Pediatric Surgery Basics Practice Questions

Q: In congenital diaphragmatic hernia, which of the following is not typically seen?

Can be detected antenatally. In Congenital Diaphragmatic Hernia (CDH), abdominal viscera herniate into the thoracic cavity through a defect in the diaphragm (most commonly the **Foramen of Bochdalek**). ### **Explanation of Options** * **Correct Answer (C):** This question is a classic "except" style question. While CDH **can** be detected antenatally via ultrasound (showing polyhydramnios or abdominal organs in the chest), in the context of this specific MCQ, **Abdominal Distension (B)** is the classic "not seen" feature. *Note: If the provided key marks C as correct, it is likely a technical error in the source material, as B is the hallmark negative finding in CDH.* * **Why Abdominal Distension (B) is typically the correct "Not Seen" answer:** In CDH, the abdomen is characteristically **scaphoid (sunken)** because the abdominal contents (stomach, intestines) have migrated into the chest. Distension would only occur if there were an associated distal bowel obstruction or after resuscitation with bag-mask ventilation (which is contraindicated). * **Option A:** CDH is significantly more common on the **left side (80-85%)** because the liver provides a protective barrier on the right side. * **Option D:** Due to the mass effect of herniated contents on the left, the mediastinum is pushed to the opposite side, resulting in **dextrocardia** (heart sounds heard on the right). ### **High-Yield Clinical Pearls for NEET-PG** 1. **The Classic Triad:** Cyanosis, Dyspnea, and Dextrocardia. 2. **Management Contraindication:** Never use **Bag and Mask ventilation**, as it distends the intrathoracic gut and worsens pulmonary compression. Always perform immediate endotracheal intubation. 3. **Primary Pathology:** The most critical prognostic factor is **Pulmonary Hypoplasia** and associated Pulmonary Hypertension, not the diaphragmatic defect itself. 4. **LHR (Lung-to-Head Ratio):** A key antenatal prognostic marker used on ultrasound.

Q: A 6-week-old boy presents with a palpable abdominal mass in the epigastrium. The clinical diagnosis is:

Pyloric stenosis. ***Pyloric stenosis*** - A **6-week-old infant** with a palpable **epigastric mass** (olive-shaped) is classic for **hypertrophic pyloric stenosis**, which typically presents between 2-8 weeks of age. - Ultrasound shows the characteristic **"donut" or "target" sign**, and barium studies reveal the **"string sign"** due to narrowed pyloric channel. *Duodenal Atresia* - Presents in **neonates** (within first few days of life) with **bilious vomiting** and **"double bubble" sign** on X-ray. - Does not cause a palpable **epigastric mass** like pyloric stenosis does. *Choledochal cyst* - Typically presents with the classic **triad of jaundice, pain, and palpable mass**, but the mass is usually in the **right upper quadrant**. - More commonly diagnosed in **older infants** and children, not typically at 6 weeks of age. *Oesophageal Atresia* - Presents in **neonates** immediately after birth with **inability to swallow**, **excessive drooling**, and **choking** during feeding attempts. - Does not cause a palpable **abdominal mass** as it involves the esophagus, not intra-abdominal structures.

Q: A 3-week-old child presents with projectile postprandial vomiting and is diagnosed with hypertrophic pyloric stenosis. Congenital hypertrophic pyloric stenosis is associated with which of the following acid-base and electrolyte disturbances?

Hypokalemic alkalosis. **Explanation:** In Hypertrophic Pyloric Stenosis (HPS), the hallmark metabolic derangement is **Hypochloremic Hypokalemic Metabolic Alkalosis**. **1. Why Hypokalemic Alkalosis is correct:** * **Vomiting:** The infant loses gastric juice rich in Hydrochloric acid (HCl) and water. The loss of H+ ions directly causes **metabolic alkalosis**. * **Chloride Loss:** Loss of Cl- leads to a compensatory increase in bicarbonate (HCO3-) retention by the kidneys to maintain electrical neutrality, worsening the alkalosis. * **Renal Compensation & Hypokalemia:** Initially, the kidney tries to excrete HCO3- along with Na+. However, as the child becomes dehydrated (volume depleted), the RAAS (Renin-Angiotensin-Aldosterone System) is activated. To conserve Na+ and water, the kidney begins excreting K+ and H+ in exchange for Na+. This leads to **hypokalemia**. * **Paradoxical Aciduria:** In severe cases, to save the last bits of K+, the kidney excretes H+ ions into the urine despite systemic alkalosis. **2. Why other options are incorrect:** * **Acidosis (A & C):** HPS involves the loss of acid (HCl). Acidosis would occur in conditions involving the loss of base (e.g., severe diarrhea) or tissue hypoxia (lactic acidosis). * **Hyperkalemia (C & D):** Potassium is lost both through vomiting (minor) and primarily through renal excretion in exchange for sodium during dehydration. Hyperkalemia is typically seen in renal failure or adrenal insufficiency. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** 3–6 week old male, non-bilious projectile vomiting, and a palpable "olive-shaped" mass in the epigastrium. * **Diagnosis:** Ultrasound is the investigation of choice (Pyloric thickness >4mm, length >14mm). * **Management:** HPS is a **medical emergency, not a surgical one**. Correct electrolytes and dehydration first (using 0.45% or 0.9% NS with KCL) before performing **Ramstedt’s Myotomy**.

Q: Gasless abdomen on X-ray is seen with what type of tracheo-esophageal fistula?

Esophageal atresia with proximal TEF. ### Explanation The presence or absence of bowel gas on an abdominal X-ray in cases of Esophageal Atresia (EA) depends entirely on whether there is a communication (fistula) between the **trachea** and the **distal esophagus**. **1. Why Option B is Correct:** In **Esophageal Atresia with Proximal TEF**, the upper segment of the esophagus connects to the trachea, but the lower (distal) segment is a blind pouch. Since there is no connection between the airway and the stomach, air cannot reach the gastrointestinal tract. This results in a **"Gasless Abdomen"** (scaphoid abdomen) on X-ray. This is a rare variant (approx. 1-2%). **2. Analysis of Incorrect Options:** * **Isolated TEF (H-type):** There is no atresia; the esophagus is continuous. Air easily passes from the trachea into the esophagus through the fistula, leading to excessive bowel gas. * **EA with Distal TEF (Type C):** This is the **most common type (85%)**. Air travels from the trachea through the distal fistula into the stomach, resulting in a **gas-filled abdomen**. * **EA with Double TEF:** Since there is a distal fistula present, air will enter the stomach, leading to bowel gas. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Type:** EA with Distal TEF (Vogt-type IIIb / Gross-type C). * **Pure Esophageal Atresia (Type A):** Also presents with a **gasless abdomen** because there is no fistula at all. * **Clinical Presentation:** Excessive salivation, drooling, choking, and cyanosis upon the first feed. * **Diagnosis:** Inability to pass a firm orogastric catheter (coils in the upper pouch on X-ray). * **VACTERL Association:** Always screen for Vertebral, Anal, Cardiac, TEF, Renal, and Limb anomalies. The most common associated cardiac defect is VSD.

Q: A child is born with bilious vomiting and failure to thrive. Which of the following is true about this condition?

Associated with Down syndrome. The clinical presentation of **bilious vomiting** in a neonate is a surgical emergency until proven otherwise. In the context of the options provided, the diagnosis is **Duodenal Atresia**. ### **Explanation of the Correct Answer** **B. Associated with Down syndrome:** Duodenal atresia is the most common cause of neonatal intestinal obstruction. Approximately **30% of infants with duodenal atresia have Trisomy 21 (Down syndrome)**. The condition results from a failure of recanalization of the duodenum during the 8th–10th week of gestation. ### **Why the Other Options are Incorrect** * **A & C (Ramstedt’s Surgery & Olive-shaped mass):** These are classic features of **Infantile Hypertrophic Pyloric Stenosis (IHPS)**. IHPS presents with **non-bilious** projectile vomiting (as the obstruction is proximal to the ampulla of Vater) and typically appears at 3–6 weeks of age, not immediately at birth. * **D (Red currant jelly stools):** This is the hallmark clinical sign of **Intussusception**, caused by the sloughing of intestinal mucosa and blood. It usually presents in older infants (6–18 months) with intermittent colicky abdominal pain. ### **High-Yield Clinical Pearls for NEET-PG** * **Radiology:** The pathognomonic finding is the **"Double Bubble Sign"** on X-ray (air in the stomach and the proximal duodenum). * **Antenatal Clue:** Often associated with **maternal polyhydramnios** due to the fetus's inability to swallow and absorb amniotic fluid. * **Surgical Management:** The procedure of choice is **Duodenoduodenostomy** (Diamond-shaped anastomosis). * **Vomiting Rule:** Bilious vomiting = Obstruction distal to the ampulla of Vater; Non-bilious = Obstruction proximal to the ampulla.

Q: Prenatal ultrasound at 20 weeks revealed a midline mass that appeared to contain intestines and was membrane-bound. What is the probable diagnosis?

Omphalocele. **Explanation:** The clinical presentation described—a **midline mass** containing intestines that is **membrane-bound**—is the classic hallmark of an **Omphalocele**. **1. Why Omphalocele is correct:** An omphalocele occurs due to the failure of the midgut to return to the abdominal cavity from the umbilical cord during the 10th-12th week of gestation. The herniated viscera (intestines, and often the liver) are located at the **base of the umbilical cord** and are covered by a three-layered sac consisting of **amnion, Wharton’s jelly, and peritoneum**. This explains the "membrane-bound" appearance on ultrasound. **2. Why other options are incorrect:** * **Gastroschisis:** This is a full-thickness defect usually to the **right** of the umbilical cord insertion. Crucially, there is **no protective sac**; the bowel loops float freely in the amniotic fluid, appearing "thickened and matted" on ultrasound. * **Diaphragmatic Hernia:** This involves the herniation of abdominal contents into the **thoracic cavity** through a defect in the diaphragm (most commonly Bochdalek). It would not present as an external midline mass. **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Omphalocele is frequently associated with **chromosomal anomalies** (Trisomy 13, 18, 21) and syndromes like **Beckwith-Wiedemann syndrome** (macroglossia, organomegaly, hypoglycemia). Gastroschisis is usually an isolated defect. * **AFP Levels:** Maternal Serum Alpha-Fetoprotein (MSAFP) is elevated in both, but significantly higher in Gastroschisis due to direct contact of the bowel with amniotic fluid. * **Management:** Small omphaloceles can undergo primary closure; giant omphaloceles may require staged closure using a "Silo" to prevent abdominal compartment syndrome.

Q: What is the probable diagnosis for a cyst in a child that is located at and associated with vertebral defects?

Neuroenteric cyst. ### Explanation **Correct Answer: C. Neuroenteric Cyst** **1. Why it is correct:** A **neuroenteric cyst** (also known as a gastrocystoma) is a rare congenital anomaly resulting from the failure of the **notochord** to separate from the **foregut** during the 3rd week of embryogenesis. This persistent connection creates a tract between the spinal canal and the gastrointestinal tract. * **Key Diagnostic Triad:** A posterior mediastinal mass (cyst), associated **vertebral anomalies** (such as hemivertebrae, butterfly vertebrae, or scoliosis), and occasionally intraspinal extensions. The presence of vertebral defects is the hallmark that distinguishes it from other mediastinal cysts. **2. Why other options are incorrect:** * **A. Myelocele:** This is a form of spina bifida aperta where the neural plate is exposed. While it involves vertebral defects, it is a defect of the neural tube closure, not a discrete internal cyst associated with the gut. * **B. Bronchogenic cyst:** These are the most common foregut cysts, usually located in the middle mediastinum. While they are cystic, they are **not** typically associated with vertebral anomalies. * **D. Neuroblastoma:** This is a solid tumor (not a cyst) arising from neural crest cells. While it can cause vertebral erosion or "dumbbell" extension into the spinal canal, it does not typically present as a congenital cyst associated with primary vertebral malformations. **3. High-Yield Pearls for NEET-PG:** * **Location:** Most commonly found in the **posterior mediastinum**. * **Lining:** These cysts are lined by ectopic gastrointestinal or respiratory epithelium. * **Presentation:** May present with respiratory distress (compression) or meningitis (if a fistula exists). * **Imaging:** X-ray showing "butterfly vertebrae" or "hemivertebrae" in a child with a mediastinal mass is a classic "spotter" for Neuroenteric cyst.

Q: In a 2-year-old child, what is the most likely diagnosis for a bluish, dome-shaped swelling on the inner side of the lip?

Mucocele. ### Explanation **Correct Answer: B. Mucocele** **1. Why it is correct:** A **mucocele** (mucous extravasation cyst) is the most common benign minor salivary gland lesion in children. It typically occurs due to mechanical trauma (like accidental biting) that causes the rupture of a salivary gland duct, leading to the leakage and accumulation of mucus into the surrounding submucosal tissue. * **Clinical Presentation:** It characteristically presents as a **painless, bluish, dome-shaped, fluctuant swelling**. * **Location:** The **lower lip** (inner aspect) is the most common site because it is most prone to trauma. The bluish hue is due to the **Tyndall effect** (light scattering through the translucent fluid). **2. Why the other options are incorrect:** * **A. Hematoma:** While a hematoma is associated with trauma, it usually appears dark red or purple immediately after injury and is often tender. It does not typically present as a persistent, dome-shaped translucent cyst. * **C. Hemangioma:** These are vascular malformations. While they can be bluish-red, they usually demonstrate **pulsatility** or **blanching** upon pressure (diascopy test), which a mucocele does not. Hemangiomas are often present from birth or early infancy and have a different growth pattern. **3. NEET-PG High-Yield Pearls:** * **Ranula:** A mucocele specifically located on the **floor of the mouth** (arising from the sublingual gland). If it extends below the mylohyoid muscle into the neck, it is called a **Plunging Ranula**. * **Treatment:** The gold standard is **surgical excision** of the cyst along with the associated minor salivary gland to prevent recurrence. * **Most common site:** Lower lip (Mucocele); Floor of mouth (Ranula).

Q: Which of the following is false regarding Bochdalek hernia?

It always occurs on the right side.. **Explanation:** Congenital Diaphragmatic Hernia (CDH) most commonly presents as a **Bochdalek hernia**. The statement that it "always occurs on the right side" is **false**, making it the correct answer. **1. Why Option C is False:** Bochdalek hernias occur due to the failure of the pleuroperitoneal canal to close. This closure occurs later on the left side than the right. Furthermore, the presence of the **liver** on the right side acts as a physical barrier, protecting the right diaphragm. Consequently, **80–85% of Bochdalek hernias occur on the left side**, not the right. **2. Analysis of Other Options:** * **Option A:** Since the defect is large and posterolateral, various abdominal organs can herniate, most commonly the small bowel, but the **spleen, stomach, and even the kidney** are frequently involved. * **Option B:** The anatomical location of a Bochdalek hernia is characteristically **posterolateral** (mnemonic: *Bochdalek is Back and Lateral*). * **Option C:** While most cases (90%) lack a true peritoneal sac (allowing direct contact between viscera and lungs), a **sac may be present** in about 10–15% of cases. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Presentation:** Scaphoid abdomen, respiratory distress, and dextrocardia (if left-sided). * **Most Important Prognostic Factor:** The degree of **Pulmonary Hypoplasia** and associated Pulmonary Hypertension, rather than the surgery itself. * **Management:** It is a **medical, not surgical, emergency**. Stabilization (gentle ventilation, avoiding bag-mask ventilation) is required before surgical repair. * **Morgagni Hernia:** Contrastingly, this is anterior, retrosternal, and more common on the right side.

Question 1

In congenital diaphragmatic hernia, which of the following is not typically seen?

Accepted Answer

Can be detected antenatally

Answer

More common on the left side

Answer

Abdominal distension

Answer

Heart beat shifted to the right

Question 2

A 6-week-old boy presents with a palpable abdominal mass in the epigastrium. The clinical diagnosis is:

Accepted Answer

Pyloric stenosis

Answer

Duodenal Atresia

Answer

Choledochal cyst

Answer

Oesophageal Atresia

Question 3

A 3-week-old child presents with projectile postprandial vomiting and is diagnosed with hypertrophic pyloric stenosis. Congenital hypertrophic pyloric stenosis is associated with which of the following acid-base and electrolyte disturbances?

Accepted Answer

Hypokalemic alkalosis

Answer

Hypokalemic acidosis

Answer

Hyperkalemic acidosis

Answer

Hyperkalemic alkalosis

Question 4

What is true about cystic hygroma?

Accepted Answer

Pre-operative MRI is crucial for surgical planning.

Answer

It most commonly presents in the posterior triangle of the neck.

Answer

Sclerosing agents can be useful in its management.

Answer

Surgery is not always indicated.

Question 5

Gasless abdomen on X-ray is seen with what type of tracheo-esophageal fistula?

Accepted Answer

Esophageal atresia with proximal TEF

Answer

Isolated TEF

Answer

Esophageal atresia with distal TEF

Answer

Esophageal atresia with double TEF

Question 6

A child is born with bilious vomiting and failure to thrive. Which of the following is true about this condition?

Accepted Answer

Associated with Down syndrome

Answer

Treatment is Ramsted's surgery

Answer

An olive-shaped mass is present

Answer

Red currant jelly stools

Question 7

Prenatal ultrasound at 20 weeks revealed a midline mass that appeared to contain intestines and was membrane-bound. What is the probable diagnosis?

Accepted Answer

Omphalocele

Answer

Gastroschisis

Answer

Diaphragmatic hernia

Answer

None of the above

Question 8

What is the probable diagnosis for a cyst in a child that is located at and associated with vertebral defects?

Accepted Answer

Neuroenteric cyst

Answer

Myelocele

Answer

Bronchogenic cyst

Answer

Neuroblastoma

Question 9

In a 2-year-old child, what is the most likely diagnosis for a bluish, dome-shaped swelling on the inner side of the lip?

Accepted Answer

Mucocele

Answer

Hematoma

Answer

Hemangioma

Answer

None of the above

Question 10

Which of the following is false regarding Bochdalek hernia?

Accepted Answer

It always occurs on the right side.

Answer

Spleen and kidney can herniate through it.

Answer

It occurs posterolaterally.

Answer

The hernia may or may not have a sac.

Pediatric Surgery Basics — MCQs

Pediatric Surgery Basics — MCQs

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