Intestinal Obstruction — MCQs
Most common cause of acute intestinal obstruction in children is
Patient presents with peritonitis and during surgery a diverticular perforation is seen with fecal peritonitis. What is the Hinchey stage?
A 60-year-old patient with air in the biliary tree, colicky abdominal pain, and hyper-peristaltic abdominal sounds. What is the diagnosis?
Which of the following is the best combination of clinical features of intestinal obstruction?
Which radiological finding is shown in the image?
What is the commonest cause of intestinal obstruction in children between 3 months to 6 years of age?
Which of the following is a cause of Hirschsprung disease in a patient?
What condition is associated with a greater risk of gastric carcinoma?
Urobilinogen levels in obstructed jaundice due to gallstones will be:
A 10-month-old infant presents with acute intestinal obstruction. Contrast enema X-ray shows intussusception, likely cause is –
Intestinal Obstruction Indian Medical PG Practice Questions and MCQs
Question 1: Most common cause of acute intestinal obstruction in children is
- A. Inguinal hernia
- B. Intussusception (Correct Answer)
- C. Volvulus
- D. None of the options
Explanation: ***Intussusception*** - **Intussusception** is the most common cause of **acute intestinal obstruction** in children, particularly between 3 months and 3 years of age. - It occurs when a segment of the intestine telescopes into an adjacent segment, leading to obstruction and potentially **ischemia**. *Inguinal hernia* - While an **incarcerated inguinal hernia** can cause intestinal obstruction, it is less common than intussusception as the primary cause of acute obstruction in children generally. - It is more frequent in **neonates and infants** but overall incidence of obstruction is lower than intussusception. *Volvulus* - **Volvulus** refers to a twisting of the intestine on its mesentery, often associated with **malrotation**, leading to obstruction and vascular compromise. - While a serious cause of obstruction, especially in neonates, it is less common overall than intussusception in the pediatric population. *None of the options* - This option is incorrect because **intussusception** is a recognized and frequent cause of acute intestinal obstruction in children.
Question 2: Patient presents with peritonitis and during surgery a diverticular perforation is seen with fecal peritonitis. What is the Hinchey stage?
- A. Localized mesenteric or pericolic abscess (Grade I)
- B. Diffuse fecal contamination (Grade IV) (Correct Answer)
- C. Diffuse purulent contamination (Grade III)
- D. Localized pelvic abscess (Grade II)
Explanation: **Diffuse fecal contamination (Grade IV)** * The Hinchey classification system for perforated diverticulitis grades the severity based on operative findings; **fecal peritonitis** indicates the highest grade due to gross contamination of the abdominal cavity. * **Hinchey Stage IV** is specifically defined by **diffuse fecal peritonitis**, which is a life-threatening condition requiring urgent surgical intervention. *Localized mesenteric or pericolic abscess (Grade I)* * This stage involves a **localized pericolic or mesenteric phlegmon or abscess** and does not involve diffuse peritonitis. * The presence of **fecal peritonitis** in the patient rules out this less severe stage. *Diffuse purulent contamination (Grade III)* * **Diffuse purulent peritonitis** (Hinchey Stage III) involves the presence of pus spread throughout the abdominal cavity, but without macroscopic fecal contamination. * The key finding of **fecal peritonitis** in the patient indicates a more severe form of contamination than purulent peritonitis. *Localized pelvic abscess (Grade II)* * This stage represents a **more extensive abscess** that may be located in the pelvis or retroperitoneum, but it is still localized, not diffuse. * **Fecal peritonitis** implies generalized contamination of the peritoneal cavity, which is much more severe than a localized abscess.
Question 3: A 60-year-old patient with air in the biliary tree, colicky abdominal pain, and hyper-peristaltic abdominal sounds. What is the diagnosis?
- A. Hemobilia
- B. Cholangitis
- C. Pneumobilia
- D. Gallstone ileus (Correct Answer)
Explanation: ***Gallstone ileus*** - This condition presents with the classic triad of **pneumobilia** (air in the biliary tree), symptoms of **small bowel obstruction** (colicky abdominal pain, hyper-peristaltic sounds), and evidence of a **gallstone in the ileum**. - The gallstone typically erodes through the gallbladder wall into the small intestine, causing obstruction, often at the **ileocecal valve**. *Hemobilia* - Characterized by **bleeding into the biliary tree**, which presents with upper gastrointestinal bleeding, biliary colic, and jaundice. - It does not cause bowel obstruction or pneumobilia and is often associated with trauma, iatrogenic injury, or vascular malformations. *Cholangitis* - An **infection of the bile ducts**, typically presenting with **Charcot's triad**: fever, right upper quadrant pain, and jaundice. - While it involves the biliary tree, it does not typically cause air in the biliary tree or small bowel obstruction. *Pneumobilia* - Refers specifically to the presence of **air in the biliary tree** and is a sign, not a diagnosis for the entire clinical picture. - While present in this case, pneumobilia alone does not explain the colicky abdominal pain, hyper-peristaltic sounds, and bowel obstruction.
Question 4: Which of the following is the best combination of clinical features of intestinal obstruction?
- A. Vomiting
- B. Fluid level in X-ray > 4
- C. Abdominal distension and vomiting (Correct Answer)
- D. Abdominal distension
Explanation: ***Abdominal distension and vomiting*** - This combination represents **two of the cardinal clinical features** of intestinal obstruction from the classic tetrad (pain, vomiting, distension, constipation). - **Abdominal distension** occurs due to accumulation of gas and fluid proximal to the obstruction. - **Vomiting** occurs as the body attempts to expel contents that cannot pass through the blocked intestine. - The **combination** makes this the most specific and complete answer among the given options. *Vomiting* - While vomiting is indeed a prominent clinical feature of intestinal obstruction, it can occur in numerous other conditions (gastroenteritis, metabolic disorders, CNS pathology). - **Isolated vomiting lacks specificity** for diagnosing intestinal obstruction. *Fluid level in X-ray > 4* - This refers to **multiple air-fluid levels** seen on erect abdominal X-ray, which is a **radiologic/diagnostic finding**, not a clinical feature. - Clinical features are symptoms and signs (what the patient experiences or what is observed on examination), whereas X-ray findings are **investigative/imaging findings**. *Abdominal distension* - While abdominal distension is a key clinical feature of intestinal obstruction, it can also occur in other conditions (ascites, pregnancy, obesity, bowel perforation). - **Isolated distension lacks specificity** compared to the combination with vomiting.
Question 5: Which radiological finding is shown in the image?
- A. Intussusception (Correct Answer)
- B. Colon carcinoma
- C. Sigmoid volvulus
- D. Ileus
Explanation: ***Intussusception*** - The image clearly displays the classic "coiled spring" appearance, which is pathognomonic for **intussusception** on a barium enema study. This pattern is created by barium trapped between the intussusceptum and intussuscipiens. - The arrow specifically points to the leading edge of the intussusception, where the bowel telescopes into an adjacent segment. *Colon carcinoma* - Colon carcinoma typically presents as an **irregular narrowing** or an **apple-core lesion** on barium studies, a sign of luminal stricture due to a mass. - The radiological appearance for carcinoma would not show the distinct layered or coiled pattern seen in the provided image. *Sigmoid volvulus* - Sigmoid volvulus is characterized by a **"coffee bean" sign** on plain radiographs due to the massively dilated, inverted U-shaped loop of colon, or a **"bird's beak" appearance** on contrast studies at the twisted obstruction point. - This contrasts significantly with the concentric rings and linear striations indicative of intussusception. *Ileus* - Ileus, or paralytic ileus, involves generalized **bowel dilation** without a clear point of mechanical obstruction, often with gas present throughout the large and small bowel. - The image shows a very specific, localized abnormality with a characteristic pattern, not generalized bowel distension associated with ileus.
Question 6: What is the commonest cause of intestinal obstruction in children between 3 months to 6 years of age?
- A. Nonspecific cause
- B. Intestinal polyp
- C. Meckel's diverticulum
- D. Intussusception (Correct Answer)
Explanation: ***Intussusception*** - **Intussusception** is the most frequent cause of **intestinal obstruction** in children between 3 months and 6 years, where a segment of intestine telescopes into an adjacent segment. - This condition presents with classic symptoms like **abdominal pain**, vomiting, and bloody stools (currant jelly stools). *Nonspecific cause* - While many childhood illnesses have nonspecific causes, **intestinal obstruction** is a specific and severe condition requiring prompt diagnosis. - Attributing it to a "nonspecific cause" would delay proper identification of the underlying pathology. *Intestinal polyp* - While intestinal polyps can cause **gastrointestinal bleeding** and, less commonly, obstruction in children, they are not the most common cause of obstruction in this age group. - Polyps usually present with intermittent bleeding or prolapse rather than acute, severe obstruction. *Meckel's diverticulum* - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract and can cause obstruction, bleeding, or inflammation (diverticulitis). - However, it is a less common cause of intestinal obstruction in this specific age range compared to **intussusception**.
Question 7: Which of the following is a cause of Hirschsprung disease in a patient?
- A. Failure of involution of vitelline duct
- B. Failure of migration of neural crest cells (Correct Answer)
- C. Excessive peristalsis of the affected part of the gut
- D. Obstruction secondary to an infectious agent
Explanation: ***Failure of migration of neural crest cells*** - Hirschsprung disease is characterized by the absence of **ganglion cells** (Auerbach and Meissner plexuses) in the distal colon [1]. - This aganglionosis results from the failure of **neural crest cells** to migrate completely from the esophagus to the anus during embryonic development [1]. *Failure of involution of vitelline duct* - This condition is associated with **Meckel's diverticulum**, which is a remnant of the vitelline duct, not Hirschsprung disease. - **Meckel's diverticulum** can cause symptoms like GI bleeding or obstruction, but it does not involve aganglionosis of the colon. *Excessive peristalsis of the affected part of the gut* - Hirschsprung disease is characterized by a **lack of peristalsis** in the aganglionic segment, leading to functional obstruction [1]. - The healthy, proximal colon may show increased peristalsis in an attempt to overcome the obstruction, but the affected segment itself is aperistaltic. *Obstruction secondary to an infectious agent* - Obstruction due to an infectious agent is typically related to **inflammatory processes** or strictures caused by infections (e.g., severe colitis). - This mechanism of obstruction does not involve the **developmental anomaly** of missing ganglion cells, which is central to Hirschsprung disease. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 94-95.
Question 8: What condition is associated with a greater risk of gastric carcinoma?
- A. Old age
- B. Cardiac end ulcer
- C. Prepyloric ulcer
- D. Intestinal metaplasia (Correct Answer)
Explanation: ***Intestinal metaplasia*** - Intestinal metaplasia is a known **precursor** condition associated with an increased risk of gastric carcinoma due to the transformation of gastric epithelium [1,2]. - This condition often arises from **chronic gastritis**, particularly after **H. pylori** infection, advancing the risk of malignant transformation [1,2]. *Old age* - While old age is a **risk factor** for various cancers, it is not specifically associated with gastric carcinoma without other factors. - The incidence of gastric cancer is more correlated with specific **precursor lesions** rather than just age alone. *Cardiac end ulcer* - Cardiac ulcers are typically **benign lesions** and not directly pre-cancerous. - They are often related to **chronic reflux disease**, which does not significantly increase the risk of gastric carcinoma. *Prepyloric ulcer* - Prepyloric ulcers may arise due to **peptic ulcer disease** but do not significantly predispose to gastric cancer. - The majority of ulcers can be healing or benign, lacking the malignant potential seen in precancerous lesions like intestinal metaplasia. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 777-779. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 354-355.
Question 9: Urobilinogen levels in obstructed jaundice due to gallstones will be:
- A. Completely absent (Correct Answer)
- B. Significantly elevated
- C. Mildly elevated
- D. Unchanged
Explanation: ***Completely absent*** - In **obstructive jaundice**, **bile flow** from the liver to the intestine is blocked, preventing **bilirubin** from reaching the gut. [1] - Since **urobilinogen** is formed in the intestines from bilirubin by bacterial action, its absence in the gut means it cannot be reabsorbed and excreted, leading to its complete absence in urine and feces. [1] *Significantly elevated* - This would typically occur in conditions causing **hemolysis** or **hepatocellular damage**, where large amounts of bilirubin are processed by the liver and then passed into the intestine. [1] - In such cases, increased bilirubin reaching the gut leads to increased urobilinogen formation and subsequent high excretion. *Mildly elevated* - A mild increase might be seen in cases of incomplete obstruction or mild liver dysfunction, where some bilirubin still reaches the intestine. - This level is not consistent with the complete blockage seen in **obstructive jaundice** from **gallstones**. *Unchanged* - This would imply that the normal process of bilirubin metabolism and urobilinogen formation is unaffected. - In **obstructive jaundice**, the very definition involves a disruption of this pathway, making an unchanged level highly unlikely. [1]
Question 10: A 10-month-old infant presents with acute intestinal obstruction. Contrast enema X-ray shows intussusception, likely cause is –
- A. Mucosal polyp
- B. Duplication cyst
- C. Meckel's diverticulum
- D. Peyer's patch hypertrophy (Correct Answer)
Explanation: ***Peyer's patch hypertrophy*** - In infants, **Peyer's patch hypertrophy**, often due to viral infections like **rotavirus**, is the most common lead point for **idiopathic intussusception**. - These enlarged lymphoid tissues act as a fixed mass, allowing the proximal bowel to telescope into the distal bowel. *Mucosal polyp* - While polyps can cause intussusception, they are **rare in infants** and more commonly seen in older children or adults. - They tend to be a lead point for intussusception in contexts like **Peutz-Jeghers syndrome**, which is less likely in an otherwise healthy 10-month-old. *Duplication cyst* - **Duplication cysts** are a less common cause of intussusception compared to Peyer's patch hypertrophy in this age group. - They are usually congenital and present as a fixed mass, but are not the most likely cause in an acute, otherwise unexplained obstruction. *Meclde's diverticulum* - **Meckel's diverticulum** is a potential cause of intussusception, often by acting as a lead point or by causing an inversion. - However, it is less common than Peyer's patch hypertrophy as the underlying cause of intussusception in typically healthy infants.
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