General

Question 1

1. A 54-year-old woman with a sensation of incomplete evacuation on defecation undergoes conventional defecography. Following introduction of barium paste into the rectum, in which position should the patient be placed for imaging?

A. supine

B. prone

C. left lateral

D. right lateral

E. sitting

Answer 1

E. sitting

Conventional defecography is used in the imaging evaluation of obstructed defecation.

Barium paste is instilled into the rectum with a Foley catheter, with the patient in the left lateral position.

Prior opacification of the small bowel, bladder, vagina or peritoneum may also be performed to aid diagnosis. With the patient sitting on a commode placed on the footrest of a standard fluoroscopic table, static images are first obtained at rest and with contraction of the pelvic floor muscles.

A cine-loop of evacuation is then obtained until the rectum is empty or three 30-second attempts at evacuation have been made.

A variety of conditions may be demonstrated, including rectocele, enterocele, rectal intussusception and anismus.

Question 2

2. A 72-year-old man attends for a barium enema examination. He has no known allergies. In considering administration of intravenous hyoscine-N-butylbromide (Buscopan), which factor in his medical history is it most important to be aware of?

A. prostatism

B. type I diabetes

C. glaucoma

D. migraine

E. unstable cardiac disease

Answer 2

E. unstable cardiac disease

Buscopan is commonly used in radiological practice as a smooth muscle relaxant. As a non-selective muscarinic antagonist, it produces other autonomic responses including pupillary dilatation and tachycardia, and may potentially precipitate an attack of acuteangle-closure glaucoma that requires prompt treatment to prevent permanent visual loss. However, most glaucoma is of the open-angle form, which is unaffected by Buscopan, and it is therefore advised that routine enquiry about a history of glaucoma is unnecessary. Instead patient information leaflets should advise all patients to attend hospital immediately should they develop painful, blurred vision. Routine enquiry about prostatism, porphyria and myasthenia gravis is also not recommended. However, inpatients with unstable cardiac disease, the tachycardia and slight increase in diastolic blood pressure caused by Buscopan carry the potential risk of arrhythmia. The presence of unstable cardiac disease is therefore deemed to be the only potential reason towithhold Buscopan.

Question 3

3. The gastroduodenal artery normally has its origin from which vessel?

A. superior mesenteric artery

B. common hepatic artery

C. left gastric artery

D. coeliac axis

E. aorta

Answer 3

B. common hepatic artery

In 75% of cases, the gastroduodenal artery arises from the common hepatic artery
before its division into right and left branches.

Less common origins include the left hepatic artery (4–11%), the right hepatic artery (7%) and the superior mesenteric artery via a replaced hepatic trunk (4–11%).

The artery descends behind the first part of the duodenum, lying anterior to the pancreas and to the left of the common bile duct. At this site, erosion of the posterior duodenal wall by an ulcer may produce life-threatening hemorrhage if the gastroduodenal artery is involved.

Its main branches are the posterior and anterior superior pancreaticoduodenal arteries, and the right gastroepiploic artery.

Question 4

4. Which is the most appropriate contrast medium for a barium follow-through examination of the small bowel?

A. 100 ml of 250% w/v barium sulphate

B. 135 ml of 250% w/v barium sulphate

C. 300 ml of 100% w/v barium sulphate

D. 1500 ml of 20% w/v barium sulphate

E. 500 ml of 115% w/v barium sulphate

Answer 4

C. 300 ml of 100% w/v barium sulphate

The recommended contrast is 300 ml of 100% w/v barium sulphate. Transit time may be reduced by the addition of 10 ml of Gastrografin to the barium. Nonionic, water-soluble contrast media may be used as an alternative where barium is contraindicated. The recommended concentrations and volumes for the other gastrointestinal contrast examinations are barium swallow (a), barium meal (b), small bowel enema (d) and double-contrast barium enema (e).

Question 5

5. At abdominal ultrasound scan, when scanning the abdomen in a transverse plane at the level of the pancreas, which of the following structures may normally be seen lying between the superior mesenteric artery and the aorta?

A. splenic vein

B. left renal vein

C. neck of the pancreas

D. inferior vena cava

E. common bile duct

Answer 5

B. left renal vein

Ultrasound scan of the pancreas may be difficult and vascular landmarks are important in its identification. In the transverse plane, the splenic vein can be seen coursing from the splenic hilum towards the liver, and the body and tail of the pancreas lie immediately anterior to this. The neck of the pancreas lies immediately anterior to the confluence of the splenic and superior mesenteric veins, and the head and uncinate process of the pancreas lie around this confluence, anterior to the inferior vena cava. At this level, the left renal vein can be seen entering the inferior vena cava, passing between the superior mesenteric artery and aorta.

Question 6

@# 6. A 45-year-old man is admitted after a road traffic accident in which he sustained abdominal injuries. After fluid resuscitation he undergoes CT of the abdomen and pelvis with intravenous contrast. This demonstrates a serpiginous area of attenuation value 130 HU at the splenic hilum with surrounding lower-attenuation material. What is this most likely to represent?

A. active arterial extravasation

B. acute clotted blood

C. acute unclotted blood

D. splenic arterial calcification

E. ascites

Answer 6

A. active arterial extravasation

In the evaluation of haemoperitoneum by CT, attenuation values can help differentiate ascites, unclotted blood, active bleeding and haematoma.

Blood usually has a higher measured attenuation than other body fluids, but its appearance depends on the age, extent and location of hemorrhage.

Unclotted blood has an attenuation value of 30–45 HU, but this may be lower in patients with a lower serum haematocrit and if the hemorrhage is more than 48 hours old.

Clotted blood has an attenuation value of 45–70 HU, and identification of the area of highest-attenuation haematoma (sentinel clot) on CT indicates the site of bleeding.

Active arterial extravasation is seen as an area of higher attenuation resembling that in the aorta, ranging from 85 HU to 370 HU.

It may be surrounded by lower-attenuation haematoma. This finding indicates the need for urgent embolization or surgical treatment.

Question 7

7. Which of the following best describes the intravenous iodinated contrast agent iodixanol (Visipaque)?

A. ionic, high-osmolar, monomeric

B. non-ionic, iso-osmolar, dimeric

C. ionic, low-osmolar, dimeric

D. non-ionic, low-osmolar, monomeric

E. ionic, high-osmolar, dimeric

Answer 7

B. non-ionic, iso-osmolar, dimeric

Modern water-soluble, iodinated, intravenous contrast media are based on the sixcarbonring structure tri-iodobenzoic acid. Earlier contrast agents were ionic and highosmolar, but the toxicity of these agents prompted further development. In order to decrease osmolality while maintaining an acceptable iodine concentration, the ratio between the number of iodine atoms and the number of particles in solution has been decreased either by combining two tri-iodinated benzene rings or by producingcompounds that do not ionize in solution, or, more recently, by both methods. The most recent agents such as iodixanol (Visipaque) and iotrolan (Isovist) are non-ionic dimmers with six iodine atoms per molecule in solution, enabling satisfactory iodine concentrations to be obtained at iso-osmolality.

Question 8

@# 8. A patient undergoes 111In-labelled white blood cell scintigraphy for investigation of suspected occult sepsis. Which of these would be regarded as abnormal on imaging at 4 hours?

A. uptake in the large bowel

B. splenic uptake greater than that of the liver

C. uptake in the bone marrow

D. diffuse uptake in the lungs

E. uptake in the thymus in children

Answer 8

A. uptake in the large bowel

Radiolabelled white cell imaging is used for detection of infection and inflammation. Images reflect the distribution of white blood cells within the body, and also localize areas of infection or inflammation.

Imaging is usually performed at 18–24 hours, by which time blood pool activity is normally no longer present, and the most intense uptake is seen in the spleen, followed by the liver and then the bone marrow.

Imaging is also usually performed at 2–6 hours for investigation of suspected inflammatory bowel disease, as sloughed inflamed cells may move distally and provide misleading information as to the affected site if only imaged at 24 hours.

Physiological diffuse lung uptake may be seen in the first 4 hours due to cellular activation from in vitro cell manipulation, but normally decreases after this.

Thymus activity may be seen normally in children.

Bowel and genitourinary activity are not normally seen, and gastrointestinal activity is always abnormal. In general,

focal activity outside the normal white cell distribution, which is greater than that of the spleen, suggests the presence of an abscess.

Activity equal to that of the liver indicates a significant inflammatory focus.

Activity less than that of the bone marrow suggests a low-level inflammatory response.

Question 9

9. In the assessment of tumour response to treatment, what method of tumour measurement is used in the RECIST (Response Criteria in Solid Tumours) criteria?

A. unidimensional (long axis dimension)

B. unidimensional (short axis dimension)

C. bidimensional (product of longest diameter and greatest perpendicular diameter)

D. bidimensional (product of longest diameter and shortest diameter)

E. volumetric

Answer 9

A. unidimensional (long axis dimension)

The WHO response criteria were devised in 1981 to standardize the criteria used for measuring therapeutic response in cancer patients. These criteria set out definitions of complete response, partial response, no change and progressive disease, based upon bidimensional measurements of tumour lesions in the axial plane. The product of the longest diameter multiplied by the greatest perpendicular diameter is calculated for each measurable lesion, and the sum of these products is used to determine treatment response. The RECIST criteria were introduced in 2000, and were designed to be used in clinical trials. The criteria involve classifying the disease burden into measurable and non-measurable disease, followed by selection of up to 10 representative target lesions. The sum of the long axis dimension of the target lesions in the axial plane is used to determine the final response category. Potential concerns about the use of the RECIST criteria include possible confusion arising when lymph node measurements are performed using the short axis dimension and the increased workload involved for the radiologist.

Question 10

10. In normal anatomy, the portal vein is usually formed by the confluence of which vessels?

A. left and right portal veins

B. inferior and superior mesenteric veins

C. superior mesenteric and splenic veins

D. inferior mesenteric and splenic veins

E. left, middle and right hepatic veins

Answer 10

C. superior mesenteric and splenic veins

The splenic and superior mesenteric veins join to form the main portal vein slightly to the right of the midline behind the neck of the pancreas at L1–2 level. The extrahepatic portal vein is about 8cm long, and divides into the right and left portal veins at the porta hepatis. The inferior mesenteric vein most commonly drains into the splenic vein, but may drain into the splenic/superior mesenteric vein confluence in 30% of cases or the superior mesenteric vein in 30%.

Question 11

11. During double-contrast barium enema, a prone overcouch film with the tube angled 45° caudally, centred 5 cm above the posterior superior iliac spines, is performed to optimally visualize which segment of the large bowel?

A. caecum

B. hepatic flexure

C. transverse colon

D. splenic flexure

E. sigmoid colon

Answer 11

E. sigmoid colon

The prone-angled, overcouch view performed as described separates overlying loops of sigmoid colon.

Question 12

12. For a standard portal-phase spiral CT of the abdomen and pelvis, after what period of time following commencement of the intravenous contrast injection should image acquisition begin?

A. 0 seconds

B. 10–15 seconds

C. 25–30 seconds

D. 65–70 seconds

E. 120–180 seconds

Answer 12

D. 65–70 seconds

For a standard, single-slice, spiral CT of the abdomen and pelvis in a single breathhold, 100–150ml of 300mg/ml iodine intravenous contrast medium should be administered at 3–4ml/s. For a portal phase examination, image acquisition should begin 65–70 s after commencement of the injection

Question 13

@# 13. What is the most common side effect associated with administration of superparamagnetic iron oxide particles as a contrast agent during MRI?

A. urticarial skin rash

B. back pain

C. nephrotoxicity

D. nausea

E. headache

Answer 13

B. back pain

‘The most common complication of administration of superparamagnetic iron oxide particles is acute severe back pain, which is seen in approximately 4% of patients. This isthought to be a side effect of particulate agents in general, and lasts for the duration of the infusion and slightly beyond. The risk is higher in patients with liver dysfunction, and when the infusion is administered more rapidly than over the recommended 30 minutes. Slowing of the infusion rate or termination of the infusion with recommencement after resolution of the back pain is usually sufficient to alleviate the symptoms

Question 14

14. From which vessel does the majority of the arterial supply to the pancreas derive?

A.splenic artery

B. left gastric artery

C. superior pancreaticoduodenal artery

D. right hepatic artery

E. superior mesenteric artery

Answer 14

A.splenic artery

The main arterial supply to the pancreas is from the splenic artery, which provides numerous small branches into the pancreatic substance as it runs along the superior pancreatic border, as well as several larger arteries including the dorsal pancreatic artery from its proximal end (which may alternatively arise from the coeliac artery) and the arteria pancreatica magna halfway along its length. The pancreatic head has a dual blood supply, from the superior pancreaticoduodenal artery (derived from the gastroduodenal artery) and the inferior pancreaticoduodenal artery (derived from the superior mesenteric artery). The transverse pancreatic artery also runs along the length of the pancreas beside the main duct, and there are multiple anastomoses between the various vessels, allowing multidirectional flow.

Question 15

39 On review of a pelvic MRI of a patient who has previously received radiotherapy, high signal intensity change is noted on the lumbar spine and sacrum. On the T2 images, which of the following would also be expected to be demonstrated post-radiotherapy?

A. Bladder wall thickened

B. Ovaries increased SI

C. Rectum decreased SI

D. Granulation tissue with decreased SI

E. Fibrous tissue with decreased SI

Answer 15

A. Bladder wall thickened

The urinary bladder and rectum are thickened and oedematous and can show increased T2 and SI.

Post-radiotherapy, the ovaries tend to atrophy and therefore decrease in SI

but bone marrow, fbrous, glandular tissue can also show increased

Question 16

A patient was found unconscious with external signs of abdominal trauma. A CT of their abdomen demonstrated an abnormality around the duodenum with surrounding fluid and further free fluid in the pelvis. The fluid surrounding the duodenum had a measured density of 80 HU. What is this measured area most likely to represent?

a Active bleeding

b Fresh unclotted blood

c Clotted blood

d Urine

e Bile

Answer 16

Answer C: Clotted blood

Serum: 0-20 HU, Fresh unclotted blood: 30-45 HU, Clotted blood: 60-100 HU: Active arterial extravasation >180HU (on enhanced scan).

Question 17

In a normal adult patient, what is the relative signal intensity of the liver, muscle and spleen on T1-weighted imaging? (Options are presented in order of decreasing signal intensity, i.e. highest signal first.)

a Liver > muscle > spleen

b Liver > spleen > muscle

C Muscle > spleen > liver

d Muscle > liver > spleen

e Spleen > muscle > liver

Answer 17

Answer B: Liver > spleen > muscle

Signal intensity is related to ratio of red to white pulp. Under eight months of age spleen < liver on Ti and T2 due to red pulp. In children and adults on Ti liver > spleen > muscle, and on T2 spleen > liver.

Question 18

An 82-year-old man attended for an outpatient double-contrast barium enema to investigate alteration in bowel habit. When reviewing the patient’s history what is the most definite contraindication to the technique that should be excluded?

a Rigid endoscope rectal biopsy three days ago

b Type 2 diabetes mellitus

C Angina

d Open-angle glaucoma

e Colonic resection two years previously

Answer 18

Answer A: Rigid endoscope rectal biopsy three days ago

Absolute contraindications to double-contrast barium enema include: toxic megacolon,pseudomembranous colitis and rectal biopsy (within previous five days via rigid endoscope or withinprevious 24 hours via flexible endoscope). Relative contraindications include: incomplete bowelpreparation, recent barium meal and patient frailty.

Question 19

A patient with a history of closed angle glaucoma was due to undergo a barium meal and substitution of glucagon for hyoscine-N-butyl bromide (Buscopan®) was planned. What would bea contraindication to glucagon use?

a Iodine allergy

b Myasthenia gravis

C Phaeochromocytoma

d Prostatic enlargement

e Pyloric stenosis

Answer 19

Answer C: Phaeochromocytoma

Contraindications to glucagon administration include: phaeochromocytoma, insulinoma and glucagonoma. Myasthenia gravis, prostatic enlargement and pyloric stenosis are contraindications to Buscopan® administration

Question 20

A new drug is being evaluated and the results of a placebo controlled trial are published. The primary end point was all cause death and the trial reports that of 400 people studied 20 of the 200 in the treatment arm died and 40 of the 200 in the control group. What is the number needed to treat (NNT) for this drug?

a 0.1

b2

c 5

d 9

e 10

Answer 20

Answer B: 2

The number needed to treat (NNT) is a measure of the effectiveness of the drug and is the number of patients who need to be treated to prevent one death (or other adverse outcome). It is defined as the inverse of the absolute risk reduction. In this case the probability of death in the control group is 40/200 and in the treatment group 20/200, hence the absolute risk reduction is 20/200=0.1 and the NNT is 10. The number needed to harm (NNH) is similar and is the inverse of the attributable risk (the risk in the exposed group minus the risk in the non-exposed group).

Question 21

(Chest) 27. An area of abnormality is noted within the juxtahepatic IVC of a patient with cirrhosis undergoing an MR scan. The area is hyperintense on T1-weighted imaging, and appears as a filling defect on three-dimensional fat-suppressed volume-interpolated breathhold sequence. Appearances vary in shape and location on different images. The abnormality is likely to represent:

a. Flowing blood

b. Thrombus

c. Tumour thrombus

d. Artefact due to aortic pulsation

e. Pseudolipoma

Answer 21

27. e. Pseudolipoma

The described feature is a partial volume artefact called pseudolipoma caused by juxtacaval fat above the caudate lobe. It has an association with cirrhosis of liver.

Question 22

A young patient is diagnosed with multiple endocrine neoplasia (MEN) type 3 (also known as type 2b) after an episode of bowel obstruction. Which one of the following features would he be unlikely to have or develop in the future with this diagnosis?

a. Medullary carcinoma of the thyroid

b. Marfanoid appearance

c. Mucosal neuromas of the small bowel

d. Facial angiofibromas

e. Prognathism

Answer 22

d. Facial angiofibromas

MEN type 3 is a non-inherited syndrome primarily composing medullary thyroid carcinoma, phaeochromocytomas and mucosal neuromas of the gastro-intestinal tract. Other features include prognathism, marfanoid appearance and cutaneous neuromas. Facial angiofibromas are associated with MEN type 1 and occur in greater than 80% of cases.

Question 23

A patient with proven Hodgkin lymphoma is referred for a staging PET-CT. This shows a solitary focal lung lesion with cervical and mediastinal lymph node enlargement. All of these lesions are PET positive with no other sites of disease. What stage is this disease?

(a) I

(b) II

(c) IIE

(d) III

(e) IV

Answer 23

(c) IIE

This describes stage IIE: localised involvement of a single extralymphatic organ or site and its regional lymph nodes with or without involvement of other lymph node regions on the same side of the diaphragm. Disseminated or multifocal extra lymphatic disease would constitute stage IV disease.

Question 24

A 47-year-old man undergoes a CT and subsequently MRI. These an area of focal fat accumulation adjacent to the falciform ligament anteriorly.
This may be attributed to flow within of the following?

(a) Vein of Sappey

(b) Cholecystic vein

(c) Right gastric vein

(d) Anterior gastric vein

(e) Inferior epigastric vein

Answer 24

(a) Vein of Sappey

This is a common aberrant vein which drains the superior epigastric vein and/ or the internal thoracic veins and communicates with the left portal vein branches.

Question 25

A patient with multiple medical problems is referred forCT colonography and requires intravenous hyoscine butylbromide (Buscopan) as part of procedure. Which of medical conditions listed are contraindications?

(a) Open angle glaucoma

(b) Hypertension

(c) Ischemic heart disease

(d) Myasthenia Gravis

(e) Parkinson’s disease

Answer 25

(d) Myasthenia Gravis

In addition, Buscopan is contraindicated in patients with megacolon, untreated narrow angle glaucoma, tachycardia, hypertrophy of prostate with urinary retention, and mechanical stenoses of gastrointestinal tract.

Question 26

Regarding 2nd generation US contrast agents, which of the following statements is true?

(a) Hepatocyte-specific agents are of particular value in characterizing liver lesions

(b) Microbubbles persist for 30 minutes

(c) Excretion is mainly through biliary pathways

(d) A high mechanical index setting is required for dynamic imaging

(e) metastases are best seen in the delayed phase (2-5 min)

Answer 26

(e) metastases are best seen in the delayed phase (2-5 min)

US contrast agents are microbubbles comprising a ‘shell’ containing an inert gas, which is injected i.v. and may persist for up to 6 hours. The agents stay within the blood pool, but for an unknown reason pool in the sinusoids during the delayed (2-5 min) phase, hence metastases are depicted. Imaging is performed using a mechanical index (0.1-0.2) to avoid bursting the bubbles.

Question 27

A patient with Hodgkin’s lymphoma undergoes a PET-CT which shows a 10 x 5 cm nodal mass is PET positive. Following 2 cycles of chemotherapy, the nodal mass measures 6 x 3 cm but there is no uptake of FDG within the mass. How should you report this study?

(a) Partial response

(b) Stable disease

(c) Mixed response

(d) Too early to assess response

(e) Complete response

Answer 27

(e) Complete response

If a PET positive lesion becomes PET negative, this is regarded as a CR irrespective of the size of the nodal mass. Early assessment (after 1 or 2 cycles of chemotherapy) appears to be a better predictor of long termoutcome than later imaging.

Question 28

A patient is referred for an abdominal radiograph and telephones the department to ask about radiation. What is the typical effective dose of a plain abdominal radiograph?

(a) 0.02 mSv

(b) 0.3 mSv

(c) 0.7 mSv

(d) 1 mSv

(e) 1.5 mSv

Answer 28

(c) 0.7 mSv

A chest radiograph has an effective doseOf approximately 0.02mSv or 3 days background radiation. An abdominal film has a dose that at 0.7mSv, equivalent to 4 months background radiation

Question 29

A 56.year.old HIV-positive mam presents with diarrhea which the clinical team feel is due to a gastrointestinal infection. His CD4 count is 350. Which of the following is most likely?

(a) Mycobacterium tuberculosis

(b) Herpes simplex virus

(c) Candida albicans

(d) Cytomegalovirus

(e) Cryptosporidium

Answer 29

(a) Mycobacterium tuberculosis

Extrapulmonary TB is seen as the CD4 < 400. Candida and Cryptosporidium are associated with a CD4 < 200; HSV and are associated with a CD4 < 100.

Question 30

Which of the techniques is not used to reduce patient dose during abdominal CT?

(a) Dual energy CT

(b) Reduced mAs

(c) Increased kV

(d) Iterative reconstruction

(e) Automatic exposure control

Answer 30

(c) Increased kV

Increasing the kV will increase patient dose. Automatic exposure control modulates the mAs delivered in real time & reduces the dose to patient. Dual energy CT alternates 2 energy sources and the result of reducing dose.

Question 31

What volume of hemorrhage, approximately, would be required to give a positive result on at scintigraphy with radio-labelled red blood cells?

(a) 5 ml

(b) 25 ml

(c) 50 ml

(d) 100 ml

(e) 200 ml

Answer 31

(c) 50 ml

Approximately 50 ml, which is similar to the volume required to give melena. Nuclear medicine techniques are unlikely to be of value when GI bleeding is only detected by chemical tests, e.g. faecal occult blood.

Question 32

A patient with multiple medical conditions is referred for the further investigation of a neuroendocrine tumour with mIBG. Which of the following drug classes do not affect mIBG

(a) Opioids

(b) Tricyclic antidepressants

(c) Calcium channel blockers

(d) Non-steroidal anti-inflammatory drugs

(e) Angiotensin converting enzyme inhibitors

Answer 32

(d) Non-steroidal anti-inflammatory drugs

Tramadol, antipsychotics, phenothiazines, butyrophenones, salbutamol, amiodarone and cocaine may also interfere with MIBG uptake.

Question 33

According to the RCR’s ‘Making the best use of clinical radiology services’, for which of the following indications is an abdominal radiograph given the recommendation indicated?

(a) Acute GI bleeding

(b) Ingested coin

(c) Chronic pancreatitis

(d) Palpable mass

(e) Constipation

Answer 33

(c) Chronic pancreatitis

The AXR may show calcification, but is of little value in excluding this diagnosis. Ingested foreign bodies should only have abdominal radiographs if they may be dangerous e.g. battery. Constipation is only an indication in specific circumstances.

Question 34

In abdominal imaging with 3T MRI, parallel imaging is commonly used to reduce aliasing and susceptibility artefacts. Which of the following is not a feature of parallel imaging?

(a) Increased signal-to-noise ratio

(b) Reduced acquisition time

(c) Increased homogeneity of signal across the field of view

(d) Improved contrast on T1-weighted images

(e) Reduced T2 blurring

Answer 34

(a) Increased signal-to-noise ratio

Parallel imaging has a number of advantages, but reduces the signal-to-noise ratio. Abdominal imaging at 3.0 T brings a number of challenges which are more difficult to overcome than in neurological or musculoskeletal imaging.

Question 35

19. You are left in charge of a barium meal list. Due to an acute staff shortage there is only a student radiographer with you, who wants to know about which barium to use and why. Which one of the following statements regarding barium contrast media is correct?

A. Simethicone is added to reduce flocculation.

B. The weight/volume ratio of barium for barium meals is 150%.

C. The same weight/volume ratio is used for barium meals and follow-through examinations.

D. Uniform particle size improves mucosal coating.

E. Gastrografin can be added to improve transit time

Answer 35

19. E. Gastrografin can be added to improve transit time.

Simethicone is an antifoaming agent. While a uniform particle size helps reduce flocculation, a heterogeneous particle size improves mucosal coating. The barium densities used for different examinations are barium swallow 150%, barium meal 250%, barium follow-through 50%, barium small bowel enteroclysis 18%, double-contrast barium enema 125%, and single-contrast barium enema 70%.

Question 36

43. A 73-year-old woman is referred from surgical outpatients for a barium enema. She has a 3-month history of weight loss and a microcytic anaemia. The procedure is unremarkable, and you leave the screening room to go and continue some plain film reporting. Ten minutes later you are contacted by one of the radiographers who was helping during the enema. She is distressed and tells you that she found the patient collapsed in the bathroom having what appeared to be a seizure. You immediately attend and assess the patient. She is drowsy, but heart rate, blood pressure, andSaO2 are normal. What is the most likely complication to have caused her acute illness?

A. Cardiac arrhythmia secondary to rectal distension.

B. Venous intravasation.

C. Water intoxication.

D. Intramural barium.

E. Side-effect of hyoscine butyl bromide (Buscopan).

Answer 36

43. C. Water intoxication.

All five options are complications of barium enema. Additional potential complications include bowel perforation, barium impaction, and transient bacteremia. Complications during barium enema are rare. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02–0.04% of patients. Venous intravasation may result in a barium pulmonary embolus, which carries an 80% mortality. Water intoxication causes drowsiness and convulsions, as in this case. There is an increased risk in megacolon because of the large area of bowel mucosa available for the absorption of water. Water intoxication has also been attributed to the preparatory laxatives used. Buscopan may cause cardiac arrhythmia and should be used with caution in those with cardiac disease; other relative contraindications include angle-closure glaucoma, myasthenia gravis, paralytic ileus, pyloric stenosis, and prostatic enlargement.

Question 37

62. A patient with a known history of malignancy undergoes a CT scan of the chest, abdomen, and pelvis for staging purposes. This examination identifies a solitary hypodense lesion in the spleen measuring 4 cm in diameter, but no other evidence of metastatic disease. A PET-CT is considered as a possible mechanism for determining whether or not this is a metastasis, but is considered not likely to be helpful. Which malignancy is the patient most likely to have?

A. Melanoma.

B. Lung carcinoma.

C. Lymphoma.

D. Renal cell carcinoma.

E. Colon carcinoma.

Answer 37

62. D. Renal cell carcinoma.

All the other tumours are more likely to be FDG avid than renal cell carcinoma.

Question 38

65. You have been asked to give a presentation on MRI of the liver to your radiological colleagues. One of the audiences asks if any of the contrast agents used in MRI of the liver works best with any sequence other than aT1WI sequence. What do you respond?

A. Yes, gadopentatedimeglumine.

B. Yes, mangafodipirtrisodium.

C. Yes, gadobenatedimeglumine (hepatocyte specific).

D. Yes, SPIO.

E. No, all liver contrast agents work best with T1WI

Answer 38

65. D. Yes, SPIO.

Gadolinium chelates are extracellular agents. Gadolinium shortens the T1 relaxation time of adjacent water protons, resulting in signal enhancement on T1WI. It can be used for lesion detection, characterization, and liver vasculature assessment. Gadopentatedimeglumine (Magnevist) is a commonly used extracellular agent.
SPIO particles are reticulo-endothelial agents that are phagocytosed by Kupffer cells. SPIO causes local magnetic field inhomogeneity and T2 and T2* shortening, resulting in signal loss on T2WIand T2*WI. Most liver tumours, including HCC, are deficient in Kupffer cells (cf. focal nodular hyperplasia) therefore after administration of SPIO the tumour appears hyperintense relative to the background liver.
Mangafodipirtrisodium (Teslascan) is a manganese-based hepatocyte specific agent that increases the signal intensity of the liver, bile ducts, and some hepatocyte-containing lesions (e.g. FNH) at T1WI. Similarly, gadobenatedimeglumine (Multihance) is a gadolinium-based hepatocyte specific agent, which also works best with T1WI due to the T1 shortening effects of gadolinium.

Question 39

QUESTION 53
An 80-year-old man is referred to the gastroenterology outpatient clinic with a1-year history of dysphagia. He describes worsening difficulty swallowing solids and liquids with associated loss of 3 kg in weight. The past medical history includes Parkinson’s disease and right lower lobe pneumonia 6 months ago. An upper gastrointestinal endoscopy is normal and the patient is referred for a contrast swallow examination for suspected oesophageal dysmotility. Which statement is true regarding this examination?

A If aspiration is suspected, water-soluble meglumine diatrizoate (Gastrografin)should be used initially.

B In suspected oesophageal dysmotility, an antispasmodic (eg Buscopan) should be administered prior to prone swallow.

C Motility of the mid- and lower oesophagus is best assessed with the patient standing erect in the left anterior oblique position.

D Repeated swallowing should be avoided and only single boluses of barium be used to assess for oesophageal dysmotility.

E Secondary oesophageal contractions are chaotic and do not propel the barium bolus.

Answer 39

D Repeated swallowing should be avoided and only single boluses of barium be used to assess for oesophageal dysmotility.

Repeated swallowing can interrupt normal peristalsis and produce a falsely abnormal appearance.

Question 40

QUESTION 7
A 54-year-old woman attends a well woman clinic and is found to have abnormal liver function tests. She is referred to the hepatology outpatient clinic and an abdominal ultrasound is performed. This demonstrates diffuse increased reflectivity of the liver parenchyma but no focal parenchyma abnormality. The hepatology team request an ultrasound-guided percutaneous liver biopsy. Which statement is true regarding this procedure?

A Ten to 20% of complications occur in the first 2 hours post procedure.

B Ascites is an absolute contraindication to percutaneous liver biopsy.

C Mortality rate is 1 in 500.

D Over 90% of complications occur in the first 24 hours post procedure.

E There is no increased risk of complications with malignant liver lesions.

Answer 40

D Over 90% of complications occur in the first 24 hours post procedure.

Following an ultrasound-guided liver biopsy, nearly two-thirds of complications occur in the first 2 hours, with 96% of complications having occurred by 24 hours.

Question 41

QUESTION 22
A 59-year-old man is diagnosed with squamous cell carcinoma of the lower esophagus. A contrast-enhanced CT of the chest and abdomen demonstrates a right paratracheal lymph node that measures 9 mm in the short axis, with no evidence of distant metastases. The patient is considered for surgery and a PET-CT examination is performed. The PET-CT demonstrates no uptake in the right paratracheal lymph node, but there is symmetrical uptake of18-FDG in both supraclavicular areas. What is the most likely explanation for this finding?

A Brown adipose tissue

B Paraneoplastic polymyositis

C Recent trauma

D Recent viral upper respiratory tract infection

E Uncontrolled diabetes mellitus

Answer 41

A Brown adipose tissue

Brown fat is a well-recognized physiological cause of 18-FDG uptake (the location and symmetrical distribution are typical) and benzodiazepines can be administered to reduce brown fat uptake. Hyperglycemia is likely to result in reduced 18-FDG uptake as the radioisotope has to compete with glucose for uptake into metabolically active cells.

Question 42

QUESTION 65
A 49-year-old woman is an emergency admission to the surgical admissions unit with a 5-day history of upper abdominal pain. On clinical examination, there is right upper quadrant tenderness and laboratory investigations show an elevated white cell count and CRP. An abdominal ultrasound is performed, but is of limited value due to the patient’s body habitus and the gallbladder is poorly visualized. The patient undergoes dynamic radioisotope hepatobiliary scintigraphy with an intravenous injection of a Tc-99 m-Labelle pharmaceutical. Which one of the following statements is true regarding radioisotope hepatobiliary scintigraphy?

A Increased isotope activity in the region of the gallbladder is consistent with acute cholecystitis.

B Nonvisualisation of the gallbladder after 2 hours is consistent with acute cholecystitis.

C Sulphur colloid is the most commonly used pharmaceutical in this

D The administration of intravenous morphine causes sphincter of Odd relaxation.

E Visualisation of isotope activity in the duodenum is abnormal.

Answer 42

B Nonvisualisation of the gallbladder after 2 hours is consistent with acute cholecystitis.

The normal gallbladder will appear after approximately 20 minutes. In acute cholecystitis, the gallbladder is typically not seen due to cystic duct obstruction.

Question 43

QUESTION 67
A 63-year-old man attends the Radiology Department for an MRCP. He was recently found to have abnormal liver function tests and an abdominal ultrasound showed multiple stones in the gallbladder with a dilated common bile duct. The surgical team have requested the MRCP to assess whether there are gallstones in the bile ducts. Which statement is true regarding MRCP in this setting?

A Blood in the biliary tree is a recognised cause of a false positive MRCP.

B MRCP diagnostic quality reduces as the serum bilirubin rises.

C MRCP is reliant on contrast excretion into the biliary tree.

D The sensitivity of MRCP for choledocholithiasis is 60—70%.

E The sequences are heavily T1 weighted in the majority of cases.

Answer 43

A Blood in the biliary tree is a recognised cause of a false positive MRCP.

Gas, blood or flow voids can all produce filling defects in the biliary tree on MRCP.

Question 44

QUESTION 72
A 35-year-old man has a history of excess alcohol intake and is referred for an abdominal ultrasound by his GP. This demonstrates a 3-cm area of increased reflectivity within liver segment 4a. The lesion does not have any mass effect on adjacent vessels and has a geographic margin. A diagnosis of focal fat deposition is suspected and an MRI of the liver is performed. Which MRI artefact can be utilized to confirm this diagnosis?

A Aliasing

B Chemical shift

C Magic angle

D Susceptibility

E Truncation

Answer 44

B Chemical shift

In- and out-of-phase sequences utilize chemical shift artefact. Fat deposition in the liver will show a significant reduction in signal during the out-of-phase images.

Question 45

QUESTION 80
A 67-year-old woman undergoes surgical resection of a distal sigmoid adenocarcinoma. The surgeon performs a primary anastomosis between the descending colon and rectum and leaves a defunctioning loop colostomy. Nine days later, the patient is experiencing fevers and low abdominal pain. A contrast-enhanced CT shows a small fluid collection around the anastomosis with no definite abscess identified. The surgical team are concerned about the integrity of anastomosis. Which investigation would you choose to look for anastomotic leak?

A Barium enema

B Barium follow-through

C MRI pelvis with intravenous gadolinium

D Water-soluble contrast cystogram

E Water-soluble contrast enema

Answer 45

E Water-soluble contrast enema

Combination of water-soluble contrast enema & CT is used to look for anastomotic leakage & abscess.

Question 46

QUESTION 86
A 32-year-old man presents to his GP with increasing pain on swallowing solids and liquids. He has lost 15 kg in weight over the preceding 2 months. After a full history and examination, he is found to be HIV positive with a very low CD4 count. The GP refers him for a barium swallow examination and this demonstrates a single ulcer in the mid-oesophagus. The ulcer has a smooth margin, measures 4 cm in length and is oval in shape. There is no stricture identified. Which diagnosis is most likely?

A Candida esophagitis

B CMV esophagitis

C Intramural pseudo diverticulosis

D Oesophageal lymphoma

E Squamous cell carcinoma of the oesophagus

Answer 46

B CMV esophagitis

A single ‘giant’ ulcer in an immunocompromised host is highly suggestive of a viral esophagitis (eg CMV or herpes simplex).

Question 47

QUESTION 89
A 44-year-old man has liver cirrhosis due to chronic hepatitis B infection. He is admitted to hospital with decompensated liver disease and a serum alpha-fetoprotein level is found to be markedly elevated. An abdominal ultrasound demonstrates a 3-cm hypoechoic mass in liver segment 5 with no colour flow demonstrated in an adjacent branch of the portal vein. The ultrasound probe is positioned over this focal lesion and an intravenous microbubble contrast agent is injected in the patient’s left arm. At what stage will this liver lesion appear most echogenic?

A Pre contrast injection

B 15—30 seconds post injection

C 60—80 seconds post injection

D 5 minutes post injection

E 10 minutes post injection

Answer 47

B 15—30 seconds post injection

Microbubble contrast agents act as positive contrast on ultrasound, and enhancement is seen as increasing echogenicity following contrast injection.

Question 48

QUESTION 91
A 27-yeat-old woman presents to the Emergency Department with a 3-dayhistory of sharp pain in the left iliac fossa. A transvaginal pelvic ultrasound performed and shows a 5-cm unilocular cyst in the left ovary. The radiologist then performs a transabdominal ultrasound to assess the kidneys. It is noted that the liver parenchyma extends significantly below the right costal margin and passes anterior to the right kidney. The liver texture appears uniformly normal. What is the most likely explanation for the appearance of the liver?

A Biliary hamartoma

B Fitz-Hugh-Curtis syndrome

C Focal fatty infiltration

D Focal nodular hyperplasia (FNH)

E Riedel’s lobe

Answer 48

E Riedel’s lobe

Riedel’s lobe is described as a ‘tongue-like’ projection of the anterior tip of the right lobe of liver. It is a variant of normal and is more common in women.

Question 49

QUESTION 100
A 72-year-old woman is brought to the Emergency Department with an 8-hour history of profuse fresh rectal bleeding. She had been awaiting endoscopic investigation of iron deficiency anemia, but has no other significant medical history. On examination, she is hemodynamically unstable and blood tests reveal Hb = 5-0 g/dL. Following resuscitation, the patient’s condition stabilizes and the surgical team request radiological investigation to identify the source of GI bleeding. Which statement is true regarding this clinical scenario?

A. Catheter angiography of the mesenteric vessels is the most sensitive method for detecting lower GI bleeding.

B. Colorectal cancer is the most common cause of profuse lower GI hemorrhage.

C. In fresh rectal bleeding, selective catheterization of the coeliac axis is not required during catheter angiography.

D. Isotope studies with Tc-99 m-labelled red blood cells can detect bleeding rates as low as 0.1 ml/min.

E. The most common site of colonic angiodysplasia is the descending colon.

Answer 49

D. Isotope studies with Tc-99 m-labelled red blood cells can detect bleeding rates as low as 0.1 ml/min.

Red cell scintigraphy is the most sensitive method of detecting active GI bleeding (catheter angiography can only detect bleeding of 0.5 ml/min).