Appendicitis in Children — MCQs
An infant presents with colicky pain and vomiting, along with a sausage-shaped lump in the abdomen, and the diagnosis is:
A 25-year-old patient presents with RLQ pain, fever, and vomiting. CT shows a ruptured appendix. What is the next step?
In a female with appendicitis in pregnancy the treatment of choice is:
A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
In which of the following conditions is Alvarado score indicated?
A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?
What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?
Investigation of choice to diagnose hypertrophic pyloric stenosis in infants is
A 5-year-old child was admitted to the hospital for a prolapsing rectal mass and painless rectal bleeding. Histopathological examination reveals enlarged and inflamed glands filled with mucin. What is the likely diagnosis?
Juvenile polyp is a type of which of the following?
Appendicitis in Children Indian Medical PG Practice Questions and MCQs
Question 1: An infant presents with colicky pain and vomiting, along with a sausage-shaped lump in the abdomen, and the diagnosis is:
- A. Enterocolitis
- B. Perforation of the abdomen
- C. Intussusception (Correct Answer)
- D. Acute appendicitis
Explanation: ***Intussusception*** - This classic presentation of **colicky pain, vomiting, and a sausage-shaped abdominal lump** is highly indicative of intussusception, where one part of the intestine telescopes into another. - Most commonly occurs in **infants between 5-9 months of age**. - The symptoms are due to **bowel obstruction** and **ischemia**, which can progress to currant jelly stools. *Enterocolitis* - While enterocolitis can cause abdominal pain and vomiting, it typically presents with **diarrhea** and **fever**, and does not involve a palpable "sausage-shaped lump." - It involves **inflammation of the intestine** and colon, often due to infection. *Perforation of the abdomen* - Abdominal perforation would present with signs of **peritonitis**, severe acute pain, **abdominal distension**, and **rigidity**, often with signs of shock, and typically no palpable mass. - It is a severe condition that implies a hole in the gastrointestinal tract, leading to leakage of contents into the peritoneal cavity. *Acute appendicitis* - Though it causes abdominal pain and vomiting, acute appendicitis is **uncommon in infants** and typically localized to the **right lower quadrant**, not forming a "sausage-shaped lump." - Inflammation of the appendix is usually associated with **fever** and specific tenderness at **McBurney's point**.
Question 2: A 25-year-old patient presents with RLQ pain, fever, and vomiting. CT shows a ruptured appendix. What is the next step?
- A. Percutaneous drainage
- B. Open appendectomy (Correct Answer)
- C. Conservative treatment
- D. Laparoscopic appendectomy
Explanation: ***Open appendectomy*** - For a **ruptured appendix** with generalized peritonitis, **open appendectomy** is the traditional gold standard and most appropriate approach. - Open surgery allows for **thorough peritoneal lavage**, better visualization of the entire abdominal cavity, and effective drainage of contaminated fluid. - In the setting of **perforation with peritoneal contamination**, open approach ensures complete source control and reduces risk of missed abscesses or inadequate irrigation. *Laparoscopic appendectomy* - While laparoscopic appendectomy can be used in **selected cases** of perforated appendicitis, it is not the first-line approach for a ruptured appendix with generalized peritonitis. - Laparoscopic approach may be limited in cases with **extensive contamination** and may not allow adequate peritoneal toilet. - It is more appropriate for **uncomplicated appendicitis** or **early/localized perforation** in experienced hands. *Percutaneous drainage* - This is typically reserved for patients with a **well-defined appendiceal abscess** presenting late (>5 days after symptom onset) where a phlegmon or organized abscess has formed. - Used as part of **interval appendectomy** approach: drain abscess, treat with antibiotics, then perform appendectomy 6-8 weeks later. - Not appropriate for **acute rupture** with active peritonitis requiring immediate surgical source control. *Conservative treatment* - **Antibiotics alone** might be considered for **uncomplicated appendicitis** in select cases or when surgery is contraindicated. - A **ruptured appendix** is a surgical emergency requiring operative intervention to prevent sepsis, abscess formation, and other life-threatening complications. - Conservative management is contraindicated in the presence of perforation and peritonitis.
Question 3: In a female with appendicitis in pregnancy the treatment of choice is:
- A. Continue pregnancy with medical Rx
- B. Surgery after delivery
- C. Surgery at earliest (Correct Answer)
- D. Abortion with appendectomy
Explanation: ***Surgery at earliest*** - **Prompt surgical intervention** is crucial for appendicitis in pregnancy to prevent complications such as perforation, peritonitis, and maternal or fetal morbidity and mortality. - Delaying surgery increases the risk of rupture, which can be devastating for both the mother and the fetus. *Continue pregnancy with medical Rx* - **Medical management (antibiotics alone)** is generally ineffective for acute appendicitis in pregnant women and carries a high risk of progression to perforation. - This approach would expose the mother and fetus to serious complications, including sepsis and preterm labor, without addressing the underlying surgical pathology. *Surgery after delivery* - Delaying surgery until after delivery is unsafe and potentially fatal, as **appendiceal rupture could occur at any time** during pregnancy. - The risk of **perforation, peritonitis, and subsequent complications** is too high to justify waiting. *Abortion with appendectomy* - **Therapeutic abortion** is not indicated for uncomplicated appendicitis in pregnancy and does not improve the maternal prognosis for the appendicitis itself. - The focus is on treating the underlying medical condition (appendicitis) while preserving the pregnancy, if possible.
Question 4: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
- A. Proceed to laparotomy and appendicectomy (Correct Answer)
- B. Intravenous antibiotics
- C. Continue Ochsner Sherren regimen with close monitoring
- D. Continue conservative management
Explanation: ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.
Question 5: In which of the following conditions is Alvarado score indicated?
- A. Pancreatitis
- B. Appendicitis (Correct Answer)
- C. Cholangitis
- D. Cholecystitis
Explanation: ***Appendicitis*** - The Alvarado score, also known as the MANTRELS score, is a clinical scoring system used to assess the likelihood of **acute appendicitis**. - It considers symptoms (e.g., **migratory right iliac fossa pain**, **anorexia**, **nausea/vomiting**), signs (e.g., **tenderness in the right iliac fossa**, **rebound tenderness**), and laboratory findings (e.g., **leukocytosis**, **shift to the left of neutrophils**). *Pancreatitis* - Pancreatitis is typically diagnosed and managed using criteria such as the **Ranson criteria** or **APACHE II score** for severity assessment, and imaging like CT scans. - The Alvarado score is not applicable for the diagnosis or severity assessment of pancreatitis. *Cholangitis* - Cholangitis is an infection of the bile ducts which is usually diagnosed clinically using the **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension). - The Alvarado score has no role in the evaluation of cholangitis. *Cholecystitis* - Cholecystitis, inflammation of the gallbladder, is primarily diagnosed based on clinical symptoms (e.g., **right upper quadrant pain**, **fever**, **leukocytosis**), Murphy's sign, and imaging (ultrasound). - The Alvarado score is specifically designed for appendicitis and is not used for cholecystitis.
Question 6: A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?
- A. Ileal (Meckel) diverticulum (Correct Answer)
- B. External hemorrhoids
- C. Internal hemorrhoids
- D. Diverticulosis
Explanation: ***Ileal (Meckel) diverticulum*** - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract, present in approximately 2% of the population. - It is the **most common cause of painless, profuse rectal bleeding** in the pediatric age group, typically presenting with brick-red or maroon stools. - The bleeding results from **peptic ulceration of the ileal mucosa** adjacent to ectopic (heterotopic) gastric mucosa within the diverticulum, which secretes acid. - Diagnosis is often confirmed with a **Technetium-99m pertechnetate scan** (Meckel's scan), which detects ectopic gastric mucosa. *External hemorrhoids* - External hemorrhoids typically present with **pain, itching, and a palpable perianal lump**, especially when thrombosed. - While they can cause bleeding, it is usually **minimal and bright red**, not the profuse rectal bleeding described in this case. - Hemorrhoids are **uncommon in children** and usually associated with chronic constipation or straining. *Internal hemorrhoids* - Internal hemorrhoids can cause **painless bleeding**, but this typically manifests as bright red blood coating the stool or dripping into the toilet bowl. - The bleeding is usually **minor and intermittent**, not profuse or life-threatening. - They are **much less common in the pediatric population** compared to adults and are not a typical cause of significant hemorrhage in children. *Diverticulosis* - Colonic diverticulosis is predominantly a **disease of older adults** (typically >40 years of age) related to dietary factors and increased intraluminal pressure. - It is **extremely rare in the pediatric age group** and would not be a primary consideration in a 12-year-old. - While diverticulosis can cause significant painless bleeding in adults, its occurrence in children is highly unlikely.
Question 7: What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?
- A. USG (Correct Answer)
- B. CT Scan
- C. X-ray
- D. MRI
Explanation: ***USG*** - An **ultrasound (USG)** is the preferred initial imaging modality in pediatric acute abdomen due to its **lack of ionizing radiation**, ease of use, and ability to visualize common causes like appendicitis and intussusception. - It is particularly useful for assessing **fluid collections**, inflammation, and obstruction in a non-invasive manner suitable for children. *CT Scan* - While it offers detailed anatomical views, **CT scans** involve significant **ionizing radiation**, which is a concern in children due to increased lifetime cancer risk. - It is typically reserved for cases where **USG is inconclusive** or if there is a high suspicion of conditions not well visualized by ultrasound. *X-ray* - **X-rays** provide limited information for soft tissue pathologies and are primarily useful for detecting **bowel obstruction (air-fluid levels)** or **free air** (perforation). - They lack the resolution to diagnose many common causes of acute abdomen in children, such as appendicitis or intussusception. *MRI* - **MRI** provides excellent soft tissue contrast without ionizing radiation but often requires **sedation** in young children due to the long scan times and need for stillness. - It is less readily available and more expensive than USG, making it a less practical first-line investigation for an acute presentation.
Question 8: Investigation of choice to diagnose hypertrophic pyloric stenosis in infants is
- A. Gastroscopy
- B. CT scan abdomen
- C. Ultrasound abdomen (Correct Answer)
- D. Contrast radiology
Explanation: ***Ultrasound abdomen*** - **Abdominal ultrasound** is the diagnostic procedure of choice due to its **non-invasive nature**, **lack of radiation exposure**, and high accuracy in visualizing the pylorus. - It allows for direct measurement of the **pyloric muscle wall thickness** (typically >3-4 mm) and **pyloric channel length** (typically >14-17 mm), which are characteristic findings of hypertrophic pyloric stenosis. *Gastroscopy* - While gastroscopy can visualize the gastric outlet, it is an **invasive procedure** and not the primary diagnostic tool due to the risk associated with endoscopy in infants. - It is often reserved for cases where the diagnosis is unclear or other upper gastrointestinal pathologies are suspected. *CT scan abdomen* - **CT scans** expose infants to **ionizing radiation**, making it an unsuitable primary diagnostic investigation, especially when a highly accurate non-irradiating alternative exists. - Although it can show pyloric thickening, its disadvantages outweigh its benefits for this diagnosis. *Contrast radiology* - **Barium studies** are less sensitive and specific than ultrasound for diagnosing pyloric stenosis, especially for distinguishing muscle thickening from spasm. - This method also involves **radiation exposure** and poses a risk of aspiration, making it a secondary choice.
Question 9: A 5-year-old child was admitted to the hospital for a prolapsing rectal mass and painless rectal bleeding. Histopathological examination reveals enlarged and inflamed glands filled with mucin. What is the likely diagnosis?
- A. Adenoma (precancerous lesion in adults)
- B. Juvenile polyp (Hamartoma) (Correct Answer)
- C. Carcinoma (malignant tumor, rare in children)
- D. Choristoma (benign growth of normal tissue in an abnormal location)
Explanation: ***Juvenile polyp (Hamartoma)*** - **Juvenile polyps** are the most common cause of rectal bleeding in children, often presenting as a **prolapsing rectal mass** and **painless bleeding**. - Histologically, they are characterized by **enlarged, inflamed glands filled with mucin**, consistent with a hamartomatous origin. *Adenoma (precancerous lesion in adults)* - While adenomas can cause rectal bleeding and prolapse, they are typically found in **adults** and are considered **precancerous lesions** [1]. - The patient's young age (5-year-old) makes an adenoma highly unlikely [1]. *Carcinoma (malignant tumor, rare in children)* - **Colorectal carcinoma** is exceedingly **rare in children** and usually presents with more aggressive symptoms than painless bleeding, such as weight loss or anemia [2]. - The histological description of inflamed, mucin-filled glands is not typical for carcinoma [2]. *Choristoma (benign growth of normal tissue in an abnormal location)* - A **choristoma** is a benign growth of normal tissue in an abnormal location, but it does not typically present as a rectal mass or cause rectal bleeding. - The microscopic findings of enlarged and inflamed glands filled with mucin are not characteristic of a choristoma. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 371-372. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 821-822.
Question 10: Juvenile polyp is a type of which of the following?
- A. Hamartomatous polyp (Correct Answer)
- B. Lymphoid polyp
- C. Hyperplastic type
- D. Inflammatory polyp
Explanation: ***Hamartomatous polyp*** - Juvenile polyps are classified as **hamartomatous polyps**, characterized by an excessive growth of tissue normally present in the area. - They are typically found in children and can be associated with **Juvenile Polyposis Syndrome** if multiple polyps are present [1]. *Hyperplastic type* - Hyperplastic polyps are usually small, **sessile polyps** found mainly in the colon and are not associated with significant risk of malignancy. - They do not have the **hamartomatous** features characteristic of juvenile polyps. *Lymphoid polyp* - Lymphoid polyps are composed primarily of **lymphoid tissue** and are often incidental findings in children; they are not the same as juvenile polyps. - These polyps are more common in the **ileum** and do not exhibit the same histological characteristics as hamartomatous polyps. *Inflammatory polyp* - Inflammatory polyps arise as a result of **inflammation** and are commonly associated with conditions like **ulcerative colitis**. - They differ from juvenile polyps, which arise from abnormal growth and are typically **non-inflammatory** in nature. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 813.
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