Images

Question 1

Label the signs shown in A & B [2]
What pathology does these signs indicate? [1]

Answer 1

A: Cullens sign
B: Grey-Turners sign

Cullen’s and Grey-Turner’s signs are associated with severe necrotising pancreatitis

Question 2

What does this yellow arrow depict in non-proliferative diabetic retinopathy? [1]

Answer 2

Hard exudates

Question 3

What does the yellow arrow on the image of non-proliferative retinopathy depict? [1]

Answer 3

Lipid exudates

Question 4

Describe what the arrows & circle depict on this image of non proliferative diabetic retinopathy [3]

Answer 4

intraretinal microvascular abnormality (IRMA; green arrow)

venous beading and segmentation (blue arrow)

cluster haemorrhage (red circle)

featureless retina suggestive of capillary non-perfusion (white ellipse)

Question 5

What is the arrow pointing to on this NPDR? [1]

Answer 5

Cotton wool spots (severe NPDR

Question 6

Which pathology is depicted? [1]

Answer 6

Diabetic maculopathy: hard exudates near to the macula

Question 7

What is depicted in this image? [1]

Answer 7

Proliferative diabetic retinopathy:
extensive vitreous haemorrhage obscuring most of fundus (white circle)}

Question 8

What is the arrow pointing to? [1]

Answer 8

Cotton wool spot

Question 9

What is depicted in this image? [1]

Answer 9

Non-proliferative diabetic retinopathy: blot haemorrhage (white circle)}

Question 10

Describe what is happening in this image [1]

Answer 10

Proliferative diabetic retinopathy: NVD new vessels on the optic disc

Question 11

What does the green arrows point to? [1]

Answer 11

Kimmelstein-Wilson lesion

Question 12

What is this skin condition associated with diabetes? [1]

Answer 12

Necrobiosis Lipoidica Diabeticorum

Question 13

What is the name of this skin complication of diabetes? [1]

Answer 13

Granuloma annulare

Question 14

What is the name for this diabetic skin complication? [1]

Answer 14

Bullosis Diabeticorum

Question 15

Name this complication of diabetes

Answer 15

Charcot neuroarthropathy

Question 16

Name this sign [1] and disease [1] that is a complication of diabetes

Answer 16

Prayer sign; diabetic cheiroarthropathy

Question 17

What is the name of this treatment for diabetic retinopathy? [1]

Answer 17

Pan-retinal photocoagulation (PRP)

Question 18

Patient with severe abdominal pain. What does the image show?

Ascites
Lead pipe colon
Normal gas pattern
Rigler’s/ double wall sign
Thumbprinting

Answer 18

Patient with severe abdominal pain. What does the image show?

Rigler’s/ double wall sign

Free gas (pneumoperitoneum) can be seen on both sides of the bowel wall. This is Rigler’s sign or the double wall sign.

Whenever sharp points or triangles of low density are seen adjacent to loops of bowel, pneumoperitoneum should be suspected.

Note: In patients with an acute abdomen an erect chest X-ray is more sensitive for small volumes of free gas.

Question 19

Patient with severe abdominal pain. What does the image show?

What is the likely pathology?

Ascites
Lead pipe colon
Normal gas pattern
Rigler’s/ double wall sign
Thumbprinting

Answer 19

Patient with severe abdominal pain. What does the image show?

Ascites
Lead pipe colon
Normal gas pattern
Rigler’s/ double wall sign
Thumbprinting

Inflammation of the bowel wall leads to thickening of the haustral folds. This results in the radiological sign of thumbprinting, a characteristic finding in patients with active ulcerative colitis.

Question 20

What is the cause of the abnormal calcification?

Adrenal calcification
Appendicolith
Gallstones
Pancreatic calcification
Staghorn renal calculus

Answer 20

What is the cause of the abnormal calcification?

Staghorn renal calculus

Question 21

24-year-old patient with suspected appendicitis. What does the image show?

Caecal volvulus
Normal appearances
Pneumoperitoneum
Small bowel obstruction
Toxic megacolon

Answer 21

24-year-old patient with suspected appendicitis. What does the image show?

Small bowel obstruction

Dilated loops of bowel with valvulae conniventes – lines crossing the full width of the bowel – indicates small bowel obstruction.

Question 22

Patient with severe abdominal pain. What is the cause of pain demonstrated on this abdominal X-ray?

Caecal volvulus
Normal appearances
Pneumoperitoneum
Small bowel obstruction
Toxic megacolon

Answer 22

Patient with severe abdominal pain. What is the cause of pain demonstrated on this abdominal X-ray?

Caecal volvulus
Normal appearances
Pneumoperitoneum
Small bowel obstruction
Toxic megacolon

Question 23

What is the artifact shown in this image?

Biliary stent
Colonic stent
External tubing
Percutaneous nephrostomy tube
Ureteric stent

Answer 23

What is the artifact shown in this image?

Biliary stent
Colonic stent
External tubing
Percutaneous nephrostomy tube
Ureteric stent

Question 24

Patient with abdominal pain and vomiting. What is the radiological diagnosis?

Caecal volvulus
Large bowel obstruction
Small bowel obstruction
Bowel perforation
Normal

Answer 24

Patient with abdominal pain and vomiting. What is the radiological diagnosis?

Caecal volvulus
Large bowel obstruction
Small bowel obstruction
Bowel perforation
Normal

Question 25

What is the radiological diagnosis? Sigmoid volvulus Normal Ascites Small bowel obstruction Pneumoperitoneum

Answer 25

What is the radiological diagnosis? Sigmoid volvulus Normal **Ascites** Small bowel obstruction Pneumoperitoneum

Question 26

What is the cause of the abnormal calcification in this image? Calcified gallstones Calcified mesenteric lymph nodes Pancreatic calcification Malignant calcification Calcified uterine fibroid

Answer 26

What is the cause of the abnormal calcification in this image? Calcified gallstones Calcified mesenteric lymph nodes **Pancreatic calcification** Malignant calcification Calcified uterine fibroid

Question 27

Patient with abdominal pain, vomiting, and constipation. What is the radiological diagnosis? Caecal volvulus Sigmoid volvulus Small bowel obstruction Perforation Normal

Answer 27

Patient with abdominal pain, vomiting, and constipation. What is the radiological diagnosis? **Caecal volvulus** Sigmoid volvulus Small bowel obstruction Perforation Normal

Question 28

What is the cause of the area of increased density in the pelvis? Calcified pelvic kidney Calcified abdominal lymph node Calcified uterine fibroid Ingested barium Calcified adrenal gland

Answer 28

What is the cause of the area of increased density in the pelvis? Calcified pelvic kidney Calcified abdominal lymph node **Calcified uterine fibroid** Ingested barium Calcified adrenal gland

Question 29

History of abdominal surgery 7 years ago. Presented with a 24 hour history of severe abdominal pain and vomiting. What is the radiological diagnosis? Small bowel obstruction Post-operative ileus Normal Perforation Sigmoid volvulus

Answer 29

History of abdominal surgery 7 years ago. Presented with a 24 hour history of severe abdominal pain and vomiting. What is the radiological diagnosis? **Small bowel obstruction** Post-operative ileus Normal Perforation Sigmoid volvulus

Question 30

If you saw these X-ray appearances in the setting of acute abdominal pain, what would be the most appropriate course of action? Place an abdominal drain Request abdominal ultrasound Request abdominal MRI Resuscitate the patient and inform the surgeons Take a break

Answer 30

If you saw these X-ray appearances in the setting of acute abdominal pain, what would be the most appropriate course of action? Place an abdominal drain Request abdominal ultrasound Request abdominal MRI **Resuscitate the patient and inform the surgeons** Take a break ## Footnote A large volume of free gas is present under the diaphragm. In the context of acute abdominal pain this finding indicates perforation. Emergency resuscitation and informing the surgeons would be the most appropriate action.

Question 31

Patient with abdominal pain and vomiting. Which answer best describes the X-ray appearances? Pneumoperitoneum Ascites Psoas abscess Small bowel obstruction Normal

Answer 31

Patient with abdominal pain and vomiting. Which answer best describes the X-ray appearances? Pneumoperitoneum Ascites Psoas abscess Small bowel obstruction **Normal**

Question 32

Patient with abdominal pain and absolute constipation. Which answer best describes the X-ray appearances? Large bowel obstruction Sigmoid volvulus Caecal volvulus Perforation Small bowel obstruction

Answer 32

Patient with abdominal pain and absolute constipation. Which answer best describes the X-ray appearances? Large bowel obstruction **Sigmoid volvulus** Caecal volvulus Perforation Small bowel obstruction

Question 33

Describe what Rigler's double wall sign appears like [1] What does this indicate?

Answer 33

Normally **only the inner wall** of the bowel is visible If there is **pneumoperitoneum** **both** **sides** of the **bowel** **wall** may be visible

Question 34

What may a liver edge silhouette indicate on an AXR? [1]

Answer 34

When **perforation** of a **duodenal** **ulcer** **occurs**, and results in a **pneumoperitoneum**: **Gas** collects in **Morison's pouch** (the hepato-renal space), and **rise on the supine film to the anterior abdominal wall outlining the edge of the liver** diagnostic of duodenal perforation.

Question 35

What pathology is indicated in this AXR? [1]

Answer 35

**False Rigler's/double wall sign** * Be careful not to mistake the gas within two adjacent bowel segments for Rigler's sign. * Gas seen on both sides of the bowel wall is contained within adjacent bowel * There are no black triangles or sharp angles on the outside of the bowel wall

Question 36

Describe what is seen in this AXR [3]

Answer 36

**Small bowel obstruction - features** **Centrally located** multiple dilated loops of gas filled bowel (arrowheads) **Valvulae conniventes** (arrow) are visible - confirming this is small bowel

Question 37

Describe what is depicted in this AXR [1]

Answer 37

**Large bowel obstruction** * Here the colon is dilated down to the level of the distal descending colon. There is the impression of soft tissue density at the level of obstruction (X). No gas is seen within the sigmoid colon. * Obstruction is not absolute in this patient as a small volume of gas has reached the rectum (arrow). * An obstructing colon carcinoma was confirmed on CT and at surgery.

Question 38

Which of the following is a caecal and sigmoid volvulus? [2]

Answer 38

Question 39

What sign does this AXR show? [1] What pathology does this indicate? [1]

Answer 39

**Mucosal thickening - 'thumbprinting'** This patient presented with an exacerbation of symptoms of **ulcerative colitis.**

Question 40

What sign does this AXR show? [1] What pathology does this indicate? [1]

Answer 40

**Lead pipe colon** This patient with **ulcerative** **colitis** has a featureless segment of transverse colon with loss of the normal haustral markings. This 'lead pipe' appearance is associated with longstanding ulcerative colitis.

Question 41

What sign does this AXR show? [1] What pathology does this indicate? [1]

Answer 41

**Toxic megacolon** The colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of **ulcerative colitis.** The clinical features and X-ray appearances are consistent with toxic megacolon.

Question 42

Where is the ureteric stone in this AXR? [1]

Answer 42

Question 43

What is depicted here? [1] State a cause of this [1]

Answer 43

**Bladder stones** form in the bladder as a result of **urinary stasis**, e.g. **bladder outflow obstruction** (enlarged prostate) or in **patients with a neurogenic bladder** (loss of bladder function due to spinal cord injury/disease)

Question 44

What is depicted in this AXR? [1] What does this indicate? [1]

Answer 44

**Vascular calcification** There is striking calcification of the aorta and iliac vessels **This is a sign of generalised atherosclerosis elsewhere in the body**

Question 45

What is depicted in this AXR? [1] What does this indicate? [1]

Answer 45

**Abdominal aortic aneurysm - AAA** There is calcification of the dilated aortic wall Frequently only one side of the aneurysm is visible - as in this image - the other being projected over the spine

Question 46

What is the cause of the abnormal calcification? Adrenal calcification Appendicolith Gallstones Pancreatic calcification Staghorn renal calculus

Answer 46

What is the cause of the abnormal calcification? **Adrenal calcification** Appendicolith Gallstones Pancreatic calcification Staghorn renal calculus

Question 47

What is the cause of the abnormal calcification? Adrenal calcification Appendicolith Gallstones Pancreatic calcification Staghorn renal calculus

Answer 47

What is the cause of the abnormal calcification? Adrenal calcification Appendicolith Gallstones **Pancreatic calcification** Staghorn renal calculus

Question 48

What is depicted in this AXR? [1] What does this indicate? [1]

Answer 48

**Appendicolith** Appendicoliths are highly predictive of appendicitis in patients presenting with right iliac fossa pain ## Footnote Appendicoliths are calcific masses in the appendix, formed as a result of the aggregation of faecal particulates and inorganic salts within the lumen of the appendix

Question 49

**What is the artifact shown in this image?** **What pathology does it reduce the risk of?** Naso-jejunal tube Colonic stent Pig-tail (JJ) stent Percutaneous nephrostomy tube Inferior vena cava (IVC) filter

Answer 49

**Inferior vena cava (IVC) filter** An IVC filter may be used to reduce the risk of large pulmonary emboli

Question 50

**What is the artifact shown in this image?** **What pathology does it reduce the risk of?** Naso-jejunal tube Colonic stent Pig-tail (JJ) stent Percutaneous nephrostomy tube Inferior vena cava (IVC) filter

Answer 50

**Colonic stent** Large bowel obstruction can be treated with placement of a metallic colonic stent This is often used as a temporary measure allowing a patient to recover from the effects of obstruction prior to definitive colonic resection

Question 51

**What is the artifact shown in this image?** Naso-jejunal tube Colonic stent Pig-tail (JJ) stent Percutaneous nephrostomy tube Inferior vena cava (IVC) filter

Answer 51

**Pig-tail (JJ) stent** A ureteric stent has been placed to relieve ureteric obstruction The catheter has loops (pig-tails) at both ends which hold it in place

Question 52

**What is the artifact shown in this image?** Naso-jejunal tube Colonic stent Pig-tail (JJ) stent Percutaneous nephrostomy tube Inferior vena cava (IVC) filter

Answer 52

**Naso-jejunal tube** Placed for the purpose of enteral feeding The tube passes through the stomach and forms a C-shape as it navigates the 4 parts of the duodenum (D1-4) The tube tip lies beyond the duodenojejunal flexure which lies on the left

Question 53

What is depicted in this AXR? [1] What does this indicate? [1]

Answer 53

**Ascites** There is generalised hazy density of the entire abdomen In the presence of ascites gas within bowel is located centrally

Question 54

A 73-year-old male presents with a 2-hour history of sudden-onset abdominal pain, accompanied by a bowel motion and vomiting. He has a history of non-specific heart problems and takes antihypertensive medication. He also had a previous appendicectomy performed 45 years ago. Examination of the abdomen reveals a distended and generally tender abdomen with no guarding. There is a scar present in the right iliac fossa and bowel sounds are absent. Rectal examination is unremarkable. An ECG performed is shown below: What is the most likely diagnosis? Small bowel obstruction Large bowel obstruction Caecal volvulus Mesenteric ischaemia Ileus

Answer 54

A 73-year-old male presents with a 2-hour history of sudden-onset abdominal pain, accompanied by a bowel motion and vomiting. He has a history of non-specific heart problems and takes antihypertensive medication. He also had a previous appendicectomy performed 45 years ago. Examination of the abdomen reveals a distended and generally tender abdomen with no guarding. There is a scar present in the right iliac fossa and bowel sounds are absent. Rectal examination is unremarkable. An ECG performed is shown below: What is the most likely diagnosis? Small bowel obstruction Large bowel obstruction Caecal volvulus **Mesenteric ischaemia** Ileus

Question 55

What does this chest CT depict? [1]

Answer 55

Figure 4 – CT Chest of Stanford Type B Aortic Dissection

Question 56

What is the DeBakey classification this aortic dissection? Type I Type II Type IIIa Type IIIB

Answer 56

What is DeBakey classification for aortic dissection is this? Type I **Type II** Type IIIa Type IIIB The Aortic dissection classified as involving the aorta proximal to the left subclavian artery and requires further surgical intervention to avoid coronary artery occlusion or cardiac tamponade.

Question 57

What is the most likely aetiology of the vascular abnormality shown? atherosclerosis hypertension trauma vasculitis

Answer 57

This is a case of aortic dissection: **hypertension** is the most likely etiology for a dissection.

Question 58

What is the DeBakey classification this aortic dissection? Type I Type II Type IIIa Type IIIB

Answer 58

This aortic dissection is essentially limited to the ascending aorta making it a Stanford type A / **DeBakey type 2.**

Question 59

What is the DeBakey classification this aortic dissection? Type I Type II Type IIIa Type IIIB

Answer 59

**DeBakey type 2.**

Question 60

What is the DeBakey classification this aortic dissection? Type I Type II Type IIIa Type IIIB

Answer 60

Type IIIa

Question 61

What is the DeBakey classification this aortic dissection? Type I Type II Type IIIa Type IIIB

Answer 61

Type IIIa

Question 62

What is this complication of varicose veins? Lipodermatosclerosis Thrombophlebitis Haemosiderin Varicose eczema

Answer 62

What is this complication of varicose veins? Lipodermatosclerosis Thrombophlebitis **Haemosiderin** Varicose eczema

Question 63

What is this complication of varicose veins? Lipodermatosclerosis Thrombophlebitis Haemosiderin Varicose eczema

Answer 63

What is this complication of varicose veins? Lipodermatosclerosis **Thrombophlebitis** Haemosiderin Varicose eczema

Question 64

What is this complication of varicose veins? Lipodermatosclerosis Thrombophlebitis Haemosiderin Varicose eczema

Answer 64

**Lipodermatosclerosis**

Question 65

What treatment is suggested for this pathology? [1]

Answer 65

**Laser photocoagulation therapy is performed to stop the growth of new blood vessels.** *The white circular lesions represent focal laser surgery for proliferative diabetic retinopathy. Cotton wool spots, microhaemorrhages and neovascularisation can be seen across the remaining retina.*

Question 66

Describe your findings of this fundoscopy [3]

Answer 66

Extensive new vessel proliferation / **neovascularisation** **Cotton wool spots** **Microhaemorrhages**

Question 67

What is the exacct name for this sign? [1]

Answer 67

Icteric sclera

Question 68

What is this most likely a diagnosis of? [1]

Answer 68

**Pseudomembrane colitis**: inflammation of the colon associated with an overgrowth of the bacterium Clostridioides difficile

Question 69

A patient undergoes a barium swallow of their oesophagus after presenting with dysphagia. What is the most likely diagnosis? [1]

Answer 69

**Achalasia** * bird beak sign * esophageal dilatation

Question 70

**Presentation** History of chronic alcohol abuse with long time chest pain, dysphagia and nocturnal cough. **Patient Data** Age: 60 years Gender: Male What is the most likely diagnosis? [1]

Answer 70

Findings are most suggestive of **achalasia**. There is a classic bird beak sign at the gastro-esophageal junction.

Question 71

A 40-year-old female presents with dysphagia and barium swallow is performed. What is the most likely diagnosis? achalasia diffuse oesophageal spasm gastro-oesophageal reflux disease non-specific oesophageal motility disorder presbyoesophagus scleroderma

Answer 71

**achalasia**

Question 72

What pathology does this drawing imitate? [1]

Answer 72

**eosinophilic oesophagitis**

Question 73

What pathology is likely shown? [1]

Answer 73

**eosinophilic oesophagitis** Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated esophagus"

Question 74

What pathology is likely shown? [1]

Answer 74

**eosinophilic oesophagitis** Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated esophagus"