Pediatric Surgery Basics Practice Questions

Q: A four-month-old baby has cleft lip and palate. How would you manage the baby?

Immediate repair of the lip. ***Immediate repair of the lip*** - A **cleft lip** is typically repaired around **3-6 months of age** ("Rule of 10s": 10 weeks old, 10 pounds weight, 10 g/dL hemoglobin), which aligns with the baby's age of four months, to facilitate feeding and encourage normal facial bone and dental development. - Early lip closure also aids in better **feeding**, improved **speech development**, and addressing initial aesthetic concerns. *Delayed repair of the lip and palate until pre-school age* - Delaying **lip repair** until pre-school age would negatively impact feeding, speech development, and psychosocial well-being, as well as potentially affecting facial growth. - **Palate repair** is generally performed between **9-18 months of age** to optimize speech development, not pre-school age. *Immediate repair of the lip and palate* - While **lip repair** can be done relatively early, **palate repair** is usually delayed until later (9-18 months) to allow for facial growth and to optimize speech outcomes. - Performing both immediately might pose greater surgical risks and interfere with the natural growth of the maxilla and skull base. *Delayed repair of the lip and palate until 2 years* - Delaying **lip repair** until 2 years is too late, as it significantly impacts feeding, speech development, and facial aesthetics during critical developmental periods. - While some **palate repairs** may occur up to 18 months, delaying beyond this, particularly for the lip, is not optimal for function or aesthetics.

Q: Consider the following conditions: 1. Otitis media 2. Speech problems 3. Dentition abnormalities Which of the above is/are associated with cleft palate?

1, 2 and 3. ***1, 2 and 3*** - All three conditions—**otitis media, speech problems, and dentition abnormalities**—are commonly associated with **cleft palate** due to anatomical and functional disruptions. - The abnormal palatal structure affects Eustachian tube function, speech articulation, and proper tooth development and alignment. *1 and 3 only* - This option incorrectly excludes **speech problems**, which are a very common and significant consequence of cleft palate. - The inability of the palate to close off the nasal cavity during speech leads to hypernasality and articulatory difficulties. *2 and 3 only* - This option incorrectly excludes **otitis media**, which is a frequent complication in individuals with cleft palate due to impaired **Eustachian tube function**. - The muscle attachments involving the soft palate and Eustachian tube orifice are often anomalous, leading to chronic middle ear fluid and infections. *1 only* - This option is incomplete as it only includes **otitis media**, while **speech problems** and **dentition abnormalities** are also major and well-documented sequelae of cleft palate. - The structural defect impacts multiple orofacial and auditory functions.

Q: A five-year-old child presents with ballooning of prepuce after micturition. Examination reveals preputial adhesions. Which of the following is the best treatment?

Conservative management. ***Conservative management*** - In a 5-year-old child, **preputial adhesions** and **ballooning of prepuce** represent **physiological phimosis**, which is a normal developmental finding. - **Ballooning during micturition** is common and benign in young children and does NOT indicate significant obstruction requiring surgical intervention. - **First-line treatment** involves **reassurance, observation**, and if needed, **topical steroid cream** (0.05% betamethasone) applied for 4-6 weeks to facilitate gentle retraction. - Most cases resolve spontaneously with conservative management as the prepuce naturally separates from the glans over time. - Surgical intervention is reserved for **pathological phimosis** (e.g., BXO/lichen sclerosus), recurrent UTIs, or recurrent balanitis. *Adhesionlysis & dilatation* - This invasive approach is **NOT recommended** as routine treatment for physiological phimosis. - Forced retraction and adhesionlysis can cause **trauma, bleeding, scarring**, and potentially convert physiological phimosis into **pathological phimosis**. - Should only be considered in specific cases where conservative management has failed after adequate trial. *Dorsal slit* - This surgical procedure involves making an incision along the dorsal aspect of the prepuce. - It is an **invasive intervention** reserved for cases of **pathological phimosis** or when conservative management has failed. - Not indicated as first-line treatment for physiological phimosis with simple adhesions. *Circumcision* - This involves complete surgical removal of the foreskin. - It is the **most invasive and irreversible** option. - Reserved for **pathological phimosis** (BXO), recurrent infections unresponsive to medical management, or cultural/religious reasons. - Not indicated for routine physiological phimosis in a 5-year-old child.

Q: A 2-year-old boy presented to the ER with stridor, shortness of breath, and difficulty in swallowing. The patient also has a history of recurrent chest infections in the past, for which the child was frequently hospitalized. Upper GI endoscopy was normal. Lab findings revealed normal studies. Chest X-ray. What is the most likely diagnosis?

Dysphagia lusoria. **Dysphagia lusoria** * Dysphagia lusoria is a **vascular anomaly** (e.g., an aberrant right subclavian artery) that compresses the esophagus or trachea, leading to symptoms like **stridor**, **shortness of breath**, and **dysphagia** (difficulty swallowing). * The history of recurrent chest infections points to chronic airway compression, which can lead to **tracheomalacia** and an increased risk of respiratory infections. *Achalasia cardia* * Achalasia is characterized by the **failure of the lower esophageal sphincter (LES) to relax** and loss of peristalsis in the esophageal body, primarily presenting with dysphagia for both solids and liquids. * While it causes dysphagia, it typically doesn't cause stridor or recurrent chest infections in a 2-year-old in the absence of severe aspiration. *Diffuse esophageal spasm* * Diffuse esophageal spasm involves **uncoordinated, high-amplitude esophageal contractions** and can cause dysphagia and chest pain. * It is less likely to present with significant respiratory symptoms like stridor or recurrent chest infections, especially in a young child. *Nutcracker esophagus* * Nutcracker esophagus is characterized by **high-amplitude, coordinated esophageal contractions** and is typically associated with chest pain and dysphagia. * Similar to diffuse esophageal spasm, it does not typically cause stridor or recurrent chest infections in a pediatric patient.

Q: Esophageal atresia may occur as a part of VACTERL group of anomalies. What does 'TE' stand for?

Tracheo-esophageal fistula. ***Tracheo-esophageal fistula*** - The 'TE' in **VACTERL** stands for **Tracheo-Esophageal fistula**, which is a common congenital anomaly associated with esophageal atresia. - This condition involves an abnormal connection between the **trachea** and the esophagus, often leading to feeding difficulties and respiratory complications. *Thoracic empyema* - **Thoracic empyema** is an accumulation of pus in the pleural cavity, typically a complication of pneumonia or chest trauma. - It is an acquired condition and not a congenital anomaly part of the **VACTERL** association. *Talipes equinovarus* - **Talipes equinovarus**, also known as **clubfoot**, is a congenital deformity of the foot. - While it is a congenital anomaly, it is represented by the 'L' (Limb defects) in the **VACTERL** association, not 'TE'. *Tetralogy of Fallot* - **Tetralogy of Fallot** is a complex congenital heart defect involving four specific abnormalities. - This condition is represented by the 'C' (Cardiac defects) in the **VACTERL** association, as it's a type of cardiac anomaly.

Q: A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

MRI with contrast. ***MRI with contrast*** - An **MRI with contrast** is the most sensitive and specific imaging modality for detecting early changes in **osteomyelitis** or **septic arthritis**, which are serious conditions given the child's symptoms and elevated inflammatory markers. - It can visualize soft tissue and bone marrow edema, joint effusions, and abscesses, guiding immediate treatment. *CT Scan* - While useful for bony detail, a CT scan is **less sensitive than MRI** for detecting early bone marrow changes or soft tissue inflammation in the hip joint. - It also involves **radiation exposure**, which should be limited in children when other effective modalities are available. *Bone Scan* - A bone scan using **technetium-99m** is sensitive for detecting increased bone turnover, but it is **not specific for infection** and cannot differentiate between inflammatory processes, tumors, or fractures. - It provides less anatomical detail compared to MRI, making precise localization of an infection more challenging. *Plain Radiograph* - Plain radiographs are typically the **initial imaging study** for orthopedic complaints but are often **normal in early stages** of septic arthritis or osteomyelitis. - Significant radiographic changes, such as bone erosion or joint space widening, usually appear much later in the disease process.

Q: True about congenital diaphragmatic hernia (CDH) except:

Occurs anteriorly in the diaphragm. ***Occurs anteriorly in the diaphragm*** - Congenital diaphragmatic hernias (CDH) typically occur through the **foramen of Bochdalek**, which is a posterolateral defect in the diaphragm. - Herniations through the **foramen of Morgagni** are anterior, but these are far less common than Bochdalek hernias (only 2-3% of cases). *Causes pulmonary hypoplasia* - The presence of abdominal organs in the thoracic cavity during fetal development **compresses the developing lungs**, leading to underdevelopment. - This results in **reduced lung volume** and **abnormal pulmonary vasculature**. *Occurs mostly on the left side* - Approximately **80-85% of CDH cases are left-sided**, possibly due to the protective effect of the liver on the right side. - The left pleuroperitoneal canal typically closes later than the right side, making it more susceptible to defects. *Leads to cyanosis at birth* - **Pulmonary hypoplasia** and **persistent pulmonary hypertension** result in right-to-left shunting of blood, causing severe hypoxia and cyanosis. - Infants often present with acute respiratory distress, cyanosis, and scaphoid abdomen soon after birth.

Q: A newborn presents with bilious vomiting and abdominal distension. An X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

Duodenal atresia. ***Duodenal atresia*** - The **"double bubble" sign** on abdominal X-ray is pathognomonic for duodenal atresia, representing air trapped in the stomach and the dilated proximal duodenum separated by the pylorus. - **Bilious vomiting** and **abdominal distension** in a newborn further support this diagnosis, indicating a high-grade obstruction distal to the ampulla of Vater. *Intussusception* - Typically presents with intermittent episodes of **colicky abdominal pain**, **vomiting**, and sometimes **"currant jelly" stools** (blood and mucus), not usually bilious vomiting as the primary symptom in newborns. - The X-ray findings for intussusception would not show a "double bubble" sign, but rather signs of bowel obstruction or a **target sign** on ultrasound. *Midgut volvulus* - While it can cause bilious vomiting and abdominal distension, a midgut volvulus typically does not present with a "double bubble" sign because the obstruction is usually distal to the duodenum and often involves **ischemia** of a larger segment of the bowel. - The characteristic imaging finding for midgut volvulus is the **"corkscrew" sign** on upper GI series due to twisting of the small bowel. *Hirschsprung disease* - This condition usually presents with **delayed passage of meconium**, **abdominal distension**, and **bilious vomiting** in later stages, but it does not cause a "double bubble" sign. - The obstruction in Hirschsprung disease is due to an **aganglionic segment of the colon**, leading to a transition zone on imaging and often showing dilated loops of bowel distal to the stomach and duodenum.

Q: Prevalence of omphalocele at birth is

1 in 4000 live births. ***1 in 4000 live births*** - **Omphalocele** is a congenital abdominal wall defect with a prevalence commonly cited as approximately **1 in 4000 to 1 in 5000 live births** in standard pediatric textbooks and Indian medical literature. - This figure represents the **most frequently used estimate** for exam purposes and clinical reference, though actual prevalence may vary by population and detection methods. - The embryological malformation involves failure of the abdominal wall to close, leading to protrusion of abdominal organs covered by a **peritoneal sac**. *1 in 100 live births* - A prevalence of **1 in 100 live births** would indicate a much higher incidence than what is observed for omphalocele. - This rate is more consistent with common conditions like congenital heart defects, which are significantly more frequent than abdominal wall defects. *1 in 2000 live births* - **1 in 2000 live births** is higher than the accepted prevalence for omphalocele. - This would represent approximately twice the actual incidence, making it an overestimate. *1 in 10,000 live births* - While some population-based studies report prevalence as low as **1 in 10,000 live births**, this represents the **lower end of the range** and is less commonly cited. - More recent epidemiological data shows variability between 1 in 4000 to 1 in 10,000 depending on geographic region and inclusion criteria, but **1 in 4000-5000 remains the standard reference** for medical education and examinations.

Q: All of the following are clinical features suggestive of tracheoesophageal fistula except -

Fever. ***Fever*** - **Fever is NOT a primary clinical feature** of tracheoesophageal fistula (TEF) itself. - While fever might occur as a **complication** if aspiration pneumonia develops, it is not a direct presenting sign of TEF. - The classic presentation of TEF occurs in **newborns within hours of birth** and involves the "3 Cs" - not fever. *Choking and Coughing* - Part of the classic **"3 Cs" triad** (Choking, Coughing, Cyanosis) of TEF presentation. - Occurs during the **first feeding attempt** when milk enters the trachea through the abnormal fistulous connection. - This is a **cardinal diagnostic feature** that should immediately raise suspicion for TEF. *Regurgitation* - **Immediate regurgitation** of feeds is characteristic, especially in TEF with esophageal atresia (most common type - Type C). - The **blind-ending proximal esophageal pouch** prevents normal passage of saliva and feeds, causing regurgitation. - Often accompanied by **excessive drooling and frothy secretions** from the mouth and nose. *Cyanosis* - The third component of the **"3 Cs" triad** and a key clinical feature. - Results from **aspiration of feeds or saliva** into the trachea and lungs, causing acute respiratory distress. - May also occur from **laryngospasm** as a protective reflex when fluid enters the airway.

Question 1

A four-month-old baby has cleft lip and palate. How would you manage the baby?

Accepted Answer

Immediate repair of the lip

Answer

Delayed repair of the lip and palate until pre-school age

Answer

Immediate repair of the lip and palate

Answer

Delayed repair of the lip and palate until 2 years

Question 2

Consider the following conditions:

1. Otitis media
2. Speech problems
3. Dentition abnormalities
Which of the above is/are associated with cleft palate?

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 3 only

Answer

1 only

Question 3

A five-year-old child presents with ballooning of prepuce after micturition. Examination reveals preputial adhesions. Which of the following is the best treatment?

Accepted Answer

Conservative management

Answer

Dorsal slit

Answer

Circumcision

Answer

Adhesionlysis & dilatation

Question 4

A 2-year-old boy presented to the ER with stridor, shortness of breath, and difficulty in swallowing. The patient also has a history of recurrent chest infections in the past, for which the child was frequently hospitalized. Upper GI endoscopy was normal. Lab findings revealed normal studies. Chest X-ray. What is the most likely diagnosis?

Accepted Answer

Dysphagia lusoria

Answer

Achalasia cardia

Answer

Diffuse esophageal spasm

Answer

Nutcracker esophagus

Question 5

Esophageal atresia may occur as a part of VACTERL group of anomalies. What does 'TE' stand for?

Accepted Answer

Tracheo-esophageal fistula

Answer

Thoracic empyema

Answer

Talipes equinovarus

Answer

Tetralogy of Fallot

Question 6

A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

Accepted Answer

MRI with contrast

Answer

CT Scan

Answer

Bone Scan

Answer

Plain Radiograph

Question 7

True about congenital diaphragmatic hernia (CDH) except:

Accepted Answer

Occurs anteriorly in the diaphragm

Answer

Causes pulmonary hypoplasia

Answer

Occurs mostly on the left side

Answer

Leads to cyanosis at birth

Question 8

A newborn presents with bilious vomiting and abdominal distension. An X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

Accepted Answer

Duodenal atresia

Answer

Intussusception

Answer

Midgut volvulus

Answer

Hirschsprung disease

Question 9

Prevalence of omphalocele at birth is

Accepted Answer

1 in 4000 live births

Answer

1 in 100 live births

Answer

1 in 2000 live births

Answer

1 in 10,000 live births

Question 10

All of the following are clinical features suggestive of tracheoesophageal fistula except -

Accepted Answer

Fever

Answer

Choking and Coughing

Answer

Regurgitation

Answer

Cyanosis

Pediatric Surgery Basics — MCQs

Pediatric Surgery Basics — MCQs

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