Congenital Diaphragmatic Hernia — MCQs
What is the most common site of congenital diaphragmatic hernia?
A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?
A young child presented with mild intermittent upper abdominal pain. X-ray is given below. What is the diagnosis?
Which one of the following life-threatening congenital anomalies in the newborn presents with polyhydramnios, aspiration pneumonia, excessive salivation and difficulty in passing a nasogastric tube?
True about congenital diaphragmatic hernia (CDH) except:
A newborn male child presenting with severe respiratory distress, absent respiratory breath sounds, and a scaphoid abdomen is suffering from.
Which of the following are correct for herniation via foramen of Morgagni? 1. It occurs posteriorly in chest. 2. Transverse colon is the commonest content. 3. Defect is between sternal and costal attachments. 4. It is a type of congenital hernia. Select the answer using the code given below.
In Congenital Diaphragmatic Hernia (CDH), the most commonly associated anomaly affects the
Most common congenital diaphragmatic hernia is:
Oesophageal atresia may occur as part of the VACTERL group of anomalies. What does "TE" refer to in this context?
Congenital Diaphragmatic Hernia Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common site of congenital diaphragmatic hernia?
- A. Central tendon
- B. Posterolateral (Correct Answer)
- C. Crural
- D. Anterolateral
- E. Esophageal hiatus
Explanation: ***Posterolateral*** - The **posterolateral** region, specifically the foramen of Bochdalek, is the most common site for congenital diaphragmatic hernia (CDH). - This type of hernia accounts for approximately 80-90% of all CDH cases and usually occurs on the **left side**. *Central tendon* - Hernias through the **central tendon** are extremely rare and are distinct from the more common forms of CDH. - Defects in the central tendon are often associated with **pericardial defects** rather than typical diaphragmatic hernias which allow abdominal contents into the thoracic cavity. *Crural* - Hernias involving the **crura** of the diaphragm are typically **hiatal hernias** (e.g., sliding or paraesophageal), which are different in origin and presentation from CDH. - These are usually acquired and involve the stomach moving into the mediastinum, rather than a congenital defect leading to abdominal viscera migrating into the chest. *Anterolateral* - While congenital diaphragmatic hernias can occur **anterolaterally** through the foramen of Morgagni, these are much less common than posterolateral hernias. - Morgagni hernias account for a small percentage of CDH cases (around 2-5%) and are typically located on the right side, often containing omentum or colon. *Esophageal hiatus* - The **esophageal hiatus** is the normal opening in the diaphragm through which the esophagus passes. - While hiatal hernias can occur at this site, these are typically **acquired hernias** in adults, not congenital diaphragmatic hernias. - Congenital CDH refers to developmental defects in the diaphragm itself, not enlargement of normal openings.
Question 2: A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?
- A. Immediate surgical repair
- B. Elective surgery at 5 years of age
- C. Hernioplasty for repair
- D. Observation until 2 years of age, then surgery if unresolved (Correct Answer)
Explanation: ***Observation until 2 years of age, then surgery if unresolved*** - Most **umbilical hernias** in infants and young children **resolve spontaneously** by the age of 2 years, making observation the initial management for uncomplicated cases. - Surgical intervention is typically considered if the hernia persists beyond **2-4 years of age**, is symptomatic, or demonstrates features of incarceration regardless of age. *Immediate surgical repair* - Immediate surgery is reserved for cases with **incarceration** or **strangulation**, which are not indicated by a "symptomatic" hernia in this context. - Given the high rate of spontaneous closure, most umbilical hernias do not require urgent intervention. *Elective surgery at 5 years of age* - Waiting until 5 years of age to consider surgery might delay treatment for some children whose hernias are unlikely to close spontaneously after the age of 2-4 and could lead to prolonged parental anxiety. - The general consensus is to recommend surgery if the hernia persists beyond **2-4 years**, rather than a fixed age of 5. *Hernioplasty for repair* - While hernioplasty is the surgical technique for repair, the question asks about the overall management protocol, which includes initial observation. - Applying this term as an immediate solution for a 6-month-old's uncomplicated umbilical hernia would bypass the recommended period of **conservative management**.
Question 3: A young child presented with mild intermittent upper abdominal pain. X-ray is given below. What is the diagnosis?
- A. Morgagni hernia (Correct Answer)
- B. Bochdalek hernia
- C. Gastric volvulus
- D. Eventration of diaphragm
Explanation: ***Morgagni hernia*** - The X-ray shows a **gas-filled lesion** in the **right cardiophrenic angle**, which is characteristic of a Morgagni hernia, where abdominal contents (often colon or omentum) herniate through the foramen of Morgagni. - The mild intermittent **upper abdominal pain** in a child is consistent with the infrequent or non-specific symptoms these hernias can present, as they are often discovered incidentally. *Bochdalek hernia* - **Bochdalek hernias** typically occur posteriorly and laterally, predominately on the **left side**, and are usually identified in the **neonatal period** with severe respiratory distress. - The radiographic appearance would be of abdominal contents (bowel loops, liver, spleen) largely filling the ipsilateral hemithorax, causing significant mediastinal shift, which is not seen here. *Gastric volvulus* - **Gastric volvulus** involves abnormal rotation of the stomach, often presenting with acute symptoms like **epigastric pain, vomiting, and inability to pass a nasogastric tube (Borchardt's triad)**. - Radiographically, it would show a **distended stomach** with an abnormal position, often high in the chest, but without the distinct localized air-filled mass in the cardiophrenic angle. *Eventration of diaphragm* - **Diaphragmatic eventration** is an abnormal elevation of part or all of an intact hemidiaphragm, usually due to muscular hypoplasia. - The X-ray would show a **uniformly elevated hemidiaphragm** with normal continuity, and there would be no discrete air-filled structures above the diaphragm to suggest herniated bowel.
Question 4: Which one of the following life-threatening congenital anomalies in the newborn presents with polyhydramnios, aspiration pneumonia, excessive salivation and difficulty in passing a nasogastric tube?
- A. Choanal atresia
- B. Gastroschisis
- C. Diaphragmatic hernia
- D. Tracheo-esophageal fistula (Correct Answer)
Explanation: ***Tracheo-esophageal fistula*** - This condition presents with **polyhydramnios** due to the fetus being unable to swallow amniotic fluid, **excessive salivation** from accumulated secretions in the blind-ending esophageal pouch, and difficulty passing a **nasogastric tube** because of the esophageal obstruction. - **Aspiration pneumonia** is a common complication as saliva and gastric contents can be aspirated into the lungs through the fistula. *Choanal atresia* - Characterized by **blocked nasal passages**, leading to **cyclical cyanosis** relieved by crying, but not typically associated with polyhydramnios or excessive salivation in this manner. - While it can cause respiratory distress, it does not involve esophageal obstruction or directly cause aspiration pneumonia from swallowed fluids. *Gastroschisis* - This is an **abdominal wall defect** where intestines protrude outside the body, unrelated to swallowing difficulties, polyhydramnios caused by inability to swallow, or excessive salivation. - It does not involve difficulty in passing a nasogastric tube or directly cause aspiration pneumonia. *Diaphragmatic hernia* - Involves **abdominal contents herniating into the chest cavity**, leading to **pulmonary hypoplasia** and respiratory distress. - It does not explain polyhydramnios due to impaired swallowing, excessive salivation, or the characteristic inability to pass a nasogastric tube.
Question 5: True about congenital diaphragmatic hernia (CDH) except:
- A. Causes pulmonary hypoplasia
- B. Occurs mostly on the left side
- C. Occurs anteriorly in the diaphragm (Correct Answer)
- D. Leads to cyanosis at birth
Explanation: ***Occurs anteriorly in the diaphragm*** - This statement is incorrect. Most CDHs, specifically **Bochdalek hernias**, occur in the **posterolateral** aspect of the diaphragm. **Morgagni hernias** are anterior but are much less common. - The question asks for the statement that is *not* true about CDH, making this the correct answer. *Causes pulmonary hypoplasia* - This is true because the herniated abdominal contents in the chest cavity compress the developing lungs, preventing them from growing to their normal size. - **Pulmonary hypoplasia** is the primary cause of morbidity and mortality in infants with CDH due to insufficient lung tissue and underdeveloped pulmonary vasculature. *Occurs mostly on the left side* - This is true, as approximately 85% of CDH cases involve a defect in the **left hemidiaphragm**. - The exact reason for the left-sided predominance is not fully understood but may relate to the faster closure of the right pleuroperitoneal canal during development. *Leads to cyanosis at birth* - This is true due to severe **respiratory distress** and **pulmonary hypertension** resulting from pulmonary hypoplasia and abnormal pulmonary vascular development. - The newborn's inability to adequately oxygenate blood causes a bluish discoloration of the skin and mucous membranes.
Question 6: A newborn male child presenting with severe respiratory distress, absent respiratory breath sounds, and a scaphoid abdomen is suffering from.
- A. Congenital pyloric stenosis
- B. Diaphragmatic hernia (Correct Answer)
- C. Intussusception
- D. Meconium ileus
Explanation: ***Diaphragmatic hernia*** * The classic triad of **respiratory distress**, the absence of **breath sounds** on the affected side, and a **scaphoid abdomen** is highly indicative of a **congenital diaphragmatic hernia (CDH)**. * In CDH, abdominal contents herniate into the chest cavity, compressing the lungs and causing **pulmonary hypoplasia**, leading to severe respiratory compromise. *Congenital pyloric stenosis* * Pyloric stenosis typically presents with **non-bilious projectile vomiting** and an **olive-shaped mass** in the epigastrium, usually in infants between 3-6 weeks of age, not in a newborn with respiratory distress. * It does not cause absent breath sounds or a scaphoid abdomen, as it is a gastrointestinal obstruction without thoracic involvement. *Intussusception* * Intussusception involves the telescoping of one part of the intestine into another, presenting with **colicky abdominal pain**, **vomiting**, and **"currant jelly" stools**. * This condition primarily affects older infants and young children, is an acute abdominal emergency, and does not directly cause severe respiratory distress or absent breath sounds unless there is significant abdominal distension compromising respiration. *Meconium ileus* * Meconium ileus is an obstruction of the small intestine by abnormally thick meconium, often associated with **cystic fibrosis**. * It presents with **abdominal distension**, **vomiting**, and **failure to pass meconium**, but not typically with severe respiratory distress unrelated to abdominal distension.
Question 7: Which of the following are correct for herniation via foramen of Morgagni? 1. It occurs posteriorly in chest. 2. Transverse colon is the commonest content. 3. Defect is between sternal and costal attachments. 4. It is a type of congenital hernia. Select the answer using the code given below.
- A. 1, 3 and 4
- B. 1, 2 and 4
- C. 1, 2 and 3
- D. 2, 3 and 4 (Correct Answer)
Explanation: ***2, 3 and 4*** - The **foramen of Morgagni** hernia (also known as a parasternal or retrosternal hernia) is a type of **congenital diaphragmatic hernia (CDH)** - statement 4 is **correct**. - The defect is located in the **anterior diaphragm**, specifically between the **sternal and costal attachments** - statement 3 is **correct**. - The **transverse colon** is indeed a common content (most common visceral organ), though omentum is actually the most frequent overall content - statement 2 is considered **correct** in clinical practice. - Statement 1 is **incorrect** as Morgagni hernias occur **anteriorly**, not posteriorly. *1, 3 and 4* - This option incorrectly includes statement 1, which claims the herniation occurs **posteriorly** in the chest. - **Morgagni hernias** are **anterior** diaphragmatic defects (parasternal location). - Posterior diaphragmatic hernias are **Bochdalek hernias**, not Morgagni hernias. *1, 2 and 4* - This option is incorrect because statement 1 states the hernia occurs **posteriorly**, which is wrong. - **Morgagni hernias** are located in the **anterior diaphragm** between sternal and costal attachments. - While statements 2 and 4 are correct, the inclusion of statement 1 makes this option incorrect. *1, 2 and 3* - This option is incorrect because statement 1 claims the hernia occurs **posteriorly**, which is inaccurate. - **Morgagni hernias** are **anterior** defects, representing only 2-3% of congenital diaphragmatic hernias. - The key distinguishing feature is the anterior parasternal location, not posterior.
Question 8: In Congenital Diaphragmatic Hernia (CDH), the most commonly associated anomaly affects the
- A. Congenital heart defects (Correct Answer)
- B. Anomalies of the urinary tract
- C. Anomalies of the skull
- D. Craniofacial anomalies
Explanation: ***Congenital heart defects*** - **Congenital diaphragmatic hernia (CDH)** is frequently associated with other congenital anomalies. - **Cardiac malformations** are the most common co-occurring defects, affecting a significant proportion of CDH patients. *Anomalies of the urinary tract* - While **urogenital anomalies** can occur with CDH, they are less prevalent than congenital heart defects. - These typically include conditions like **renal agenesis** or **hydronephrosis**. *Anomalies of the skull* - **Skull anomalies** are not a primary or common association with congenital diaphragmatic hernia. - Genetic syndromes associated with both CDH and skull anomalies are relatively rare. *Craniofacial anomalies* - **Craniofacial anomalies**, such as **cleft lip/palate**, can occur with CDH but are less common than cardiac anomalies. - These are often seen within the context of specific genetic syndromes.
Question 9: Most common congenital diaphragmatic hernia is:
- A. Bochdalek hernia (Correct Answer)
- B. Morgagni hernia
- C. None of the options
- D. Paraesophageal hernia
Explanation: ***Bochdalek hernia*** - This is the most common type of **congenital diaphragmatic hernia (CDH)**, accounting for approximately **95% of all CDH cases**. - It occurs due to a defect in the **posterolateral diaphragm** (pleuroperitoneal membrane), typically on the **left side**. - Presents in neonates with respiratory distress due to herniation of abdominal contents into the thorax. *Morgagni hernia* - This is a rare type of **congenital diaphragmatic hernia**, occurring through the **anterior retrosternal diaphragm** (foramen of Morgagni). - Accounts for only **2-5% of all CDH cases**, usually on the right side. - Often asymptomatic and diagnosed incidentally in adults. *Paraesophageal hernia* - This is an **acquired hiatal hernia** where part of the stomach herniates alongside the esophagus through the esophageal hiatus. - While **hiatal hernias are the most common diaphragmatic hernias overall**, they are **not congenital** and therefore not the answer to this question. - Seen commonly in older adults. *None of the options* - Incorrect, as **Bochdalek hernia** is definitively the most common congenital diaphragmatic hernia.
Question 10: Oesophageal atresia may occur as part of the VACTERL group of anomalies. What does "TE" refer to in this context?
- A. Tetralogy of Fallot
- B. Thoracic empyema
- C. Tracheo-oesophageal fistula (Correct Answer)
- D. Talipes equinovarus
Explanation: ***Tracheo-oesophageal fistula*** - The acronym VACTERL stands for **V**ertebral defects, **A**nal atresia, **C**ardiac defects, **T**racheo-**E**sophageal fistula, **R**enal anomalies, and **L**imb defects. - Oesophageal atresia often coexists with a **tracheo-oesophageal fistula (TE)**, which explains the "TE" component in the VACTERL association. *Tetralogy of Fallot* - This is a type of **cardiac defect (C)**, which is covered by the "C" in VACTERL, not "TE." - It involves four specific heart abnormalities but doesn't directly relate to the **oesophageal or tracheal components**. *Thoracic empyema* - **Thoracic empyema** describes a collection of pus in the pleural space, usually due to infection, and is not a congenital anomaly. - It is an **acquired condition** and not part of the VACTERL association. *Talipes equinovarus* - This condition, also known as **clubfoot**, is a **limb defect (L)**. - While it is a recognized part of the VACTERL association, it specifically relates to the "L" and not the "TE."
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