Pediatric Surgery — MCQs

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 161: What is the commonest type of tracheo-esophageal fistula?

A. Proximal end blind; distal end communicating with the trachea (Correct Answer)
B. Distal end blind; proximal end communicating with the trachea
C. Both ends blind
D. Both ends open

Explanation: Tracheoesophageal fistula (TEF) with Esophageal Atresia (EA) is a congenital anomaly resulting from the failure of the tracheoesophageal septum to divide the foregut into the trachea and esophagus. **Explanation of the Correct Answer:** * **Option A (Type C):** This is the most common variant, accounting for approximately **85-87%** of cases. In this type, the upper esophagus ends in a blind pouch (Atresia), while the lower (distal) segment of the esophagus communicates with the trachea, usually near the carina. This leads to the classic clinical triad of drooling, choking, and cyanosis during feeding, along with abdominal distension due to air entering the stomach through the fistula. **Explanation of Incorrect Options:** * **Option B (Type B):** Proximal fistula with distal atresia is rare (<1%). It presents with immediate aspiration of saliva/milk into the lungs. * **Option C (Type A):** Pure Esophageal Atresia (both ends blind) is the second most common type (~8%). A key diagnostic feature is a **"gasless abdomen"** on X-ray because no air can reach the stomach. * **Option D (Type D):** Both ends communicating with the trachea is extremely rare (<1%). **High-Yield Clinical Pearls for NEET-PG:** * **VACTERL Association:** 50% of cases are associated with other anomalies (Vertebral, Anal atresia, Cardiac, TEF, Renal, Limb). * **Diagnosis:** Inability to pass a firm, radio-opaque 8-10 Fr nasogastric tube into the stomach. * **H-type Fistula (Type E):** Fistula without atresia. It often presents late with recurrent pneumonia and "cyanotic spells" while feeding. * **Radiology:** The presence of air in the stomach on a plain X-ray confirms the presence of a distal fistula.

Question 162: Hirschsprung's disease is characterized by which of the following features?

A. Inherited in an autosomal recessive fashion.
B. Caused by unopposed parasympathetic activity in the affected segment of the bowel.
C. Has an equal incidence in girls and boys.
D. Seen more frequently in children with Down's syndrome than in the general population. (Correct Answer)

Explanation: **Explanation:** **Hirschsprung’s Disease (Congenital Aganglionic Megacolon)** is caused by the failure of neural crest cells to migrate cranio-caudally into the distal bowel between the 5th and 12th weeks of gestation. This results in an absence of Meissner’s and Auerbach’s plexuses in the affected segment. **Why Option D is Correct:** There is a strong genetic association between Hirschsprung’s disease and **Down’s syndrome (Trisomy 21)**. Approximately 10% of children with Hirschsprung’s disease have Down’s syndrome, which is significantly higher than the general population. Other associated conditions include Waardenburg syndrome and Mowat-Wilson syndrome. **Analysis of Incorrect Options:** * **Option A:** While 10-20% of cases are familial (associated with **RET proto-oncogene** mutations), the inheritance pattern is complex and typically follows an **autosomal dominant** pattern with incomplete penetrance, rather than autosomal recessive. * **Option B:** The aganglionic segment lacks both inhibitory and excitatory intrinsic neurons. This leads to **unopposed sympathetic activity** (not parasympathetic), causing the affected segment to remain in a state of tonic contraction, leading to functional obstruction. * **Option C:** There is a distinct male preponderance. The **male-to-female ratio is approximately 4:1**, although this ratio decreases in long-segment disease. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Rectal Suction Biopsy (shows absence of ganglion cells and **increased Acetylcholinesterase** staining). * **Clinical Presentation:** Failure to pass meconium within 48 hours, abdominal distension, and "blast sign" (explosive release of stool/gas) on digital rectal exam. * **Radiology:** Barium enema shows a "transition zone" (dilated proximal bowel and narrowed distal aganglionic segment). * **Surgery:** Definitive treatment involves "pull-through" procedures (e.g., Duhamel, Soave, or Swenson).

Question 163: What is a cystic compressible, translucent swelling typically found in the posterior triangle of the neck?

A. Cystic hygroma (Correct Answer)
B. Branchial cyst
C. Thyroglossal cyst
D. Dermoid cyst

Explanation: ### Explanation **Cystic Hygroma (Correct Answer)** A cystic hygroma is a congenital malformation of the lymphatic system (lymphangioma) where lymph sacs fail to communicate with the venous system. * **Location:** Most commonly found in the **posterior triangle** of the neck (80% of cases). * **Clinical Features:** It is characteristically **soft, cystic, compressible, and painless**. * **Pathognomonic Sign:** Because it contains clear lymph and has thin walls, it is **brilliantly translucent**. It often exhibits a "cross-fluctuation" sign due to its multilocular nature. **Why the others are incorrect:** * **Branchial Cyst:** Typically located at the junction of the upper 1/3rd and lower 2/3rds of the **anterior border of the sternocleidomastoid muscle**. It is usually opaque (not translucent) and contains cholesterol crystals in the fluid. * **Thyroglossal Cyst:** Found in the **midline** of the neck, usually below the hyoid bone. Its hallmark feature is that it **moves upward on protrusion of the tongue** and deglutition. * **Dermoid Cyst:** Also found in the midline (submental region). It is a "doughy" feeling, opaque swelling that does not transilluminate. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Cystic hygromas are frequently associated with chromosomal anomalies, most notably **Turner Syndrome** (45, XO) and Down Syndrome. * **Complications:** Sudden increase in size usually indicates **intracystic hemorrhage** or infection. * **Treatment of Choice:** Surgical excision is preferred. For unresectable cases, sclerotherapy (e.g., **OK-432** or Bleomycin) is used. * **Radiology:** On USG/MRI, it appears as a multilocular cystic mass with internal septations.

Question 164: Which of the following is NOT true regarding congenital hypertrophic pyloric stenosis?

A. Alkalosis
B. Length of pyloric canal < 14 mm (Correct Answer)
C. Non-bilious vomiting
D. Visible peristalsis

Explanation: **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is a common cause of gastric outlet obstruction in infants, typically presenting between 3 to 6 weeks of life. ### **Explanation of the Correct Answer** **Option B** is the correct answer because it is a **false** statement. In CHPS, the pyloric canal is **thickened and elongated**. On ultrasonography (the gold standard investigation), the diagnostic criteria for CHPS are: * **Pyloric canal length:** > 14 mm (not less than 14 mm). * **Pyloric muscle thickness:** > 3 mm (or 4 mm). * **Pyloric diameter:** > 11 mm. ### **Analysis of Incorrect Options** * **A. Alkalosis:** This is a classic feature. Persistent vomiting of gastric acid (HCl) leads to **hypochloremic, hypokalemic, metabolic alkalosis** with paradoxical aciduria. * **C. Non-bilious vomiting:** Since the obstruction is proximal to the Ampulla of Vater (where bile enters the duodenum), the vomitus never contains bile. It is typically "projectile" in nature. * **D. Visible peristalsis:** Due to the stomach's effort to overcome the obstruction, left-to-right gastric peristaltic waves may be visible on the upper abdomen during feeding. ### **High-Yield Clinical Pearls for NEET-PG** * **Epidemiology:** Most common in **first-born male** infants; associated with **erythromycin** use in early infancy. * **Physical Exam:** A palpable, olive-shaped mass in the epigastrium (best felt after vomiting). * **Radiology:** On Barium swallow, look for the **"String sign"** (narrowed canal) or **"Beak sign."** * **Management:** The initial priority is **resuscitation** (correcting dehydration and alkalosis with 0.45% or 0.9% NS). The definitive surgery is **Ramstedt’s Pyloromyotomy**.

Question 165: What is the most common type of anorectal malformation?

A. Imperforate anus
B. Anal agenesis
C. Anorectal agenesis (Correct Answer)
D. Rectal atresia

Explanation: **Explanation:** Anorectal malformations (ARMs) are a spectrum of congenital defects resulting from the abnormal development of the urorectal septum. **Why Anorectal Agenesis is Correct:** Anorectal agenesis is the **most common type** of ARM overall. In this condition, the rectum ends blindly above the level of the levator ani muscle (High/Intermediate anomaly). It is frequently associated with a **fistula**: * **In Males:** Most commonly a rectourethral fistula. * **In Females:** Most commonly a rectovestibular fistula. **Analysis of Incorrect Options:** * **Imperforate Anus:** This is a general descriptive term for any ARM where the anal opening is absent, rather than a specific anatomical classification. * **Anal Agenesis:** This is a "Low" anomaly where the anal canal is absent but the rectum is normally developed. It is less common than the higher anorectal agenesis. * **Rectal Atresia:** This is a rare variant where the anal canal and rectum are present but separated by a membrane or a gap. It accounts for only about 1-2% of all ARMs. **NEET-PG High-Yield Pearls:** * **Most common ARM in Males:** Anorectal agenesis with **Rectourethral fistula**. * **Most common ARM in Females:** Anorectal agenesis with **Rectovestibular fistula**. * **Most common "Low" Anomaly:** Rectoperineal fistula. * **VACTERL Association:** Always screen for other anomalies (Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, and Limb). Renal anomalies are the most frequent association. * **Initial Management:** Keep NPO, start IV fluids, and perform an **Invertogram** (or cross-table lateral X-ray) after 18–24 hours to allow gas to reach the distal pouch.

Question 166: Which of the following statements about a Bochdalek hernia is FALSE?

A. The defect is posterolateral.
B. It is more common on the right side. (Correct Answer)
C. It may lead to pulmonary hypoplasia and respiratory distress.
D. It can be diagnosed prenatally.

Explanation: **Explanation:** Congenital Diaphragmatic Hernia (CDH) is a critical topic in pediatric surgery, with the Bochdalek hernia being the most common type (approximately 85-90% of cases). **Why Option B is the Correct Answer (The False Statement):** Bochdalek hernias occur significantly more frequently on the **left side (80-85%)** than on the right side. This is primarily because the left pleuroperitoneal canal closes later than the right, and the presence of the **liver** on the right side acts as a physical barrier, preventing abdominal viscera from herniating through a right-sided defect. **Analysis of Other Options:** * **Option A:** The Bochdalek defect is anatomically **posterolateral**, resulting from the failure of the pleuroperitoneal membranes to fuse with the septum transversum and dorsal mesentery. * **Option C:** The herniated abdominal contents (bowel, spleen, stomach) occupy the thoracic cavity during fetal development. This compresses the developing lungs, leading to **pulmonary hypoplasia** and persistent pulmonary hypertension, which manifest as immediate respiratory distress at birth. * **Option D:** It can be diagnosed **prenatally** via ultrasound (showing polyhydramnios or abdominal organs in the chest) or fetal MRI, allowing for planned delivery at a tertiary care center. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Cyanosis, Dyspnea, and Dextrocardia (if left-sided). * **Physical Exam:** Scaphoid abdomen and absent breath sounds on the affected side. * **Management:** Initial stabilization is key. **Avoid bag-and-mask ventilation** (it distends the stomach and further compresses the lungs); instead, perform immediate endotracheal intubation and insert a nasogastric tube. * **Morgagni Hernia:** A rarer type of CDH that is **anterior/retrosternal** and more common on the **right side**.

Question 167: What is the end-stage treatment for Tetralogy of Fallot?

A. Blalock-Taussig shunt
B. Modified Blalock-Taussig shunt (Correct Answer)
C. Waterston shunt
D. Pott shunt operation

Explanation: **Explanation:** Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. The definitive treatment is total surgical correction; however, in neonates or infants with severe cyanosis, small pulmonary arteries, or "tet spells," a palliative systemic-to-pulmonary artery shunt is required to increase pulmonary blood flow. **Why Option B is correct:** The **Modified Blalock-Taussig (BT) Shunt** is currently the "gold standard" palliative procedure. It involves placing a synthetic **Gore-Tex (PTFE) graft** between the subclavian artery and the ipsilateral pulmonary artery. It is preferred because it is easier to perform, easier to take down during definitive repair, and carries a lower risk of distorting the pulmonary arteries compared to the original version. **Analysis of Incorrect Options:** * **A. Blalock-Taussig Shunt:** The "classic" BT shunt involves a direct end-to-side anastomosis of the subclavian artery to the pulmonary artery. It is rarely performed now because it often led to limb ischemia and kinking of the vessel. * **C. Waterston Shunt:** This involves an anastomosis between the **ascending aorta** and the right pulmonary artery. It is obsolete due to complications like heart failure from excessive flow and pulmonary hypertension. * **D. Potts Shunt:** This involves an anastomosis between the **descending aorta** and the left pulmonary artery. It is no longer used because it is extremely difficult to reverse during definitive surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Treatment:** Total correction (VSD closure + relief of RVOT obstruction) is ideally performed at **3–6 months** of age. * **X-ray Finding:** "Boot-shaped heart" (Coeur en sabot) due to right ventricular hypertrophy. * **Components of TOF:** VSD, Overriding of Aorta, RVOT obstruction (Infundibular stenosis), and RV Hypertrophy. * **Tet Spells:** Managed by Knee-chest position, Oxygen, Morphine, and Beta-blockers (Propranolol).

Question 168: A newborn infant presents with bilious vomiting and epigastric distention immediately following birth. What is the most likely diagnosis?

A. Esophageal atresia
B. Congenital pyloric stenosis
C. Gastric outlet obstruction
D. Atresia of the third part of the duodenum (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **bilious vomiting** in a newborn is a surgical emergency until proven otherwise. It indicates an obstruction **distal to the Ampulla of Vater** (where the common bile duct enters the second part of the duodenum). **1. Why Option D is Correct:** Duodenal atresia most commonly occurs at the junction of the 2nd and 3rd parts of the duodenum. Because the obstruction is distal to the biliary drainage, the vomitus contains bile. The **epigastric distention** occurs because the stomach and the proximal duodenum become dilated (the classic "Double Bubble" sign on X-ray), while the rest of the abdomen remains scaphoid or flat. **2. Why Other Options are Incorrect:** * **Esophageal Atresia (A):** Presents with drooling, choking, and cyanosis during feeds. Vomiting is non-bilious as the food never reaches the stomach. * **Congenital Hypertrophic Pyloric Stenosis (B):** Typically presents at **3–6 weeks** of age (not at birth) with **non-bilious**, projectile vomiting. The obstruction is proximal to the Ampulla of Vater. * **Gastric Outlet Obstruction (C):** Similar to pyloric stenosis, any obstruction at the level of the stomach or pylorus results in **non-bilious** vomiting. **High-Yield Clinical Pearls for NEET-PG:** * **Duodenal Atresia Association:** 30% of cases are associated with **Down Syndrome (Trisomy 21)**. * **Radiology:** The pathognomonic finding is the **"Double Bubble Sign"** (air in the stomach and proximal duodenum). * **Polyhydramnios:** Often noted in the maternal prenatal history due to the fetus's inability to swallow and absorb amniotic fluid. * **Management:** Initial resuscitation followed by **Duodenoduodenostomy** (Diamond-shaped anastomosis).

Question 169: Which of the following is NOT true about Bochdalek hernia?

A. It is typically seen on the right side. (Correct Answer)
B. It is associated with hypoplasia of the lung.
C. It is associated with a hiatus hernia.
D. A pericardial cyst is a differential diagnosis.

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. **Explanation of the Correct Answer:** * **Option A is NOT true** because Bochdalek hernia occurs predominantly on the **left side (80-85%)**. The right side is protected by the presence of the liver, which acts as a physical barrier during development. Therefore, stating it is typically seen on the right is factually incorrect. **Analysis of Other Options:** * **Option B:** Pulmonary hypoplasia is the hallmark of CDH. The herniated abdominal viscera occupy the thoracic cavity during critical stages of lung development, leading to reduced bronchial branching and thickened pulmonary arterioles (causing pulmonary hypertension). * **Option C:** While distinct entities, CDH is frequently associated with other foregut anomalies, including malrotation and gastroesophageal reflux/hiatus hernia, due to the altered anatomy of the esophageal hiatus and abdominal pressure dynamics. * **Option D:** Differential diagnoses for a mass in the lower posterior/middle mediastinum include duplication cysts, neurogenic tumors, and occasionally pericardial cysts (though these are more common in the anterior cardiophrenic angle). **NEET-PG High-Yield Pearls:** * **Location:** Posterolateral (Bochdalek = **B**ack and **L**eft). * **Morgagni Hernia:** Anterior and right-sided (less common). * **Clinical Triad:** Dyspnea, Cyanosis, and Dextrocardia (due to mediastinal shift). * **Radiology:** "Bag of snakes" appearance (bowel loops in the chest); scaphoid abdomen. * **Management:** Initial stabilization is key (O2 via ET tube, **avoid bag-and-mask** to prevent bowel distension). Surgery is not an emergency; it is performed after stabilizing pulmonary hypertension.

Question 170: What is the recommended treatment for annular pancreas?

A. Conservative management
B. Gastrojejunostomy
C. Duodenoduodenostomy (Correct Answer)
D. Surgical resection of the affected pancreatic segment

Explanation: **Explanation:** **Annular pancreas** is a congenital anomaly where a ring of pancreatic tissue encircles the second part of the duodenum, leading to extrinsic obstruction. **Why Duodenoduodenostomy is the Correct Answer:** The gold standard treatment for symptomatic annular pancreas is a **bypass procedure**, specifically **Duodenoduodenostomy** (Kimura’s procedure). This involves creating an anastomosis between the proximal dilated duodenum and the distal collapsed duodenum. It is preferred because it is the most physiological bypass, restoring normal intestinal continuity while avoiding the risks associated with direct pancreatic surgery. **Why Other Options are Incorrect:** * **Conservative management:** This is inappropriate for symptomatic cases as the mechanical obstruction requires surgical intervention to allow feeding and prevent complications. * **Gastrojejunostomy:** While it bypasses the obstruction, it is less physiological than duodenoduodenostomy and carries a higher risk of stomal ulcers and "blind loop" syndrome in neonates. * **Surgical resection of the pancreatic segment:** This is **strictly contraindicated**. Attempting to divide or resect the ring often leads to pancreatic fistulas, pancreatitis, or damage to the underlying common bile duct or pancreatic ducts which are often intramural. **High-Yield Clinical Pearls for NEET-PG:** * **Embryology:** Caused by the failure of the **ventral pancreatic bud** to rotate correctly. * **Clinical Presentation:** Presents with features of proximal intestinal obstruction (non-bilious or bilious vomiting depending on the site of the ring relative to the Ampulla of Vater). * **Radiology:** Characterized by the **"Double Bubble Sign"** on X-ray (similar to duodenal atresia). * **Associations:** Frequently associated with **Down Syndrome (Trisomy 21)**, malrotation, and cardiac defects.

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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