Intestinal Obstruction — MCQs
Most common cause of acute intestinal obstruction in children is
Failure to pass meconium within 48 hours of birth in a newborn with no obvious external abnormality should lead to the suspicion of which condition?
What are the primary criteria for considering operative treatment in Hirschsprung's disease?
A postnatal X-ray of the abdomen of a neonate shows a "double bubble sign". It is seen with:
Organic causes of constipation in infants include all of the following EXCEPT:
A 10-month-old infant presents with acute intestinal obstruction. Contrast enema X-ray shows intussusception, likely cause is –
Shirodkar cerclage may be associated with all complications except:
Urobilinogen levels in obstructed jaundice due to gallstones will be:
A 10-year-old child presents with recurrent episodes of blood in stool. On examination, his lips show pigmented macules. He may be suffering from?
A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:
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: Failure to pass meconium within 48 hours of birth in a newborn with no obvious external abnormality should lead to the suspicion of which condition?
- A. Anal atresia
- B. Congenital pouch colon
- C. Meconium ileus
- D. Hirschsprung's disease (Correct Answer)
Explanation: ***Hirschsprung's disease*** - **Failure to pass meconium** within the first 24-48 hours of life is a classic presentation due to the **absence of ganglion cells** in the distal colon, preventing normal peristalsis. - Absence of obvious external abnormality further points towards an internal cause of intestinal obstruction. *Anal atresia* - This condition involves a **malformation of the anus** or rectum, which would typically be an **obvious external abnormality** on physical examination. - While it causes failure to pass meconium, the key differentiating factor is the visible anatomical defect. *Congenital pouch colon* - This is a rare anomaly where the colon forms a large, dilated pouch, often associated with **Hirschsprung's disease** or **atresia**. - While it can cause meconium retention, the primary suspicion (especially without other signs) for isolated meconium retention is Hirschsprung's. *Meconium ileus* - Meconium ileus is often the earliest manifestation of **cystic fibrosis**, characterized by thick, inspissated meconium obstructing the ileum. - While it causes failure to pass meconium, it usually presents with additional signs of **abdominal distension** and **bilious vomiting** soon after birth.
Question 3: What are the primary criteria for considering operative treatment in Hirschsprung's disease?
- A. Has failed to respond to conservative treatment (Correct Answer)
- B. Is 2 years of age
- C. Has no distension of abdomen
- D. Is at least 8 kg in weight and thriving
Explanation: ***Has failed to respond to conservative treatment*** - Children with **Hirschsprung's disease** who do not respond to initial **conservative management**, such as bowel irrigation and laxatives, require surgical intervention to remove the aganglionic segment. - **Persistent symptoms** like severe constipation, abdominal distension, and failure to thrive despite medical therapy indicate the need for operative treatment. *Is 2 years of age* - Age itself is **not a primary criterion** for deciding operative treatment in Hirschsprung's disease; the decision is based on clinical presentation and response to treatment. - While many cases are diagnosed and treated surgically in infancy, some present later, and the timing of surgery depends on symptom severity and the child's overall condition. *Has no distension of abdomen* - The presence of **abdominal distension** is a common symptom in Hirschsprung's disease, and its absence would suggest **less severe disease** or effective conservative management, rather than an indication for surgery. - If a child has no distension, it implies that obstruction is not significant or is being managed, making operative intervention less urgent. *Is at least 8 kg in weight and thriving* - Being **at least 8 kg in weight and thriving** generally indicates a child is in good health and a suitable candidate for surgery, but these are **preconditions for safe surgery** rather than the primary criteria for deciding *if* surgery is needed. - The decision to operate is driven by the failure of conservative treatment and the persistence of disease-related symptoms, not solely by the child's weight or general thriving status.
Question 4: A postnatal X-ray of the abdomen of a neonate shows a "double bubble sign". It is seen with:
- A. Duodenal atresia (Correct Answer)
- B. Ileal atresia
- C. Pyloric stenosis
- D. Esophageal atresia
Explanation: **Duodenal atresia** - The **"double bubble sign"** on an abdominal X-ray is classic for **duodenal atresia**, representing a dilated stomach and a dilated proximal duodenum separated by the pylorus. - This finding indicates a complete obstruction at the level of the duodenum, preventing the passage of gas distally. *Ileal atresia (may show distension throughout the bowel)* - In **ileal atresia**, the obstruction is further down the small bowel, leading to multiple dilated loops of bowel proximal to the atresia. - The X-ray would typically show more widespread **abdominal distension** with multiple air-fluid levels rather than the distinct double bubble. *Pyloric stenosis (typically presents with a single bubble sign)* - **Pyloric stenosis** involves narrowing of the pylorus but not an complete obstruction in the same way as duodenal atresia, leading to gastric outlet obstruction. - While it might show a **distended stomach (single bubble)**, it typically does not obstruct distally enough to create a second prominent bubble in the duodenum. *Esophageal atresia (associated with airless abdomen on X-ray)* - **Esophageal atresia** is an interruption in the continuity of the esophagus, preventing swallowed air from reaching the stomach and intestines. - An abdominal X-ray in this condition would typically show an **airless abdomen** because air cannot pass into the gastrointestinal tract.
Question 5: Organic causes of constipation in infants include all of the following EXCEPT:
- A. Hirschsprung's disease
- B. Cystic fibrosis
- C. Hypothyroidism
- D. Infantile dyschezia (Correct Answer)
Explanation: ***Infantile dyschezia*** - This is a **functional condition** where infants strain and cry before passing a soft stool, due to a lack of coordination between relaxing the pelvic floor and increasing intra-abdominal pressure. It is not an organic cause of constipation. - The stool consistency in infantile dyschezia is typically **soft**, differentiating it from true constipation. *Hirschsprung's disease* - This is an **organic cause of constipation** due to the absence of **ganglion cells** in the distal colon, leading to a functional obstruction. - Infants typically present with **failure to pass meconium** within the first 24-48 hours of life, distended abdomen, and forceful expulsion of stool upon rectal examination. *Cystic fibrosis* - This is an **organic cause of constipation** in infants due to the production of thick, sticky intestinal secretions, often leading to **meconium ileus** at birth. - Constipation can also result from **pancreatic insufficiency**, which impairs fat digestion and absorption, leading to hard, dry stools later in infancy. *Hypothyroidism* - This is an **organic cause of constipation** because thyroid hormones are essential for normal gastrointestinal motility. - Infants with hypothyroidism often present with **decreased bowel movements**, lethargy, poor feeding, and prolonged jaundice.
Question 6: 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.
Question 7: Shirodkar cerclage may be associated with all complications except:
- A. Enterocele
- B. Ureteral injury
- C. Subacute intestinal obstructions
- D. Paresthesia over inner aspect (Correct Answer)
Explanation: ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.
Question 8: 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 9: A 10-year-old child presents with recurrent episodes of blood in stool. On examination, his lips show pigmented macules. He may be suffering from?
- A. Crohn disease
- B. Intussusception
- C. Peutz Jegher syndrome (Correct Answer)
- D. Meckel's diverticulum
Explanation: ***Peutz Jegher syndrome*** - This syndrome is characterized by **hamartomatous polyps** in the gastrointestinal tract and **melanin spots** on the mucous membranes (lips, buccal mucosa) and digits. - The polyps can lead to complications such as **bleeding** (blood in stool), intussusception, and an increased risk of various cancers. *Crohn disease* - This is an **inflammatory bowel disease** causing chronic inflammation of the GI tract, which can lead to blood in stool. - However, Crohn's disease is not associated with **pigmented macules** on the lips. *Intussusception* - This condition involves the **telescoping of one part of the intestine into another**, which can cause sudden onset severe abdominal pain, vomiting, and "current jelly" stools (blood and mucus). - It is not primarily associated with **pigmented macules** on the lips as a diagnostic feature. *Meckel's diverticulum* - This is a common congenital anomaly where a remnant of the **vitelline duct** persists, often containing ectopic gastric or pancreatic tissue. - It can cause **painless rectal bleeding**, but it is not associated with **pigmented macules** on the lips.
Question 10: A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:
- A. Recurrence of hernia
- B. New hernia
- C. Acute appendicitis
- D. Bowel adhesion to mesh (Correct Answer)
Explanation: ***Bowel adhesion to mesh*** - The patient's history of **laparoscopic ventral hernia repair** using polypropylene mesh, followed by recurrent colicky pain and a subacute intestinal obstruction, strongly suggests **adhesion formation involving the mesh and bowel**. - **Polypropylene mesh** is known to induce an inflammatory response, leading to scar tissue formation and potential adhesion to nearby organs, which can cause chronic pain and obstruction. *Recurrence of hernia* - While hernia recurrence is possible, the presentation primarily with **recurrent colicky pain** and a single episode of **subacute intestinal obstruction** is less characteristic of a simple recurrence, which often presents with a palpable bulge or more direct obstructive symptoms. - The conservative management of the obstruction episode further suggests a non-strangulated or irreducible recurrence, which would typically warrant surgical intervention if severely symptomatic. *New hernia* - A new hernia is unlikely given the history of a recent repair at a different site, unless specified. - The symptoms are more directly attributable to complications related to the previous surgery and the implanted mesh. *Acute appendicitis* - **Acute appendicitis** typically presents with right lower quadrant pain, fever, and leukocytosis, which are not described in the patient's symptoms of recurrent colicky pain and subacute obstruction. - The onset of symptoms months after a hernia repair, and their chronic, recurrent nature, makes acute appendicitis an improbable diagnosis.
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