Pediatric Surgery Basics Practice Questions

Q: Which of the following metabolic derangements is associated with congenital pyloric stenosis?

Hypochloremic alkalosis. ***Hypochloremic alkalosis*** - The forceful vomiting in **pyloric stenosis** leads to a significant loss of **gastric acid (HCl)**, resulting in **hypochloremia** and the metabolic picture of **alkalosis**. - The body attempts to compensate by retaining bicarbonate and excreting hydrogen ions, further contributing to the alkalosis. *Hypochloremic acidosis* - This condition is characterized by a low chloride level accompanied by **acidosis**, which contradicts the loss of acidic gastric contents seen in pyloric stenosis. - While chloride is lost, the predominant acid-base disturbance is alkalosis due to hydrogen ion loss. *Hyperchloremic acidosis* - This condition involves an elevated chloride level and acidosis, often seen in cases like **renal tubular acidosis** or severe diarrhea where bicarbonate is lost. - It is the opposite of the metabolic disturbance caused by the loss of gastric acid through vomiting. *Hyperchloremic alkalosis* - This imbalance would involve increased chloride and alkalosis, which does not align with the pathophysiology of pyloric stenosis where chloride is lost. - The body's compensatory mechanisms do not involve increasing chloride to an elevated level in this context.

Q: What is the commonest cause of intestinal obstruction in children between 3 months to 6 years of age?

Intussusception. ***Intussusception*** - **Intussusception** is the most frequent cause of **intestinal obstruction** in children between 3 months and 6 years, where a segment of intestine telescopes into an adjacent segment. - This condition presents with classic symptoms like **abdominal pain**, vomiting, and bloody stools (currant jelly stools). *Nonspecific cause* - While many childhood illnesses have nonspecific causes, **intestinal obstruction** is a specific and severe condition requiring prompt diagnosis. - Attributing it to a "nonspecific cause" would delay proper identification of the underlying pathology. *Intestinal polyp* - While intestinal polyps can cause **gastrointestinal bleeding** and, less commonly, obstruction in children, they are not the most common cause of obstruction in this age group. - Polyps usually present with intermittent bleeding or prolapse rather than acute, severe obstruction. *Meckel's diverticulum* - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract and can cause obstruction, bleeding, or inflammation (diverticulitis). - However, it is a less common cause of intestinal obstruction in this specific age range compared to **intussusception**.

Q: 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?

Intussusception. ***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.

Q: A 5-month old child rushed into hospital with complaint of colicky pain, bilious vomiting and red current jelly like appearance of stools. On examination, there was a sausage shaped mass in the right lumbar region. Which of the following is the preferred modality that is used as both diagnostic and therapeutic?

Air enema. ***Air enema*** - An **air enema** can be both diagnostic and therapeutic for **intussusception**, using air pressure to reduce the telescoping bowel segment. - The classic triad of **colicky pain, bilious vomiting, and red currant jelly stools** strongly suggests intussusception, and an air enema is often the first-line intervention. *MRI* - **MRI** is not typically used for the initial diagnosis or treatment of pediatric intussusception due to its long imaging times and need for sedation. - While it can provide detailed anatomical information, it is not a **therapeutic** modality for this condition. *Anoscopy* - **Anoscopy** is a procedure used to visualize the anal canal and distal rectum, primarily for conditions like hemorrhoids or anal fissures. - It is **not suitable** for diagnosing or treating intussusception, which involves a more proximal bowel obstruction. *Barium enema* - A **barium enema** can be diagnostic and therapeutic for intussusception, using barium solution to reduce the intussusception. - However, **air enema** is generally preferred due to a lower risk of perforation and easier interpretation of reduction, making it the more common choice.

Q: A 10 month old infant presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusception, likely cause is -

Peyer's patch hypertrophy. ***Peyer's patch hypertrophy*** - In infants, **idiopathic intussusception** is most often linked to **lymphoid hyperplasia** (Peyer's patch hypertrophy) in the terminal ileum, often triggered by viral infections. - Enlarged Peyer's patches act as a **leading point** for the intussusception into the colon. *Mucosal polyp* - While polyps can act as a leading point for intussusception, they are a **less common cause** in this age group than lymphoid hyperplasia. - **Pediatric polyps** are typically **juvenile polyps**, usually asymptomatic or causing painless rectal bleeding, and rarely trigger intussusception in infants. *Duplication cyst* - **Duplication cysts** can serve as a leading point for intussusception, but they are relatively **rare** compared to Peyer's patch hypertrophy. - They are usually discovered due to their mass effect or complications like hemorrhage or obstruction, but are not the most common cause of intussusception in an otherwise healthy infant. *Meckel's diverticulum* - **Meckel's diverticulum** can indeed cause intussusception, especially in older children or adults, but it's **less likely** than lymphoid hyperplasia in a typically developing 10-month-old infant. - When Meckel's diverticulum causes intussusception, it often presents with other symptoms like **painless rectal bleeding** due to ectopic gastric mucosa.

Q: A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

IV Fluids - antibiotics - air enema. ***IV Fluids - antibiotics - air enema*** - The presentation of an excessive cry, a **right iliac fossa sausage-shaped lump**, and **blood in stools** (currant jelly stools) is classic for **intussusception** in an infant. - An **air enema** is the preferred initial treatment for uncomplicated intussusception as it is diagnostic and therapeutic, often reducing the intussusception while being safer than barium. Prompt IV fluids and antibiotics are crucial for stabilization and infection prophylaxis. *IV Fluids - antibiotics - barium enema* - While a **barium enema** can also be used for reduction, it carries a higher risk of **perforation** and is less frequently used than air enema due to its lower safety profile. - The diagnostic capabilities are similar, but the therapeutic benefits of air enema, particularly with lower complications, make it the preferred option. *IV Fluids - antibiotics - NG tube* - An **NG tube** is used for **gastric decompression** in cases of intestinal obstruction, which might be a part of the management if patients are vomiting or have significant abdominal distension. - However, an NG tube alone does not address the underlying **intussusception** and is not a definitive treatment for reducing the telescoped bowel itself. *IV Fluids - antibiotics - warm saline enema* - A **warm saline enema** is primarily used for evacuating contents from the bowel or for diagnostic purposes (e.g., imaging the colon). - It is **ineffective in reducing intussusception**, as it lacks the pressure capabilities required to successfully push back the invaginated bowel.

Q: A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

MRI with contrast. ***MRI with contrast*** - An **MRI with contrast** is the most sensitive and specific imaging modality for detecting early changes in **osteomyelitis** or **septic arthritis**, which are serious conditions given the child's symptoms and elevated inflammatory markers. - It can visualize soft tissue and bone marrow edema, joint effusions, and abscesses, guiding immediate treatment. *CT Scan* - While useful for bony detail, a CT scan is **less sensitive than MRI** for detecting early bone marrow changes or soft tissue inflammation in the hip joint. - It also involves **radiation exposure**, which should be limited in children when other effective modalities are available. *Bone Scan* - A bone scan using **technetium-99m** is sensitive for detecting increased bone turnover, but it is **not specific for infection** and cannot differentiate between inflammatory processes, tumors, or fractures. - It provides less anatomical detail compared to MRI, making precise localization of an infection more challenging. *Plain Radiograph* - Plain radiographs are typically the **initial imaging study** for orthopedic complaints but are often **normal in early stages** of septic arthritis or osteomyelitis. - Significant radiographic changes, such as bone erosion or joint space widening, usually appear much later in the disease process.

Q: A 3-month-old with projectile vomiting and olive-shaped mass in abdomen is diagnosed with?

Pyloric stenosis. ***Pyloric stenosis*** - The classic triad of **projectile vomiting**, a palpable **olive-shaped mass** (hypertrophied pylorus), and age of presentation (2-8 weeks, though 3 months is still possible) are highly indicative of **pyloric stenosis**. - This condition involves thickening of the **pyloric muscle**, leading to gastric outlet obstruction and non-bilious emesis. *Hirschsprung disease* - This typically presents with **constipation**, **abdominal distension**, and failure to pass meconium, rather than projectile vomiting. - It results from the absence of **ganglion cells** in the distal colon, causing functional obstruction. *GERD* - While GERD can cause vomiting in infants, it is usually not **projectile** and is rarely associated with a palpable **olive-shaped mass**. - Infants with GERD typically respond to conservative measures like thickening feeds or acid suppressants. *Duodenal atresia* - This condition presents with **bilious vomiting** (as the obstruction is distal to the ampulla of Vater) usually within the first 24-48 hours of life. - An abdominal X-ray would show a **double bubble sign**, which is not mentioned in the presentation for pyloric stenosis.

Q: True about congenital diaphragmatic hernia (CDH) except:

Occurs anteriorly in the diaphragm. ***Occurs anteriorly in the diaphragm*** - Congenital diaphragmatic hernias (CDH) typically occur through the **foramen of Bochdalek**, which is a posterolateral defect in the diaphragm. - Herniations through the **foramen of Morgagni** are anterior, but these are far less common than Bochdalek hernias (only 2-3% of cases). *Causes pulmonary hypoplasia* - The presence of abdominal organs in the thoracic cavity during fetal development **compresses the developing lungs**, leading to underdevelopment. - This results in **reduced lung volume** and **abnormal pulmonary vasculature**. *Occurs mostly on the left side* - Approximately **80-85% of CDH cases are left-sided**, possibly due to the protective effect of the liver on the right side. - The left pleuroperitoneal canal typically closes later than the right side, making it more susceptible to defects. *Leads to cyanosis at birth* - **Pulmonary hypoplasia** and **persistent pulmonary hypertension** result in right-to-left shunting of blood, causing severe hypoxia and cyanosis. - Infants often present with acute respiratory distress, cyanosis, and scaphoid abdomen soon after birth.

Q: A child presents with acute abdominal pain, vomiting, and currant jelly stools. The attending physician suspects intussusception. What is the definitive diagnostic and therapeutic procedure for this condition?

Air enema (pneumatic reduction). ***Air enema (pneumatic reduction)*** - An **air enema** is both diagnostic, by confirming the characteristic "telescoping" on imaging, and therapeutic, as the injected air pressure can **reduce the intussusception**. - It is a **first-line treatment** for uncomplicated intussusception in children, avoiding the need for surgery in most cases. *Abdominal ultrasound* - An **abdominal ultrasound** is often the initial diagnostic tool, revealing the **"target sign"** or **"donut sign"**, indicative of intussusception. - While diagnostic, it is **not therapeutic** and does not resolve the intussusception itself. *CT scan of the abdomen* - A **CT scan** can confirm intussusception with high accuracy but exposes the child to **radiation** and is generally not the preferred first-line diagnostic method for this condition in children. - It is **not therapeutic** and is typically reserved for cases where ultrasound is inconclusive or complications are suspected. *Exploratory laparotomy* - An **exploratory laparotomy** is a surgical procedure that is reserved for cases where **non-operative reduction (e.g., air enema)** fails or when there are signs of bowel perforation or peritonitis. - While it can definitively treat intussusception, it is an **invasive procedure** with associated risks, making it a last resort.

Question 1

Which of the following metabolic derangements is associated with congenital pyloric stenosis?

Accepted Answer

Hypochloremic alkalosis

Answer

Hypochloremic acidosis

Answer

Hyperchloremic acidosis

Answer

Hyperchloremic alkalosis

Question 2

What is the commonest cause of intestinal obstruction in children between 3 months to 6 years of age?

Accepted Answer

Intussusception

Answer

Nonspecific cause

Answer

Intestinal polyp

Answer

Meckel's diverticulum

Question 3

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?

Accepted Answer

Intussusception

Answer

Malrotation

Answer

Meckel's diverticulum

Answer

Intestinal obstruction

Question 4

A 5-month old child rushed into hospital with complaint of colicky pain, bilious vomiting and red current jelly like appearance of stools. On examination, there was a sausage shaped mass in the right lumbar region. Which of the following is the preferred modality that is used as both diagnostic and therapeutic?

Accepted Answer

Air enema

Answer

MRI

Answer

Anoscopy

Answer

Barium enema

Question 5

A 10 month old infant presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusception, likely cause is -

Accepted Answer

Peyer's patch hypertrophy

Answer

Mucosal polyp

Answer

Duplication cyst

Answer

Meckel's diverticulum

Question 6

A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

Accepted Answer

IV Fluids - antibiotics - air enema

Answer

IV Fluids - antibiotics - barium enema

Answer

IV Fluids - antibiotics - NG tube

Answer

IV Fluids - antibiotics - warm saline enema

Question 7

A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

Accepted Answer

MRI with contrast

Answer

CT Scan

Answer

Bone Scan

Answer

Plain Radiograph

Question 8

A 3-month-old with projectile vomiting and olive-shaped mass in abdomen is diagnosed with?

Accepted Answer

Pyloric stenosis

Answer

Hirschsprung disease

Answer

GERD

Answer

Duodenal atresia

Question 9

True about congenital diaphragmatic hernia (CDH) except:

Accepted Answer

Occurs anteriorly in the diaphragm

Answer

Causes pulmonary hypoplasia

Answer

Occurs mostly on the left side

Answer

Leads to cyanosis at birth

Question 10

A child presents with acute abdominal pain, vomiting, and currant jelly stools. The attending physician suspects intussusception. What is the definitive diagnostic and therapeutic procedure for this condition?

Accepted Answer

Air enema (pneumatic reduction)

Answer

Abdominal ultrasound

Answer

CT scan of the abdomen

Answer

Exploratory laparotomy

Pediatric Surgery Basics — MCQs

Pediatric Surgery Basics — MCQs

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