hyperplasia (BPH). - However, in the context of prostate cancer, while volume measurement is possible, guided biopsy is its most crucial role for diagnosis.

Question 10: Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:

A. USG (Correct Answer)
B. Barium meal
C. Barium meal follow through
D. CT scan with contrast

Explanation: ***USG*** - **Ultrasound** is the preferred initial imaging modality due to its non-invasiveness, lack of radiation, and high accuracy in visualizing the thickened pyloric muscle. - The classic ultrasound findings include a **pyloric muscle thickness** of ≥ 4 mm and a **pyloric channel length** of ≥ 14 mm. *Barium meal* - While a barium meal can show findings like the "string sign" or "shoulder sign," it involves **radiation exposure** and is generally considered a second-line investigation. - Its diagnostic accuracy is good, but it is less convenient and riskier than ultrasound for this condition. *Barium meal follow through* - This procedure tracks barium through the entire gastrointestinal tract, which is **excessive and unnecessary** for diagnosing pyloric stenosis, which is a localized obstruction. - It also involves significant **radiation exposure** and a prolonged examination time. *CT scan with contrast* - A **CT scan** involves significant **radiation exposure** and is not typically used for diagnosing congenital hypertrophic pyloric stenosis. - It is also less sensitive than ultrasound for visualizing the specific soft tissue changes in the pyloric muscle.

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