Pediatric Surgery — MCQs

An infant girl is found to have persistent jaundice after birth. A metabolic screen is normal, ultrasound demonstrates an absent gallbladder, and a technetium-99m iminodiacetic acid scan shows radionuclide that is concentrated in the liver but not excreted into the intestine. Which of the following is true?

Q95Medium

What indicates a complete reduction of intussusception?

Q96Medium

A 4-month-old male child presented with an inguinal mass noticed at 2 weeks of age. What is the management?

Q97Medium

Which of the following statements about omphalocele is incorrect?

Q98Medium

Paradoxical aciduria is seen in which of the following conditions?

Q99Easy

A 2-year-old child presents with a brilliantly translucent swelling in the neck region. What is the most likely diagnosis?

Q100Easy

What is the most frequent congenital anomaly of the gastrointestinal tract?

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 91: All of the following statements regarding cleft lip and palate are true, EXCEPT:

A. It can be associated with Treacher-Collins syndrome.
B. Cleft lip with cleft palate is the most common type.
C. Pierre Robin sequence is the most common syndrome.
D. Isolated cleft palate can be diagnosed by ultrasound after 28 weeks gestation. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. While a cleft lip (with or without palate) is easily detectable via prenatal ultrasound (usually by 18–20 weeks), an **isolated cleft palate** is notoriously difficult to diagnose in utero. Because the intact upper lip obscures the view of the secondary palate and the fetal mouth is often closed, prenatal ultrasound has a very low sensitivity (often <10%) for detecting isolated cleft palate, regardless of gestational age. **Analysis of other options:** * **Option A:** Cleft lip and palate are indeed associated with various craniofacial syndromes, including **Treacher-Collins syndrome** (mandibulofacial dysostosis), which involves malformations of the ears, eyes, cheekbones, and jaws. * **Option B:** Epidemiologically, **cleft lip with cleft palate** is the most common presentation (approx. 45%), followed by isolated cleft palate (30%) and isolated cleft lip (25%). * **Option C:** **Pierre Robin sequence** (Micrognathia, Glossoptosis, and Cleft Palate) is the most frequently cited syndrome associated specifically with cleft palate. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s (Millard’s criteria for Cleft Lip repair):** 10 weeks of age, 10 lbs weight, 10 g/dL Hemoglobin. * **Surgical Timing:** Cleft lip repair (Cheiloplasty) is usually done at **3–6 months**; Cleft palate repair (Palatoplasty) is done at **9–18 months** (to allow for speech development but minimize maxillary growth inhibition). * **Epidemiology:** Cleft lip (+/- palate) is more common in **males**, whereas isolated cleft palate is more common in **females**.

Question 92: True about cystic hygroma?

A. Congenital sequestration of lymphatics
B. Resolves spontaneously by 5 years of age (Correct Answer)
C. Common in the upper one-third of the lateral neck
D. Surgery is the treatment of choice

Explanation: ### Explanation: Cystic Hygroma Cystic hygroma (macrocystic lymphatic malformation) is a benign congenital malformation of the lymphatic system. **Why Option B is Correct:** While many cystic hygromas require intervention due to size or complications, a significant characteristic is their potential for **spontaneous regression**. Approximately 15–20% of cases resolve spontaneously, typically by the age of 5, often following an episode of infection or inflammation that causes the lymphatic channels to fibrose. **Analysis of Incorrect Options:** * **Option A:** Cystic hygroma is not a sequestration (which implies separation from the main organ system, like pulmonary sequestration). It is a **failure of communication** between the lymphatic spaces and the venous system, leading to the formation of large, fluid-filled cysts. * **Option C:** They are most commonly found in the **posterior triangle** of the neck (lower one-third), not the upper lateral neck. They are typically soft, painless, and brilliantly transilluminant. * **Option D:** While surgery was historically the mainstay, **Sclerotherapy** (using agents like OK-432/Picibanil or Bleomycin) is now often considered the first-line treatment for macrocystic lesions to avoid injury to vital structures (e.g., facial or hypoglossal nerves). **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Frequently associated with chromosomal anomalies, most notably **Turner Syndrome** (45, XO) and Down Syndrome. * **Clinical Feature:** It is **brilliantly transilluminant** (unlike a branchial cyst or hemangioma). * **Complications:** Sudden increase in size is usually due to **intracystic hemorrhage** or infection. * **Anatomy:** It has a "finger-like" infiltrative growth pattern, often making complete surgical excision difficult without damaging surrounding nerves.

Question 93: What is the treatment of choice for cystic hygroma?

A. Percutaneous aspiration
B. Intralesional sclerosant injection
C. En bloc resection
D. Surgical excision (Correct Answer)

Explanation: **Explanation:** **Cystic hygroma** (Cystic Lymphangioma) is a benign congenital malformation of the lymphatic system, most commonly occurring in the posterior triangle of the neck. **Why Surgical Excision is the Treatment of Choice:** The gold standard treatment is **complete surgical excision**. The primary goal is to remove the entire multicystic mass while preserving vital structures (nerves and vessels) that may be draped over or embedded within the cysts. Early surgery is indicated to prevent complications like infection, hemorrhage, or airway compromise. **Analysis of Incorrect Options:** * **A. Percutaneous aspiration:** This is never a definitive treatment. Fluid rapidly re-accumulates, and the procedure carries a high risk of introducing infection, which can lead to fibrosis and make subsequent surgery more difficult. * **B. Intralesional sclerosant injection:** While agents like OK-432 (Picibanil) or Bleomycin are used for **macrocystic** lesions (especially when surgery poses a high risk to cranial nerves), they are generally considered second-line or adjuncts to surgery. They are less effective for microcystic variants. * **C. En bloc resection:** This implies removing the lesion along with a margin of normal surrounding tissue and lymph nodes. Since cystic hygroma is a benign lesion and often infiltrates between vital structures, radical "en bloc" resection is unnecessary and potentially mutilating. **Clinical Pearls for NEET-PG:** * **Most common site:** Left side of the neck (Posterior triangle). * **Transillumination:** Cystic hygromas are characteristically **brilliantly transilluminant** (unlike hemangiomas). * **Association:** Frequently associated with chromosomal anomalies like **Turner syndrome** and Down syndrome. * **Complication:** Sudden increase in size usually indicates internal hemorrhage or secondary infection. * **Sclerosant of choice:** OK-432 is often preferred as it causes minimal scarring.

Question 94: An infant girl is found to have persistent jaundice after birth. A metabolic screen is normal, ultrasound demonstrates an absent gallbladder, and a technetium-99m iminodiacetic acid scan shows radionuclide that is concentrated in the liver but not excreted into the intestine. Which of the following is true?

A. This condition is usually managed nonoperatively.
B. Surgery should be performed within 60 days of life. (Correct Answer)
C. Cystoenterostomy provides adequate biliary drainage.
D. Most of these patients will not require transplantation.

Explanation: ### Explanation The clinical presentation of persistent jaundice, an absent gallbladder on ultrasound, and a HIDA scan showing hepatic uptake without excretion into the intestine is diagnostic of **Biliary Atresia (BA)**. **1. Why Option B is Correct:** Biliary atresia is a progressive fibro-obliterative disease of the extrahepatic biliary tree. The definitive surgical management is the **Kasai Portoenterostomy**. The success of this procedure is highly time-dependent. If performed **within 60 days of life**, approximately 70-80% of patients achieve bile drainage. Beyond 90 days, the success rate drops significantly (<20%) due to irreversible secondary biliary cirrhosis. **2. Why Other Options are Incorrect:** * **Option A:** BA is a surgical emergency. Nonoperative management leads to liver failure and death, usually within two years. * **Option C:** Cystoenterostomy is the treatment for *Choledochal Cysts*. In BA, the entire extrahepatic ductal system is typically fibrotic; therefore, a portoenterostomy (attaching the bowel to the transected porta hepatis) is required, not a simple cyst drainage. * **Option D:** Even with a successful Kasai procedure, BA remains the **most common indication for pediatric liver transplantation**. Most patients will eventually require a transplant due to progressive intrahepatic fibrosis or portal hypertension. ### High-Yield Clinical Pearls for NEET-PG: * **Triad of BA:** Jaundice (conjugated), Acholic stools, and Hepatomegaly. * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOC). * **HIDA Scan:** High sensitivity for BA if there is no excretion into the bowel after 24 hours (pre-treatment with Phenobarbital for 5 days can improve specificity). * **Kasai Procedure:** Also known as Hepatic Portoenterostomy. * **Post-op Complication:** Ascending cholangitis is the most common early complication.

Question 95: What indicates a complete reduction of intussusception?

A. Free passage of barium in the terminal ileum (Correct Answer)
B. Passage of feces and flatus along with barium
C. Improvement of the clinical condition
D. None of the above

Explanation: **Explanation:** Intussusception is the telescoping of one segment of the intestine into another, most commonly the ileum into the colon (ileocolic). Non-operative reduction (using hydrostatic or pneumatic pressure) is the first-line treatment for stable patients. **Why Option A is Correct:** The definitive radiological sign of a successful reduction is the **free reflux of the contrast material (barium, water-soluble contrast, or air) into the terminal ileum.** Since intussusception usually involves the ileocecal valve, the presence of contrast in the small bowel confirms that the "lead point" has been pushed back completely and the valve is patent. **Why Other Options are Incorrect:** * **Option B:** While the passage of feces and flatus indicates returning bowel function, it is not a definitive radiological sign of complete reduction. Barium may pass around a partial intussusception or residual edema, leading to a false sense of security. * **Option C:** Clinical improvement (cessation of screaming fits, decreased vomiting) is a positive sign but is subjective. A "pseudo-reduction" can occur where the mass is partially reduced, leading to temporary clinical relief followed by rapid recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Intermittent abdominal pain (colic), palpable sausage-shaped mass (usually in the right upper quadrant), and **"red currant jelly" stools.** * **Dance’s Sign:** An empty right iliac fossa on palpation. * **Ultrasound:** The investigation of choice; shows the **"Target sign"** or **"Donut sign"** in transverse view and the **"Pseudokidney sign"** in longitudinal view. * **Contraindications to Hydrostatic Reduction:** Peritonitis, intestinal perforation (pneumoperitoneum), or profound shock. * **Recurrence Rate:** Approximately 5–10% after non-operative reduction.

Question 96: A 4-month-old male child presented with an inguinal mass noticed at 2 weeks of age. What is the management?

A. Observation
B. Surgical repair on the affected side and exploration on the other side (Correct Answer)
C. Laparotomy
D. Surgical repair on the affected side

Explanation: **Explanation:** The clinical presentation describes a **Congenital Inguinal Hernia**, which in children is almost always an **indirect hernia** caused by a patent processus vaginalis (PPV). **1. Why Option B is Correct:** In pediatric practice, inguinal hernias do not resolve spontaneously and carry a high risk of incarceration (especially in infants under 1 year). Therefore, surgical repair (**Herniotomy**) is indicated shortly after diagnosis. The controversy lies in **contralateral exploration**. In infants (especially those under 6 months to 1 year), there is a high incidence (up to 60%) of a "silent" or occult PPV on the opposite side. To prevent a second surgery later, many pediatric surgeons perform a contralateral exploration or use laparoscopy to check the internal ring. **2. Why Other Options are Wrong:** * **Option A (Observation):** Unlike umbilical hernias, inguinal hernias never resolve on their own and pose a risk of strangulation. Observation is contraindicated. * **Option C (Laparotomy):** Inguinal hernias are repaired via a small groin incision (inguinal approach). Laparotomy (abdominal midline incision) is unnecessary and overly invasive. * **Option D (Repair on affected side only):** While common in adults, limiting repair to one side in a 4-month-old ignores the high probability of a bilateral defect, potentially leading to a second anesthesia and surgery in the near future. **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** High ligation of the sac (Herniotomy). Unlike adults, posterior wall repair (Hernioplasty/Herniorrhaphy) is **not** required in children. * **Urgency:** If the hernia is reducible, schedule surgery electively but soon. If incarcerated, attempt manual reduction; if successful, delay surgery for 24–48 hours to allow edema to subside. * **Gender:** More common in males (8:1 ratio) and more common on the **right side** (due to later descent of the right testis).

Question 97: Which of the following statements about omphalocele is incorrect?

A. The umbilical cord inserts into the sac.
B. The incidence is approximately 1 in 5000 live births.
C. The abdominal wall defect measures \u2265 4 cm in diameter.
D. None of the above. (Correct Answer)

Explanation: **Explanation:** Omphalocele is a midline ventral abdominal wall defect at the base of the umbilical cord, where herniated viscera are covered by a three-layered sac (amnion, Wharton’s jelly, and peritoneum). **Why Option D is correct:** All statements (A, B, and C) are clinically accurate descriptions of omphalocele. Therefore, "None of the above" is the correct choice as there are no incorrect statements provided. **Analysis of Options:** * **Option A:** In omphalocele, the **umbilical cord inserts directly into the apex of the sac**. This is a key diagnostic feature that differentiates it from gastroschisis, where the cord inserts normally to the left of the defect. * **Option B:** The incidence is approximately **1 in 4,000 to 5,000 live births**, making this statement statistically correct. * **Option C:** Omphaloceles are categorized by size. A "giant omphalocele" is typically defined by a defect **≥ 4 cm** in diameter or one containing the liver. Small defects (< 4 cm) are often termed hernia of the umbilical cord. **High-Yield Clinical Pearls for NEET-PG:** 1. **Associated Anomalies:** Unlike gastroschisis, omphalocele is highly associated with other anomalies (up to 50-70%), including **Beckwith-Wiedemann Syndrome** (macroglossia, organomegaly, hypoglycemia) and trisomies (13, 18, 21). 2. **Pentalogy of Cantrell:** Includes omphalocele, ectopic cordis, diaphragmatic defect, sternal cleft, and intracardiac defects (VSD/Diverticulum). 3. **Management:** Small defects undergo primary closure. Giant omphaloceles may require "paint and wait" (topical escharotic agents like silver sulfadiazine) or staged closure using a Silastic silo to prevent abdominal compartment syndrome. 4. **AFP Levels:** Maternal Serum Alpha-Fetoprotein (MSAFP) is elevated, though usually lower than in gastroschisis.

Question 98: Paradoxical aciduria is seen in which of the following conditions?

A. Congenital hypertrophic pyloric stenosis (Correct Answer)
B. Duodenal ulcer
C. Achalasia cardia
D. Crohn's disease

Explanation: **Explanation:** **Paradoxical Aciduria** is a classic biochemical hallmark of **Congenital Hypertrophic Pyloric Stenosis (CHPS)**. It refers to the excretion of acidic urine (low pH) despite the presence of systemic metabolic alkalosis. **Pathophysiology in CHPS:** 1. **Initial Insult:** Persistent non-bilious vomiting leads to the loss of gastric HCl, resulting in **Hypochloremic, Hypokalemic, Metabolic Alkalosis**. 2. **Renal Compensation:** Initially, the kidney tries to compensate by excreting bicarbonate ($HCO_3^-$). To maintain electrical neutrality, it excretes Sodium ($Na^+$) along with it. 3. **Dehydration:** Continued vomiting leads to severe dehydration and volume depletion. This activates the **Renin-Angiotensin-Aldosterone System (RAAS)**. 4. **The "Paradox":** Aldosterone acts on the distal tubule to reabsorb $Na^+$ (to restore volume). Normally, $Na^+$ is exchanged for $K^+$. However, due to chronic vomiting, the body is already **hypokalemic**. To conserve the remaining $K^+$, the kidney is forced to exchange $Na^+$ for Hydrogen ions ($H^+$) instead. This results in the excretion of $H^+$ into the urine, making it acidic despite systemic alkalosis. **Analysis of Incorrect Options:** * **B & C (Duodenal Ulcer/Achalasia):** While these can cause vomiting, they do not typically cause the profound, repetitive loss of pure gastric acid required to trigger the complex RAAS-mediated paradoxical aciduria seen in CHPS. * **D (Crohn’s Disease):** This typically presents with malabsorption or diarrhea, which leads to metabolic **acidosis** (due to bicarbonate loss), not alkalosis. **High-Yield Clinical Pearls for NEET-PG:** * **Electrolyte Triad in CHPS:** Hypochloremia, Hypokalemia, and Metabolic Alkalosis. * **Clinical Sign:** "Olive-shaped" mass in the epigastrium and visible gastric peristalsis. * **Diagnosis:** Ultrasound is the gold standard (Pyloric muscle thickness >4mm, length >14mm). * **Management:** Initial priority is resuscitation with **0.9% Normal Saline** (to correct chloride deficit) before definitive surgery (**Ramstedt’s Pyloromyotomy**).

Question 99: A 2-year-old child presents with a brilliantly translucent swelling in the neck region. What is the most likely diagnosis?

A. Lipoma
B. Teratoma
C. Cystic Hygroma (Correct Answer)
D. Thyroglossal cyst

Explanation: **Explanation:** The correct answer is **Cystic Hygroma**. **1. Why Cystic Hygroma is correct:** Cystic hygroma (also known as macrocystic lymphatic malformation) is a congenital malformation of the lymphatic system. It most commonly occurs in the posterior triangle of the neck. The hallmark clinical feature is a soft, painless, fluctuant, and **brilliantly translucent** swelling. The translucency occurs because the lesion consists of large, thin-walled lymphatic spaces filled with clear, protein-rich lymph fluid, which allows light to pass through easily. **2. Why other options are incorrect:** * **Lipoma:** While soft and painless, lipomas are composed of fat cells and are **opaque** on transillumination. * **Teratoma:** These are germ cell tumors containing multiple tissue types (solid and cystic). They are firm or variegated in consistency and do not show brilliant translucency. * **Thyroglossal Cyst:** These typically present in the **midline** of the neck and move upward on protrusion of the tongue. While they can be transilluminant, they are rarely "brilliantly" so compared to cystic hygromas. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Posterior triangle of the neck (Left side > Right side). * **Association:** Often associated with chromosomal abnormalities like **Turner Syndrome** and Down Syndrome. * **Complications:** Sudden increase in size usually indicates **intracystic hemorrhage** or infection. * **Management:** Surgical excision is the traditional gold standard; however, **Sclerotherapy** (using OK-432 or Bleomycin) is an effective non-surgical alternative for macrocystic lesions. * **Diagnostic Sign:** It shows a "positive fluid thrill" and is not attached to the skin or underlying structures.

Question 100: What is the most frequent congenital anomaly of the gastrointestinal tract?

A. Imperforate anus
B. Meckel's diverticulum (Correct Answer)
C. Malrotation
D. Duodenal atresia

Explanation: **Explanation:** **Meckel’s Diverticulum** is the most frequent congenital anomaly of the gastrointestinal tract, occurring in approximately **2% of the general population**. It is a true diverticulum (containing all layers of the intestinal wall) resulting from the failure of the **vitelline duct (omphalomesenteric duct)** to obliterate during the 5th–8th week of gestation. It typically follows the "Rule of 2s": 2% of the population, 2 inches long, 2 feet proximal to the ileocecal valve, and often presents before age 2. **Analysis of Incorrect Options:** * **Imperforate Anus:** A common cause of neonatal intestinal obstruction, but its incidence (1 in 5,000 births) is significantly lower than Meckel’s. * **Malrotation:** While a critical surgical condition involving the failure of the midgut to rotate 270° counter-clockwise, it occurs in roughly 1 in 500 live births. * **Duodenal Atresia:** Characterized by the "double bubble" sign on X-ray and associated with Down Syndrome, it is relatively rare (1 in 5,000–10,000 births). **High-Yield Clinical Pearls for NEET-PG:** * **Ectopic Tissue:** The most common ectopic tissue found in Meckel’s is **gastric mucosa** (responsible for painless bleeding), followed by pancreatic tissue. * **Diagnosis:** The investigation of choice for a bleeding Meckel’s is the **Technetium-99m pertechnetate scan** (Meckel’s scan), which identifies ectopic gastric mucosa. * **Complications:** In children, the most common presentation is **painless lower GI bleeding**; in adults, it is more likely to cause **intestinal obstruction** (via intussusception or volvulus). * **Location:** It is always located on the **antimesenteric border** of the ileum.

Practice by Chapter

Neonatal Physiology

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Congenital Anomalies Overview

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Neonatal Intestinal Obstruction

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Necrotizing Enterocolitis

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Hirschsprung's Disease

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Anorectal Malformations

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Pediatric Hernias

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Pyloric Stenosis

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Biliary Atresia

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Pediatric Tumors

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Congenital Diaphragmatic Hernia

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Pediatric Trauma

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