Pediatric Surgery Practice Questions

Q: All are features of congenital megacolon except:

Large bulky stools. ***Large bulky stools*** - Patients with **congenital megacolon** (Hirschsprung disease) typically have difficulty passing stool, leading to small, pellet-like stools or significant constipation, not large bulky stools. - The absence of **ganglion cells** in the affected segment prevents proper relaxation and propulsion, resulting in stool retention and a narrow, spastic segment. *Pseudodiarrhoea* - **Pseudodiarrhoea** can occur in congenital megacolon when liquid stool bypasses the impaction, leading to overflow incontinence. - This symptom is often mistaken for true diarrhea but is characteristic of severe constipation. *Tight anal ring* - A **tight anal ring** on digital rectal examination is a classic finding in Hirschsprung disease due to the spastic, aganglionic segment extending down to the internal anal sphincter. - This spasticity prevents normal relaxation of the internal anal sphincter. *Failure to thrive* - **Failure to thrive** is a common complication of congenital megacolon due to chronic constipation, poor nutrient absorption secondary to bowel stasis, and recurrent enterocolitis. - Chronic poor feeding and malabsorption contribute to inadequate weight gain and growth.

Q: Congenital megacolon is confirmed by:

Rectal biopsy. ***Rectal biopsy*** - **Rectal biopsy** is the **gold standard** for diagnosing congenital megacolon (Hirschsprung disease) by demonstrating the **absence of ganglion cells** in the myenteric and submucosal plexuses [1]. - This absence of innervation leads to a functional obstruction, causing proximal bowel dilation [1]. *Sigmoidoscopy* - While **sigmoidoscopy** allows visualization of the mucosa, it cannot directly confirm the **absence of ganglion cells**, which is the hallmark of Hirschsprung disease. - It may reveal features like a **narrowed segment** transition to a dilated segment but requires further diagnostic confirmation. *Invertogram* - An **invertogram** is used to assess the **anal position** and check for imperforate anus by showing the gas bubble in the rectum relative to the skin marker. - It does not provide information about the **innervation of the rectosigmoid colon** or the presence of ganglion cells. *Barium enema* - A **barium enema** can reveal characteristic findings like a **transition zone** between a narrowed aganglionic segment and a dilated, normally innervated colon. - However, it is a **radiological study** and cannot definitively confirm the histopathological absence of ganglion cells, which requires a tissue biopsy. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 759-760.

Q: A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

Peritoneal drainage. ***Peritoneal drainage*** - In a newborn with **perforated necrotizing enterocolitis (NEC)** and **poor general condition**, peritoneal drainage is the preferred initial surgical approach to address sepsis while avoiding major abdominal surgery. - This procedure involves draining accumulated fluid and pus from the peritoneal cavity, reducing intra-abdominal pressure and systemic inflammation in a medically unstable patient. *Resection and anastomosis* - **Resection and primary anastomosis** is a more extensive surgical procedure that carries higher risks in a globally unstable neonate. - This surgery is typically reserved for more stable patients or as a secondary procedure once the patient's condition has improved following initial decompression. *Conservative treatment* - **Conservative treatment** alone is insufficient and inappropriate for **perforated necrotizing enterocolitis**, as perforation implies the need for surgical intervention to address peritonitis and sepsis. - Delaying surgical management in perforation can lead to rapid deterioration, severe sepsis, and increased mortality. *Stabilization with membrane oxygenator and defer surgery* - While an **extracorporeal membrane oxygenator (ECMO)** might be used for respiratory or cardiovascular support in severe cases, it does not address the underlying **perforation and peritonitis**. - **Deferring surgery** for perforation is not an option as surgical source control is necessary to manage the acute peritonitis and sepsis, even if the patient is on ECMO.

Q: A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

Ileal (Meckel) diverticulum. ***Ileal (Meckel) diverticulum*** - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract, present in approximately 2% of the population. - It is the **most common cause of painless, profuse rectal bleeding** in the pediatric age group, typically presenting with brick-red or maroon stools. - The bleeding results from **peptic ulceration of the ileal mucosa** adjacent to ectopic (heterotopic) gastric mucosa within the diverticulum, which secretes acid. - Diagnosis is often confirmed with a **Technetium-99m pertechnetate scan** (Meckel's scan), which detects ectopic gastric mucosa. *External hemorrhoids* - External hemorrhoids typically present with **pain, itching, and a palpable perianal lump**, especially when thrombosed. - While they can cause bleeding, it is usually **minimal and bright red**, not the profuse rectal bleeding described in this case. - Hemorrhoids are **uncommon in children** and usually associated with chronic constipation or straining. *Internal hemorrhoids* - Internal hemorrhoids can cause **painless bleeding**, but this typically manifests as bright red blood coating the stool or dripping into the toilet bowl. - The bleeding is usually **minor and intermittent**, not profuse or life-threatening. - They are **much less common in the pediatric population** compared to adults and are not a typical cause of significant hemorrhage in children. *Diverticulosis* - Colonic diverticulosis is predominantly a **disease of older adults** (typically >40 years of age) related to dietary factors and increased intraluminal pressure. - It is **extremely rare in the pediatric age group** and would not be a primary consideration in a 12-year-old. - While diverticulosis can cause significant painless bleeding in adults, its occurrence in children is highly unlikely.

Q: A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?

Malrotation with volvulus. ***Malrotation with volvulus*** - The acute onset of **bilious vomiting** in a 1-week-old infant is a **surgical emergency** and highly suggestive of intestinal obstruction, with malrotation with volvulus being a critical consideration. - The barium enema image (B) shows the **ligament of Treitz** located to the right of the midline, indicating **intestinal malrotation** and a **corkscrew pattern** of the duodenum, which is pathognomonic for **midgut volvulus**. *Hypertrophic pyloric stenosis* - Typically presents with **non-bilious projectile vomiting** and palpable **pyloric olive mass**, usually appearing between 3 to 6 weeks of age, not at 1 week with bilious vomiting. - Imaging would reveal an **elongated, narrowed pyloric channel** (string sign) and thickened pyloric muscle, not the findings seen in the barium study. *Acute appendicitis* - This is an **extremely rare diagnosis** in a 1-week-old infant and typically presents with localized pain, fever, and leukocytosis, which are not the primary symptoms described. - Acute appendicitis would not explain the **bilious vomiting** or the specific findings on the barium study related to intestinal rotation. *Jejunal atresia* - Presents with bilious vomiting and abdominal distension, often diagnosed prenatally or shortly after birth due to proximal dilation and distal collapse of the bowel. - While it causes obstruction, the barium study in jejunal atresia would show a **blind-ending jejunum** and not the distinct malrotation and volvulus features (e.g., corkscrew sign, abnormal Treitz location).

Q: A 6 year old girl presents with Recurrent E.coli infection in urine. Ultrasound of abdomen shows Hydroureter and Hydronephrosis. Micturating cystourethrogram shows filling defect in urinary bladder. The likely diagnosis is –

Ureterocele. ***Ureterocele*** - A ureterocele is a **congenital dilation** of the distal ureter that protrudes into the bladder, often causing urinary obstruction and reflux. - The imaging findings of **hydroureter**, **hydronephrosis**, and a **filling defect** on MCUG are classic for ureterocele, which can lead to recurrent UTIs. *Duplication of Ureter* - While ureteral duplication can cause issues, it typically presents with two separate ureters entering the bladder or one ectopic ureter, and does not inherently cause a filling defect within the bladder itself unless complicated by an obstructed lower pole ureterocele or ectopic ureter. - The presence of a **filling defect** on MCUG is more characteristic of a ureterocele rather than isolated ureteral duplication. *Vesicoureteric Reflux – grade II* - **Vesicoureteric reflux (VUR)** involves the retrograde flow of urine from the bladder into the ureter and kidney, leading to recurrent UTIs, hydronephrosis, and hydroureter. - While VUR explains the recurrent UTIs and hydronephrosis, it does not account for the **filling defect** observed within the bladder on MCUG, which suggests an anatomical obstruction. *Sacrococcygeal Teratoma* - A **sacrococcygeal teratoma** is a tumor found at the base of the spine, primarily affecting newborns. - While it can cause bladder dysfunction due to mass effect if very large, it does not typically present as a **filling defect within the urinary bladder** itself and is usually diagnosed much earlier in life.

Q: A 6 year old boy has been complaining of headache, failing to notice objects on the sides for four months. On examination he is not mentally retarded, his grades at school are good, and visual acuity is diminished in both the eyes. Visual field testing showed significant field defect. CT scan of the head showed suprasellar mass with calcification. Which of the following is the most probable diagnosis?

Craniopharyngioma. ***Craniopharyngioma*** - A **suprasellar mass with calcification** in a child presenting with **visual field defects** and **headaches** is highly suggestive of craniopharyngioma. - These tumors typically arise from Rathke's pouch remnants and commonly cause **endocrine dysfunction** (though not explicitly stated as present here, it's a common association) and **visual pathway compression**. *Meningioma* - **Meningiomas** are rare in children and typically present as **dural-based masses** without characteristic calcification in the suprasellar region. - They are more common in adults, especially women, and often have a slower growth pattern. *Astrocytoma* - While astrocytomas can occur in children, they are usually **intra-axial** (within the brain parenchyma) and would typically cause focal neurological deficits related to their location, rather than a suprasellar mass with specific calcification. - **Pilocytic astrocytomas** are common in the cerebellar region but not characteristically suprasellar with calcification. *Pituitary adenoma* - **Pituitary adenomas** are extremely rare in children and grow within the sella turcica, originating from pituitary cells. - While they can cause visual field defects (classically **bitemporal hemianopsia**), they are typically soft tissue masses and calcification is not a common feature.

Q: Tumor involves inferior vena cava, what is the staging of Wilms tumour?

Stage III. ***Stage III*** - **Stage III Wilms tumor** is characterized by **residual non-hematogenous tumor** confined to the abdomen, including tumor extension into the **inferior vena cava (IVC)** or other **great vessels**. - IVC involvement represents **tumor thrombus in major vessels**, which classifies the disease as Stage III even without distant metastases. - Other Stage III criteria include peritoneal contamination, lymph node involvement, positive surgical margins, or tumor spillage. *Stage I* - **Stage I Wilms tumor** is **limited to the kidney** and has been **completely resected** with clear margins. - The renal capsule is intact with no vascular invasion, making IVC involvement inconsistent with Stage I. *Stage II* - **Stage II Wilms tumor** extends **beyond the kidney** (through renal capsule into perirenal fat) but has been **completely resected** with clear margins. - This stage does not involve macroscopic tumor thrombus in major vessels like the IVC. *Stage IV* - **Stage IV Wilms tumor** involves **hematogenous metastases** to distant sites such as lungs, liver, brain, or bone. - While IVC involvement is serious, it represents local vascular extension, not distant metastasis.

Q: A 5-month old child rushed into hospital with complaint of colicky pain, bilious vomiting and red current jelly like appearance of stools. On examination, there was a sausage shaped mass in the right lumbar region. Which of the following is the preferred modality that is used as both diagnostic and therapeutic?

Air enema. ***Air enema*** - An **air enema** can be both diagnostic and therapeutic for **intussusception**, using air pressure to reduce the telescoping bowel segment. - The classic triad of **colicky pain, bilious vomiting, and red currant jelly stools** strongly suggests intussusception, and an air enema is often the first-line intervention. *MRI* - **MRI** is not typically used for the initial diagnosis or treatment of pediatric intussusception due to its long imaging times and need for sedation. - While it can provide detailed anatomical information, it is not a **therapeutic** modality for this condition. *Anoscopy* - **Anoscopy** is a procedure used to visualize the anal canal and distal rectum, primarily for conditions like hemorrhoids or anal fissures. - It is **not suitable** for diagnosing or treating intussusception, which involves a more proximal bowel obstruction. *Barium enema* - A **barium enema** can be diagnostic and therapeutic for intussusception, using barium solution to reduce the intussusception. - However, **air enema** is generally preferred due to a lower risk of perforation and easier interpretation of reduction, making it the more common choice.

Q: Most common cause of urinary obstruction in a male infant is -

Posterior urethral valves. ***Posterior urethral valves*** - **Posterior urethral valves (PUV)** are the most common cause of significant **urinary tract obstruction** in male infants and are a congenital anomaly. - They are a membrane-like structure in the **posterior urethra** that obstructs urine outflow from the bladder. *Stone* - **Urinary stones** are a less common cause of obstruction in infants and are often associated with metabolic disorders or anatomical abnormalities. - While they can cause obstruction, they are not the most frequent cause in male infants. *Anterior urethral valves* - **Anterior urethral valves (AUV)** are a much rarer cause of urethral obstruction than PUV. - They occur more distally in the urethra and typically present with a **dilated anterior urethra**. *Stricture* - **Urethral strictures** in infants are usually acquired due to trauma, instrumentation, or infection, rather than being congenital. - They are less common than PUV as a primary cause of congenital urinary obstruction.

Question 1

All are features of congenital megacolon except:

Accepted Answer

Large bulky stools

Answer

Pseudodiarrhoea

Answer

Tight anal ring

Answer

Failure to thrive

Question 2

Congenital megacolon is confirmed by:

Accepted Answer

Rectal biopsy

Answer

Sigmoidoscopy

Answer

Invertogram

Answer

Barium enema

Question 3

A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

Accepted Answer

Peritoneal drainage

Answer

Resection and anastomosis

Answer

Conservative treatment

Answer

Stabilization with membrane oxygenator and defer surgery

Question 4

A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

Accepted Answer

Ileal (Meckel) diverticulum

Answer

External hemorrhoids

Answer

Internal hemorrhoids

Answer

Diverticulosis

Question 5

A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?

Accepted Answer

Malrotation with volvulus

Answer

Hypertrophic pyloric stenosis

Answer

Acute appendicitis

Answer

Jejunal atresia

Question 6

A 6 year old girl presents with Recurrent E.coli infection in urine. Ultrasound of abdomen shows Hydroureter and Hydronephrosis. Micturating cystourethrogram shows filling defect in urinary bladder. The likely diagnosis is –

Accepted Answer

Ureterocele

Answer

Duplication of Ureter

Answer

Vesicoureteric Reflux – grade II

Answer

Sacrococcygeal Teratoma

Question 7

A 6 year old boy has been complaining of headache, failing to notice objects on the sides for four months. On examination he is not mentally retarded, his grades at school are good, and visual acuity is diminished in both the eyes. Visual field testing showed significant field defect. CT scan of the head showed suprasellar mass with calcification. Which of the following is the most probable diagnosis?

Accepted Answer

Craniopharyngioma

Answer

Meningioma

Answer

Astrocytoma

Answer

Pituitary adenoma

Question 8

Tumor involves inferior vena cava, what is the staging of Wilms tumour?

Accepted Answer

Stage III

Answer

Stage II

Answer

Stage I

Answer

Stage IV

Question 9

A 5-month old child rushed into hospital with complaint of colicky pain, bilious vomiting and red current jelly like appearance of stools. On examination, there was a sausage shaped mass in the right lumbar region. Which of the following is the preferred modality that is used as both diagnostic and therapeutic?

Accepted Answer

Air enema

Answer

MRI

Answer

Anoscopy

Answer

Barium enema

Question 10

Most common cause of urinary obstruction in a male infant is -

Accepted Answer

Posterior urethral valves

Answer

Stone

Answer

Anterior urethral valves

Answer

Stricture

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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