Pediatric Surgery Practice Questions

Q: Snow storm ascites is seen in:

Meconium ileus. **Explanation:** **Meconium ileus** is the correct answer. This condition occurs in neonates (often associated with Cystic Fibrosis) where thick, inspissated meconium obstructs the terminal ileum. If antenatal perforation occurs, meconium escapes into the peritoneal cavity, leading to **meconium peritonitis**. On ultrasonography, the presence of scattered, echogenic flakes of meconium within the ascitic fluid creates a characteristic **"snowstorm" appearance**. Over time, these areas may calcify, appearing as bright linear or clumped echoes on X-ray or USG. **Why other options are incorrect:** * **Hirschsprung's disease:** Presents with distal bowel obstruction due to aganglionosis. While it can lead to enterocolitis or perforation, it does not typically present with the "snowstorm" sonographic pattern characteristic of meconium. * **Ileocaecal tuberculosis:** Characterized by "wet" or "dry" peritonitis. USG usually shows "matted loops" of bowel or a "stellate" appearance of the mesentery, but not a snowstorm pattern. * **Pseudomyxoma Peritonei:** Known for the **"scalloping" of the liver surface** and mucinous ascites. While the fluid is gelatinous, the specific "snowstorm" terminology is classically reserved for meconium peritonitis in pediatric surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Neuhauser’s Sign (Ground glass appearance):** Seen on X-ray in Meconium Ileus due to tiny air bubbles trapped in thick meconium. * **Microcolon:** A common finding on contrast enema in Meconium Ileus due to disuse. * **Cystic Fibrosis:** 90% of infants with meconium ileus have CF; it is the earliest clinical manifestation of the disease. * **Egg-shell calcification:** Often seen on abdominal X-ray in healed meconium peritonitis.

Q: A newborn, within a few hours of birth, develops bile-stained vomiting and epigastric distention. On examination, the abdomen is scaphoid with visible peristalsis in the upper abdomen. Per-rectal examination shows no stool in the rectum. X-ray of the abdomen shows air trapped in the stomach and proximal duodenum. What is the treatment of choice in this case?

Duodenoduodenostomy. ### Explanation The clinical presentation of **bilious vomiting**, epigastric distention with a **scaphoid abdomen**, and an X-ray showing the classic **"Double Bubble" sign** (air in the stomach and proximal duodenum) is pathognomonic for **Duodenal Atresia**. **Why Duodenoduodenostomy is Correct:** Duodenal atresia is a complete congenital obstruction of the duodenum. Once the patient is stabilized (nasogastric decompression and IV fluids), the definitive surgical treatment is a **Duodenoduodenostomy** (specifically the **Kimura "Diamond-shaped" anastomosis**). This procedure bypasses the atretic segment to restore bowel continuity. **Why Other Options are Incorrect:** * **Ramstedt Pyloromyotomy:** This is the treatment for Congenital Hypertrophic Pyloric Stenosis (CHPS). CHPS presents with *non-bilious* projectile vomiting and a palpable olive-shaped mass, typically at 3–6 weeks of age, not at birth. * **Conservative Management:** Duodenal atresia is a mechanical obstruction; it cannot be managed conservatively and is fatal without surgical intervention. * **Barium/Air Enema:** These are diagnostic and therapeutic modalities for **Intussusception** or **Sigmoid Volvulus**. While a contrast enema may be used to rule out associated malrotation, it does not treat duodenal atresia. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Approximately 30% of infants with duodenal atresia have **Down Syndrome (Trisomy 21)**. * **Prenatal Finding:** Often associated with **maternal polyhydramnios** due to the fetus's inability to swallow and absorb amniotic fluid. * **X-ray Sign:** The "Double Bubble" sign is the hallmark. If distal gas is present on X-ray, consider **Duodenal Stenosis** or **Malrotation with Midgut Volvulus** instead of complete atresia. * **Vomiting:** Bilious vomiting in a neonate is a surgical emergency until proven otherwise.

Q: Which of the following signs is NOT seen in hypertrophic pyloric stenosis?

Troseier sign. **Explanation:** **Hypertrophic Pyloric Stenosis (HPS)** is a common cause of gastric outlet obstruction in infants (typically 3–6 weeks old) due to hypertrophy of the pyloric sphincter muscle. **Why Troseier Sign is the Correct Answer:** **Troisier sign** refers to the clinical finding of a hard, enlarged left supraclavicular lymph node (**Virchow’s node**). It is a classic sign of metastatic spread from an intra-abdominal malignancy, most commonly **gastric adenocarcinoma** in adults. It has no clinical or radiological association with congenital HPS. **Analysis of Incorrect Options (Signs of HPS):** The other options are classic radiological signs seen on **Barium Swallow/Meal** studies in HPS: * **String sign:** Represents a thin, elongated column of barium passing through the narrowed, constricted pyloric canal. * **Shoulder sign:** Occurs when the hypertrophied pyloric muscle bulges into the gastric antrum, creating a "shoulder" of barium. * **Double track sign:** Seen when barium is trapped between the folds of the redundant mucosa within the narrowed pyloric canal, appearing as two parallel lines. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Non-bilious, projectile vomiting in a "hungry feeder." * **Physical Exam:** A palpable, firm, mobile "olive-shaped" mass in the epigastrium. * **Investigation of Choice:** **Ultrasound (USG)**. Diagnostic criteria include a pyloric muscle thickness **>3 mm** and a pyloric canal length **>14–15 mm**. * **Metabolic Abnormality:** Hypochloremic, hypokalemic metabolic alkalosis (paradoxical aciduria). * **Treatment:** Ramstedt’s pyloromyotomy.

Q: Kasai procedure is used in the treatment of which condition?

Congenital Biliary Atresia. ### Explanation **Correct Answer: A. Congenital Biliary Atresia** **Congenital Biliary Atresia (CBA)** is a progressive fibro-inflammatory obliteration of the extrahepatic biliary tree, leading to obstructive jaundice in neonates. The **Kasai procedure**, also known as **Hepatoportoenterostomy**, is the standard initial surgical treatment. In this procedure, the obliterated extrahepatic biliary remnants are excised, and a Roux-en-Y loop of the jejunum is anastomosed directly to the transected fibrous stroma at the porta hepatis. This allows bile to drain from the microscopic patent intrahepatic ducts directly into the intestine. **Why other options are incorrect:** * **Primary Sclerosing Cholangitis (B):** This is a chronic cholestatic liver disease characterized by inflammation and fibrosis of both intra- and extrahepatic bile ducts. Management is primarily medical (UDCA) or liver transplantation; the Kasai procedure has no role here. * **Cholangiocarcinoma (C):** This is a malignancy of the bile ducts. Treatment involves radical surgical resection (like Whipple’s procedure or hemihepatectomy) or palliative stenting, depending on the location (Klatskin tumor). * **Carcinoma of the Gallbladder (D):** Treatment typically involves radical cholecystectomy (including liver wedge resection and lymphadenectomy), not portoenterostomy. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** The Kasai procedure is most successful when performed early, ideally **before 60 days of life**. Success rates drop significantly after 90 days. * **Diagnosis:** The "Gold Standard" for diagnosis is **Intraoperative Cholangiography (IOC)**. On ultrasound, the **"Triangular Cord Sign"** is a classic finding. * **Prognosis:** While Kasai can delay the need for surgery, Biliary Atresia remains the **most common indication for liver transplantation in the pediatric age group**.

Q: An 8-month-old boy has impalpable undescended testes. What is the next step in management?

Laparoscopy. ### Explanation **Correct Answer: D. Laparoscopy** The management of undescended testes (UDT) depends on whether the testis is palpable or impalpable. In this case, the 8-month-old boy has **impalpable** testes. **Diagnostic Laparoscopy** is the "Gold Standard" for managing impalpable testes. It serves a dual purpose: 1. **Diagnostic:** It identifies the presence, location (intra-abdominal vs. absent), and morphology of the testis. 2. **Therapeutic:** If an intra-abdominal testis is found, definitive surgery (Laparoscopic Orchiopexy or Fowler-Stephens procedure) can be performed in the same sitting. --- ### Why the other options are incorrect: * **A. Reassurance:** Spontaneous descent of the testis is rare after **6 months** of age. Since the child is 8 months old, surgical intervention is indicated to prevent complications like infertility and malignancy. * **B. Ultrasound (USG):** While commonly used, USG has very low sensitivity (approx. 45%) for locating impalpable testes. A negative USG does not rule out an intra-abdominal testis; therefore, it should not delay definitive management. * **C. MRI:** Although more accurate than USG, MRI is expensive, requires sedation in infants, and does not offer the therapeutic advantage that laparoscopy provides. --- ### High-Yield Clinical Pearls for NEET-PG: * **Timing of Surgery:** The ideal age for Orchiopexy is **6 to 12 months** (latest by 18 months). * **Most Common Site:** The most common site for an undescended testis is the **Inguinal Canal**. * **Vanishing Testis Syndrome:** If laparoscopy reveals blind-ending spermatic vessels above the internal ring, it confirms an absent testis (monorchism). * **Malignancy Risk:** Orchiopexy does not eliminate the risk of testicular cancer (Seminoma is most common), but it makes the testis accessible for clinical screening. * **Hormonal Therapy:** HCG or GnRH analogues are generally not recommended as primary treatment for UDT.

Q: All of the following are true about cystic hygroma EXCEPT?

Aspiration is diagnostic.. **Explanation:** Cystic hygroma (Cystic Lymphangioma) is a benign congenital malformation of the lymphatic system. **1. Why Option A is the Correct Answer (The Exception):** While aspiration of a cystic hygroma typically yields **clear, straw-colored fluid** (serous fluid), it is **not diagnostic**. Aspiration is primarily used for temporary decompression or to rule out other pathologies, but it carries a high risk of infection and hemorrhage. The diagnosis is primarily **clinical** (soft, painless, brilliantly transilluminant mass) and confirmed by **Ultrasonography (USG)**, which shows a multiloculated cystic mass with internal septations. **2. Analysis of Other Options:** * **Option B:** Approximately **50-60%** of cases are present at birth, and nearly 90% manifest by the age of 2 years. * **Option C:** The most common site (75-80%) is the **posterior triangle of the neck** (cervical region). It can also occur in the axilla, mediastinum, and groin. * **Option D:** The embryological basis is the **sequestration of lymphatic tissue** from the primitive jugular lymph sacs, which fail to communicate with the main lymphatic system. **NEET-PG High-Yield Pearls:** * **Clinical Sign:** It is **brilliantly transilluminant** because it contains clear fluid and has thin walls. * **Association:** Frequently associated with chromosomal anomalies like **Turner Syndrome** (45, XO), Down Syndrome, and Noonan Syndrome. * **Complications:** Sudden increase in size usually indicates **intracystic hemorrhage** or infection. * **Treatment of Choice:** Surgical excision is the gold standard. For unresectable cases, **Sclerotherapy** (using OK-432 or Bleomycin) is an effective alternative.

Q: Which of the following are better prognostic factors for operation of biliary duct obstruction in a newborn?

Size of ductule > 200 micron. **Explanation:** The question refers to the surgical management of **Biliary Atresia**, specifically the **Kasai Procedure (Hepatoportoenterostomy)**. The primary goal of this surgery is to establish bile flow by anastomosing the bowel to the transected fibrous cone at the porta hepatis. **Why Option B is Correct:** The success of the Kasai procedure depends heavily on the presence and size of microscopic biliary channels within the fibrous remnants at the porta hepatis. Studies (notably by Chandra and Altman) have shown that the **diameter of the largest biliary ductules** is a critical prognostic indicator. * **Ductules > 200 microns:** Associated with excellent bile drainage and a better long-term prognosis. * **Ductules < 150 microns:** Associated with poor drainage and higher failure rates of the procedure. **Analysis of Incorrect Options:** * **Option A (No passage of bile):** This is a clinical sign of complete obstruction or surgical failure; it indicates a poor prognosis, not a better one. * **Option C & D (Weight and Prematurity):** While the overall health and maturity of the baby affect surgical risk, they are not specific prognostic indicators for the success of biliary drainage compared to the histological diameter of the ductules and the **age at surgery** (the most important clinical factor). **NEET-PG High-Yield Pearls:** * **Golden Period:** The Kasai procedure should ideally be performed **before 60 days of life**. Success rates drop significantly after 90 days due to irreversible secondary biliary cirrhosis. * **Investigation of Choice:** **HIDA Scan** (demonstrates absent excretion into the bowel). * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOC). * **Most Common Indication:** Biliary atresia is the most common indication for pediatric liver transplantation.

Question 1

Which of the following statements is NOT true about gastroschisis?

Accepted Answer

None of the above

Answer

Results from fibrosis of the sternocleidomastoid muscle

Answer

Lesion is characterized by the deposition of collagen

Answer

Surgical transection of the sternocleidomastoid muscle may be indicated

Question 2

A 5-year-old child presents with erythema and edema over the prepuce after pulling at the penile skin while urinating. What is the most likely diagnosis?

Accepted Answer

Phimosis

Answer

Hypospadias

Answer

Urethral stone

Answer

Posterior urethral valve

Question 3

Snow storm ascites is seen in:

Accepted Answer

Meconium ileus

Answer

Hirschsprung's disease

Answer

Ileocaecal tuberculosis

Answer

Pseudomyxoma Peritonei

Question 4

A child presents with recurrent abdominal pain and bilious vomiting. The condition was diagnosed by barium follow-through and treated surgically with mesenteric widening, appendectomy, and division of Ladd's bands. What is the most likely diagnosis?

Accepted Answer

Malrotation with Ladd's procedure

Answer

Recurrent cecal volvulus

Answer

Recurrent appendicitis

Answer

Intestinal stricture due to tuberculosis

Question 5

A newborn, within a few hours of birth, develops bile-stained vomiting and epigastric distention. On examination, the abdomen is scaphoid with visible peristalsis in the upper abdomen. Per-rectal examination shows no stool in the rectum. X-ray of the abdomen shows air trapped in the stomach and proximal duodenum. What is the treatment of choice in this case?

Accepted Answer

Duodenoduodenostomy

Answer

Ramstedt pyloromyotomy

Answer

Conservative management

Answer

Barium enema and air enema

Question 6

Which of the following signs is NOT seen in hypertrophic pyloric stenosis?

Accepted Answer

Troseier sign

Answer

String sign

Answer

Shoulder sign

Answer

Double track sign

Question 7

Kasai procedure is used in the treatment of which condition?

Accepted Answer

Congenital Biliary Atresia

Answer

Primary Sclerosing Cholangitis

Answer

Cholangiocarcinoma

Answer

Carcinoma of the gallbladder

Question 8

An 8-month-old boy has impalpable undescended testes. What is the next step in management?

Accepted Answer

Laparoscopy

Answer

Reassurance

Answer

Ultrasound abdomen and scrotum

Answer

MRI abdomen

Question 9

All of the following are true about cystic hygroma EXCEPT?

Accepted Answer

Aspiration is diagnostic.

Answer

50% present at birth.

Answer

Presents as posterior cervical swelling.

Answer

Sequestration of lymphatic tissue.

Question 10

Which of the following are better prognostic factors for operation of biliary duct obstruction in a newborn?

Accepted Answer

Size of ductule > 200 micron

Answer

No passage of bile

Answer

Weight of baby > 3 kg

Answer

Preterm baby

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?