GIT

Question 1

1. A 71 year old female with scleroderma undergoes a barium swallow examination.
   Which one of the following findings concerning the oesophagus would not be consistent
   with this diagnosis?
   a. Oesophageal dilatation
   b. Superficial ulcers
   c. Hypoperistalsis in the upper third of the oesophagus
   d. Stricture 5 cm above the gastro-oesophageal junction
   e. Oesophageal shortening

Answer 1

1. c. Hypoperistalsis in the upper third of the oesophagus
   The oesophagus is the most commonly involved location of the gastro-intestinal tract in
   patients with scleroderma. Smooth muscle atrophy causes hypoperistalsis and eventually
   aperistalsis in the lower two-thirds of the oesophagus. The upper third of the oesophageal
   wall contains skeletal muscle and is therefore unaffected by the disease process.

Question 2

2. A 32 year old male front seat passenger is involved in a road traffic accident and sustains
   blunt abdominal trauma. He is admitted via the emergency department and CT reveals a
   splenic laceration with subcapsular haematoma. Which one of the following associated
   injuries is most likely to be found?
   a. Diaphragmatic rupture
   b. Injury to the liver
   c. Injury to the left kidney
   d. Ipsilateral rib fractures
   e. Injury to the small bowel mesentery

Answer 2

2. d. Ipsilateral rib fractures
   All are potential associated injuries and should be actively searched for in the context of
   blunt abdominal trauma. Rib fractures are found in up to 50% of patients with splenic
   injuries and as such are the most common association. The left kidney is injured in 10% of
   patients with splenic injury, and diaphragm rupture is even rarer. Diaphragm rupture may
   be difficult to appreciate on axial slices, and may be more evident on coronal reformats

Question 3

3. A neonate is diagnosed with congenital tracheoesophageal (TE) fistula. A plain film demonstrates
   a gasless abdomen.Which type of TE fistula is associated with this finding?
   a. Type B
   b. Type C
   c. Type D
   d. Type E
   e. None of the above

Answer 3

3. a. Type B
   Congenital TE fistula and oesophageal atresia occur in approximately 1 in 4000 live births.
   They are divided into five subtypes, A to E. Type C is the most common, comprising 75% of
   all types and involves oesophageal atresia with a distal TE fistula. Type D involves oesophageal
   atresia with both proximal and distal TE fistula, and type E is a TE fistula without
   oesophageal atresia. Therefore types C to E do not typically present with gasless abdomen.
   Type B is oesophageal atresia with a proximal TE fistula; there is no communication
   between the trachea and the distal oesophagus, and therefore a gasless abdomen is typical.
   Type A is oesophageal atresia without TE fistula and therefore may also present with a
   gasless abdomen, but is not a listed option

Question 4

4. A 60 year old female has a plain abdominal film which shows a grossly distended
   segment of bowel. Which one of the following features makes a diagnosis of caecal
   volvulus more likely than sigmoid volvulus?
   a. Pelvic overlap sign
   b. Apex lying above the level of T10
   c. Liver overlap sign
   d. Coffee bean sign
   e. Presence of haustral markings

Answer 4

4. e. Presence of haustral markings
   Sigmoid and caecal volvulus can sometimes be difficult to differentiate on plain abdominal
   film. With caecal volvulus the haustral markings are typically present, whereas these are
   usually absent in sigmoid volvulus. The pelvic overlap, liver overlap and coffee bean signs
   are typical of sigmoid volvulus. In sigmoid volvulus the apex lies high in the abdomen
   underneath the left hemi-diaphragm, typically above the level of T10

Question 5

5. A 40 year old man is admitted to the surgical ward with acute abdominal pain and
   subsequently a CT abdomen and pelvis is requested. The findings include a 3 cm oval mass with central fat density adjacent to the sigmoid colon and with associated fat
   stranding. Which one of the following is the most likely diagnosis?
   a. Diverticulitis
   b. Epiploic appendagitis
   c. Mesenteric lymphadenitis
   d. Meckel’s diverticulitis
   e. Infected enteric duplication cyst

Answer 5

5. b. Epiploic appendagitis
   Epiploic appendagitis is inflammation of one of the epiploic appendages of the colon, with
   the sigmoid being the commonest site. It typically presents with acute abdominal pain and is an important radiological diagnosis as it can often mimic appendicitis, and management
   is conservative. The diagnosis is usually made on CT with the features described in the
   question. Ultrasound is rarely used for diagnosis, and features include a non-compressible
   hyperechoic mass with hypoechoic margins.

Question 6

6. A seven year old boy on chemotherapy for acute leukaemia develops severe right iliac
   fossa pain and diarrhoea. CT shows ascending colon and caecal wall thickening, with
   inflammation extending to involve the appendix and terminal ileum and fat stranding in
   the adjacent mesentery. The most likely diagnosis is:
   a. Typhlitis
   b. Crohn’s disease
   c. Acute appendicitis
   d. Necrotising enterocolitis
   e. Acute leukaemic infiltration

Answer 6

6. a. Typhlitis
   Typhlitis, or neutropaenic enterocolitis, is acute inflammation of the caecum, ascending
   colon, terminal ileum or appendix. It is typically described in children with neutropaenia
   secondary to lymphoma, leukaemia and immunosuppression. Concentric, often marked,
   bowel wall thickening with pericolic inflammatory changes is typical, and such changes in a
   young immunosuppressed child should raise suspicion of typhlitis as a cause. Perforation is
   a risk factor and therefore contrast examinations are usually avoided

Question 7

7. 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 7

7. 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 8

8. A 48 year old woman with upper abdominal pain is found to have a 4 cm hypervascular
   lesion in the head of the pancreas on contrast-enhanced CT. She subsequently has an
   MR scan; the lesion is of low intensity on fat-saturated T1-weighted and high intensity
   on T2-weighted imaging. Which of the following is the most likely diagnosis?
   a. Pancreatic adenocarcinoma
   b. Gastrinoma
   c. Insulinoma
   d. Macrocystic adenoma
   e. Pancreatic pseudocyst

Answer 8

8. b. Gastrinoma
   Pancreatic adenocarcinoma is a hypovascular lesion. Macrocystic adenoma is also hypovascular,
   and is only rarely found in the head of the pancreas, with a predilection for the tail.
   The differential therefore lies between insulinoma and gastrinoma. Although both CT and
   MR imaging characteristics are similar, the majority of insulinomas are less than 1 cm in
   size, whereas gastrinomas tend to be larger at presentation with an average size of approximately
   3 cm. Gastrinoma is associated with peptic ulceration and Zollinger–Ellison
   syndrome.

Question 9

9. An 83 year old woman is investigated for weight loss, and undergoes contrastenhanced
   CT scan of the chest, abdomen and pelvis. Multiple hypervascular metastases
   are found in the liver. Which one of the following is most likely to be the primary
   tumour?
   a. Adenocarcinoma of the stomach
   b. Invasive ductal carcinoma of the breast
   c. Carcinoid tumour
   d. Adenocarcinoma of the sigmoid
   e. Pancreatic ductal adenocarcinoma

Answer 9

9. c. Carcinoid tumour
   Of the options listed, carcinoid tumour is the only primary tumour that typically causes
   hypervascular liver metastases. Other causes of hypervascular liver metastases are pancreatic
   islet cell tumours, phaeochromocytoma and renal cell carcinoma. Stomach, breast, lung
   and colon cancers are associated with hypovascular liver metastases. Liver metastases from
   carcinoid tumours are more common with increasing size of the primary tumour. The
   incidence of metastases depends on the location of the primary tumour, where approximately
   30% of carcinoids of the ileum metastasise compared to less than 5% of carcinoids of
   the appendix.

Question 10

10. A 32 year old male is referred for a barium swallow by his GP due to dysphagia
    resistant to medical treatment. A smooth, lobulated, eccentric mass is seen in the
    middle third of the oesophagus containing foci of calcification. The diagnosis is most
    likely to be which one of the following?
    a. Leiomyoma
    b. Squamous cell carcinoma
    c. Adenocarcinoma
    d. Oesophageal web
    e. Intramural pseudodiverticulosis

Answer 10

10. a. Leiomyoma
    Oesophageal leiomyoma is the most common benign submucosal tumour of the oesophagus,
    typically occurring in young men. The classical features of oesophageal leiomyoma
    include a smooth intramural mass in the lower or middle third of the oesophagus with intact overlying mucosa. It is the only tumour of the oesophagus that calcifies, although
    calcification is rare.

Question 11

11. A 56 year old woman is diagnosed with pancreatic adenocarcinoma. Which one of the
    following features on the pancreatic MR contraindicates curative surgery?
    a. Splenic vein invasion
    b. Tumour size of 2 cm
    c. Portal vein invasion
    d. Hepatic artery invasion
    e. Invasion of the second part of the duodenum

Answer 11

11. d. Hepatic artery invasion
    The only widely recognised absolute contraindication to curative surgical resection of the
    options listed is invasion of the hepatic artery. Invasion of the splenic and portal veins are
    relative contraindications as long as the veins are not completely occluded. Invasion of the
    second part of the duodenum is not a contraindication as it is resected at surgery. Other
    features that make the tumour unsuitable for curative resection are distant metastases,
    ascites, distant organ invasion, SMA/coeliac/aortic invasion and involved lymph nodes
    outside the boundaries of the resection

Question 12

12. A 67 year old man is referred for a barium swallow from the surgical outpatient
    department with a history of dysphagia to solids. A mid-oesophageal stricture is
    demonstrated. Which one of the following causes is unlikely to be in the differential?
    a. Barrett’s oesophagus
    b. Squamous cell carcinoma of the oesophagus
    c. Schatzki ring
    d. Caustic substance ingestion
    e. Epidermolysis bullosa

Answer 12

12. c. Schatzki ring
    All are reasonable differentials for a mid-oesophageal stricture, albeit with varying degrees
    of frequency, with the exception of a Schatzki ring which is found in the lower oesophagus.
    It occurs near the squamocolumnar junction and is associated with reflux. It is nondistensible
    and best seen in the prone position on barium swallow examinations. Schatzki
    rings are often asymptomatic, but oesophageal dilatation may be required where dysphagia
    is severe.

Question 13

13. A 71 year old man is referred to CT for unexplained abdominal distension. Lowattenuation
    intraperitoneal collections with enhancing septae are demonstrated. There
    is scalloping of the liver border and omental thickening. Which one of the following is
    most likely to be the underlying cause?
    a. Carcinoid tumour of the appendix
    b. Cystadenocarcinoma of the appendix
    c. Melanosis coli
    d. Mastocytosis
    e. Retroperitoneal fibrosis

Answer 13

13. b. Cystadenocarcinoma of the appendix
    The CT findings described are consistent with pseudomyxoma peritonei. This describes
    abdominal distension secondary to the accumulation of large quantities of gelatinous
    ascites. It is most commonly caused by cystadenocarcinoma of the appendix in males and
    cystadenocarcinoma of the ovary in females. Surgical debulking and intraperitoneal chemotherapy
    may be offered as a treatment. Bowel obstruction is a frequent complication that
    may necessitate surgery

Question 14

14. A 78 year old previously well female is admitted with acute abdominal pain and
    diarrhoea. Contrast-enhanced CT of the abdomen and pelvis shows thickening of
    a 13 cm segment of proximal descending colon and mucosal hyperenhancement.
    The rest of the colon is normal, and the small bowel is unaffected. There is a
    small amount of free fluid in the pelvis. Which one of the following diagnoses is
    most likely?
    a. Crohn’s colitis
    b. Ulcerative colitis
    c. Ischaemic colitis
    d. Infectious colitis
    e. Pseudomembranous colitis

Answer 14

14. c. Ischaemic colitis
    Crohn’s colitis is relatively unlikely due to lack of prior history or small bowel involvement
    and age of the patient. Ulcerative colitis and pseudomembranous colitis are both unlikely as
    the rectum is usually involved in these two conditions. Infectious colitis does not normally
    affect the left-sided colon only, regardless of the underlying pathogen. Ischaemic colitis is
    the most likely diagnosis of those listed. It typically affects a segment of bowel, with the
    majority of cases having left-sided colonic involvement

Question 15

15. A 27 year old male has recurrent admissions for intermittent low-grade small bowel
    obstruction of unknown cause. Which one of the following investigations would be
    most appropriate?
    a. Contrast-enhanced CT abdomen and pelvis
    b. Barium meal
    c. Small bowel enteroclysis
    d. Serial abdominal plain films
    e. Barium follow-through

Answer 15

15. c. Small bowel enteroclysis
    Small bowel enteroclysis is the most appropriate examination. CT is sensitive for high-grade
    obstruction as it will readily identify the level of obstruction and can demonstrate complications
    such as ischaemia and perforation. Enteroclysis is the preferred investigation for
    recurrent low-grade obstruction as it is more likely to demonstrate the presence of a transition
    point (for example from non-obstructing adhesions) because the bowel is distended
    The examination involves passing a nasojejunal tube just distal to the duodenojejunal
    flexure and distending the small bowel using either dilute barium or a double-contrast
    examination with high-density barium and methylcellulose

Question 16

16. An asymptomatic 46 year old woman has an MR liver following an incidental finding
    of a focal mass in the right lobe of the liver on ultrasound. The MR shows an 8 cm
    isolated lesion. It is high signal on T1-weighted sequences and isointense on
    T2-weighted sequences relative to the normal liver parenchyma. The lesion is most
    likely to be which one of the following?
    a. Hepatocellular carcinoma
    b. Liver metastasis
    c. Haemangioma
    d. Fibronodular hyperplasia

Answer 16

16. e. Adenoma
    The lesion is most likely to be a hepatic adenoma. None of the other diagnoses typically
    share these imaging characteristics. Adenomas are benign growths of hepatocytes and are
    most commonly seen in young women, particularly associated with oral contraceptive
    use. Eighty per cent are solitary and found in the right lobe of the liver. The high signal
    on T1-weighted sequences is due to the presence of fat and/or haemorrhage and can
    distinguish between this and many other lesions in the liver which tend to be of low T1
    signal on MR (e.g. metastases, HCC, haemangiomas and FNH). Occasionally, imaging
    features can overlap with FNH and the two lesions can be difficult to distinguish.
    However, the majority of FNH lesions are less than 5 cm in size, whereas adenomas tend
    to be larger.

Question 17

17. A 26 year old female has an ultrasound scan for right upper quadrant pain and a
    heterogenous 5 cm solitary liver lesion with central calcifications, and a hyperechoic
    scar is seen. Blood tests reveal a negative alpha-fetoprotein. MR shows the lesion
    is hypointense on T1 and hyperintense on T2-weighted imaging. The central scar is
    hypointense on both sequences. Which of the following diagnoses is most likely?
    a. Hepatic lymphoma
    b. Hepatocellular carcinoma
    c. Fibrolamellar carcinoma
    d. Hepatoblastoma
    e. Hepatic angiosarcoma

Answer 17

17. c. Fibrolamellar carcinoma
    Fibrolamellar carcinoma occurs in young adults in the absence of normal risk factors for
    hepatocellular carcinoma. On ultrasound, fibrolamellar carcinoma is of mixed or increased
    echogenicity, and the hyperechoic central scar is often evident. On unenhanced CT the
    lesion is of low attenuation, displaying heterogenous enhancement with intravenous contrast
    administration. The central scar is typically of low signal on both T1- and T2-weighted
    imaging, which can help differentiate it from FNH (whose scar typically is of low signal on
    T1 but high signal on T2-weighted imaging). The central scar is present in up to 60% of
    patients. Calcifications are present in up to 55% and are more common than in hepatocellular
    carcinoma

Question 18

18. A 72 year old woman has a pancreatic MR to investigate recurrent episodes of
    pancreatitis. There is generalised pancreatic atrophy with dilatation of the main
    pancreatic duct and branch ducts, particularly in the tail. No focal lesion or intraductal
    calculi are present. Which one of the following diagnoses is most likely?
    a. Microcystic cystadenoma
    b. Intraductal papillary mucinous tumour of the pancreas
    c. Cystic metastases
    d. Cystic islet cell tumour
    e. Pancreatic lipomatosis

Answer 18

18. b. Intraductal papillary mucinous tumour of the pancreas
    Intraductal papillary mucinous tumour (IPMT) of the pancreas is a rare tumour. It tends to
    present in the elderly population and can be a cause of recurrent pancreatitis. Two
    recognised types include main duct IPMT, in which the main pancreatic duct is dilated,
    and branch duct IPMT, in which the main duct is usually uninvolved. It is a risk factor for
    mucinous carcinoma of the pancreas. Pancreatic atrophy is often present. Imaging characteristics
    are often similar to those seen in chronic pancreatitis, although calcification is not a
    feature of IPMT.

Question 19

19. A 25 year old male presents with abdominal cramps and pain with rectal bleeding.
    Colonoscopy is normal. CT enteroclysis is performed as part of the investigation,
    which reveals multiple sessile polyps throughout the jejunum and ileum. Subsequent
    biopsies reveal these polyps to be hamartomas. Which one of the following syndromes
    is he most likely to be diagnosed with?
    a. Peutz–Jeghers
    b. Cowden’s
    c. Turcot’s
    d. Familial polyposis
    e. Gardner’s

Answer 19

19. a. Peutz–Jeghers
    Peutz–Jeghers syndrome is most consistent with these findings. It is an autosomal dominant
    syndrome but often arises as a spontaneous mutation. Hamartomas are found throughout
    the gastro-intestinal tract, with the exception of the oesophagus. The polyps have almost no
    malignant potential, but life expectancy is decreased due to associated cancers arising in the
    stomach, duodenum, colon and ovary. Gardner’s syndrome and familial polyposis are both
    associated with small bowel adenomas in approximately 5% of cases. Cowden’s syndrome does involve hamartomatous polyps, but these are typically rectosigmoid, and small bowel
    involvement is not a feature. Small bowel polyps are not a feature of Turcot’s syndrome

Question 20

20. A 17 year old female undergoes screening colonoscopy and is found to have multiple
    adenomatous polyps throughout the colon. OGD and biopsy reveal multiple hamartomas
    of the stomach and duodenum. She subsequently has investigation for a painful
    jaw that reveals a 1 cm round, discrete, dense lesion in the mandible. Which one of the
    following syndromes is the most likely underlying diagnosis?
    a. Lynch syndrome
    b. Cronkhite–Canada syndrome
    c. Familial adenomatous polyposis
    d. Gardner’s syndrome
    e. Peutz–Jegher syndrome

Answer 20

20. d. Gardner’s syndrome
    Gardner’s syndrome is an autosomal dominant condition with colonic polyps present in all
    patients. Small bowel, duodenal and stomach polyps are also a feature. Extra-intestinal
    features include osteomas of membranous bone (typically the mandible as described in the
    question), other soft-tissue tumours and periampullary carcinomas. Osteomas are not a
    feature of the other conditions. Cronkhite–Canada syndrome and Peutz–Jegher syndrome
    are associated with multiple hamartomatous polyps of the colon and stomach. Cronkhite–
    Canada syndrome is a sporadic non-familial disorder. Lynch syndrome, or hereditary nonpolyposis
    colorectal carcinoma (HNPCC), is associated with increased risk of colorectal
    adenomas and other malignancies such as endometrial and other gastro-intestinal tract
    malignancies.

Question 21

21. A 58 year old male has a CT staging scan following a diagnosis of adenocarcinoma
    of the body of the pancreas. The tumour is 3 cm in size and extends beyond the
    boundaries of the pancreas but does not invade any vessels or adjacent organs. Two
    1 cm lymph nodes lie adjacent to the tumour. No other nodes, or metastatic disease in
    the chest, abdomen or pelvis, are identified. The tumour is best staged as which one of
    the following?
    a. T1N0M0
    b. T1N1M0
    c. T2N0M0
    d. T3N0M0
    e. T3N1M0

Answer 21

21. e. T3N1M0
    T1 tumour is disease confined to the pancreas and less than 2 cm in diameter. T2 tumour is
    also confined to the pancreas but greater than 2 cm in diameter. As the tumour extends
    beyond the boundary of the pancreas, it is at least T3. Invasion of the coeliac or superior
    mesenteric arteries would make this a T4 tumour, but as these features are not present it is
    T3. The presence of regional nodes make it N1 rather than N0 (no nodes involved), and there
    is no metastatic disease so it is M0. Therefore the correct radiological stage is T3N1M0

Question 22

22. A 41 year old woman has an outpatient ultrasound scan for intermittent right upper
    quadrant pain. Five 5mm gallstones and sludge are present. In addition, there is wall
    thickening of the gallbladder fundus with multiple foci of increased echogenicity
    within the wall, each associated with bright artefacts deep to them. Which one of the
    following is the most likely diagnosis?
    a. Porcelain gallbladder
    b. Emphysematous cholecystitis
    c. Acute cholecystitis
    d. Adenomyomatosis of the gallbladder
    e. Gallbladder carcinoma

Answer 22

22. d. Adenomyomatosis of the gallbladder
    The correct diagnosis is adenomyomatosis. This is an uncommon condition, more
    common in females, and is associated with gallstones in the majority of cases. It is
    characterised by generalised or focal mural thickening with intramural diverticula
    (Rokitansky–Aschoff sinuses). The ultrasound artefact from cholesterol crystals in the
    sinuses produces bright ‘comet-tail’ reverberation artefacts

Question 23

23. A 32 year old man has an ultrasound scan for obstructive jaundice. Areas of intrahepatic
    duct dilatation are seen, with increased echogenicity of the portal triads. ERCP
    reveals alternating segments of dilatation and stenosis of both the intra- and extrahepatic
    ducts. Which one of the following diagnoses is most likely?
    a. Primary sclerosing cholangitis
    b. Primary biliary sclerosis
    c. Ascending cholangitis
    d. Choledochal cyst
    e. Congenital hepatic fibrosis

Answer 23

23. a. Primary sclerosing cholangitis
    These ultrasound and ERCP features are typical of primary sclerosing cholangitis, which is
    an idiopathic condition characterised by progressive fibrosis of the biliary tree. It primarily
    affects young men with inflammatory bowel disease (more common in ulcerative colitis
    than Crohn’s) although pancreatitis, liver cirrhosis and chronic active hepatitis are other
    associated conditions. Primary biliary cirrhosis may also cause scattered areas of focal
    intrahepatic duct dilatation, but this condition is much more common in females and the
    extrahepatic ducts are not involved.

Question 24

24. A neonate is investigated for obstructive jaundice and as part of the investigation
    has a hepatobiliary iminodiacetic acid (HIDA) nuclear medicine scan. This shows a photopaenic area within the liver and lack of visualisation of the small bowel. Which
    one of the following conditions would be most consistent with these findings?
    a. Enteric duplication cyst
    b. Biliary duct atresia
    c. Choledochal cyst
    d. Pancreatic pseudocyst
    e. Hepatic cyst

Answer 24

24. c. Choledochal cyst
    The only one of the listed diagnoses that would have both these features on HIDA scan is a
    choledochal cyst. This is a congenital condition characterised by dilatation of the common bile duct and common hepatic duct. Patients typically present in childhood with right upper
    quadrant pain, a mass and/or obstructive jaundice. Although the diagnosis is usually made
    with MRCP, HIDA scan can show typical features that include a photopaenic area in the
    liver representing the dilated CBD/CHD. Although a hepatic cyst would also show a
    photopaenic area within the liver, small bowel visualisation would be expected. Congenital
    biliary atresia would cause lack of small bowel visualisation, but the whole liver would take
    up HIDA and photopaenia would not be present.

Question 25

25. A one year old boy is admitted unwell with generalised abdominal tenderness and
    guarding. A supine plain abdominal film is requested, which shows a large oval
    radiolucency in the middle of the abdomen, with a well-defined linear opacity in the
    right upper quadrant. Which one of the following conditions would best explain
    these appearances?
    a. Enteric duplication cyst
    b. Choledocal cyst
    c. Pneumoperitoneum
    d. Duodenal atresia
    e. Caecal volvulus

Answer 25

25. c. Pneumoperitoneum
    Whilst uncommon, the appearances seen on plain film are consistent with massive pneumoperitoneum.
    The oval radiolucency is called the ‘football sign’ and arises due to free air
    collecting anterior to the intra-abdominal viscera. This sign is only seen in 2% of adults with
    pneumoperitoneum due to the large quantities of air required to produce it. It is much
    more common in infants who may present at a later stage. The opacity in the right
    upper quadrant is produced by air outlining the falciform ligament, which again is a
    sign of pneumoperitoneum. Causes of perforation in this age group include trauma,
    intussusception and complications of Meckel’s diverticulum.

Question 26

26. A 50 year old male is admitted with epigastric pain, diarrhoea and vomiting. Ascites is
    present clinically. Serum albumin is low and the patient is anaemic. Colonoscopy is
    normal but the patient is intolerant of upper gastro-intestinal endoscopy. Barium meal
    reveals a normal antrum but elsewhere there are diffusely thickened and enlarged
    gastric folds despite good gastric distension. Which one of the following is the most
    likely diagnosis?
    a. Gastric lymphoma
    b. Menetrier’s disease
    c. Gastric adenocarcinoma
    d. Acute gastritis
    e. Linitis plastica

Answer 26

26. b. Menetrier’s disease
    Menetrier’s disease is a condition characterised by gastric mucosal hypertrophy and
    protein-losing enteropathy. It is often associated with anaemia. The changes are most
    marked along the greater curve and the antrum is spared in approximately 50% of cases.
    Gastric lymphoma typically involves the antrum. With gastric adenocarcinoma and linitis
    plastica, stomach distension is not typically preserved

Question 27

27. A 31 year old male is investigated as an outpatient for diarrhoea. A small bowel meal
    study reveals jejunal dilatation with thickened valvulae conniventes. In the ileum an
    increased number of mucosal folds are seen. Which of the following diagnoses is
    most likely?
    a. Lymphoma
    b. Crohn’s disease
    c. Coeliac disease
    d. Whipple disease
    e. Behcet syndrome

Answer 27

27. c. Coeliac disease
    Jejunal dilatation and jejunisation of the ileal loops are characteristic features of coeliac
    disease. This is an immunological intolerance to gluten that causes villous atrophy in the
    small intestine. In Whipple disease there is thickening of the jejunal and duodenal mucosal
    folds but typically no luminal dilatation. Dilatation of the small bowel does occur with
    lymphoma but jejunisation of the ileum is not a feature

Question 28

28. A 53 year old male is investigated for recurrent episodes of biliary colic. Blood tests
    reveal eosinophilia and normal liver function tests. Abdominal ultrasound demonstrates
    a 7 cm cystic structure with a thin hyperechoic wall and several smaller satellite
    cysts up to 2 cm adjacent to the lesion. Which one of the following diagnoses is most
    likely?
    a. Hydatid cyst
    b. Pyogenic abscess
    c. Amoebic abscess
    d. Schistosomiasis
    e. Hepatocellular carcinoma

Answer 28

28. a. Hydatid cyst
    The most likely diagnosis is hydatid cyst disease. This condition is caused by infection of the
    liver with the parasite Echinococcus granulosus. Blood eosinophilia is present in up to 50%
    of patients. It is more common in the right lobe of the liver and is multiple in 20% of cases.
    Daughter cysts are typical. Percutaneous aspiration of the cyst is positive for hydatid disease
    in 70%.

Question 29

29. A 71 year old female is admitted via A&E with abdominal pain, abdominal distension
    and vomiting. Plain abdominal film shows multiple dilated loops of small bowel.
    In addition there is gas projected over the liver shadow which is prominent centrally
    and has a branching appearance. Gas is not visible over the periphery of the liver.
    No other abnormality is seen on the plain film. Which of the following diagnoses is
    most likely?
    a. Small bowel perforation
    b. Small bowel infarction
    c. Gallstone ileus
    d. Emphysematous cholecystitis
    e. Pneumatosis intestinalis

Answer 29

29. c. Gallstone ileus
    Specific signs of gallstone ileus can be seen on the plain abdominal film in up to 40% of
    patients. Fifty per cent of patients have evidence of small bowel obstruction and up to 30% have gas in the biliary tree. Biliary tree gas is typically more prominent centrally and spares
    the periphery of the liver, whereas portal venous gas is more easily visualised in the
    periphery of the liver, which may be associated with small bowel infarction. The gallstone
    most frequently lodges in the terminal ileum, but is often not seen on the plain film. The
    presence of small bowel obstruction, pneumobilia and a visible stone are called Rigler’s
    triad.

Question 30

30. A 35 year old male with known ulcerative colitis presents to A&E with severe
    abdominal pain, pyrexia and diarrhoea. There is no peritonism. Toxic megacolon is
    suspected clinically. Which one of the following is the most appropriate as first line
    imaging?
    a. CT
    b. Plain abdominal film
    c. Double contrast barium enema
    d. Single contrast water-soluble enema
    e. Targeted bowel ultrasound

Answer 30

30. b. Plain abdominal film
    Toxic megacolon is a complication of ulcerative colitis, Crohn’s and other forms of acute
    colitis. It has a poor prognosis with up to 20% mortality. Plain abdominal radiography
    should be the first line investigation for suspected toxic megacolon, and can be repeated
    24 or 48 hourly if necessary. It can often confirm the diagnosis without the need for CT,
    which is especially useful when considering radiation dose issues in this group of young
    patients. Typical features on plain film include transverse colon dilatation >5.5 cm, loss of
    normal haustral folds, thumbprinting of the colon and the presence of mucosal islands
    (pseudopolyps). CT better demonstrates potential complications of toxic megacolon such as
    perforation of the bowel.

Question 31

31. As part of an investigation for altered bowel habit, a 32 year old female has a double
    contrast barium enema performed. Findings include deep and superficial aphthous
    ulceration from the caecum proximally to the sigmoid colon and the presence of
    pseudodiverticula. Which one of the following is most likely?
    a. Crohn’s disease
    b. Ulcerative colitis
    c. Tuberculosis
    d. Yersinia
    e. Lymphoma

Answer 31

31. a. Crohn’s disease
    These features are highly suggestive of Crohn’s disease. Signs on double contrast barium
    enema that favour a diagnosis of Crohn’s disease over ulcerative colitis include apthoid
    ulcers, deep ulcers, discontinuous ulceration, rectal sparing, pseudodiverticulae, fistulae and
    abscess formation. Ulcerative colitis can be suggested by rectal involvement, continuous
    pathology with no skip lesions and the presence of mucosal granularity. However, these
    features may also be present in Crohn’s and are not specific for ulcerative colitis. Although
    tuberculosis is a mimic, colonic involvement in this pattern is uncommon compared with
    Crohn’s disease.

Question 32

32. A 38 year old patient with AIDS presents with diarrhoea and steatorrhoea. As part of
    the work-up, small bowel enteroclysis shows thickened jejunal folds with nodularity
    and evidence of marked jejunal spasm. The ileum has normal appearances. Which one
    of the following is the most likely underlying cause?
    a. Cytomegalovirus
    b. Tuberculosis
    c. Mycobacterium avium intracellulare
    d. Cryptosporidium
    e. Giardiasis

Answer 32

32. e. Giardiasis
    All the stems are potential causes for these symptoms in a patient with AIDS, however
    giardiasis is the most likely cause given these imaging appearances. Cytomegalovirus most
    typically affects the caecum, and tuberculosis affects the caecum and ileocaecal valve.
    Mycobacterium avium intracellulare can affect the ileum and jejunum but does not usually
    cause spasm. Cryptosporidium affects the duodenum and the jejunum can be affected, but
    dilatation is more common than spasm

Question 33

33. An 81 year old man is investigated for anaemia of unknown cause. He has a barium
    enema as an outpatient that is reported as normal, but is subsequently admitted with a
    large gastro-intestinal bleed. Initial upper gastro-intestinal endoscopy is normal. He is
    haemodynamically unstable and therefore has a mesenteric angiogram, which shows early opacification and slow emptying of the ileocolic vein. Which one of the following
    diagnoses is most likely?
    a. Angiodysplasia
    b. Diverticulosis
    c. Meckel’s diverticulum
    d. Adenomatous polyp
    e. Radiation enteritis

Answer 33

33. a. Angiodysplasia
    The typical angiographic feature of a Meckel’s diverticulum is presence of the vitelline
    artery. Meckel’s diverticulum also typically (although not exclusively) presents in younger
    patients. With diverticulosis, radiation enteritis and polyps, one might expect an abnormal
    barium enema, and in addition these angiographic features are not typical. Angiodysplasia
    is the second most common cause of gastro-intestinal bleed in the elderly population after
    diverticular disease. It is due to dilatation of the submucosal vessels and occurs most commonly on the right side of the colon. Angiographic features include visualisation of a
    cluster of vessels on the antimesenteric border, early filling of the ileocolic vein in the
    arterial phase and delayed emptying of the same vein.

Question 34

34. A 37 year old female has a pelvic MRI for investigation of rectal pain and bleeding,
    following a normal flexible sigmoidoscopy. This shows a thin-walled dumbbell-shaped
    7 cm multilocular cyst. It is in contact anteriorly to the rectum and posteriorly to the
    presacral fascia, but contained within the mesorectal fascia. Although the rectum is
    distorted by the mass, the rectum and sigmoid are normal. What is the most likely
    diagnosis?
    a. Rectal duplication cyst
    b. Anterior sacral meningocoele
    c. Mucinous rectal carcinoma
    d. Presacral dermoid
    e. Tailgut cyst

Answer 34

34. e. Tailgut cyst
    Tailgut cysts or cystic hamartomas are presacral, multilocular, mucous-secreting cysts
    found distal to the normal embryonic termination of the hindgut. Small cysts may be
    asymptomatic, but larger cysts may present with rectal pain or bleeding, constipation, anal
    fistulae or recurrent rectal abscesses. A long and tail-like coccyx is often associated, and can
    help distinguish between many other cystic lesions in this region. Malignant transformation
    is a complication, most commonly adenocarcinoma. Duplication cysts are most often
    unilocular unless complicated by haemorrhage or infection, a meningocele is likely to arise
    from the sacral foramina, piercing the presacral fascia, and dermoid tumour would be
    expected to contain fat or layering of contents as seen in dermoid tumours in other
    locations.

Question 35

35. A 34 year old female is investigated for intermittent abdominal pain and malabsorption.
    Small bowel meal shows dilatation of the proximal small bowel loops but a
    normal mucosal fold pattern. Which one of the following is the most likely underlying
    diagnosis?
    a. Coeliac disease
    b. Amyloid
    c. Whipple disease
    d. Giardiasis
    e. Eosinophilic gastroenteritis

Answer 35

35. a. Coeliac disease
    All of these may cause malabsorption. Amyloid can cause dilatation but also causes diffuse thickening of the valvulae conniventes throughout the small bowel. With Whipple disease and eosinophilic gastroenteritis, one would not see dilatation of the bowel, but thickening
    of the mucosa is again a prominent feature. Giardiasis causes thickening and marked
    distortion of the mucosal folds in the duodenum and jejunum. One of the hallmark
    features of untreated coeliac disease is jejunal dilatation. Typically the mucosal folds are of
    normal thickness.

Question 36

36. A six week old child has an ultrasound scan of the abdomen performed for non-bilious
    projectile vomiting. Which one of the following features would support a diagnosis of
    infantile pylorospasm over a diagnosis of hypertrophic pyloric stenosis?
    a. Pyloric muscle wall thickness of 2mm
    b. Pyloric canal length of 19mm
    c. Target sign
    d. Antral nipple sign
    e. Transverse pyloric diameter of 14mm

Answer 36

36. a. Pyloric muscle wall thickness of 2mm
    Hypertrophic pyloric stenosis presents between four and six weeks of life with non-bilious
    vomiting, typically in first-born males. A palpable olive-shaped mass is a sign with reported
    sensitivity of up to 80%, but ultrasound is the most frequently used imaging modality.
    Typical ultrasound features include the target sign (central hyperechoic mucosa with
    surrounding hypoechoic pyloric muscle), the nipple sign (pyloric mucosa indenting the
    gastric antrum), pyloric canal length >16 mm, transverse pyloric diameter >13mm and
    pyloric muscle wall thickness >3 mm. Pyloric stenosis can be difficult to differentiate
    radiologically from infantile pylorospasm. Typically with pylorospasm the appearances
    change with time, and so if the pyloric muscle thickness is measured at less than 3mm
    this makes infantile pylorospasm the more likely diagnosis

Question 37

37. A 52 year old male has an unenhanced CT KUB for left renal colic. No cause for the
    pain is discovered on the CT, however the liver is found to be of increased density
    relative to the spleen. Which one of the following would be most likely to explain this
    incidental finding?
    a. Excess alcohol intake
    b. Amiodarone use
    c. Diabetes
    d. Steroids
    e. Past history of chemotherapy

Answer 37

37. b. Amiodarone use
    The normal liver is between 30 and 70HU on unenhanced CT, and should be 10–15HU
    lower than spleen density. On portal venous phase the liver will be approximately 25HU
    less than the spleen. Amiodarone contains iodine and can cause the liver to appear of
    increased density on CT. Other causes include cisplatin use, haemochromatosis, Wilson
    disease and glycogen storage diseases. The more common finding on CT is a liver of decreased density due to a fatty liver. This has many causes including alcohol use, steroids,
    chemotherapy, diabetes and nutritional causes

Question 38

38. A 68 year old female has a pancreatic MR for characterisation of an isolated lesion
    within the pancreas seen initially on CT performed for unexplained weight loss.
    The lesion is 3 cm in diameter, isointense on T1, isointense on T2 STIR and hypointense
    to pancreatic parenchyma during the arterial phase of gadolinium enhancement.
    It remains hypointense on the venous and delayed phases of contrast enhancement.
    Which one of the following is the most likely diagnosis?
    a. Ductal adenocarcinoma
    b. Insulinoma
    c. Simple pancreatic cyst
    d. Gastrinoma
    e. Glucagonoma

Answer 38

38. a. Ductal adenocarcinoma
    Insulinoma tends to be hyperintense on contrast-enhanced images. Gastrinoma is usually
    hyperintense on STIR imaging and on contrast-enhanced sequences. In a series of
    25 patients, an article by Chandarana et al. showed that pancreatic adenocarcinomas were
    either iso- or hypointense on T1-weighted imaging and iso- or hyperintense on T2 or STIR.
    All adenocarcinomas were hypointense to pancreatic parenchyma during the arterial phase
    of gadolinium enhancement on MR, 80% remained hypointense in the venous phase of
    enhancement and 68% remained hypointense in the delayed phase.
    (Ref: Chandarana H et al. Signal characteristic and enhancement patterns of pancreatic
    adenocarcinoma

Question 39

39. A 45 year old female has a CT for abdominal pain and weight loss. Findings include a
    soft-tissue mass at the root of the small bowel mesentery with eccentric calcifications
    and tethering of adjacent small bowel loops resulting in a moderate degree of small
    bowel obstruction. There is a desmoplastic reaction within the surrounding mesentery.
    Which one of the following is the most likely diagnosis?
    a. Lymphoma
    b. Carcinoid tumour
    c. Melanoma metastases
    d. Tuberculosis
    e. Paraganglioma

Answer 39

39. b. Carcinoid tumour
    These features are typical of carcinoid tumour. The desmoplastic reaction appears on CT as
    thickened mesentery in a radiating pattern away from the soft-tissue mass, with beading of
    the mesenteric vascular bundles.

Question 40

40. A 50 year old female presents to A&E with acute abdominal pain. On examination
    there is point tenderness over an area in the right iliac fossa. CT reveals a well-defined
    triangular area of high-attenuation fat density anteriorly in the lower right abdomen.
    The large and small bowel are normal. Which one of the following is most likely?
    a. Segmental omental infarction
    b. Rectus haematoma
    c. Epiploic appendagitis
    d. Carcinoid tumour
    e. Mesenteric vein thrombosis

Answer 40

40. a. Segmental omental infarction
    Segmental omental infarction is the most likely cause and most commonly affects the right
    half of the greater omentum. It mimics surgical pathology such as appendicitis. Highattenuation
    streaks in the omental fat with apparent ‘mass effect’ in the absence of any
    other findings is suggestive of the diagnosis. Point tenderness over the specific area of CT
    abnormality is often discovered. Management is conservative.

Question 41

41. A 32 year old woman with no significant past medical history has a CT scan as an
    outpatient for right iliac fossa pain. No cause for the pain is discovered on this
    investigation. However, a 1 cm diameter, smoothly marginated, circular, homogenous
    area of tissue is seen next to the splenic hilum. This area of tissue is isodense compared
    to normal splenic parenchyma. What is this most likely to be?
    a. Splenosis
    b. Splenunculus
    c. Lymphoma
    d. Splenic hamartoma
    e. Wandering spleen

Answer 41

41. b. Splenunculus
    Splenunculus is most likely, and is often seen incidentally. It is much more common than
    splenosis and is more likely to occur at the splenic hilum than splenosis. A splenunculus, or
    accessory spleen, is present in up to 30% of people and is most often located near the splenic
    hilum, but can occur anywhere in the abdomen. Splenogonadal fusion is a recognised entity
    whereby the accessory splenic tissue is attached to the left ovary or testis. Splenosis occurs
    following trauma, whereby splenic tissue autotransplants elsewhere in the abdomen, and
    can also implant above the diaphragm if associated with diaphragm rupture. A wandering
    spleen denotes abnormal mobility of the spleen on long peritoneal ligaments

Question 42

42. A 58 year old male with unexplained elevated alkaline phosphatase has an MRCP and
    the ‘double-duct’ sign is observed. Which one of the following diagnoses is most
    likely to cause this finding?
    a. Acute pancreatitis
    b. Annular pancreas
    c. Pancreas divisum
    d. Periampullary tumour
    e. Duodenal perforation

Answer 42

42. d. Periampullary tumour
    The ‘double-duct’ sign is dilatation of the main pancreatic duct and the common bile duct as
    seen at ERCP and MRCP, and less commonly with CT and ultrasound. It occurs due to an
    obstructing lesion at the ampulla, most commonly a carcinoma of the head of the pancreas (in up to 77% of cases) or a carcinoma of the ampulla of Vater (in up to 52% of cases).
    The sign may be absent if there is an accessory pancreatic duct or when the main
    pancreatic duct drains into the minor papilla.

Question 43

43. A 42 year old woman undergoes a CT abdomen and pelvis for the investigation of right
    upper quadrant pain and deranged liver function tests. On early post-intravenous
    contrast images there is prominent enhancement of the central liver and weak
    enhancement of the peripheral liver. This pattern is reversed on delayed images.
    In addition there is hypertrophy of the caudate lobe. Which one of the following
    would most likely explain these findings?
    a. Acute hepatitis
    b. Cirrhosis
    c. Budd–Chiari syndrome
    d. Portal hypertension
    e. Fatty liver

Answer 43

43. c. Budd–Chiari syndrome
    Budd–Chiari syndrome is outflow obstruction of the hepatic veins due to a wide variety of
    causes, but two-thirds are idiopathic. CT features include ‘flip-flop’ enhancement pattern as
    described in the question, ascites, hepatosplenomegaly, gallbladder wall thickening and
    increased portal vein diameter. An enlarged caudate lobe is seen in up to 88%, which
    enhances normally due its venous drainage passing directly into the IVC.

Question 44

44. A 61 year old man undergoes CT abdomen and pelvis for characterisation of a
    well-defined hyperechoic area seen on ultrasound in the perihilar region of the liver.
    On CT the area is of decreased attenuation but has no obvious mass effect. There is no
    abnormal enhancement with intravenous contrast administration. Which one of the
    following diagnoses is most likely?
    a. Focal nodular hyperplasia
    b. Focal fatty infiltration
    c. Hepatic cyst
    d. Liver haemangioma
    e. Fibrolamellar carcinoma

Answer 44

44. b. Focal fatty infiltration
    Focal fatty infiltration occurs typically in the periportal and centrilobar regions of the liver
    and is commonest adjacent to the falciform ligament. Ultrasound features include a
    hyperechoic area with geographic margins. CT shows an area of decreased attenuation
    which does not alter the course of blood vessels or liver contour. The lesions are of high
    signal on T1-weighted MR imaging, and isointense or low signal on T2-weighted imaging.
    Haemangiomas would also typically be of increased echogenicity on ultrasound, but would
    be expected to show increased peripheral enhancement with intravenous contrast on CT.

Question 45

45. A 39 year old woman has an ultrasound scan for right upper quadrant pain and
    jaundice which reveals biliary ductal dilatation to the level of the common hepatic duct
    adjacent to a stone in the gallbladder neck. The gallbladder is thick-walled and tender.
    MRCP confirms these findings and excludes common duct stones. Which one of the
    following is the most likely diagnosis?
    a. Primary sclerosing cholangitis
    b. Mirizzi syndrome
    c. Caroli’s disease
    d. Fascioliasis
    e. Acute cholecystitis

Answer 45

45. b. Mirizzi syndrome
    Mirizzi syndrome is narrowing of the common hepatic duct caused by a gallstone impacted
    in the neck of the gallbladder or the cystic duct. The stricture is smooth and often concave
    to the right as seen on ERCP. Fistulae can develop between the gallbladder and the common
    duct, and the stone may pass into the common duct. It is associated with acute cholecystitis.
    Fascioliasis is caused by liver fluke infestation which may cause bile duct wall thickening
    and multiple hepatic abscesses. Caroli’s disease is a congenital disorder characterised by
    cystic dilatation of the intrahepatic bile ducts.

Question 46

46. A 48 year old male presents with abdominal pain, nausea and weight loss.
    Contrast-enhanced CT of the abdomen and pelvis reveals a heterogeneous, welldefined
    fatty mass at the root of the small bowel mesentery. The mesenteric vessels
    are surrounded but not distorted by the mass, and the vessels are surrounded by an
    apparent low-attenuation halo. The small bowel and right colon are normal. Which
    is the most likely diagnosis?
    a. Tuberculosis
    b. Mesenteric lymphadenitis
    c. Mesenteric panniculitis
    d. Radiation enteritis
    e. Mesenteric lipoma

Answer 46

46. c. Mesenteric panniculitis
    These CT findings are typical of mesenteric panniculitis. This is an idiopathic, indolent
    condition characterised by inflammation of the small bowel mesentery adipose tissue.
    Fibrosis can predominate, in which case the CT appearances are of an infiltrative soft-tissue
    mass with soft-tissue density strands radiating away from it. In this situation it has similar
    appearance to lymphoma, carcinoid or desmoid tumours or retroperitoneal fibrosis, and
    biopsy is required to differentiate. Mesenteric panniculitis often presents with non-specific
    symptoms such as abdominal pain, weight loss, nausea, vomiting and pyrexia, and is usually
    indolent and self-limiting.

Question 47

47. A 76 year old male on ITU has a CT abdomen and pelvis for the investigation of
    abdominal pain, pyrexia and diarrhoea. The CT reveals 12mm diffuse large bowel wall
    thickening with intense mucosal enhancement and low attenuation of the submucosa
    involving the entire colon including the rectum, and a small volume of ascites. Which
    one of the following diagnoses is the most likely to explain the above findings?
    a. Crohn’s colitis
    b. Pseudomembranous colitis
    c. Ischaemic colitis
    d. Yersinia
    e. Giardiasis

Answer 47

47. b. Pseudomembranous colitis
    Pseudomembranous colitis results from overgrowth of Clostridium difficile most commonly
    due to broad spectrumantibiotic use in the hospital population.Ascites is often present in severe cases and wall thickening >10mm is highly suggestive of this diagnosis. A layered pattern
    of enhancement is often present in severe cases with oedema in the submucosa producing
    low attenuation in the wall, deep to the enhancing mucosa. The accordion sign is caused by
    marked submucosal oedema producing thickening of the colonic haustra. The rectum is
    involved in the majority of cases but any location within the large bowel may be involved.

Question 48

48. A 41 year old female has an MRI liver following a solitary 3 cm lesion in the right lobe
    of the liver. The lesion is isointense on T1-weighted and slightly hyperintense to liver
    parenchyma on T2-weighted imaging. There is immediate intense homogenous
    enhancement with gadolinium in the arterial phase, which becomes isointense on the
    venous phase. A central scar is hypointense on T1 and hyperintense on T2-weighted
    sequences. Which one of the following is the most likely diagnosis?
    a. Adenoma
    b. Cavernous haemangioma
    c. Fibrolamellar carcinoma
    d. Regenerative nodules
    e. Focal nodular hyperplasia

Answer 48

48. e. Focal nodular hyperplasia
    These imaging features are typical of focal nodular hyperplasia. This is the second most
    common benign liver tumour and typically occurs in women more often than in men.
    Adenomas are usually larger, enhance less brightly and do not typically have a central fibrous
    scar. Cavernous haemangiomas are usually high signal on T2-weighted images, and of blood
    pool intensity on contrast-enhanced T1-weighted images. Fibrolamellar carcinoma also has a
    central scar, but this is typically of low signal intensity on T2-weighted imaging. Regenerative
    nodules show high signal intensity on unenhanced T1-weighted imaging and do not have a scar.
    (Ref: Marin D et al. Focal nodular hyperplasia: typical and atypical MRI findings with
    emphasis on the use of contrast media.

Question 49

49. A 71 year old woman with no significant past medical history has an abdominal
    ultrasound as part of an investigation for right upper quadrant pain, anaemia and
    weight loss. Multiple, poorly defined, markedly echogenic lesions are seen throughout
    the liver. Biopsy reveals these to be metastases. Which one of the following is most
    likely to be the primary tumour?
    a. Adenocarcinoma of the colon
    b. Melanoma
    c. Invasive ductal carcinoma of the breast
    d. Gastric cancer
    e. Pancreatic ductal adenocarcinoma

Answer 49

49. a. Adenocarcinoma of the colon
    The most common primary tumours that cause brightly echogenic liver metastases are
    colonic adenocarcinoma, treated breast cancer and hepatoma. The differential here therefore
    lies between breast cancer and colon cancer. Colon cancer makes up at least 50% of
    highly echogenic metastases. In addition the question states that the patient has no
    significant past medical history, and therefore treated breast cancer is unlikely.

Question 50

50. A 51 year old male patient has a barium swallow for the investigation of dysphagia.
    This shows a 10 cm tapered stricture in the mid oesophagus along with multiple fine
    linear projections perpendicular to the lumen, each 3–4mm long, in this segment.
    There are occasional tertiary contractions and mild gastro-oesophageal reflux. What
    is the most likely diagnosis?
    a. Chagas disease
    b. Oesophageal intramural pseudodiverticulosis
    c. Oesophageal varices
    d. Cytomegalovirus infection
    e. Oesophageal carcinoma

Answer 50

50. b. Oesophageal intramural pseudodiverticulosis
    Oesophageal intramural diverticulosis relates to dilated excretory ducts of the deep mucous
    glands of the oesophagus. They are best demonstrated on barium swallow and have the
    classical appearance as described in the question. The pseudodiverticular can appear to float
    outside the oesophagus when no communication with the lumen is seen. Most patients have
    dysphagia at presentation and associated conditions include diabetes, candida infection,
    oesophagitis, stricture and alcohol abuse

Question 51

51. A 25 year old female becomes unwell six hours after induced delivery for pre-eclampsia
    with severe right upper quadrant pain, oedema and nausea. CT of the abdomen and pelvis
    reveals copious ascites and multiple wedge-shaped areas of liver non-enhancement consistent with hepatic infarction. Which of the following is the most likely
    underlying cause?
    a. Hepatic artery embolus
    b. Portal vein thrombosis
    c. SVC occlusion
    d. HELLP syndrome
    e. Splenic vein thrombosis

Answer 51

51. d. HELLP syndrome
    Hepatic infarction is rare because of the dual blood supply to the liver via the hepatic
    arterial system and the portal venous system. Isolated pathology in either of these vascular
    supplies is unlikely to cause hepatic necrosis as the other supply will usually compensate.
    HELLP is characterised by haemolysis, elevated liver enzymes and low platelets and is one of
    the causes of liver infarction

Question 52

52. A 47 year old female with a history of surgery for breast carcinoma is referred for
    ultrasound after liver function tests show a mildly elevated alkaline phosphatase.
    The bile ducts are normal but a 3 cm hyperechoic liver lesion is seen in the right lobe.
    CT is recommended, which shows a focal mass with nodular hyperenhancement of the
    periphery on arterial phase imaging becoming isointense to the background liver on
    delayed phase scanning at five minutes. Which one of the following is the most likely
    diagnosis?
    a. Fibrolamellar carcinoma
    b. Adenoma
    c. Cavernous haemangioma
    d. Adenocarcinoma metastases
    e. Focal nodular hyperplasia

Answer 52

52. c. Cavernous haemangioma
    Metastases may show peripheral enhancement with complete fill-in on delayed images, but
    they typically show complete rather than nodular peripheral enhancement and washout
    on delayed phase imaging. Only haemangiomas typically show peripheral nodular enhancement. Cavernous haemangiomas are the most common benign liver tumours and
    are usually less than 4 cm in size. Seventy per cent are hyperechoic on ultrasound and they
    may show acoustic enhancement.

Question 53

53. A 33 year old female presents to A&E with right upper quadrant pain, hypotensive and
    tachycardic. CT abdomen and pelvis reveals an 11 cm diameter well-defined heterogenous
    mass within the right lobe of the liver, predominantly of low density but with
    three focal areas of higher attenuation (>90 HU) within it. There is layered highattenuation
    fluid within the subhepatic and right subdiaphragmatic space tracking
    down to the pelvis. Which one of the following is the correct combination of
    recommendations?
    a. Adenoma – recommend surgical referral
    b. Adenoma – recommend correct coagulopathy and rescan if it deteriorates
    c. Adenoma – recommend endovascular embolisation
    d. Metastatic hepatocellular carcinoma – recommend gastroenterology referral
    e. Trauma – needs CT thorax to clear other injuries

Answer 53

53. c. Adenoma – recommend endovascular embolisation
    Adenomas are vascular lesions comprising hepatocytes. They may occasionally present with
    massive haemorrhage, and are the most common liver lesion to do so in young people. In
    this scenario there is active extravasation of contrast implying active bleeding and haemoperitoneum.
    Urgent embolisation is the most appropriate treatment to halt bleeding.
    Conservative or surgical management is unlikely to provide rapid haemostasis. As a
    proportion of adenomas become malignant, they are usually removed surgically

Question 54

54. A 54 year old male has a liver MR for characterisation of a 3 cm low-attenuation lesion
    found on staging CT for rectal carcinoma. Which one of the following characteristics
    would be most worrying for a metastasis rather than a benign lesion?
    a. Peripheral washout on delayed imaging
    b. Intense arterial enhancement
    c. Peripheral nodular enhancement
    d. Presence of a pseudocapsule
    e. Low signal intensity on T1-weighted imaging

Answer 54

54. a. Peripheral washout on delayed imaging
    Peripheral washout of contrast on delayed imaging is virtually diagnostic of malignancy. On
    post-gadolinium-enhanced T1-weighted images most metastases are hypovascular compared
    with the surrounding liver and are most conspicuous at the portal phase of enhancement.
    However, virtually all metastases exhibit a complete ring of peripheral enhancement,
    which is best seen in the early arterial phase.
    (Ref: Mahfouz AE et al. Peripheral washout: a sign of malignancy on dynamic gadoliniumenhanced
    MR images of focal liver lesions

Question 55

55. A 63 year old male has a CT abdomen and pelvis for the investigation of change in
    bowel habit and weight loss. A sigmoid tumour is demonstrated and there is a solitary
    liver metastasis. Which one of the following observations on CT would render the
    patient ineligible for curative resection of the liver metastasis?
    a. Presence of a single peripheral left lower lobe pulmonary metastasis
    b. Presence of splenic metastasis
    c. Direct extension of the liver metastasis into the right adrenal gland
    d. Involvement of the caudate lobe
    e. Peritoneal metastases

Answer 55

55. e. Peritoneal metastases
    Generally accepted contraindications to liver resection would include uncontrollable extrahepatic
    disease such as: non-treatable primary tumour; widespread pulmonary disease;
    locoregional recurrence; peritoneal disease; extensive nodal disease, such as retroperitoneal,
    mediastinal or portal nodes; and bone or CNS metastases. Patients with extrahepatic disease
    that should be considered for liver resection include: resectable/ablatable pulmonary metastases;
    resectable/ablatable isolated extrahepatic sites – for example, spleen, adrenal or
    resectable local recurrence; and local direct extension of liver metastases to, for example,
    the diaphragm or adrenal glands, which can be resected.

Question 56

56. An ultrasound of the abdomen is performed on a 21 year old female presenting to A&E
    with acute right iliac fossa pain, pyrexia, tenderness and guarding. Which one of the
    following findings would suggest perforation of the appendix?
    a. Appendix diameter of 8mm
    b. Appendix wall thickness of 4mm
    c. Decreased resistance of arterial waveform
    d. Loss of visualisation of hyperechoic submucosa
    e. Increased echogenicity of surrounding fat

Answer 56

56. d. Loss of visualisation of hyperechoic submucosa
    The use of ultrasound for the diagnosis of acute appendicitis is particularly useful in
    children and women of child-bearing age. Findings indicating acute appendicitis include
    a tubular non-compressible blind-ending structure with diameter >6 mm and wall
    thickness >2 mm, although these signs do not necessarily indicate perforation. Features
    suggesting perforation include a fluid collection adjacent to the appendix, gas bubbles near
    the appendix and loss of visualisation of the submucosal layer.

Question 57

57. A 52 year old male with a metal heart valve has a transrectal ultrasound performed to
    stage rectal carcinoma as MRI is contraindicated. A 3 cm hypoechoic mass is identified
    from three to seven o’clock in the lower rectum. It extends through an inner hypoechoic
    layer and into the outer hypoechoic layer, but the outermost hyperechoic layer
    is intact and unaffected. What is the correct T staging (TNM system) based on these
    observations?
    a. T0
    b. T1
    c. T2
    d. T3
    e. T4

Answer 57

57. c. T2
    The layers of the rectum are well demonstrated at transrectal ultrasound. The innermost
    hyperechoic layer represents the balloon-mucosa interface, the middle hyperechoic layer represents the submucosa and the outermost hyperechoic layer represents the serosa. The tumour described in the question extends through the submucosa into the muscularis
    propria (outer hypoechoic layer) but does not involve the serosa. T1 disease is limited to
    the submucosa, T2 is limited to the muscularis propria, T3 extends through the serosa and
    T4 represents invasion of adjacent organs. The correct staging for the tumour described in
    the question is therefore T2.

Question 58

58. A 73 year old female has a CT abdomen and pelvis for the investigation of anaemia and
    weight loss. Massive splenomegaly (30 cm) is present with no other abnormalities.
    Which of the following conditions is most likely to be the underlying cause?
    a. Sarcoidosis
    b. Felty’s syndrome
    c. Chronic myeloid leukaemia
    d. Haemochromatosis
    e. Non-Hodgkin’s lymphoma

Answer 58

58. c. Chronic myeloid leukaemia
    Splenomegaly is a relatively common finding in many different diseases, but massive
    splenomegaly always indicates underlying pathology. Although there is no unifying definition,
    it is often recognised to be enlargement of the spleen into the left lower quadrant of
    the abdomen or crossing the midline. All the options listed are causes of splenomegaly,
    however chronic myeloid leukaemia is the only listed cause of massive splenomegaly. Other
    causes of massive splenomegaly include Gaucher’s disease, malaria, myelofibrosis, schistosomiasis
    and Leishmaniasis.

Question 59

59. A 57 year old diet-compliant male patient with coeliac disease has a CT abdomen
    and pelvis for the investigation of cachexia and two stone weight loss over six months.
    A 7 cm segment of ileum shows mild dilatation and circumferential thickening, with
    multiple low-attenuation mesenteric and para-aortic lymph nodes. Which one of the
    following is the most likely diagnosis?
    a. Tuberculosis
    b. Gastro-intestinal lymphoma
    c. Coeliac disease
    d. Whipple disease
    e. Crohn’s disease

Answer 59

59. b. Gastro-intestinal lymphoma
    Hypoattenuating lymph nodes can be attributed to many causes, but lymphoma and
    tuberculosis are the most common. Lymphoma of the gastro-intestinal tract most commonly
    affects the ileum, although lymphoma associated with coeliac disease most commonly
    affects the jejunum. Although 90% of tuberculosis of the gastro-intestinal tract
    occurs in the ileum, lymphoma is most likely in this scenario. Dilatation of the small bowel
    with lymphoma is common but obstruction is rare due to the soft pliable nature of the
    tumour.

Question 60

60. A 60 year old male has an abdominal ultrasound for the investigation of deranged LFTs. A 2 cm hyperechoic mass is seen at the porta hepatis. There is dilatation of the
    right and left hepatic ducts but the common bile duct is of normal calibre. A PET-CT is performed which shows an FDG-avid lesion corresponding to the abnormality on
    ultrasound and no other findings. Which of the following is the most likely diagnosis?
    a. Caroli’s disease
    b. Klatskin tumour
    c. Periampullary tumour
    d. Primary sclerosing cholangitis
    e. Biliary cystadenoma

Answer 60

60. b. Klatskin tumour
    Klatskin tumours are the most common form of cholangiocarcinoma, representing tumour
    at the confluence of the hepatic ducts. The finding of a hyperechoic central porta hepatis
    mass at ultrasound is typical. Risk factors include inflammatory bowel disease, primary
    sclerosing cholangitis, Caroli’s disease and cholecystolithiasis. Cholangiocarcinomas have
    a very poor prognosis with a five-year survival of less than 2%. They are FDG-avid and
    PET-CT is typically performed in the pre-operative evaluation of these tumours.