Pediatric Surgery Practice Questions

Q: Which of the following is true for Bochdalek hernia?

It is a congenital disorder.. **Explanation:** **Bochdalek Hernia** is the most common type of Congenital Diaphragmatic Hernia (CDH), accounting for approximately 85-90% of cases. 1. **Why Option B is Correct:** It is a **congenital disorder** resulting from the failure of the pleuroperitoneal membranes to fuse with the septum transversum and dorsal mesentery of the esophagus during the 8th to 10th week of intrauterine life. This creates a defect in the diaphragm through which abdominal viscera herniate into the thoracic cavity. 2. **Why Other Options are Incorrect:** * **Option A:** It occurs most commonly on the **left side (80-85%)**. The right side is protected by the presence of the liver. * **Option C:** It is a **posterolateral** defect. Anterior defects are known as **Morgagni hernias**, which are much rarer. * **Option D:** It typically causes **immediate respiratory distress** (within minutes to hours of birth), not starting on day 2-3. The distress is due to pulmonary hypoplasia and persistent pulmonary hypertension. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of CDH:** Dyspnea, Cyanosis, and Dextrocardia (if left-sided). * **Physical Exam:** Scaphoid abdomen, absent breath sounds on the affected side, and bowel sounds heard in the chest. * **Radiology:** "Bowel loops in the hemithorax" with a mediastinal shift. * **Management:** Initial stabilization is key. **Avoid bag-and-mask ventilation** (distends the gut, worsening lung compression); instead, perform immediate endotracheal intubation. Surgery is not an emergency; it is performed after the neonate is hemodynamically stable.

Q: Identify the pathology in the child.

Umbilical Hernia. ***Umbilical Hernia*** - This is a protrusion of abdominal contents through a weak spot at the **umbilicus** (belly button), which is clearly depicted in the image. It occurs due to the incomplete closure of the umbilical ring after birth. - Umbilical hernias are very common in infants, particularly those born prematurely, and most resolve spontaneously without intervention by the age of 4-5 years. *Spigelian Hernia* - A Spigelian hernia occurs through the **Spigelian fascia**, located at the lateral edge of the rectus abdominis muscle, typically below the umbilicus. The bulge in the image is midline, not lateral. - This type of hernia is rare, especially in the pediatric population, and presents as a palpable mass on the side of the lower abdomen. *Inguinal Hernia* - An inguinal hernia involves the protrusion of abdominal contents through the **inguinal canal**, resulting in a bulge in the groin or scrotum. The location in the image is the umbilicus, not the groin. - While common in children, inguinal hernias are anatomically distinct and are located inferior and lateral to the umbilicus. *Femoral Hernia* - A femoral hernia occurs through the **femoral canal**, presenting as a bulge in the upper thigh, just below the inguinal ligament. This location is significantly different from the periumbilical bulge shown. - These hernias are rare in children and are more commonly seen in adult females due to the wider pelvis.

Q: A neonate has intestines protruding from the abdomen without any external covering. What will be your next line of management?

Cover the content with a Silo bag and wait. ***Cover the content with a Silo bag and wait*** - This presentation, where intestines protrude without a covering sac, is **gastroschisis**. The primary management for gastroschisis usually involves a **staged reduction** using a pre-formed **silo bag** (or pouch). - The silo allows the edematous bowel to gradually return into the abdominal cavity by gravity over several days, minimizing the risk of **abdominal compartment syndrome** and visceral ischemia that can occur with forced primary closure. *Surgical correction* - Immediate primary surgical closure is often difficult in gastroschisis because the infant's abdominal cavity is relatively small (**abdominal paucity**). - Forcing closure when the volume is too large can significantly elevate intra-abdominal pressure, potentially leading to **intestinal ischemia** or respiratory compromise. *Conservative management with higher antibiotics* - Gastroschisis is a surgical emergency requiring definitive intervention (closure or staged reduction); simple conservative management or antibiotics alone is insufficient. - While **antibiotics** are a necessary supportive measure to prevent infection of the exposed bowel, they do not address the underlying anatomical defect or the risk of desiccation and mechanical injury. *Cover with NS-soaked gauze* - Covering the exposed bowel with warm, **NS-soaked gauze** is an essential immediate stabilization step during resuscitation and transport, protecting the viscera and minimizing fluid and heat loss. - However, the **silo bag** is considered the definitive method for long-term protection and **staged reduction** in cases where primary surgical repair is not feasible, making it the superior choice for the next line of management.

Q: A 2-month-old male infant presents with a scrotal swelling that has been present since birth. Now, the swelling has become suddenly painful, red, and irreducible. What is the most likely diagnosis?

Strangulated inguinal hernia. **Strangulated inguinal hernia** - The presence of a scrotal swelling since birth strongly suggests an underlying indirect inguinal hernia, common due to a **patent processus vaginalis** in infants. - Sudden onset of severe pain, marked **irreducibility**, and **erythema** (redness) indicates vascular compromise of the contents (often bowel), classifying it as a surgical emergency (strangulation). *Acute epididymo-orchitis* - This condition is exceedingly rare in 2-month-old infants unless associated with underlying **urinary tract anomalies** or sepsis, and typically presents acutely without a long-standing mass. - The pain and swelling would usually involve the testicle/epididymis itself, accompanied by fever, and is less likely to present with the history of a mass existing **since birth**. *Testicular torsion* - Torsion usually presents with an extremely rapid onset of severe testicular pain without a history of a chronic mass, and often occurs due to inadequate fixation (**bell-clapper deformity**). - While painful, torsion involves the testicle and is generally diagnosed by absence of flow on **Doppler ultrasound**, unlike a hernia mass. *Incarcerated inguinal hernia* - An incarcerated hernia is irreducible because the contents are trapped, but the key differentiating factor is the lack of **vascular compromise**. - The presence of severe pain, tenderness, and redness (erythema) indicates progression beyond simple incarceration to **strangulation**, necessitating immediate intervention.

Q: Identify the type of diaphragmatic hernia shown in the X-ray.

Bochdalek hernia. ***Bochdalek hernia*** - This is the most common type of congenital diaphragmatic hernia (CDH), accounting for over 80% of cases, and is characterized by a defect in the **posterolateral** aspect of the diaphragm. - The X-ray shows classic findings: multiple **gas-filled bowel loops** in the left hemithorax, causing **mediastinal shift** to the right and compression of the left lung, which is consistent with a left-sided Bochdalek hernia. *Morgagni hernia* - This is a rare, **anteromedial** diaphragmatic defect that occurs through the **foramen of Morgagni**, typically on the right side. - It is less common than Bochdalek hernia and often discovered incidentally in older children or adults, presenting with less severe respiratory symptoms. *Hiatal hernia* - This involves the protrusion of the upper part of the stomach through the **esophageal hiatus** into the chest. - It is a midline defect and typically presents with **gastroesophageal reflux disease (GERD)**, not the extensive herniation of multiple abdominal organs seen in this neonatal X-ray. *Traumatic diaphragmatic hernia* - This is an **acquired** condition resulting from severe blunt or penetrating trauma to the chest or abdomen, not a congenital defect. - While it can appear similar on imaging, the clinical context of a newborn (as suggested by the image) makes a congenital cause like Bochdalek hernia the most likely diagnosis.

Q: A newborn child is brought to the emergency department with respiratory difficulty. On evaluation, the child was found to have a posterolateral defect, as shown in the x-ray given. What is the diagnosis?

Bochdalek hernia. ***Bochdalek hernia*** - This is the most common type of **congenital diaphragmatic hernia (CDH)**, representing about 85-90% of cases, and is characterized by a defect in the **posterolateral** aspect of the diaphragm. - It most commonly occurs on the **left side**, allowing abdominal contents like the stomach and intestines to herniate into the chest, leading to **pulmonary hypoplasia** and severe respiratory distress in a newborn, which is consistent with the X-ray findings. *Morgagni hernia* - This is a rare type of CDH involving an **anteromedial** defect in the diaphragm, specifically through the foramen of Morgagni, not a posterolateral one. - It is more commonly found on the **right side** and is often asymptomatic, typically diagnosed incidentally later in life rather than causing acute respiratory failure in a newborn. *Hiatal hernia* - This involves the protrusion of the upper part of the stomach into the thorax through the **esophageal hiatus**, a different anatomical location than the defect in this case. - Hiatal hernias are most often associated with **gastroesophageal reflux disease (GERD)** and are uncommon causes of severe respiratory distress in the neonatal period. *Traumatic diaphragmatic hernia* - This is an **acquired** condition resulting from blunt or penetrating trauma to the chest or abdomen that causes a rupture of the diaphragm. - The patient is a newborn, making a **congenital defect** the cause of the hernia, not trauma.

Q: A 4-year-old boy was brought to the emergency department with complaints of melena and acute intermittent pain in the right iliac region. On surgical exploration, a diverticulum containing gastric mucosa was found. What is the diagnosis? ![img-71.jpeg](img-71.jpeg)

Meckel's diverticulum. ***Meckel's diverticulum*** - This is a remnant of the **vitelline duct** and is the most common congenital anomaly of the gastrointestinal tract, classically presenting with painless rectal bleeding in a young child. - The symptoms of **melena** and right iliac fossa pain are due to ulceration caused by acid secretion from ectopic **gastric mucosa**, which is found in about 50% of symptomatic cases. *Appendicular lump* - An appendicular lump is an inflammatory mass formed by the inflamed appendix and adjacent structures, typically presenting with fever, pain, and a palpable mass in the right iliac fossa. - It does not contain ectopic gastric mucosa and would not be the primary cause of melena; the image shows a distinct diverticulum, not an inflammatory phlegmon. *Carcinoid* - A carcinoid is a **neuroendocrine tumor** that can occur in the GI tract, but it appears as a solid, yellowish tumor, which is different from the structure shown in the image. - While it can cause bleeding or obstruction, the classic history of bleeding from ectopic gastric mucosa is not associated with carcinoid tumors. *Obstructed bowel loops* - This is a clinical finding rather than a specific diagnosis. While a Meckel's diverticulum can cause bowel obstruction (e.g., through **intussusception** or volvulus), the image and history point to the diverticulum as the primary pathology. - The image shows a specific anatomical structure (the diverticulum), not the general appearance of dilated, obstructed bowel loops proximal to a blockage.

Q: A 3-year-old child was brought to OPD with complaint of dysuria and ballooning on micturition and examination as given below, what is the diagnosis?

True phimosis. ***True phimosis*** - The image shows a severely narrowed, pinhole-like preputial opening, coupled with **dysuria** and **ballooning on micturition**, which are hallmark symptoms of symptomatic or **pathological phimosis**. - **Ballooning** occurs because the tight foreskin traps urine before it can exit, confirming significant distal urinary outflow obstruction. *Balanitis xerotica obliterans* - Although BXO is a leading cause of pathological phimosis, this diagnosis is reserved for cases showing characteristic **sclerotic, white, atrophic skin changes** around the meatus, which are absent in the image. - BXO typically develops secondary to a chronic inflammatory process and is often considered when the phimosis is **acquired** rather than purely developmental. *Recurrent balanoposthitis* - Balanoposthitis is an inflammation of the glans and prepuce, typically presenting with **erythema, swelling, and discharge**. - While repeated episodes can lead to **scarring and acquired phimosis**, the primary and most concerning diagnosis here is the resulting anatomical obstruction (phimosis) that is causing symptoms. *Recurrent urinary tract infections* - **Recurrent UTIs** are a potential complication of significant true phimosis, resulting from urine stasis and poor hygiene. - However, the symptoms described, especially **ballooning on micturition**, directly indicate the presence of urethral **outflow obstruction**, which is the diagnosis.

Q: What is the malformation shown in the image?

Penoscrotal type. ***Penoscrotal type*** - The image distinctly shows the **urethral opening** located on the **ventral aspect of the penis**, at the junction where the penis meets the scrotum. - This position, where the meatus is located proximally at the base of the penis or in the scrotum, is characteristic of the **penoscrotal type of hypospadias**. *Glandular type* - In **glandular hypospadias**, the urethral opening is located on the **glans penis**, typically slightly displaced from the tip. - The image shows the opening much further down the shaft, not on the glans. *Coronal type* - The **coronal type of hypospadias** refers to the urethral opening being located in the **corona**, the groove separating the glans from the shaft of the penis. - The opening in the image is more proximal than the coronal sulcus. *Penile type* - **Penile hypospadias** refers to the urethral opening being located anywhere along the **shaft of the penis**, but it is a broad category. - The specific location shown in the image, at the base of the penis near the scrotum, is more precisely described as **penoscrotal hypospadias**.

Question 1

Which of the following is true for Bochdalek hernia?

Accepted Answer

It is a congenital disorder.

Answer

It commonly occurs on the right side.

Answer

It is in an anterior position.

Answer

It causes breathing difficulty in newborns from day 2-3.

Question 2

Identify the pathology in the child.

Accepted Answer

Umbilical Hernia

Answer

Inguinal Hernia

Answer

Femoral Hernia

Answer

Spigelian Hernia

Question 3

A neonate has intestines protruding from the abdomen without any external covering. What will be your next line of management?

Accepted Answer

Cover the content with a Silo bag and wait

Answer

Surgical correction

Answer

Cover with NS-soaked gauze

Answer

Conservative management with higher antibiotics

Question 4

A 2-month-old male infant presents with a scrotal swelling that has been present since birth. Now, the swelling has become suddenly painful, red, and irreducible. What is the most likely diagnosis?

Accepted Answer

Strangulated inguinal hernia

Answer

Incarcerated inguinal hernia

Answer

Acute epididymo-orchitis

Answer

Testicular torsion

Question 5

Identify the type of diaphragmatic hernia shown in the X-ray.

Accepted Answer

Bochdalek hernia

Answer

Morgagni hernia

Answer

Hiatal hernia

Answer

Traumatic diaphragmatic hernia

Question 6

A newborn child is brought to the emergency department with respiratory difficulty. On evaluation, the child was found to have a posterolateral defect, as shown in the x-ray given. What is the diagnosis?

Accepted Answer

Bochdalek hernia

Answer

Morgagni hernia

Answer

Hiatal hernia

Answer

Traumatic diaphragmatic hernia

Question 7

A 4-year-old boy was brought to the emergency department with complaints of melena and acute intermittent pain in the right iliac region. On surgical exploration, a diverticulum containing gastric mucosa was found. What is the diagnosis? ![img-71.jpeg](img-71.jpeg)

Accepted Answer

Meckel's diverticulum

Answer

Appendicular lump

Answer

Obstructed bowel loops

Answer

Carcinoid

Question 8

A 2-month-old infant presents with projectile non-bilious vomiting after each feeding for the past week, weight loss, and constant hunger. On examination, a firm, olive-shaped mass is palpable in the right upper quadrant. Serum electrolytes show hypochloremic hypokalemic metabolic alkalosis. What is the definitive treatment?

Accepted Answer

Intravenous fluid resuscitation and electrolyte correction followed by pyloromyotomy

Answer

Conservative management with thickened feeds

Answer

Emergency exploratory laparotomy

Answer

Ranitidine therapy for gastroesophageal reflux

Question 9

A 3-year-old child was brought to OPD with complaint of dysuria and ballooning on micturition and examination as given below, what is the diagnosis?

Accepted Answer

True phimosis

Answer

Recurrent balanoposthitis

Answer

Balanitis xerotica obliterans

Answer

Recurrent urinary tract infections

Question 10

What is the malformation shown in the image?

Accepted Answer

Penoscrotal type

Answer

Glandular type

Answer

Coronal type

Answer

Penile type

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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