Malrotation and Volvulus — MCQs
A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?
A young child presented with mild intermittent upper abdominal pain. X-ray is given below. What is the diagnosis?
Shirodkar cerclage may be associated with all complications except:
"String of beads" appearance on horizontal abdominal view X-ray is suggestive of:
A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?
A 3-month-old infant presents with an abdominal palpable mass and non-bilious vomiting. What is the most likely diagnosis?
A 6-month-old child woke up at night, crying with severe colicky abdominal pain, and later passed red currant jelly stools. What is the most likely diagnosis?
A 6-year-old child with abdominal pain and a rash is shown. Comment on the diagnosis?
Child has not passed stool by 2nd day of life. X-Ray study done shows:
A newborn presenting with intestinal obstruction showed multiple air fluid levels on abdominal X-ray. Which of the following is NOT a likely diagnosis?
Malrotation and Volvulus Indian Medical PG Practice Questions and MCQs
Question 1: A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?
- A. Peritoneal drainage (Correct Answer)
- B. Resection and anastomosis
- C. Conservative treatment
- D. Stabilization with membrane oxygenator and defer surgery
Explanation: ***Peritoneal drainage*** - In a newborn with **perforated necrotizing enterocolitis (NEC)** and **poor general condition**, peritoneal drainage is the preferred initial surgical approach to address sepsis while avoiding major abdominal surgery. - This procedure involves draining accumulated fluid and pus from the peritoneal cavity, reducing intra-abdominal pressure and systemic inflammation in a medically unstable patient. *Resection and anastomosis* - **Resection and primary anastomosis** is a more extensive surgical procedure that carries higher risks in a globally unstable neonate. - This surgery is typically reserved for more stable patients or as a secondary procedure once the patient's condition has improved following initial decompression. *Conservative treatment* - **Conservative treatment** alone is insufficient and inappropriate for **perforated necrotizing enterocolitis**, as perforation implies the need for surgical intervention to address peritonitis and sepsis. - Delaying surgical management in perforation can lead to rapid deterioration, severe sepsis, and increased mortality. *Stabilization with membrane oxygenator and defer surgery* - While an **extracorporeal membrane oxygenator (ECMO)** might be used for respiratory or cardiovascular support in severe cases, it does not address the underlying **perforation and peritonitis**. - **Deferring surgery** for perforation is not an option as surgical source control is necessary to manage the acute peritonitis and sepsis, even if the patient is on ECMO.
Question 2: 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 3: 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 4: "String of beads" appearance on horizontal abdominal view X-ray is suggestive of:
- A. Intussusception
- B. Sigmoid volvulus
- C. Small bowel obstruction (Correct Answer)
- D. Large bowel obstruction
Explanation: ***Small bowel obstruction*** - A "string of beads" appearance on a horizontal abdominal view X-ray refers to small gas bubbles trapped between the valvulae conniventes in a dilated small bowel loop. - This finding is highly suggestive of **complete small bowel obstruction**, particularly when accompanied by multiple air-fluid levels and dilated bowel loops. *Intussusception* - While it causes obstruction, intussusception usually appears as a **target sign** (doughnut sign) on ultrasound or a **meniscus sign** on barium enema, not a string of beads on plain X-ray. - Plain X-rays may show signs of **bowel obstruction**, but the string of beads is not characteristic. *Sigmoid volvulus* - Sigmoid volvulus is characterized by a **dilated loop of colon** forming an inverted U-shape, often described as a **coffee bean sign** or **omega sign**, on plain X-ray. - This involves the large bowel, and the "string of beads" specifically relates to gas in the small bowel. *Large bowel obstruction* - Large bowel obstruction typically presents with a **dilated colon** proximal to the obstruction and a collapsed distal colon, often with absent or minimal gas in the rectum and sigmoid. - While air-fluid levels can be present, the "string of beads" is a specific sign of gas within dilated small bowel loops, distinguishing it from most large bowel obstructions.
Question 5: A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?
- A. Hypertrophic pyloric stenosis
- B. Acute appendicitis
- C. Jejunal atresia
- D. Malrotation with volvulus (Correct Answer)
Explanation: ***Malrotation with volvulus*** - The acute onset of **bilious vomiting** in a 1-week-old infant is a **surgical emergency** and highly suggestive of intestinal obstruction, with malrotation with volvulus being a critical consideration. - The barium enema image (B) shows the **ligament of Treitz** located to the right of the midline, indicating **intestinal malrotation** and a **corkscrew pattern** of the duodenum, which is pathognomonic for **midgut volvulus**. *Hypertrophic pyloric stenosis* - Typically presents with **non-bilious projectile vomiting** and palpable **pyloric olive mass**, usually appearing between 3 to 6 weeks of age, not at 1 week with bilious vomiting. - Imaging would reveal an **elongated, narrowed pyloric channel** (string sign) and thickened pyloric muscle, not the findings seen in the barium study. *Acute appendicitis* - This is an **extremely rare diagnosis** in a 1-week-old infant and typically presents with localized pain, fever, and leukocytosis, which are not the primary symptoms described. - Acute appendicitis would not explain the **bilious vomiting** or the specific findings on the barium study related to intestinal rotation. *Jejunal atresia* - Presents with bilious vomiting and abdominal distension, often diagnosed prenatally or shortly after birth due to proximal dilation and distal collapse of the bowel. - While it causes obstruction, the barium study in jejunal atresia would show a **blind-ending jejunum** and not the distinct malrotation and volvulus features (e.g., corkscrew sign, abnormal Treitz location).
Question 6: A 3-month-old infant presents with an abdominal palpable mass and non-bilious vomiting. What is the most likely diagnosis?
- A. Hypertrophic pyloric stenosis (Correct Answer)
- B. Tracheoesophageal fistula
- C. Duodenal atresia
- D. Intussusception
Explanation: ***Hypertrophic pyloric stenosis*** - The classic presentation includes **projectile non-bilious vomiting** and a palpable **olive-shaped mass** in the epigastrium of an infant typically between 3 weeks and 6 months of age. - The vomiting is non-bilious because the obstruction is proximal to the ampulla of Vater. *Intussusception* - While it can present with an **abdominal mass** and vomiting, the vomiting is often **bilious** and the classic stool is **'currant jelly'**, which is not mentioned here. - It usually presents with sudden onset of severe, **colicky abdominal pain** and occurs more commonly in slightly older infants (6-12 months). *Tracheoesophageal fistula* - This condition presents at birth with symptoms such as **choking, coughing**, and **cyanosis** during feeding. - It usually causes respiratory distress and feeding difficulties from the first days of life, not a palpable abdominal mass and non-bilious vomiting at 3 months. *Duodenal atresia* - This is a congenital obstruction that typically presents with **bilious vomiting** (as the obstruction is distal to the ampulla of Vater) within the first 24-48 hours of life. - Imaging usually shows a **“double bubble” sign** on abdominal X-ray, and an abdominal mass is not typically palpable.
Question 7: A 6-month-old child woke up at night, crying with severe colicky abdominal pain, and later passed red currant jelly stools. What is the most likely diagnosis?
- A. Malrotation
- B. Meckel's diverticulum
- C. Intestinal obstruction
- D. Intussusception (Correct Answer)
Explanation: ***Intussusception*** - The classic presentation of **intussusception** includes sudden onset of **severe colicky abdominal pain** (intermittent crying spells), drawing legs to the chest, and passing **red currant jelly stools** (blood and mucus). - The pain occurs in intermittent episodes with periods of relative calm in between. Red currant jelly stools typically appear later in the disease course (often after 12-24 hours). - This is a **pediatric emergency** with peak incidence at **6-18 months** of age. *Malrotation* - Malrotation typically presents with **bilious vomiting** due to midgut volvulus and duodenal obstruction, particularly in the neonatal period. - While it can cause abdominal pain, the hallmark is persistent bilious vomiting rather than the intermittent colicky pain with red currant jelly stools seen in intussusception. *Meckel's diverticulum* - Meckel's diverticulum typically causes **painless rectal bleeding** (due to **heterotopic gastric mucosa** causing ulceration). - When it causes pain, it's usually due to **diverticulitis** or obstruction from an inverted diverticulum, but these do not produce the classic red currant jelly stools of intussusception. *Intestinal obstruction* - While intussusception is a specific type of intestinal obstruction, this option is too general. Other forms of intestinal obstruction (e.g., from adhesions, hernias) in an infant would typically present with **bilious vomiting**, abdominal distension, and may not produce red currant jelly stools. - The combination of intermittent colicky pain and red currant jelly stools is pathognomonic for intussusception.
Question 8: A 6-year-old child with abdominal pain and a rash is shown. Comment on the diagnosis?
- A. Kawasaki
- B. Varicella
- C. Meningococcemia
- D. Henoch-Schonlein purpura (Correct Answer)
Explanation: ***Henoch Schonlein purpura*** - This diagnosis is strongly suggested by the child's age (6 years old), presentation of abdominal pain, and the characteristic **palpable purpuric rash**, particularly on the lower extremities, as seen in the image. - **Henoch-Schönlein purpura (HSP)**, now known as IgA vasculitis, is a systemic small-vessel vasculitis predominantly affecting children, characterized by the classic triad of palpable purpura, arthritis/arthralgia, and abdominal pain. *Kawasaki* - **Kawasaki disease** primarily affects children under 5 years of age and presents with persistent fever, conjunctivitis, oral mucosal changes (strawberry tongue), cervical lymphadenopathy, and a polymorphous rash. Abdominal pain is less common as a primary feature. - The rash in Kawasaki disease is typically not purpuric but can be maculopapular or scarlatiniform, and does not show the characteristic distribution seen in the image. *Varicella* - **Varicella (chickenpox)** is characterized by a pruritic vesicular rash that progresses from macules to papules to vesicles and then crusts, usually starting on the trunk and spreading centrifugally. This is distinctly different from the purpuric rash shown. - While it can cause abdominal pain, the skin lesions are the key differentiator, and the image does not depict vesicular lesions. *Meningococcemia* - **Meningococcemia** is a severe bacterial infection often presenting with petechial or purpuric rash, fever, and signs of sepsis. However, the rash in meningococcemia rapidly progresses to large ecchymoses and is often associated with signs of critical illness (e.g., hypotension, altered mental status). - While purpura is present, the widespread, relatively uniform appearance of the rash, combined with abdominal pain in a 6-year-old, points away from the fulminant course typical of meningococcemia towards a vasculitis like HSP.
Question 9: Child has not passed stool by 2nd day of life. X-Ray study done shows:
- A. Cystic fibrosis
- B. Duodenal atresia (Correct Answer)
- C. CHPS
- D. Anorectal malformation
Explanation: ***Duodenal atresia*** - The abdominal X-ray images display the classic **"double bubble sign"**, which is highly characteristic of duodenal atresia. This sign consists of two distinct air-filled loops, one representing the distended stomach and the other the dilated proximal duodenum, with no distal gas. - The clinical presentation of a neonate not passing stool by the second day of life, combined with the characteristic radiological findings, points directly to an **upper gastrointestinal obstruction** like duodenal atresia. *Cystic fibrosis* - While cystic fibrosis can cause **meconium ileus** leading to intestinal obstruction in newborns, it typically presents with diffuse intestinal distension rather than the localized "double bubble" pattern. - Meconium ileus on X-ray would show numerous dilated loops of small bowel with a **"ground-glass" appearance** due to trapped meconium, not the distinct two bubbles seen here. *CHPS* - **Congenital hypertrophic pyloric stenosis (CHPS)** typically manifests later, between 3-6 weeks of age, with projectile non-bilious vomiting, not as early as the second day of life with findings of intestinal obstruction on X-ray. - The X-ray findings in CHPS would show a **distended stomach but without the second bubble** representing a dilated duodenum often seen in duodenal atresia. *Anorectal malformation* - **Anorectal malformations** are lower gastrointestinal obstructions, meaning a significant portion of the bowel would be distended with gas, and the X-ray would not show the isolated "double bubble" sign. - Diagnosis is often made by physical examination demonstrating an **imperforate anus** or abnormal anal opening, in conjunction with plain abdominal radiographs that would show distal intestinal obstruction.
Question 10: A newborn presenting with intestinal obstruction showed multiple air fluid levels on abdominal X-ray. Which of the following is NOT a likely diagnosis?
- A. Pyloric obstruction (Correct Answer)
- B. Duodenal atresia
- C. Ileal atresia
- D. Ladd's bands
Explanation: **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).
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