Pediatric Surgery Practice Questions

Q: A 6-year-old baby is brought to the hospital by her parents complaining about right upper quadrant pain. On examination the baby is found to have jaundice and palpable abdominal mass. USG of the baby is shown below. What is the most likely cause?

Choledochal cyst. ***Choledochal cyst*** - The classic triad of **abdominal pain**, **jaundice**, and a **palpable right upper quadrant mass** in a child is highly suggestive of a choledochal cyst. - The ultrasound image shows a **cystic dilatation of the common bile duct** (labeled X), which is the hallmark of a choledochal cyst. *Pseudo pancreatic cyst* - Pancreatic pseudocysts usually develop after **pancreatitis** or pancreatic trauma, and are typically located in the **epigastric region**. - They are not directly associated with jaundice related to biliary obstruction, though large cysts can cause obstruction via compression. *Hydatid cyst* - Hydatid cysts are typically seen in the **liver** and are caused by *Echinococcus granulosus*, often presenting with a **multiloculated appearance** and daughter cysts. - While they can cause hepatomegaly and pain, jaundice and a palpable mass, they do not typically manifest as a primary dilatation of the bile duct. *Amoebic liver abscess* - An amoebic liver abscess is caused by *Entamoeba histolytica* and typically presents with **fever**, **right upper quadrant pain**, and sometimes hepatomegaly. - While it can cause biliary obstruction in rare cases, the ultrasound appearance is usually that of a **hypoechoic lesion** within the liver parenchyma, not a distinct cystic dilatation of the bile duct. *Biliary atresia* - Biliary atresia typically presents in **early infancy** (first 2-3 months of life) with progressive jaundice and acholic stools. - While it causes biliary obstruction, the ultrasound findings show **absent or atretic bile ducts** rather than cystic dilatation, and the age of presentation (6 years) makes this diagnosis unlikely.

Q: A 12-year-old patient with esophageal varices is managed by the procedure shown in the image. All of the following statements regarding this condition are true except:

This is the definitive treatment. ***This is the definitive treatment*** - The image shows a **Sengstaken-Blakemore tube** being used, which is a temporary measure for controlling **bleeding esophageal varices**. - It is an emergency treatment used for stabilization and does not address the underlying cause of varices or prevent future bleeding. - **Definitive treatments** include endoscopic variceal ligation (EVL), sclerotherapy, or TIPS procedure. *Sengstaken-Blakemore tube* - The device shown in the image, with balloons and multiple lumens, is indeed a **Sengstaken-Blakemore tube**, used for **tamponade of actively bleeding esophageal varices**. - This tube features a gastric balloon and an esophageal balloon, along with lumens for suction, designed to exert pressure on the bleeding varices. *Gastric balloon is inflated with 400 mL of air* - The **gastric balloon** of a Sengstaken-Blakemore tube is typically inflated with **200-500 mL of air** (often around 250-300 ml in adults, 150 ml in children) to anchor the tube and compress gastric varices. - While 400 mL is within the general range, the exact volume can vary based on patient size and clinical protocol. *Esophageal balloon is inflated with 40 mm Hg pressure of air* - The **esophageal balloon** is indeed inflated to a pressure of **20-45 mmHg (typically 30-45 mmHg)** to compress esophageal varices. - This pressure application is critical for achieving local hemostasis in acute bleeding episodes. *Should be kept inflated for a maximum of 24-48 hours* - The balloons should be deflated after **24-48 hours maximum** to prevent complications such as **esophageal necrosis, ulceration, or perforation**. - Prolonged inflation can cause pressure necrosis of the esophageal or gastric mucosa.

Q: What does the intraoperative image shown below depict?

Intussusception. ***Intussusception*** - The image clearly shows a segment of bowel telescoping into an adjacent segment, characteristic of **intussusception** - This condition involves the invagination of one part of the intestine into another, often presenting clinically with abdominal pain, vomiting, and **"red jelly" stools** - The classic intraoperative finding is the appearance of bowel within bowel, creating a sausage-shaped mass *Transverse colon volvulus* - **Transverse colon volvulus** involves the twisting of the transverse colon around its mesentery, which would appear as a dilated, twisted loop of bowel - The image does not show the characteristic twisting or significant dilation associated with a volvulus *Meckel's diverticulum* - A **Meckel's diverticulum** is a true diverticulum, a remnant of the vitelline duct, which appears as a small pouch or bulge on the wall of the small intestine - The image depicts a larger-scale bowel obstruction caused by one segment of bowel entering another, not an abnormal outpouching *Intestinal duplication cyst* - **Intestinal duplication cysts** are spherical or tubular structures that share a common wall with the bowel and are lined with gastrointestinal mucosa - These appear as separate cystic masses adjacent to the bowel, not as telescoping segments *Malrotation with midgut volvulus* - **Malrotation with midgut volvulus** presents with twisting of the small bowel around the superior mesenteric artery, creating a characteristic "whirlpool" or "corkscrew" appearance - The image shows telescoping of bowel segments rather than the rotational twisting pattern seen in volvulus

Q: Which of the following is true regarding this condition?

Needle aspiration yields fluid that does not coagulate. ***Needle aspiration yields fluid that does not coagulate*** - The image depicts a large, translucent, fluid-filled cystic mass, characteristic of a **cystic hygroma** (lymphatic malformation). - Aspiration of a cystic hygroma typically yields **clear to straw-colored fluid** that is rich in protein but **does not coagulate** because it is lymphatic fluid, not blood. *Most common site is anterior triangle neck* - While cystic hygromas most commonly occur in the **neck**, they are typically found in the **posterior triangle**, not the anterior triangle. - The lesion in the image appears to be a large, diffuse cystic mass extending from the neck into the mediastinum or axilla. *It is due to vascular malformation* - This condition is a **lymphatic malformation**, specifically a cystic hygroma, not a vascular malformation. - **Vascular malformations** involve blood vessels and would typically present with different characteristics, such as being compressible and potentially blanching. *Usually decreases on crying* - Crying or straining typically **increases the size** of a cystic hygroma due to increased intrathoracic pressure, which impedes lymphatic flow and causes distention of the lymphatic sacs. - This characteristic helps differentiate it from conditions that might decrease in size with pressure. *Typically appears after 5 years of age* - Cystic hygromas are **congenital malformations** that are usually present at birth or become apparent within the **first 2 years of life** (approximately 90% by age 2). - Late presentation after 5 years of age is uncommon and would be unusual for this condition.

Question 1

A 45-year-old woman presents to the emergency department with a 12-hour history of severe epigastric pain radiating to the back, nausea, and vomiting. She has a history of gallstones and drinks alcohol occasionally. On examination, she has periumbilical ecchymosis and flank ecchymosis bilaterally. Vital signs: BP 90/60 mmHg, HR 130 bpm, temp 38.1°C, SpO2 94% on 2 L nasal cannula. Serum lipase is 4,200 U/L. A plain abdominal radiograph is obtained. The image demonstrates a gas-filled loop of small bowel in the left upper quadrant with an abrupt transition and absence of gas distally. Which of the following is the most appropriate immediate next step in management?

Accepted Answer

Administer aggressive IV crystalloid resuscitation, supplemental oxygen, and arrange ICU admission

Answer

Perform urgent upper endoscopy to exclude a perforated peptic ulcer as the cause of the sentinel loop

Answer

Order CT abdomen and pelvis with IV contrast to grade the severity of pancreatitis

Answer

Initiate empiric IV antibiotics targeting gram-negative organisms and arrange surgical consultation for necrosectomy

Answer

Perform urgent ERCP with sphincterotomy given the history of gallstones and elevated lipase

Question 2

A 6-year-old baby is brought to the hospital by her parents complaining about right upper quadrant pain. On examination the baby is found to have jaundice and palpable abdominal mass. USG of the baby is shown below. What is the most likely cause?

Accepted Answer

Choledochal cyst

Answer

Pseudo pancreatic cyst

Answer

Hydatid cyst

Answer

Amoebic liver abscess

Answer

Biliary atresia

Question 3

A 12-year-old patient with esophageal varices is managed by the procedure shown in the image. All of the following statements regarding this condition are true except:

Accepted Answer

This is the definitive treatment

Answer

Sengstaken-Blakemore tube

Answer

Gastric balloon is inflated with 400 mL of air

Answer

Esophageal balloon is inflated with 40 mm Hg pressure of air

Answer

Should be kept inflated for a maximum of 24-48 hours

Question 4

What does the intraoperative image shown below depict?

Accepted Answer

Intussusception

Answer

Transverse colon volvulus

Answer

Meckel's diverticulum

Answer

Intestinal duplication cyst

Answer

Malrotation with midgut volvulus

Question 5

Which of the following is true regarding this condition?

Accepted Answer

Needle aspiration yields fluid that does not coagulate

Answer

Most common site is anterior triangle neck

Answer

It is due to vascular malformation

Answer

Usually decreases on crying

Answer

Typically appears after 5 years of age

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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