Pediatric Surgery Practice Questions

Q: All are true about extralobar pulmonary sequestration except:

Can be removed by either segmentectomy or lobectomy. Explanation: Pulmonary sequestration is a rare congenital anomaly where a portion of non-functioning lung tissue lacks communication with the tracheobronchial tree and receives its blood supply from the systemic circulation (usually the thoracic or abdominal aorta) [1]. It is divided into two types: Intralobar (ILS) and Extralobar (ELS) [1]. Why Option D is the Correct Answer (The False Statement): Extralobar sequestration (ELS) is an anatomically distinct mass located outside the normal visceral pleura. Because it has its own separate pleural investment and is not connected to the normal bronchial tree, it can be simply excised (sequestrectomy) without sacrificing any normal lung tissue. In contrast, Intralobar sequestration (ILS) is embedded within the normal lung (usually the lower lobe) and shares its visceral pleura; therefore, it requires a lobectomy or segmentectomy for removal. Analysis of Other Options: * Option A: ELS shows a strong male predilection (Male:Female ratio of approximately 3:1 or 4:1) [1]. * Option B: By definition, ELS is "extra" to the lung and is enclosed in its own separate pleural sac, making it an independent accessory organ [1]. * Option C: ELS is frequently associated with other congenital anomalies (up to 40-60% of cases), most commonly congenital diaphragmatic hernia (CDH), cardiac defects, and chest wall deformities [1]. High-Yield Clinical Pearls for NEET-PG: * Venous Drainage: ELS usually drains into the systemic venous system (azygos/hemi-azygos), whereas ILS usually drains into the pulmonary veins. * Presentation: ELS is often diagnosed in neonates/infants due to associated anomalies [1]. ILS often presents later in childhood or adulthood with recurrent pneumonia. * Location: 90% of ELS cases occur on the left side, often between the lower lobe and the diaphragm.

Q: A child presents with recurrent abdominal pain, intestinal obstruction, and a palpable mass that can be felt per rectum. What is the most likely diagnosis?

Intussusception. ### Explanation **Correct Answer: D. Intussusception** **Why it is correct:** Intussusception is the most common cause of intestinal obstruction in children aged 6 months to 2 years. It occurs when a proximal segment of the bowel (intussusceptum) telescopes into a distal segment (intussuscipiens). The classic clinical triad includes **intermittent colicky abdominal pain**, a **sausage-shaped mass** (usually in the right upper quadrant), and **"red currant jelly" stools**. A unique diagnostic feature is that in ileocolic intussusception, the mass may migrate along the colon and become **palpable on digital rectal examination (DRE)**, or even prolapse through the anus. **Why the other options are incorrect:** * **A. Internal herniation:** While it causes obstruction, it rarely presents with a palpable mass per rectum and is much less common in the pediatric age group unless there is a congenital mesenteric defect. * **B. Stricture:** Usually a late complication of Necrotizing Enterocolitis (NEC) or Crohn’s disease. It presents with chronic obstructive symptoms but does not typically present as a palpable mass reachable by DRE. * **C. Strangulated hernia:** This presents as a tense, tender, irreducible swelling at a hernial site (inguinal or umbilical). While it causes obstruction, the mass is external, not palpable per rectum. **High-Yield Clinical Pearls for NEET-PG:** * **Dance’s Sign:** An empty right iliac fossa due to the migration of the cecum. * **Target/Donut Sign:** The classic appearance on Ultrasonography (Investigation of Choice). * **Pseudokidney Sign:** Seen on longitudinal USG scans. * **Treatment:** Non-operative reduction using **Hydrostatic (saline/barium)** or **Pneumatic (air)** enema is the first-line treatment if there are no signs of peritonitis or perforation. * **Lead Point:** In children >2 years, look for a pathological lead point like **Meckel’s diverticulum** or lymphoma.

Q: A baby, who was apparently normal at birth, develops persistent regurgitation and vomiting in the second and third weeks of life. No fever is present and hematologic studies and blood chemistries are normal. Which of the following therapies is most likely to be effective in this case?

Pyloromyotomy. ### Explanation The clinical presentation describes a classic case of **Infantile Hypertrophic Pyloric Stenosis (IHPS)**. **Why Pyloromyotomy is Correct:** IHPS typically presents in the **2nd to 6th week of life** with non-bilious, projectile vomiting (regurgitation) in a previously healthy infant. The underlying pathology is hypertrophy of the pyloric sphincter muscle, leading to gastric outlet obstruction. While this question states blood chemistries are normal (likely due to early presentation), the definitive treatment is surgical: **Ramstedt’s Pyloromyotomy**, where the hypertrophied muscle is incised down to the mucosa to relieve the obstruction. **Why Other Options are Incorrect:** * **Antacids:** These treat Gastroesophageal Reflux (GERD). While GERD causes vomiting, it rarely presents with the progressive, forceful nature of IHPS and does not address the mechanical obstruction. * **Barium Enema:** This is a diagnostic/therapeutic tool for **Intussusception** or Hirschsprung disease. Intussusception usually presents later (5–10 months) with "currant jelly" stools and abdominal pain. * **Gastric Resection:** This is an invasive procedure for malignancy or severe ulceration and is never indicated for a benign hypertrophic condition in an infant. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Projectile non-bilious vomiting, palpable **"olive-shaped" mass** in the epigastrium, and visible gastric peristalsis. * **Metabolic Abnormality:** If left untreated, it leads to **Hypochloremic, Hypokalemic Metabolic Alkalosis** with paradoxical aciduria. * **Diagnosis:** Ultrasound is the gold standard (look for pyloric muscle thickness >4mm or length >14mm). * **Initial Management:** Always stabilize the infant with IV fluids (Normal Saline) to correct electrolyte imbalances *before* proceeding to surgery.

Q: What is the most common site of lymphangioima?

Head and Neck. **Explanation:** **Lymphangiomas** (also known as lymphatic malformations) are benign, congenital malformations of the lymphatic system. They result from the failure of lymphatic channels to communicate with the main lymphatic vessels, leading to the sequestration of lymph and subsequent cystic dilatation. **Why Head and Neck is correct:** The **Head and Neck** is the most common site, accounting for approximately **75% to 80%** of all cases. Within this region, the posterior triangle of the neck is the most frequent location. When these lesions occur in the neck, they are often referred to as **Cystic Hygromas**. The second most common site is the axilla (approx. 20%). **Why other options are incorrect:** * **Kidney:** Renal lymphangioma is an extremely rare condition. While lymphatic malformations can occur in the retroperitoneum, they are far less common than cervical presentations. * **Groin:** While lymphangiomas can occur in the inguinal region, it is a much rarer site compared to the neck and axilla. * **Heart:** Cardiac lymphangiomas are exceptionally rare primary tumors of the heart and are not a standard site for these malformations. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Usually present at birth (50%) or by age 2 (90%) as a soft, painless, compressible, and **transilluminant** mass. * **Classification:** Divided into Capillary (simple), Cavernous, and Cystic (Cystic Hygroma) based on the size of the lymphatic spaces. * **Complications:** Sudden increase in size may occur due to intralesional hemorrhage or infection. * **Treatment:** Surgical excision is the gold standard, though **Sclerotherapy** (using agents like OK-432, Bleomycin, or Doxycycline) is a preferred initial treatment for macrocystic lesions.

Q: Which of the following statements about Wilms' tumor is false?

Spreads mostly by lymphatics.. **Explanation:** Wilms’ tumor (Nephroblastoma) is the most common primary renal malignancy in children. Understanding its mode of spread and clinical presentation is crucial for NEET-PG. **Why Option C is False (The Correct Answer):** Wilms’ tumor primarily spreads via **hematogenous** routes, not lymphatics. The most common site of distant metastasis is the **lungs**, followed by the liver. While regional lymph node involvement can occur (seen in about 15% of cases), it is not the primary or most common mode of spread. **Analysis of Other Options:** * **Option A (Age):** True. Approximately 90% of cases present before the age of 5, with a peak incidence between **2 to 3 years**. It is rare in neonates and older children. * **Option B (Presentation):** True. The most common clinical presentation is a **painless, smooth, firm abdominal mass** that typically does not cross the midline (unlike Neuroblastoma). * **Option D (Prognosis):** True. Wilms’ tumor is a success story in pediatric oncology. With a multimodal approach (surgery, chemotherapy, and sometimes radiotherapy), the overall cure rate exceeds **90%**. **High-Yield Clinical Pearls for NEET-PG:** * **WAGR Syndrome:** Wilms’ tumor, Aniridia, Genitourinary anomalies, and intellectual disability (formerly Retardation). Associated with **WT1 gene** deletion on Chromosome 11p13. * **Beckwith-Wiedemann Syndrome:** Macroglossia, organomegaly, and hemihypertrophy. Associated with **WT2 gene** on Chromosome 11p15. * **Staging:** Unlike many tumors, Wilms’ tumor staging is often determined **after** nephrectomy (NWTS criteria), except in cases where preoperative chemotherapy is used (SIOP criteria). * **Classic Triad on Histology:** Blastemal, stromal, and epithelial cells.

Q: A 5-day-old infant presents with vomiting of stomach contents and bile that has persisted for 2 days. Radiographic examination reveals stenosis of the fourth part of the duodenum. The infant cries incessantly, appears constantly hungry, and is not gaining weight. Which of the following developmental conditions will most likely explain the infant's symptoms?

Duodenal stenosis. **Explanation:** The clinical presentation of **bilious vomiting** in a 5-day-old infant, combined with radiographic evidence of stenosis in the **fourth part of the duodenum**, points directly to **Duodenal Stenosis**. 1. **Why Duodenal Stenosis is correct:** During the 5th–6th week of gestation, the duodenal lumen is obliterated by proliferating epithelial cells. It normally undergoes **recanalization** by the 8th–10th week. Failure of complete recanalization leads to stenosis or atresia. Since the fourth part of the duodenum is distal to the **Ampulla of Vater** (where the common bile duct enters the second part), the obstruction results in **bilious vomiting** (vomitus containing bile). The infant remains hungry because nutrients cannot pass the obstruction, leading to weight loss and irritability. 2. **Why other options are incorrect:** * **Patent bile duct:** This is a normal anatomical state; it does not cause intestinal obstruction or vomiting. * **Hypertrophied Pyloric Sphincter (IHPS):** This typically presents at 3–6 weeks of age (not 5 days) with **non-bilious**, projectile vomiting, as the obstruction is proximal to the Ampulla of Vater. * **Atrophied gastric antrum:** This is not a standard developmental cause of neonatal intestinal obstruction and would typically present with non-bilious vomiting. **NEET-PG High-Yield Pearls:** * **Double Bubble Sign:** The classic radiographic finding for duodenal atresia/stenosis (gas in the stomach and proximal duodenum). * **Association:** Approximately 30% of infants with duodenal atresia/stenosis have **Down Syndrome (Trisomy 21)**. * **Bilious vs. Non-bilious:** Always check the level of obstruction relative to the Ampulla of Vater. Proximal = Non-bilious; Distal = Bilious. * **Annular Pancreas:** Another common cause of extrinsic duodenal obstruction due to failure of the ventral pancreatic bud to rotate correctly.

Q: A child presents with complaints of abdominal colic and hematuria. Ultrasonography showed a renal stone 2.5 cm in diameter in the renal pelvis. What is the next step in the management of this case?

Extracorporeal Shock Wave Lithotripsy (ESWL). **Explanation:** The management of pediatric urolithiasis differs significantly from adults due to the smaller anatomy but higher clearance rates of stone fragments. **1. Why ESWL is the correct answer:** In the pediatric population, **Extracorporeal Shock Wave Lithotripsy (ESWL)** is the first-line treatment for most renal stones, even those up to **2.5 cm** in diameter. Children have more elastic tissues and a shorter distance from the skin to the stone, which allows for more efficient fragmenting. Furthermore, their ureters are more distensible, facilitating the passage of larger fragments (the "Steinstrasse" phenomenon is less common or better tolerated in children than in adults). For a 2.5 cm stone in the renal pelvis, ESWL offers a non-invasive approach with high success rates. **2. Why other options are incorrect:** * **Pyelolithotomy:** This is an open surgical procedure. With the advent of minimally invasive techniques (ESWL and PCNL), open surgery is reserved only for complex staghorn calculi or cases with concomitant anatomical abnormalities (e.g., UPJ obstruction). * **Nephroureterostomy:** This is a diversion procedure (placing a tube) to relieve obstruction or provide drainage; it does not treat the underlying stone. * **Conservative management:** Stones >5-7 mm are unlikely to pass spontaneously, especially a 2.5 cm stone in the pelvis which requires active intervention to prevent recurrent colic and renal damage. **Clinical Pearls for NEET-PG:** * **Adults vs. Children:** In adults, ESWL is typically preferred for stones 2.5 cm or when ESWL fails. * **Lower Pole Stones:** If the stone were in the lower pole and >1 cm, PCNL might be preferred over ESWL due to poor gravity-dependent clearance.

Q: An infant girl is found to have persistent jaundice after birth. A metabolic screen is normal, ultrasound demonstrates an absent gallbladder, and a technetium-99m iminodiacetic acid scan shows radionuclide that is concentrated in the liver but not excreted into the intestine. Which of the following is true?

Surgery should be performed within 60 days of life.. ### Explanation The clinical presentation of persistent jaundice, an absent gallbladder on ultrasound, and a HIDA scan showing hepatic uptake without excretion into the intestine is diagnostic of **Biliary Atresia (BA)**. **1. Why Option B is Correct:** Biliary atresia is a progressive fibro-obliterative disease of the extrahepatic biliary tree. The definitive surgical management is the **Kasai Portoenterostomy**. The success of this procedure is highly time-dependent. If performed **within 60 days of life**, approximately 70-80% of patients achieve bile drainage. Beyond 90 days, the success rate drops significantly (<20%) due to irreversible secondary biliary cirrhosis. **2. Why Other Options are Incorrect:** * **Option A:** BA is a surgical emergency. Nonoperative management leads to liver failure and death, usually within two years. * **Option C:** Cystoenterostomy is the treatment for *Choledochal Cysts*. In BA, the entire extrahepatic ductal system is typically fibrotic; therefore, a portoenterostomy (attaching the bowel to the transected porta hepatis) is required, not a simple cyst drainage. * **Option D:** Even with a successful Kasai procedure, BA remains the **most common indication for pediatric liver transplantation**. Most patients will eventually require a transplant due to progressive intrahepatic fibrosis or portal hypertension. ### High-Yield Clinical Pearls for NEET-PG: * **Triad of BA:** Jaundice (conjugated), Acholic stools, and Hepatomegaly. * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOC). * **HIDA Scan:** High sensitivity for BA if there is no excretion into the bowel after 24 hours (pre-treatment with Phenobarbital for 5 days can improve specificity). * **Kasai Procedure:** Also known as Hepatic Portoenterostomy. * **Post-op Complication:** Ascending cholangitis is the most common early complication.

Question 1

All are true about extralobar pulmonary sequestration except:

Accepted Answer

Can be removed by either segmentectomy or lobectomy

Answer

More common in males

Answer

Surrounded by a separate pleural covering

Answer

Associated with multiple other anomalies

Question 2

A child presents with recurrent abdominal pain, intestinal obstruction, and a palpable mass that can be felt per rectum. What is the most likely diagnosis?

Accepted Answer

Intussusception

Answer

Internal herniation

Answer

Stricture

Answer

Strangulated hernia

Question 3

A baby, who was apparently normal at birth, develops persistent regurgitation and vomiting in the second and third weeks of life. No fever is present and hematologic studies and blood chemistries are normal. Which of the following therapies is most likely to be effective in this case?

Accepted Answer

Pyloromyotomy

Answer

Antacids

Answer

Barium enema

Answer

Gastric resection

Question 4

A newborn baby had normal APGAR score at birth and developed excessive frothing and choking on attempted feeds. What is the investigation of choice?

Accepted Answer

X-ray chest and abdomen with a red rubber catheter passed per orally into the esophagus

Answer

Esophagoscopy

Answer

Bronchoscopy

Answer

MRI chest

Question 5

What is the most common site of lymphangioima?

Accepted Answer

Head and Neck

Answer

Kidney

Answer

Groin

Answer

Heart

Question 6

Which of the following statements about Wilms' tumor is false?

Accepted Answer

Spreads mostly by lymphatics.

Answer

Presents before the age of 5 years.

Answer

Mostly presents as an abdominal mass.

Answer

Responds well to treatment.

Question 7

A 5-day-old infant presents with vomiting of stomach contents and bile that has persisted for 2 days. Radiographic examination reveals stenosis of the fourth part of the duodenum. The infant cries incessantly, appears constantly hungry, and is not gaining weight. Which of the following developmental conditions will most likely explain the infant's symptoms?

Accepted Answer

Duodenal stenosis

Answer

Patent bile duct

Answer

Hypertrophied pyloric sphincter

Answer

Atrophied gastric antrum

Question 8

A child presents with complaints of abdominal colic and hematuria. Ultrasonography showed a renal stone 2.5 cm in diameter in the renal pelvis. What is the next step in the management of this case?

Accepted Answer

Extracorporeal Shock Wave Lithotripsy (ESWL)

Answer

Pyelolithotomy

Answer

Nephroureterostomy

Answer

Conservative management

Question 9

An infant girl is found to have persistent jaundice after birth. A metabolic screen is normal, ultrasound demonstrates an absent gallbladder, and a technetium-99m iminodiacetic acid scan shows radionuclide that is concentrated in the liver but not excreted into the intestine. Which of the following is true?

Accepted Answer

Surgery should be performed within 60 days of life.

Answer

This condition is usually managed nonoperatively.

Answer

Cystoenterostomy provides adequate biliary drainage.

Answer

Most of these patients will not require transplantation.

Question 10

Lung sequestration occurs most commonly in which lobe?

Accepted Answer

Left posterior basal

Answer

Apical

Answer

Left posterosuperior

Answer

Right lateral basal

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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