Pediatric Surgery Practice Questions

Q: A child presents with fluid discharge from the umbilicus upon straining. What is the most likely diagnosis?

Urachal fistula. **Explanation:** The correct diagnosis is **Urachal fistula**. The urachus is a vestigial structure that connects the dome of the bladder to the umbilicus during fetal development. Normally, it obliterates to form the median umbilical ligament. If it remains completely patent, it creates a direct communication between the bladder and the umbilicus. When the child strains (increasing intra-abdominal pressure), **urine** is discharged from the umbilicus. **Analysis of Options:** * **Urachal fistula (Correct):** Characterized by the discharge of clear fluid (urine) from the umbilicus. Diagnosis is confirmed by biochemical analysis of the fluid (high urea/creatinine) or a fistulogram/ultrasound. * **Patent Vitellointestinal Duct (PVID):** This connects the midgut to the umbilicus. While it also causes umbilical discharge, the fluid is typically **fecal matter** or mucus, not clear urine. * **Gastroschisis:** A full-thickness abdominal wall defect (usually to the right of the umbilicus) where bowel loops herniate out without a covering sac. It is a neonatal emergency, not a simple discharge. * **Congenital Umbilical Hernia:** A protrusion of abdominal contents through a weak umbilical ring covered by skin. It presents as a bulge that increases with crying/straining but does not involve fluid discharge. **High-Yield Clinical Pearls for NEET-PG:** * **Urachal Remnants:** Can present as a fistula (discharge), cyst (palpable mass between umbilicus and pubis), or sinus (blind-ending tract at the umbilicus). * **Rule of 2s:** A patent vitellointestinal duct is related to Meckel’s Diverticulum. * **Management:** The definitive treatment for a symptomatic urachal fistula is surgical excision of the entire tract. * **Differential:** If the discharge is bloody or contains "cherry-red" mucosa, consider an **umbilical adenoma** (raspberry tumor).

Q: All are true about cystic hygroma, except?

Pulsatile. **Explanation:** Cystic hygroma is a **benign congenital malformation** of the lymphatic system, characterized by the failure of lymphatics to communicate with the venous system, leading to the formation of large, fluid-filled cysts (macrocystic lymphatic malformation). **Why "Pulsatile" is the Correct Answer (The Exception):** Cystic hygromas are **non-pulsatile**. Pulsatility is a clinical feature of arterial malformations or tumors in close proximity to major arteries (e.g., Carotid Body Tumor). A cystic hygroma is typically soft, cystic, painless, and most importantly, **brilliantly transilluminant** due to its clear lymph fluid content. It is also compressible but lacks a cough impulse. **Analysis of Other Options:** * **Common in the neck:** Approximately 70–80% of cystic hygromas occur in the **posterior triangle of the neck** (left side > right side). Other sites include the axilla and mediastinum. * **Present at birth:** About 50–60% are present at birth, and nearly 90% manifest by the age of two years. * **May cause respiratory obstruction:** Large hygromas can compress the trachea or involve the floor of the mouth and tongue (macroglossia), leading to acute airway compromise or feeding difficulties. **High-Yield Clinical Pearls for NEET-PG:** * **Transillumination:** The most characteristic clinical sign (Brilliantly positive). * **Association:** Frequently associated with chromosomal anomalies like **Turner Syndrome** (45, XO), Down Syndrome, and Noonan Syndrome. * **Surgical Anatomy:** They are not restricted by anatomical planes and often "interdigitate" between vital structures (nerves and vessels), making complete surgical excision challenging. * **Treatment:** Surgical excision is the gold standard; however, **Sclerosants** (e.g., OK-432/Picibanil, Bleomycin) are used for macrocystic lesions to reduce size.

Q: At what age is orchiopexy typically performed?

6 months. **Explanation:** The management of undescended testes (cryptorchidism) is a high-yield topic in pediatric surgery. The primary goal of treatment is to preserve fertility and facilitate early screening for malignancy. **1. Why 6 months is correct:** Spontaneous descent of the testes occurs frequently in the first few months of life, driven by the postnatal testosterone surge (often called "mini-puberty"). However, spontaneous descent is extremely rare after the age of **6 months**. Histological changes, such as the loss of germ cells and Leydig cell atrophy, begin as early as 6–12 months of age. Therefore, current international guidelines (AUA/EAU) recommend that orchiopexy be performed between **6 and 12 months** of age to optimize testicular health. **2. Analysis of Incorrect Options:** * **A. 2 months:** Too early. Many testes will still descend spontaneously during the first 3–4 months of life. * **C. 12 months:** While surgery can be done at this age, 6 months is the preferred starting point to minimize the duration of exposure to higher body temperatures. * **D. 24 months:** Waiting until 2 years is outdated practice. Delayed surgery significantly increases the risk of infertility and makes the testis harder to monitor for future malignancy. **Clinical Pearls for NEET-PG:** * **Most common site:** Inguinal canal. * **Most common complication of Orchiopexy:** Testicular atrophy. * **Malignancy Risk:** Orchiopexy does *not* eliminate the risk of testicular cancer (most commonly Seminoma), but it makes the testis accessible for physical examination. * **HCG Therapy:** Rarely used now; surgery is the gold standard. * **Laparoscopy:** The investigation of choice for a non-palpable testis.

Q: A newborn is found to have a defect in the central abdomen at birth. Which of the following features is NOT suggestive of Omphalocele as a diagnosis?

The defect is open. ### **Explanation** The correct answer is **A. The defect is open.** **1. Why Option A is the correct answer:** An **Omphalocele** is a midline abdominal wall defect where the herniated viscera are **covered by a sac** consisting of an inner layer of peritoneum and an outer layer of amnion. Therefore, the defect is **not open**. In contrast, **Gastroschisis** is characterized by an open defect (usually to the right of the umbilical cord) where the bowel is exposed directly to the amniotic fluid without any protective membrane. **2. Analysis of Incorrect Options:** * **Option B (Associated with trisomy 13):** This is a true feature of Omphalocele. Approximately 30-50% of cases are associated with chromosomal abnormalities, most commonly Trisomy 13, 18, and 21. * **Option C (Associated with other congenital anomalies):** This is true. Omphalocele is frequently associated with other structural defects, including cardiac anomalies (most common), neural tube defects, and syndromes like **Beckwith-Wiedemann Syndrome**. * **Option D (Umbilical cord is at the apex):** This is a hallmark diagnostic feature. In Omphalocele, the umbilical cord inserts directly into the apex of the sac, whereas in Gastroschisis, the cord inserts normally into the abdominal wall. ### **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Omphalocele is **midline** (through the umbilical ring); Gastroschisis is **para-umbilical** (usually right-sided). * **Sac:** Omphalocele = **Sac present**; Gastroschisis = **No sac** (leads to thickened, matted bowel loops due to chemical peritonitis). * **Beckwith-Wiedemann Syndrome:** Characterized by Omphalocele, Macroglossia, and Gigantism (monitor for hypoglycemia). * **Pentalogy of Cantrell:** Includes Omphalocele, diaphragmatic hernia, sternal cleft, pericardial defect, and intracardiac defects (Ectopia cordis).

Q: A neonate is found to have an imperforate anus. You recommend studies to search for other anomalies because infants with anorectal anomalies tend to have other congenital anomalies. What associated abnormalities are commonly seen with imperforate anus?

Cardiac disease. **Explanation:** Anorectal malformations (ARMs), such as imperforate anus, are frequently associated with other congenital anomalies in approximately 50–60% of cases. The most common framework for these associations is the **VACTERL association**. **1. Why Cardiac disease is correct:** Congenital Heart Disease (CHD) is one of the most frequent systemic associations in infants with imperforate anus, occurring in about **30–35%** of patients. Common defects include Ventricular Septal Defects (VSD), Atrial Septal Defects (ASD), and Tetralogy of Fallot. Because of this high prevalence, an echocardiogram is a mandatory screening tool in the initial evaluation of any neonate with an ARM. **2. Why the other options are incorrect:** * **Abnormalities of the cervical spine:** While vertebral anomalies are part of VACTERL, they most commonly involve the **lumbar and sacral spine** (e.g., hemivertebrae, sacral agenesis). Cervical spine involvement is rare. * **Hydrocephalus:** This is not a classic component of the VACTERL association. Central nervous system anomalies are generally less common than urogenital or cardiac ones in ARM patients. * **Duodenal atresia:** While GI anomalies occur, **Esophageal Atresia with Tracheoesophageal Fistula (TEF)** is the specific GI association defined in VACTERL. Duodenal atresia is more classically associated with Down Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **VACTERL mnemonic:** **V**ertebral, **A**nal atresia, **C**ardiac, **T**racheo-**E**sophageal fistula, **R**enal, and **L**imb (Radial dysplasia) anomalies. * **Most common association:** Genitourinary anomalies (40–50%) are the most frequent overall, followed by Vertebral and Cardiac. * **Initial Investigation:** After physical exam, the first steps are a **Cross-table lateral X-ray** (Invertogram) at 18–24 hours of life and screening for VACTERL (Echo, Spinal/Renal Ultrasound).

Q: What is the investigation of choice for Hirschsprung's disease?

Rectal biopsy. **Explanation:** **Hirschsprung’s Disease (Congenital Aganglionic Megacolon)** is characterized by the absence of ganglion cells in the Meissner’s and Auerbach’s plexuses, typically starting from the internal anal sphincter and extending proximally. **Why Rectal Biopsy is the Correct Answer:** Full-thickness or suction **rectal biopsy** is the **gold standard and investigation of choice**. The diagnosis is confirmed by the histological demonstration of the **absence of ganglion cells** and the presence of **hypertrophied nerve bundles**. Additionally, Acetylcholinesterase (AChE) staining shows increased nerve fiber activity, which is a key diagnostic marker. **Analysis of Incorrect Options:** * **Rectal Manometry:** This is the most sensitive **screening test**. It shows the absence of the Recto-Anal Inhibitory Reflex (RAIR)—failure of the internal sphincter to relax upon rectal distension. However, it is not confirmatory. * **Rectal Examination:** While a digital exam may result in a "blast sign" (explosive release of stool and gas), it is a clinical finding, not a definitive investigation. * **Barium Enema:** This is used to identify the **"transition zone"** (the area between the narrow aganglionic segment and the dilated proximal colon). While helpful for surgical planning, it can be normal in neonates and is not diagnostic. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Rectosigmoid region (Short-segment disease). * **Gold Standard:** Rectal Biopsy (taken at least 2 cm above the dentate line to avoid the normal hypoganglionic zone). * **Initial Management:** Rectal washouts to decompress the bowel. * **Definitive Surgery:** Pull-through procedures (e.g., Duhamel, Soave, or Swenson techniques).

Q: What is the management of a 1-week-old baby presenting with imperforate anus and meconuria?

Colostomy. In pediatric surgery, the management of Anorectal Malformations (ARM) is determined by the level of the lesion and the presence of a fistula. **Explanation of the Correct Answer:** The presence of **meconuria** (meconium in urine) is a pathognomonic sign of a **High-type ARM** with a **recto-urinary fistula** (recto-vesical or recto-urethral). In a 1-week-old neonate, a high-type lesion is a surgical emergency that cannot be managed by simple perineal procedures. The standard management is a **staged approach**: 1. **Stage 1:** Divided sigmoid **colostomy** to divert the fecal stream, prevent recurrent urinary tract infections (UTIs), and decompress the bowel. 2. **Stage 2:** Definitive repair via Posterior Sagittal Anorectoplasty (PSARP) at a later date. 3. **Stage 3:** Colostomy closure. **Why the other options are incorrect:** * **Conservative management:** This is fatal; the baby has an intestinal obstruction and a risk of severe urosepsis. * **V-Y plasty:** This is a skin flap technique used for minor reconstructive procedures, not for correcting internal anorectal defects. * **Ileostomy:** While it provides diversion, a colostomy is preferred in ARM because it allows for a "distal cologram" (the gold standard to identify the fistula site) and preserves more bowel length for water absorption. **High-Yield Clinical Pearls for NEET-PG:** * **Low-type ARM:** Managed by immediate **Anoplasty** (no colostomy needed). * **High-type ARM:** Managed by **Colostomy** followed by PSARP. * **VACTERL Association:** Always screen these babies for Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, and Limb anomalies. * **Invertogram (Wangensteen-Rice view):** Historically used to determine the level of the lesion; it is performed after 18–24 hours of life to allow air to reach the distal rectum.

Question 1

A child presents with fluid discharge from the umbilicus upon straining. What is the most likely diagnosis?

Accepted Answer

Urachal fistula

Answer

Gastroschisis

Answer

Patent vitellointestinal duct

Answer

Congenital umbilical hernia

Question 2

All are true about cystic hygroma, except?

Accepted Answer

Pulsatile

Answer

May cause respiratory obstruction

Answer

Common in the neck

Answer

Present at birth

Question 3

At what age is orchiopexy typically performed?

Accepted Answer

6 months

Answer

2 months

Answer

12 months

Answer

24 months

Question 4

A three-year-old male child presents with a two-year history of constipation and abdominal distension. A plain radiograph of the abdomen reveals fecal matter and distended bowel loops. A subsequent barium enema study shows a transition zone at the recto-sigmoid junction with reversal of the recto-sigmoid ratio. What is the most probable diagnosis?

Accepted Answer

Hirschsprung's disease

Answer

Anal atresia

Answer

Malrotation of the gut

Answer

Congenital megacolon

Question 5

A 7-day-old infant presents with bilious vomiting, gross abdominal distention, and absent bowel sounds. An X-ray of the abdomen shows multiple gas-filled loops. What is the diagnosis?

Accepted Answer

Malrotation of the gut

Answer

Hirschsprung disease

Answer

Congenital hypertrophic pyloric stenosis

Answer

Duodenal atresia

Question 6

A newborn is found to have a defect in the central abdomen at birth. Which of the following features is NOT suggestive of Omphalocele as a diagnosis?

Accepted Answer

The defect is open

Answer

Associated with trisomy 13

Answer

Associated with other congenital anomalies

Answer

Umbilical cord is at the apex of the membrane

Question 7

A neonate is found to have an imperforate anus. You recommend studies to search for other anomalies because infants with anorectal anomalies tend to have other congenital anomalies. What associated abnormalities are commonly seen with imperforate anus?

Accepted Answer

Cardiac disease

Answer

Abnormalities of the cervical spine

Answer

Hydrocephalus

Answer

Duodenal atresia

Question 8

What is the investigation of choice for Hirschsprung's disease?

Accepted Answer

Rectal biopsy

Answer

Rectal manometry

Answer

Rectal examination

Answer

Barium enema

Question 9

What is the management of a 1-week-old baby presenting with imperforate anus and meconuria?

Accepted Answer

Colostomy

Answer

Conservative management

Answer

V-Y plasty

Answer

Ileostomy

Question 10

Which of the following statements concerning imperforate anus is true?

Accepted Answer

The chance for eventual continence is greater when the rectum has descended to below the levator ani muscles.

Answer

Imperforate anus affects males more frequently than females.

Answer

In 90% of males, but only 50% of females, the rectum ends below the level of the levator ani complex.

Answer

The rectum usually ends in a blind pouch.

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?