Pediatric Surgery Basics Practice Questions

Q: A newborn presenting with intestinal obstruction showed multiple air fluid levels on abdominal X-ray. Which of the following is NOT a likely diagnosis?

Pyloric obstruction. **Explanation:** The presence of **multiple air-fluid levels** on an abdominal X-ray indicates a **low intestinal obstruction** (distal to the duodenum). **1. Why Pyloric Obstruction is the Correct Answer:** In **Pyloric obstruction** (such as Infantile Hypertrophic Pyloric Stenosis), the blockage is at the gastric outlet. Since the obstruction is proximal to the small intestine, air cannot pass into the bowel loops. The X-ray typically shows a **single large gastric air bubble** with little to no gas distally. Therefore, multiple air-fluid levels are never seen in this condition. **2. Analysis of Incorrect Options:** * **Duodenal Atresia:** While classically associated with the "double bubble" sign, if there is a partial obstruction or distal transition, it can present with fluid levels. However, it is more proximal than ileal atresia. * **Ileal Atresia:** This is a classic cause of **low intestinal obstruction**. The multiple dilated loops of small bowel proximal to the atresia fill with air and fluid, creating the characteristic "stepladder" appearance of multiple air-fluid levels. * **Ladd’s Bands:** These are fibrous stalks associated with **Malrotation**. They can compress the duodenum or cause midgut volvulus. If the obstruction is significant, it leads to proximal bowel dilatation and multiple air-fluid levels. **Clinical Pearls for NEET-PG:** * **Single Bubble:** Pyloric stenosis. * **Double Bubble:** Duodenal atresia (associated with Down Syndrome). * **Triple Bubble:** Jejunal atresia. * **Multiple Air-Fluid Levels:** Ileal atresia, Meconium ileus, or Hirschsprung’s disease. * **Ground Glass Appearance:** Suggestive of Meconium ileus (Neuhauser’s sign).

Q: A male neonate is born with an omphalocele. This entity can be distinguished from gastroschisis because, in an omphalocele, the protrusion is:

Associated with congenital malformations. ### Explanation The fundamental distinction between omphalocele and gastroschisis lies in their embryological origins and associated risks. **Why Option D is Correct:** Omphalocele is a result of the failure of the midgut to return to the abdominal cavity from the umbilical cord during the 10th week of gestation. Because this occurs early in development, it is frequently associated with **chromosomal abnormalities (Trisomy 13, 18, 21)** and **congenital syndromes** (e.g., Beckwith-Wiedemann syndrome, Pentalogy of Cantrell). Up to 50–70% of infants with omphalocele have associated cardiac, renal, or midline defects, which significantly dictate the prognosis. **Analysis of Incorrect Options:** * **Option A:** While an omphalocele is indeed covered by a sac (peritoneum and amnion), this is a **morphological feature**, not the primary clinical differentiator used to assess systemic risk or long-term prognosis in a board-style context. * **Option B:** Both omphalocele and gastroschisis involve defects in the abdominal wall/musculature; however, in gastroschisis, the defect is typically to the right of a normal umbilical cord insertion. * **Option C:** Intestinal atresia is actually more commonly associated with **gastroschisis** (due to vascular accidents or constriction at the defect site) rather than omphalocele. **High-Yield NEET-PG Pearls:** * **Location:** Omphalocele is **midline** (through the umbilical ring); Gastroschisis is usually **para-umbilical** (right side). * **Sac:** Omphalocele has a sac; Gastroschisis has **no sac** (bowel is "matted" and edematous due to amniotic fluid exposure). * **Maternal Alpha-Fetoprotein (MSAFP):** Elevated in both, but significantly **higher in gastroschisis** due to exposed bowel. * **Rule of Thumb:** Omphalocele = Associated Anomalies; Gastroschisis = Isolated Defect (usually).

Q: Hypertrophic pyloric stenosis typically presents after how many months of age?

One month. **Explanation:** **Infantile Hypertrophic Pyloric Stenosis (IHPS)** is a condition characterized by hypertrophy and hyperplasia of the pyloric sphincter muscles, leading to gastric outlet obstruction. 1. **Why Option A is correct:** The classic presentation of IHPS occurs between **3 to 6 weeks of life** (averaging around 1 month). While the anatomical predisposition may exist earlier, the muscular hypertrophy progresses over time until it causes a significant clinical obstruction. Therefore, "one month" is the most accurate timeframe for the onset of symptoms. 2. **Why Options B, C, and D are incorrect:** * **Two/Three months:** While IHPS can occasionally present later, it is rare after 12 weeks. Most cases are diagnosed well before the end of the second month. * **Six months:** This is far outside the typical window. Vomiting starting at six months is more likely due to GERD, introduction of solids, or other anatomical obstructions like malrotation. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** Non-bilious, projectile vomiting in a "hungry vomiter" (the infant wants to feed again immediately after vomiting). * **Physical Exam:** A palpable, olive-shaped mass in the epigastrium (best felt after a feed or vomiting) and visible gastric peristalsis. * **Metabolic Profile:** **Hypochloremic, hypokalemic metabolic alkalosis** with paradoxical aciduria (High-yield for exams). * **Diagnosis:** Ultrasound is the gold standard (Pyloric muscle thickness >4mm or length >14mm). * **Management:** Initial step is fluid resuscitation (Normal Saline); definitive treatment is **Ramstedt’s Pyloromyotomy**.

Q: What is the most common type of imperforate anus?

Anorectal agenesis. **Explanation:** **Anorectal agenesis** is the most common type of imperforate anus (anorectal malformation). In this condition, the rectum ends blindly above the level of the puborectalis muscle (levator ani). It is frequently associated with a **fistula**, most commonly to the prostatic urethra in males and the posterior vagina (or vestibule) in females. **Analysis of Options:** * **Anorectal agenesis (Correct):** It accounts for the majority of "high" or "intermediate" malformations. The hallmark is the failure of the urorectal septum to completely divide the cloaca. * **Anal stenosis:** This is a "low" malformation where the anal opening is present but very narrow. It is less common than agenesis. * **Anal agenesis:** In this type, the anal canal is absent, but the rectum ends just above the pelvic floor. It is less frequent than the higher anorectal agenesis. * **Membranous atresia:** Also known as a "covered anus," this is a rare low malformation where a thin epithelial membrane covers the anal opening. **High-Yield Clinical Pearls for NEET-PG:** * **VACTERL Association:** Always screen for other anomalies (Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, and Limb). * **Initial Investigation:** The first step in a newborn is a clinical examination and waiting 24 hours for "gas" to descend. * **Invertogram (Wangensteen-Rice view):** Performed after 24 hours to determine the level of the lesion (High vs. Low) based on the distance of gas from the perineal skin. * **Management:** Low anomalies usually require a primary **Anoplasty**, whereas high anomalies require a staged approach starting with a **Dividing Colostomy**, followed by a **PSARP (Posterior Sagittal Anorectoplasty/Peña procedure)**.

Q: A 6-year-old child presents with a swelling that appears to be a fluid-filled, translucent mass in the supraclavicular area. What is the most likely diagnosis?

Cystic hygroma. ### **Explanation** **Correct Answer: C. Cystic hygroma** **1. Why it is correct:** A **Cystic hygroma** (lymphangioma) is a congenital malformation of the lymphatic system. It most commonly occurs in the **posterior triangle of the neck** or the **supraclavicular area**. The hallmark clinical features are a soft, painless, compressible mass that is **brilliantly transilluminant** (due to its clear, serous fluid content). Unlike other neck masses, it lacks a solid component and often feels "cystic" or "doughy" on palpation. **2. Why the other options are incorrect:** * **Thyroglossal duct cyst:** Typically presents as a **midline** swelling (not supraclavicular) that moves upward on **protrusion of the tongue** or swallowing. * **Branchial cyst:** Usually located at the **upper third of the neck**, along the anterior border of the sternocleidomastoid muscle. It is generally not as translucent as a cystic hygroma and appears later in childhood or early adulthood. * **Lymphoma:** Presents as firm, rubbery, and **non-translucent** lymphadenopathy. It is often associated with systemic "B-symptoms" like fever, weight loss, and night sweats. **3. High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Results from the failure of the jugular lymph sacs to communicate with the venous system. * **Associations:** Frequently associated with chromosomal anomalies, most notably **Turner Syndrome** (45, XO) and Down Syndrome. * **Diagnosis:** Transillumination test is the bedside clinical diagnostic tool; **Ultrasonography** is the initial imaging of choice. * **Treatment:** Surgical excision is the gold standard; however, **Sclerotherapy** (using agents like OK-432 or Bleomycin) is an effective non-surgical alternative for macrocystic lesions.

Q: A two-month-old baby presented with non-bilious vomiting and a palpable epigastric lump. Which among the following will be the investigation of choice?

Ultrasound abdomen. **Explanation:** The clinical presentation of a two-month-old infant with **non-bilious, projectile vomiting** and a palpable epigastric mass (classically described as an **"olive-shaped" lump**) is a hallmark of **Infantile Hypertrophic Pyloric Stenosis (IHPS)**. **Why Ultrasound (USG) is the Investigation of Choice:** USG abdomen is the gold standard because it is non-invasive, avoids radiation, and provides high sensitivity and specificity. Diagnostic criteria on USG include: * **Pyloric muscle thickness:** >3 mm (most reliable) * **Pyloric canal length:** >14 mm * **Target sign** on transverse view and **Cervix sign** on longitudinal view. **Analysis of Incorrect Options:** * **B. X-ray Abdomen:** Usually non-specific. It may show a large gastric air bubble (distended stomach) with minimal distal gas, but it cannot confirm the diagnosis. * **C. Upper GI Series (Barium Swallow):** Historically used but now reserved for cases where USG is inconclusive. It shows the **"String sign"** (narrowed pyloric canal) or **"Beak sign."** It carries a risk of aspiration. * **D. CT Abdomen:** Not indicated due to high radiation exposure and the fact that soft tissue details of the pylorus are better visualized with high-frequency USG in infants. **High-Yield Clinical Pearls for NEET-PG:** * **Metabolic Abnormality:** Hypochloremic, hypokalemic, metabolic alkalosis with paradoxical aciduria (classic exam question). * **Initial Management:** Always correct fluid and electrolyte imbalances (Normal Saline is the fluid of choice) before surgery. * **Definitive Treatment:** Ramstedt’s subcutaneous pyloromyotomy. * **Age of Onset:** Typically 3 to 6 weeks of life; rare after 12 weeks.

Question 1

A newborn presenting with intestinal obstruction showed multiple air fluid levels on abdominal X-ray. Which of the following is NOT a likely diagnosis?

Accepted Answer

Pyloric obstruction

Answer

Duodenal atresia

Answer

Ileal atresia

Answer

Ladd's bands

Question 2

A male neonate is born with an omphalocele. This entity can be distinguished from gastroschisis because, in an omphalocele, the protrusion is:

Accepted Answer

Associated with partial or complete malrotation of the bowel

Answer

Covered by a sac

Answer

A defect in the abdominal musculature

Answer

Associated with an umbilicus attached to the abdominal wall musculature

Question 3

A male neonate is born with an omphalocele. This entity can be distinguished from gastroschisis because, in an omphalocele, the protrusion is:

Accepted Answer

Associated with congenital malformations

Answer

Covered by a sac

Answer

A defect in the abdominal musculature

Answer

Associated with intestinal atresia

Question 4

Hypertrophic pyloric stenosis typically presents after how many months of age?

Accepted Answer

One month

Answer

Two months

Answer

Three months

Answer

Six months

Question 5

The "double bubble" sign in children is most commonly seen in which of the following conditions?

Accepted Answer

Diaphragmatic hernia

Answer

Ladd's bands

Answer

Annular pancreas

Answer

Pancreatic pseudocyst

Question 6

All of the following are true about congenital diaphragmatic hernia EXCEPT:

Accepted Answer

Pulmonary dilators markedly improve survival

Answer

Usually associated with polyhydramnios

Answer

Most commonly seen on the left side

Answer

Mortality is associated with pulmonary hypoplasia

Question 7

What is the most common type of imperforate anus?

Accepted Answer

Anorectal agenesis

Answer

Anal stenosis

Answer

Anal agenesis

Answer

Membranous atresia

Question 8

What is the investigation of choice for Meckel's diverticulum in the pediatric age group?

Accepted Answer

99mTc-pertechnetate scan

Answer

USG

Answer

CT

Answer

Barium meal

Question 9

A 6-year-old child presents with a swelling that appears to be a fluid-filled, translucent mass in the supraclavicular area. What is the most likely diagnosis?

Accepted Answer

Cystic hygroma

Answer

Thyroglossal duct cyst

Answer

Branchial cyst

Answer

Lymphoma

Question 10

A two-month-old baby presented with non-bilious vomiting and a palpable epigastric lump. Which among the following will be the investigation of choice?

Accepted Answer

Ultrasound abdomen

Answer

X-ray abdomen

Answer

Upper GI Series

Answer

CT abdomen

Pediatric Surgery Basics — MCQs

Pediatric Surgery Basics — MCQs

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