Pediatric Surgery Practice Questions

Q: What is the initial palliative treatment for Tetralogy of Fallot?

Modified BT shunt. **Modified BT shunt** - The **Modified Blalock-Taussig (BT) shunt** is the initial palliative treatment for Tetralogy of Fallot, providing a reliable source of **pulmonary blood flow** in infants with severe cyanosis. - It involves connecting a **systemic artery** (subclavian or brachiocephalic artery) to the **pulmonary artery** using an interposition graft, increasing blood flow to the lungs. *Waterston shunt* - The **Waterston shunt** connects the **ascending aorta** to the **right pulmonary artery**. - It has a higher incidence of **pulmonary artery distortion** and pulmonary hypertension, making it less favorable than the modified BT shunt. *BT shunt* - The classic **Blalock-Taussig shunt** involves a direct anastomosis between the subclavian artery and the pulmonary artery. - While effective, the **Modified BT shunt** using a graft is generally preferred due to less vascular injury and improved long-term patency. *Potts shunt operation* - The **Potts shunt** connects the **descending aorta** to the **left pulmonary artery**. - Similar to the Waterston shunt, it carries a higher risk of **pulmonary artery distortion** and is rarely used today.

Q: A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

IV Fluids - antibiotics - air enema. ***IV Fluids - antibiotics - air enema*** - The presentation of an excessive cry, a **right iliac fossa sausage-shaped lump**, and **blood in stools** (currant jelly stools) is classic for **intussusception** in an infant. - An **air enema** is the preferred initial treatment for uncomplicated intussusception as it is diagnostic and therapeutic, often reducing the intussusception while being safer than barium. Prompt IV fluids and antibiotics are crucial for stabilization and infection prophylaxis. *IV Fluids - antibiotics - barium enema* - While a **barium enema** can also be used for reduction, it carries a higher risk of **perforation** and is less frequently used than air enema due to its lower safety profile. - The diagnostic capabilities are similar, but the therapeutic benefits of air enema, particularly with lower complications, make it the preferred option. *IV Fluids - antibiotics - NG tube* - An **NG tube** is used for **gastric decompression** in cases of intestinal obstruction, which might be a part of the management if patients are vomiting or have significant abdominal distension. - However, an NG tube alone does not address the underlying **intussusception** and is not a definitive treatment for reducing the telescoped bowel itself. *IV Fluids - antibiotics - warm saline enema* - A **warm saline enema** is primarily used for evacuating contents from the bowel or for diagnostic purposes (e.g., imaging the colon). - It is **ineffective in reducing intussusception**, as it lacks the pressure capabilities required to successfully push back the invaginated bowel.

Q: X-ray can detect congenital anorectal malformation at –

48–72 hours. ***48–72 hours*** - This timeframe is preferred for X-ray detection of **congenital anorectal malformation** because it allows for adequate **gas accumulation** in the bowel. - The gas acts as a natural contrast agent, making the distal end of the rectum visible on the X-ray and helping determine the **level of the anomaly**. *24–48 hours* - While gas may begin to accumulate by this time, it might not be sufficient to clearly delineate the **level of the rectal pouch** in all cases. - A delay is often beneficial to ensure optimal imaging conditions for **accurate surgical planning**. *Immediately after birth* - Performing an X-ray immediately after birth is often too early as there hasn't been sufficient **time for gas to fill the bowel** distal to the obstruction. - This can lead to **inaccurate assessment** of the malformation's type and level. *After 72 hours* - While sufficient gas is present, delaying beyond 72 hours may unnecessarily delay **surgical intervention**. - Additionally, if gas distension becomes excessive, it could potentially complicate the **interpretation of the exact anatomy**.

Q: A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?

Intussusception. ***Intussusception*** - This condition is characterized by a "telescoping" of one segment of the intestine into another, which can lead to **abdominal pain**, **rectal bleeding** (often described as "currant jelly" stools), and a **palpable sausage-shaped mass** on examination. - A barium study (specifically a **barium enema**) is often diagnostic and can also be therapeutic for intussusception, revealing a **coiled spring appearance** or an obstruction. *Volvulus* - Volvulus involves the **twisting of a loop of bowel** around its mesentery, often presenting with sudden onset, severe **abdominal pain**, vomiting, and constipation. - While it can cause an obstruction and pain, a palpable mass and bloody stools are less common initial findings compared to intussusception. *Meckel's Diverticulum* - Meckel's diverticulum is a **congenital outpouching** of the small intestine that can be asymptomatic or cause complications like **gastrointestinal bleeding** (due to ectopic gastric mucosa), obstruction, or diverticulitis. - While it can cause painless rectal bleeding, a palpable mass and acute, intermittent abdominal pain are not typical primary presentations for an uncomplicated Meckel’s diverticulum. *Diverticulitis* - Diverticulitis is the **inflammation of diverticula** (small pouches in the colon), typically presenting with **left lower quadrant abdominal pain**, fever, and changes in bowel habits. - While it can cause bleeding, a palpable mass is less common unless there's an abscess, and the clinical picture does not align as strongly with the "currant jelly stool" and classic palpable mass of intussusception.

Q: A 4-year-old child was brought to the hospital with right impalpable testis. During diagnostic laparoscopy for undescended testis, there are blind testicular vessels. What should be done next?

Nothing is to be done. ***Nothing is to be done*** - The presence of **blind-ending testicular vessels** on diagnostic laparoscopy is diagnostic of **vanishing testis syndrome** (testicular regression syndrome). - This finding indicates that the testis underwent **atrophy and resorption** during fetal development or early infancy, and **no viable testicular tissue remains**. - The blind vessels represent **remnant vascular structures** where the testis once existed, confirming absence of testicular tissue beyond that point. - **No further surgical exploration is required** as the laparoscopy has already provided definitive diagnosis - the testis is absent, not located elsewhere. - This completes the diagnostic and therapeutic management for this condition. *Inguinal exploration* - This would be indicated if the testicular vessels were seen **entering the internal inguinal ring**, suggesting an inguinal or high scrotal location. - With **blind-ending vessels**, the testis is confirmed absent, making inguinal exploration unnecessary and futile. - Inguinal exploration would find no testicular tissue and subject the child to unnecessary additional surgery. *Abdominal exploration* - This is not needed as **diagnostic laparoscopy has already visualized the abdomen** and identified blind vessels. - If vessels were patent and leading to an intra-abdominal testis, orchidopexy would be performed laparoscopically. - Blind vessels rule out intra-abdominal testis location. *Scrotal exploration* - This approach is only appropriate for **palpable undescended testes** in the superficial inguinal pouch or high scrotum. - The testis is **impalpable** and laparoscopy shows **no testicular tissue exists**, making scrotal exploration illogical and non-contributory.

Q: A 10 year old child came to the OPD with pain and mass in right lumbar region with no fever, with right hip flexed. The pain increased on extension and X ray showed spine changes. Most probable diagnosis is:

Psoas abscess. ***Psoas abscess*** - A **psoas abscess** can present as a lumbar mass with pain, and the classic **psoas sign** (pain on hip extension) occurs because the inflamed psoas muscle is stretched. Spine changes on X-ray suggest a potential vertebral source, such as **spinal tuberculosis (Pott's disease)**, which is a common cause of psoas abscess in children. - The absence of fever does not rule out chronic infections like tuberculosis, and the **flexed hip posture** is a common compensatory mechanism to relieve tension on the inflamed psoas muscle. *Appendicular lump in retrocecal position* - While a retrocecal appendicular lump can cause a right lumbar mass, the pain would typically worsen with hip flexion, not extension, and it is less likely to be associated with **spine changes** on X-ray. - Appendicular lumps are usually accompanied by a history of appendicitis with pain that is often more diffuse in the right lower quadrant, and may be associated with **fever and leukocytosis**. *Pyonephrosis* - **Pyonephrosis** (pus in the kidney) would typically present with significant systemic symptoms of infection, such as **fever, chills, and flank pain**. - While it can cause a flank mass, the characteristic **hip flexion and pain on extension (psoas sign)**, along with spine changes, are not typical features. *Torsion of Right undescended testis* - **Testicular torsion** presents with sudden, severe scrotal pain (or inguinal/pelvic pain if undescended) and swelling, not a lumbar mass or psoas signs. - It would also not be associated with **spine changes** on an X-ray.

Q: A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?

Thyroglossal duct cyst. ***Thyroglossal duct cyst*** - A **midline neck swelling** that is **painless** and **moves with swallowing** or protrusion of the tongue is a classic presentation of a thyroglossal duct cyst. - This cyst develops from the **remnant of the embryonic thyroglossal duct**, connecting the thyroid gland to the tongue base. *Branchial cyst* - Typically presents as a **lateral neck mass**, usually anterior to the sternocleidomastoid muscle, not midline. - They are remnants of the **branchial arches** and are less likely to move with swallowing. *Dermoid cyst* - While dermoid cysts can occur in the neck and be midline, they are generally **not mobile with swallowing** because they are not attached to the hyoid bone or tongue. - They are congenital cysts formed from trapped skin elements. *Thyroid nodule* - A thyroid nodule would be located in the **lower anterior neck** over the thyroid gland, typically not as high as a thyroglossal duct cyst. - While it might move with swallowing, it is often firmer and may be associated with thyroid dysfunction or a history of radiation exposure, which is not mentioned here.

Q: In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Pneumatic reduction under fluoroscopy. ***Pneumatic reduction under fluoroscopy*** - This is the **first-line therapeutic procedure** for intussusception in hemodynamically stable children without peritoneal signs. - Uses air pressure to un-telescope the bowel segments, with success rates of **70-90%** in appropriately selected cases. - Performed under fluoroscopic or **ultrasound guidance** (ultrasound preferred in many centers to avoid radiation). - Contraindications include peritonitis, perforation, and shock. *Exploratory laparotomy* - Reserved as **second-line treatment** when pneumatic reduction fails (occurs in 10-30% of cases). - Also indicated when there are contraindications to reduction: **peritonitis, perforation, bowel necrosis**, or hemodynamic instability. - Allows manual reduction or bowel resection if necrotic segments are present. *Observation and supportive care* - Supportive measures (IV fluids, NG decompression, antibiotics) are **adjunctive** but not definitive treatment. - Intussusception requires **prompt intervention** as it can rapidly progress to bowel ischemia, necrosis, and perforation. - Observation alone is inadequate and risks serious complications. *Abdominal ultrasound only* - Ultrasound is the **gold standard for diagnosis**, showing the characteristic "target sign" or "pseudokidney sign." - However, it is **diagnostic only** and does not treat the intussusception. - Diagnosis must be followed by therapeutic intervention (reduction or surgery).

Question 1

What is the initial palliative treatment for Tetralogy of Fallot?

Accepted Answer

Modified BT shunt

Answer

Waterston shunt

Answer

BT shunt

Answer

Potts shunt operation

Question 2

A newborn male is noted to have difficulty feeding and "turns blue and chokes when drinking formula." The prenatal records reveal that the amniotic fluid appeared normal on ultrasound. A pediatric feeding tube is passed orally to 20 cm without difficulty, with gastric secretions aspirated. Which of the following is the most likely diagnosis?

Accepted Answer

Tracheoesophageal fistula

Answer

Floppy epiglottis

Answer

Zenker diverticulum

Answer

Congenital heart disease

Question 3

A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

Accepted Answer

IV Fluids - antibiotics - air enema

Answer

IV Fluids - antibiotics - barium enema

Answer

IV Fluids - antibiotics - NG tube

Answer

IV Fluids - antibiotics - warm saline enema

Question 4

X-ray can detect congenital anorectal malformation at –

Accepted Answer

48–72 hours

Answer

24–48 hours

Answer

Immediately after birth

Answer

After 72 hours

Question 5

A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?

Accepted Answer

Intussusception

Answer

Volvulus

Answer

Meckel's Diverticulum

Answer

Diverticulitis

Question 6

A 4-year-old child was brought to the hospital with right impalpable testis. During diagnostic laparoscopy for undescended testis, there are blind testicular vessels. What should be done next?

Accepted Answer

Nothing is to be done

Answer

Abdominal exploration

Answer

Inguinal exploration

Answer

Scrotal exploration

Question 7

A 10 year old child came to the OPD with pain and mass in right lumbar region with no fever, with right hip flexed. The pain increased on extension and X ray showed spine changes. Most probable diagnosis is:

Accepted Answer

Psoas abscess

Answer

Appendicular lump in retrocecal position

Answer

Pyonephrosis

Answer

Torsion of Right undescended testis

Question 8

A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?

Accepted Answer

Thyroglossal duct cyst

Answer

Branchial cyst

Answer

Dermoid cyst

Answer

Thyroid nodule

Question 9

In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Accepted Answer

Pneumatic reduction under fluoroscopy

Answer

Exploratory laparotomy

Answer

Observation and supportive care

Answer

Abdominal ultrasound only

Question 10

A neonate presented with fever, lethargy, abdominal distension, vomiting, and constipation. What is the most likely diagnosis?

Accepted Answer

Hirschsprung disease

Answer

Volvulus neonatorum

Answer

Intestinal atresia

Answer

Necrotizing enterocolitis

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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