Pediatric Surgery Practice Questions

Q: A female newborn presents with a large midline tumor in the lower sacral area, diagnosed as a sacrococcygeal tumor. Which of the following courses of treatment is recommended for this child?

Surgical removal by age 6 months. **Explanation:** **Sacrococcygeal Teratoma (SCT)** is the most common newborn tumor. The primary goal of management is early surgical intervention to prevent malignant transformation and complications. **1. Why Option B is Correct:** The standard of care for SCT is **complete surgical excision** as soon as the patient is stabilized, typically within the first few months of life (ideally by age 6 months). The risk of malignancy in SCT is relatively low at birth (approx. 5-10%) but increases significantly with age. By 1 year of age, the risk of malignancy rises to over 50%. Therefore, early resection is curative for benign lesions and prevents the development of yolk sac tumors or other malignant components. **2. Why the Other Options are Incorrect:** * **Option A:** Chemotherapy and radiation are not primary treatments for neonatal SCT. They are reserved for malignant cases or recurrent disease following surgery. * **Options C & D:** Delaying surgery until age 4 or 15 years is contraindicated. The risk of malignant transformation increases exponentially after the neonatal period. Furthermore, large tumors can cause local complications like urinary obstruction or bowel dysfunction if left untreated. **Clinical Pearls for NEET-PG:** * **Altman Classification:** Used to categorize SCT based on its external vs. internal (pelvic) extension. Type I is mostly external; Type IV is entirely internal (highest risk of delayed diagnosis). * **Surgical Key:** Complete excision must include the **removal of the coccyx**. Failure to remove the coccyx leads to a high recurrence rate (30-40%). * **Tumor Markers:** Alpha-fetoprotein (AFP) and Beta-hCG are used for diagnosis and monitoring recurrence. * **Epidemiology:** More common in females (4:1 ratio), but malignancy is more common in males.

Q: Which one of the following statements is true of an undescended testis?

Has a higher incidence of malignancy.. **Explanation:** **Correct Answer: C. Has a higher incidence of malignancy.** Undescended testis (Cryptorchidism) is associated with a **4 to 10 times higher risk** of developing testicular germ cell tumors (most commonly **Seminoma**). This risk is attributed to the higher core body temperature in the inguinal canal or abdomen, which leads to dysplastic changes in the germ cells. Notably, orchiopexy does not eliminate the risk of malignancy but makes the testis accessible for clinical examination and early detection. **Analysis of Incorrect Options:** * **Option A:** Spontaneous descent is common in the first few months of life but is **rare after 6 months of age**. If the testis has not descended by 6 months, it is unlikely to do so at puberty. * **Option B:** Current surgical guidelines recommend Orchiopexy be performed between **6 to 12 months of age**. Delaying surgery until puberty increases the risk of infertility and malignancy significantly. * **Option C:** Cryptorchidism leads to **impaired spermatogenesis** due to the higher thermal environment. Histological changes (reduced Leydig cells and fibrosis) begin as early as 1 year of age. While testosterone production (Leydig cell function) is often preserved, sperm production is usually subnormal. **High-Yield Facts for NEET-PG:** * **Most common site:** Inguinal canal. * **Most common tumor in undescended testis:** Seminoma. * **Most common tumor in a previously corrected (orchiopexy) testis:** Seminoma. * **Risk of Malignancy:** Highest in abdominal testes (1 in 20). * **Contralateral Risk:** The normally descended testis in a patient with unilateral cryptorchidism also carries an increased risk of malignancy.

Q: What does the 'Signe de Dance' refer to?

Empty right iliac fossa in intussusception. **Explanation** **Signe de Dance** (Dance’s Sign) is a classic clinical finding in **intussusception**, most commonly seen in the ileocolic variety. It refers to a palpable **emptiness in the right iliac fossa (RIF)**. This occurs because the cecum and the ileum invaginate (telescope) into the ascending and transverse colon, physically migrating out of their normal anatomical position in the RIF. **Analysis of Options:** * **Option A (Correct):** As the intussusceptum moves distally along the colon, the RIF feels "empty" on palpation. This is often accompanied by a sausage-shaped mass felt in the right hypochondrium or epigastrium. * **Option B (Incorrect):** A "pincer-shaped" or "claw appearance" is a **radiological** finding seen on a barium enema, not a clinical sign. * **Option C (Incorrect):** Tenderness at McBurney’s point is the hallmark of **acute appendicitis**, caused by inflammation of the appendix. * **Option D (Incorrect):** Passing large quantities of urine after the relief of loin pain is known as **Dietl’s crisis**, seen in intermittent hydronephrosis (often due to PUJ obstruction). **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Intussusception:** Intermittent abdominal pain (screaming episodes), sausage-shaped mass, and **"red currant jelly" stools**. * **Target/Donut Sign:** The classic appearance on Ultrasonography (the investigation of choice). * **Treatment:** Non-operative reduction using **hydrostatic (saline) or pneumatic (air) enema** is the first-line treatment in stable patients. * **Lead Point:** In children, it is usually idiopathic (hypertrophied Peyer’s patches); in adults, it is usually a malignancy.

Q: What is the most common cause of hydronephrosis in children?

Congenital PUJ obstruction. **Explanation:** **Congenital Pelvi-Ureteric Junction (PUJ) Obstruction** is the most common cause of hydronephrosis in children and the most frequent cause of an abdominal mass in neonates. It occurs due to an anatomical or functional impairment of urine flow from the renal pelvis into the ureter. The most common underlying mechanism is an **aperistaltic segment** at the PUJ, though extrinsic compression by an accessory (aberrant) lower pole renal artery is also a significant cause. **Analysis of Options:** * **Ureterocoele (Option A):** This is a cystic dilatation of the distal intramural ureter. While it can cause hydroureteronephrosis, it is far less common than PUJ obstruction. * **Ureteric stricture (Option B):** These are usually acquired (post-inflammatory or post-surgical) and are rare in the pediatric population compared to congenital anomalies. * **Watermelon prostate (Option C):** This is a distractor term. "Watermelon stomach" (GAVE) is a clinical entity, but there is no such standard term for the prostate. Furthermore, prostatic pathologies typically cause bilateral hydronephrosis due to bladder outlet obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Most cases are now detected on **antenatal ultrasound**. Postnatally, it may present as a palpable flank mass or episodic loin pain (Dietl’s crisis) after increased fluid intake. * **Investigation of Choice:** **DTPA or MAG-3 scan** (Diuretic renogram) is used to assess the functional severity and drainage pattern. * **Surgical Gold Standard:** **Anderson-Hynes Dismembered Pyeloplasty** (can be open, laparoscopic, or robotic). * **Key Association:** If hydronephrosis is **bilateral** in a male infant, always suspect **Posterior Urethral Valves (PUV)** first.

Q: Which of the following is NOT a feature of ectopia vesicae?

X-linked dominant inheritance. **Explanation:** **Ectopia vesicae (Bladder Exstrophy)** is a complex congenital malformation resulting from the failure of the infraumbilical anterior abdominal wall and bladder neck to fuse. **Why Option D is the correct answer:** Ectopia vesicae is **not** an X-linked dominant disorder. Most cases occur **sporadically** with no clear inheritance pattern. While there is a slightly higher risk in siblings (approx. 1 in 100), it does not follow Mendelian genetics. The etiology is primarily attributed to the failure of mesenchymal migration between the ectoderm and endoderm of the cloacal membrane. **Analysis of incorrect options (Features of Ectopia Vesicae):** * **Epispadias (Option A):** This is a hallmark feature. In males, the urethra opens on the dorsal aspect of the penis. The penis is typically short and broad with a dorsal chordee. * **Bifid Clitoris (Option B):** In females, the clitoris is bifid (split), the labia are widely separated, and the vaginal orifice is displaced anteriorly. * **Undescended Testis (Option C):** Cryptorchidism and inguinal hernias are frequently associated with bladder exstrophy due to the widening of the bony pelvis and defects in the inguinal canal. **High-Yield Clinical Pearls for NEET-PG:** * **Bony Defect:** Widening of the **symphysis pubis** (diastasis) is a classic radiological finding. * **Associated Malignancy:** Patients have a significantly increased risk (up to 400-fold) of developing **Adenocarcinoma** of the bladder due to chronic irritation and glandular metaplasia of the exposed mucosa. * **Umbilicus:** The umbilicus is typically low-set, immediately above the exstrophied bladder. * **Management:** The primary goal is functional closure of the bladder, reconstruction of the bladder neck for continence, and repair of the epispadias.

Q: Which of the following is true about Hirschsprung's disease?

The aganglionic segment is contracted, not dilated.. **Explanation:** **Hirschsprung’s Disease (Congenital Aganglionic Megacolon)** is caused by the failure of neural crest cells to migrate cranio-caudally, resulting in an absence of Meissner’s and Auerbach’s plexuses in the distal bowel. 1. **Why Option A is Correct:** In Hirschsprung’s, the **aganglionic segment** lacks the inhibitory signals required for smooth muscle relaxation. Consequently, this segment remains in a state of **tonic contraction**. The proximal ganglionic bowel undergoes massive compensatory hypertrophy and **dilation** (megacolon) as it attempts to push stool past the distal obstruction. Thus, the pathology lies in the contracted segment, while the dilation is a secondary effect. 2. **Why Other Options are Incorrect:** * **Option B:** The most common site is the **Rectosigmoid region** (80% of cases), not the descending colon. * **Option C:** While a Barium enema is a useful screening tool (showing a "transition zone"), it is **not diagnostic**. The **Gold Standard** for diagnosis is a **Rectal Suction Biopsy**, which demonstrates the absence of ganglion cells and increased acetylcholinesterase staining. * **Option D:** Barium enema shows a transition zone and delayed evacuation of contrast; it does **not** show calcification. (Calcification is more characteristic of Meconium Peritonitis). **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Delayed passage of meconium (>48 hours), abdominal distension, and bilious vomiting. * **Physical Exam:** "Blast sign" or "Squirt sign" (explosive release of stool/gas on digital rectal exam). * **Associated Condition:** Strongly associated with **Down Syndrome** (Trisomy 21). * **Radiology:** Look for an "inverted cone" appearance on Barium enema. * **Management:** Definitive treatment involves surgical pull-through procedures (e.g., Duhamel, Soave, or Swenson).

Question 1

What is the first investigation to be performed in a neonate presenting with frothy mouth and dyspnea?

Accepted Answer

Nasogastric tube insertion and chest X-ray to check tube position

Answer

Bronchoscopy with injection of methylene blue

Answer

CT scan of the chest

Answer

Endoscopy

Question 2

A female newborn presents with a large midline tumor in the lower sacral area, diagnosed as a sacrococcygeal tumor. Which of the following courses of treatment is recommended for this child?

Accepted Answer

Surgical removal by age 6 months

Answer

Immediate chemotherapy and radiation treatment

Answer

Surgical removal at age 4-5 years

Answer

Surgical removal at age 13-15 years

Question 3

Which one of the following statements is true of an undescended testis?

Accepted Answer

Has a higher incidence of malignancy.

Answer

Usually descends spontaneously at puberty.

Answer

Orchiopexy is to be done if no descent by puberty.

Answer

Maintains normal sperm production.

Question 4

What does the 'Signe de Dance' refer to?

Accepted Answer

Empty right iliac fossa in intussusception

Answer

Pincer shaped appearance in barium enema in intussusception

Answer

Tenderness at McBurney's Point

Answer

Passing of large quantities of urine in hydronephrosis

Question 5

What is the most common cause of hydronephrosis in children?

Accepted Answer

Congenital PUJ obstruction

Answer

Ureterocoele

Answer

Ureteric stricture

Answer

Watermelon prostate

Question 6

What is the optimal management of bilateral undescended testicles in an infant?

Accepted Answer

Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 1 if descent has not occurred

Answer

Immediate surgical placement into the scrotum

Answer

Observation until the child is 2 years old because delayed descent is common

Answer

Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school

Question 7

What is the commonest type of tracheo-esophageal fistula?

Accepted Answer

Proximal end blind; distal end communicating with the trachea

Answer

Distal end blind; proximal end communicating with the trachea

Answer

Both ends blind

Answer

Both ends open

Question 8

Which of the following is NOT a feature of ectopia vesicae?

Accepted Answer

X-linked dominant inheritance

Answer

Epispadias

Answer

Bifid clitoris

Answer

Undescended testis

Question 9

Hirschsprung's disease is characterized by which of the following features?

Accepted Answer

Seen more frequently in children with Down's syndrome than in the general population.

Answer

Inherited in an autosomal recessive fashion.

Answer

Caused by unopposed parasympathetic activity in the affected segment of the bowel.

Answer

Has an equal incidence in girls and boys.

Question 10

Which of the following is true about Hirschsprung's disease?

Accepted Answer

The aganglionic segment is contracted, not dilated.

Answer

The descending colon is the most common site.

Answer

Barium enema is diagnostic.

Answer

Barium enema shows calcification.

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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