Pediatric Surgery — MCQs

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 101: Orthodontic treatment in the management of cleft lip and palate is usually carried out during which stage of dentition?

A. Deciduous dentition and mixed dentition
B. Mixed dentition
C. Mixed and permanent dentition (Correct Answer)
D. Permanent dentition

Explanation: The management of cleft lip and palate (CLP) is a multidisciplinary effort spanning from birth to adulthood. Orthodontic intervention is a cornerstone of this process, primarily focused on correcting dental arch collapses and preparing for alveolar bone grafting. ### **Explanation of the Correct Answer** **Option C (Mixed and permanent dentition)** is correct because orthodontic treatment is strategically timed to coincide with these stages: 1. **Mixed Dentition Stage (6–12 years):** This is the most critical period. Orthodontists use expansion appliances (like the Quad-helix) to widen the collapsed maxillary arch. This is essential to create space and provide access for the **Secondary Alveolar Bone Graft (SABG)**, which is ideally performed when the canine root is half to two-thirds formed. 2. **Permanent Dentition Stage (12+ years):** Once all permanent teeth have erupted, definitive orthodontics (fixed braces) are used to align the teeth, close gaps, and achieve a functional occlusion. ### **Analysis of Incorrect Options** * **Option A & B:** While some "pre-surgical orthopedics" (like NAM - Nasoalveolar Molding) occur in infancy, formal **orthodontic** tooth movement is generally avoided in the deciduous dentition to prevent root resorption of primary teeth and because the child’s cooperation is limited. * **Option D:** Waiting until the permanent dentition stage alone is too late. If the maxillary expansion and bone grafting are not done during the mixed dentition, the permanent canine may fail to erupt or may erupt in a malposed position. ### **High-Yield Clinical Pearls for NEET-PG** * **Rule of 10s (for Cleft Lip repair):** 10 weeks of age, 10 lbs weight, 10 gm% Hemoglobin. * **Timing of Palatoplasty:** Usually performed between **6–12 months** (before the child develops speech). * **Alveolar Bone Grafting:** The "Gold Standard" timing is during **mixed dentition** (9–11 years), just before the eruption of the permanent maxillary canine. * **Maxillary Hypoplasia:** Often requires orthognathic surgery (LeFort I osteotomy) after skeletal maturity (16–18 years).

Question 102: Congenital hypertrophic pyloric stenosis is characterized by progressive gastric outlet obstruction. Its incidence is highest in which demographic group?

A. Firstborn female infant
B. Firstborn male infant (Correct Answer)
C. Second male infant
D. Second female infant

Explanation: **Explanation:** **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is a condition characterized by hypertrophy and hyperplasia of the circular muscle layers of the pylorus, leading to a functional gastric outlet obstruction. **Why Option B is Correct:** Epidemiological studies consistently show a strong predilection for **firstborn male infants**. The male-to-female ratio is approximately **4:1 to 5:1**. While the exact etiology is multifactorial (involving genetic predisposition and environmental triggers like erythromycin exposure), the "firstborn male" association is a classic, high-yield demographic hallmark of the disease. **Why Other Options are Incorrect:** * **Options A & D (Females):** CHPS is significantly less common in females. However, it is noted that if a female is affected, she carries a higher genetic load, increasing the risk of CHPS in her future offspring (Carter’s Effect). * **Option C (Second male):** While subsequent male siblings are at a higher risk than the general population (due to genetic factors), the highest statistical incidence remains with the firstborn child. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Non-bilious, projectile vomiting typically appearing between **3 to 6 weeks** of life. * **Physical Exam:** A palpable, olive-sized mass in the epigastrium (pathognomonic) and visible gastric peristalsis. * **Metabolic Abnormality:** **Hypochloremic, hypokalemic metabolic alkalosis** with paradoxical aciduria (due to loss of HCl from vomiting). * **Diagnosis:** Ultrasound is the gold standard (Pyloric muscle thickness >4mm or length >14mm). * **Management:** Initial stabilization with IV fluids (Normal Saline) followed by **Ramstedt’s Pyloromyotomy**.

Question 103: All of the following are true regarding Wilm's tumour except?

A. Preoperative use of Actinomycin D (Correct Answer)
B. Postoperative radiotherapy
C. Good prognosis in infants
D. Neuroblastoma is the commonest differential diagnosis

Explanation: **Explanation:** **Wilms’ Tumor (Nephroblastoma)** is the most common primary renal malignancy in children. The management strategy differs significantly between North America (NWTS/COG) and Europe (SIOP). 1. **Why Option A is the correct answer (False statement):** In the standard management of Wilms’ tumor (NWTS protocol), the initial step is **upfront radical nephrectomy** followed by chemotherapy. Preoperative chemotherapy (Actinomycin D and Vincristine) is **not** routine; it is reserved only for specific cases like bilateral tumors (Stage V), tumors in a solitary kidney, or massive inoperable tumors to facilitate shrinkage. Therefore, saying preoperative use is a general rule is incorrect. 2. **Analysis of other options:** * **Postoperative radiotherapy (B):** This is a standard component of management for advanced stages (Stage III and IV) or unfavorable histology to prevent local recurrence. * **Good prognosis in infants (C):** Age is a significant prognostic factor. Children diagnosed under the age of 2 years (especially infants) generally have a better prognosis compared to older children. * **Neuroblastoma (D):** This is the most common extracranial solid tumor in children and the primary differential diagnosis. Key distinction: Wilms’ tumor is usually an intrarenal, smooth mass that **does not cross the midline**, whereas Neuroblastoma is extrarenal, irregular, and **crosses the midline**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Asymptomatic abdominal mass (often found by parents during bathing). * **WAGR Syndrome:** Wilms’ tumor, Aniridia, Genitourinary anomalies, and mental Retardation (associated with WT1 gene deletion on Chromosome 11p13). * **Beckwith-Wiedemann Syndrome:** Macroglossia, organomegaly, and hemihypertrophy (associated with WT2 gene on Chromosome 11p15). * **Metastasis:** The most common site for distant spread is the **Lungs**.

Question 104: What is the commonest site of intestinal atresia?

A. Duodenum (Correct Answer)
B. Jejunum
C. Ileum
D. Colon

Explanation: **Explanation:** Intestinal atresia is a major cause of neonatal bowel obstruction. Among all segments of the gastrointestinal tract, the **duodenum** is the most common site of atresia, accounting for nearly 40–50% of cases. **1. Why Duodenum is the Correct Answer:** The embryological basis for duodenal atresia is a **failure of recanalization**. During the 5th–6th week of gestation, the duodenal lumen is obliterated by proliferating epithelium (solid stage). By the 8th–10th week, vacuoles form and coalesce to recanalize the lumen. Failure of this process leads to atresia. It is frequently associated with **Down Syndrome (Trisomy 21)** in about 30% of cases and presents with the classic **"Double Bubble" appearance** on X-ray. **2. Why Other Options are Incorrect:** * **Jejunum and Ileum:** While common, jejunoileal atresias occur less frequently than duodenal atresia. Their pathophysiology is different, usually resulting from **late intrauterine vascular accidents** (ischemic necrosis) rather than recanalization failure. * **Colon:** Colonic atresia is the rarest form of intestinal atresia, accounting for less than 5–10% of cases. **Clinical Pearls for NEET-PG:** * **Most common site:** Duodenum > Ileum > Jejunum > Colon. * **Vascular Insult Theory:** Applies to jejunoileal atresia (leads to "Apple-peel" deformity). * **Polyhydramnios:** Frequently seen in maternal history due to the high level of obstruction. * **Bile-stained vomitus:** A hallmark of duodenal atresia (as most occur distal to the Ampulla of Vater). * **Associated Anomalies:** Duodenal atresia is often part of the VACTERL association; jejunoileal atresia is usually an isolated finding.

Question 105: Bilious vomiting is seen in all conditions except?

A. Jejunal atresia
B. Volvulus of small intestine
C. Duodenal atresia
D. Pyloric stenosis (Correct Answer)

Explanation: **Explanation:** The key to answering this question lies in the anatomical relationship between the **Ampulla of Vater** (where the common bile duct enters the second part of the duodenum) and the site of obstruction. **1. Why Pyloric Stenosis is the correct answer:** In **Congenital Hypertrophic Pyloric Stenosis (CHPS)**, the obstruction occurs at the pylorus, which is **proximal** to the Ampulla of Vater. Since the gastric outlet is blocked before bile can enter the gastrointestinal tract, the vomitus contains only gastric contents and mucus. Therefore, the hallmark of CHPS is **non-bilious, projectile vomiting**, typically appearing between 3–6 weeks of life. **2. Why the other options are incorrect:** * **Duodenal Atresia:** Most cases (85%) occur distal to the Ampulla of Vater. Thus, bile mixes with the intestinal contents, leading to **bilious vomiting**. It is classically associated with the "Double Bubble" sign on X-ray. * **Jejunal Atresia:** Since the obstruction is further down in the small intestine (distal to the duodenum), bile is always present in the refluxed material. * **Volvulus of the Small Intestine:** Midgut volvulus usually involves the small bowel distal to the duodenum. Sudden onset of bilious vomiting in a previously healthy neonate is considered midgut volvulus until proven otherwise. **Clinical Pearls for NEET-PG:** * **Metabolic Abnormality in CHPS:** Hypochloremic, hypokalemic, metabolic alkalosis with paradoxical aciduria. * **Physical Exam:** A palpable "olive-shaped" mass in the epigastrium is pathognomonic for CHPS. * **Rule of Thumb:** Any obstruction **distal** to the second part of the duodenum presents with **bilious** vomiting; any obstruction **proximal** to it presents with **non-bilious** vomiting.

Question 106: Which congenital anomaly is associated with chromosomal anomalies in more than 20% of cases?

A. Gastroschisis
B. Omphalocele (Correct Answer)
C. Spina Bifida
D. Cleft Palate

Explanation: **Explanation:** **Omphalocele** is a midline abdominal wall defect where the bowel and/or solid viscera herniate through the umbilical ring, covered by a peritoneal sac. It is highly associated with associated anomalies (up to 50–70% of cases), with **chromosomal abnormalities** occurring in approximately **30–50%** of cases. The most common chromosomal associations include **Trisomy 18 (Edwards syndrome)**, Trisomy 13 (Patau syndrome), and Trisomy 21 (Down syndrome). It is also a key feature of Beckwith-Wiedemann syndrome. **Incorrect Options:** * **Gastroschisis:** Unlike omphalocele, gastroschisis is usually an isolated defect (para-umbilical) and is rarely associated with chromosomal anomalies (<1%). The primary association here is intestinal atresia due to vascular accidents. * **Spina Bifida:** While it can be part of certain syndromes, most cases are multifactorial (folic acid deficiency) rather than primarily chromosomal. * **Cleft Palate:** Although it can occur in chromosomal syndromes (like Patau), the majority of cases are isolated or multifactorial, with a lower overall chromosomal association rate compared to omphalocele. **High-Yield Clinical Pearls for NEET-PG:** * **Omphalocele:** High association with chromosomal anomalies and cardiac defects. Always perform an **Echocardiogram** and **Karyotyping**. * **Gastroschisis:** Associated with **young maternal age** and smoking. Usually occurs to the **right** of the umbilical cord. * **Maternal Alpha-Fetoprotein (MSAFP):** Elevated in both, but significantly higher in Gastroschisis (due to lack of a covering sac). * **Management:** Small omphaloceles can undergo primary closure; large ones ("Giant Omphalocele") may require staged closure using the Schuster procedure or topical escharotics (e.g., Silvadene).

Question 107: Anorectal malformations include all of the following except?

A. Coloanal fistula (Correct Answer)
B. Rectourethral fistula
C. Imperforate anus
D. Anal stenosis

Explanation: Anorectal malformations (ARMs) are a spectrum of congenital defects resulting from the abnormal development of the urorectal septum during embryogenesis. **Why "Coloanal fistula" is the correct answer:** A **coloanal fistula** is typically an acquired condition (often a complication of surgery, inflammatory bowel disease, or malignancy) rather than a congenital malformation. In ARMs, the rectum—not the colon—is the structure that fails to descend or communicates abnormally with the urogenital tract. Therefore, the term used in classification is **recto-** (e.g., rectourethral, rectovestibular), not **colo-**. **Explanation of other options:** * **Rectourethral fistula:** This is the most common type of "high" or "intermediate" ARM in males. The rectum communicates with the prostatic or bulbar urethra. * **Imperforate anus:** This is the classic clinical presentation of ARMs where the anal opening is absent or obstructed by a membrane. * **Anal stenosis:** A "low" variety of ARM where the anal opening is present but pathologically narrow due to incomplete canalization. **High-Yield Clinical Pearls for NEET-PG:** * **VACTERL Association:** Always screen infants with ARM for other anomalies (Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, and Limb). * **Investigation of Choice:** An **Invertogram** (Wangensteen-Rice technique) is traditionally used to determine the level of the lesion, but it must be performed only after **18–24 hours** of life to allow bowel gas to reach the distal rectum. * **Management:** Low anomalies are managed with a primary **Anoplasty**. High anomalies require a staged approach: Initial diverting colostomy, followed by **PSARP (Posterior Sagittal Anorectoplasty/Peña Procedure)**, and finally colostomy closure.

Question 108: A child presents with recurrent abdominal pain and bilious vomiting. The condition was diagnosed by barium follow-through. Surgery revealed mesenteric widening, appendicectomy, and division of Ladd's bands. What is the diagnosis?

A. Recurrent caecal volvulus
B. Malrotation (Correct Answer)
C. Recurrent appendicitis
D. Stricture TB

Explanation: **Explanation:** The clinical presentation of **bilious vomiting** and recurrent abdominal pain in a child is a classic red flag for **Malrotation with or without Midgut Volvulus**. **1. Why Malrotation is correct:** Malrotation occurs due to the failure of the normal 270° counter-clockwise rotation of the midgut during embryonic development. This results in: * **Narrow Mesenteric Base:** Predisposing the gut to volvulus. * **Ladd’s Bands:** Abnormal peritoneal bands extending from the cecum (located in the RUQ) across the duodenum, causing extrinsic obstruction. * **Surgical Management (Ladd’s Procedure):** The standard treatment involves counter-clockwise detorsion, **division of Ladd’s bands**, **widening of the mesenteric base**, and a prophylactic **appendicectomy** (as the appendix will be in an abnormal position, making future diagnosis of appendicitis difficult). **2. Why other options are incorrect:** * **Recurrent Caecal Volvulus:** Rare in children; it involves twisting of the cecum itself, not the entire midgut, and wouldn't typically involve the division of Ladd's bands. * **Recurrent Appendicitis:** While it causes pain, it does not cause bilious vomiting or require mesenteric widening. * **Stricture TB:** Usually presents with features of chronic intestinal obstruction and weight loss; barium studies would show "string signs" or "pulled up cecum," but the surgical steps described (Ladd's bands) are pathognomonic for malrotation. **High-Yield Pearls for NEET-PG:** * **Gold Standard Investigation:** Upper GI Contrast Study (Barium Swallow/Follow-through) showing the **"Corkscrew appearance"** of the duodenum or the Duodenojejunal (DJ) flexure failing to cross the midline. * **Ladd’s Procedure:** Does *not* restore normal anatomy but places the small bowel on the right and the large bowel on the left. * **Whirlpool Sign:** Seen on Doppler Ultrasound, indicating midgut volvulus.

Question 109: Which of the following is true about a Bochdalek hernia?

A. Seen on the right side
B. Anterior position
C. Differential diagnosis for pleuropericardial cyst
D. Associated with lung hypoplasia (Correct Answer)

Explanation: **Explanation:** **Bochdalek Hernia** is the most common type of Congenital Diaphragmatic Hernia (CDH), occurring due to the failure of the **pleuroperitoneal canal** to close during embryonic development (usually by the 8th-10th week). **1. Why the correct answer is right:** The hallmark of CDH is the herniation of abdominal viscera into the thoracic cavity during critical stages of fetal lung development. This physical compression leads to **Lung Hypoplasia** (reduced number of bronchial generations and alveoli) and **Pulmonary Hypertension**. Lung hypoplasia is the primary determinant of survival and the most significant cause of respiratory distress in the neonatal period. **2. Why the other options are wrong:** * **Option A:** Bochdalek hernias are predominantly seen on the **Left side (80-85%)**. The right side is protected by the liver. * **Option B:** It is a **Posterolateral** defect. Anterior defects are known as **Morgagni hernias**, which occur through the Foramen of Morgagni. * **Option C:** Pleuropericardial cysts are typically located in the anterior cardiophrenic angle. The differential diagnosis for a Bochdalek hernia (posterior) usually includes CCAM (Congenital Cystic Adenomatoid Malformation) or neurogenic tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of CDH:** Respiratory distress, Scaphoid abdomen, and Dextrocardia (due to mediastinal shift). * **Management:** It is a **medical emergency**, not a surgical one. Initial stabilization involves intubation (avoid bag-mask ventilation to prevent bowel distension) and gentle ventilation. Surgery is delayed until pulmonary hypertension is stabilized. * **Radiology:** Chest X-ray shows air-filled loops of bowel in the hemithorax with a mediastinal shift to the opposite side.

Question 110: What is the least common type of intussusception?

A. Multiple (Correct Answer)
B. Colocolic
C. Ileoileal
D. Ileoilecolic

Explanation: **Explanation:** Intussusception is the telescoping of one segment of the intestine (intussusceptum) into an adjacent segment (intussuscipiens). It is the most common cause of intestinal obstruction in infants (6–36 months). **Why "Multiple" is the correct answer:** Intussusception typically occurs at a single site. **Multiple intussusceptions** (where telescoping occurs at two or more separate, non-contiguous locations simultaneously) are extremely rare. When they do occur, they are often associated with specific pathological lead points (PLPs) like Peutz-Jeghers syndrome, Henoch-Schönlein purpura, or multiple lymphoid hyperplasia. **Analysis of other options:** * **Ileoilecolic (Option D):** This is the **second most common** type. It occurs when an ileoileal intussusception subsequently prolapses through the ileocecal valve into the colon. * **Ileoileal (Option C):** This involves only the small bowel. While common in specific scenarios (like postoperative intussusception or in older children with a Meckel’s diverticulum), it is more frequent than the multiple type. * **Colocolic (Option B):** This involves only the large bowel. It is less common than ileocolic but occurs more frequently than multiple synchronous intussusceptions, often seen in older children with colonic polyps. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Type:** **Ileocolic** (accounts for ~80-90% of cases). * **Classic Triad:** Intermittent abdominal pain, "sausage-shaped" mass (usually in the right upper quadrant), and "red currant jelly" stools. * **Diagnosis:** Ultrasound is the gold standard (shows the **Target/Donut sign** or **Pseudokidney sign**). * **Management:** Non-operative reduction (Air or Hydrostatic enema) is the first line if there are no signs of peritonitis or perforation.

Practice by Chapter

Neonatal Physiology

Practice Questions

Congenital Anomalies Overview

Practice Questions

Neonatal Intestinal Obstruction

Practice Questions

Necrotizing Enterocolitis

Practice Questions

Hirschsprung's Disease

Practice Questions

Anorectal Malformations

Practice Questions

Pediatric Hernias

Practice Questions

Pyloric Stenosis

Practice Questions

Biliary Atresia

Practice Questions

Pediatric Tumors

Practice Questions

Congenital Diaphragmatic Hernia

Practice Questions

Pediatric Trauma

Practice Questions

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