Pediatric Surgery Practice Questions

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

Cystic hygroma. ### 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.

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

Length of pyloric canal < 14 mm. **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**.

Q: What is the most common type of anorectal malformation?

Anorectal agenesis. **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.

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

It is more common on the right side.. **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**.

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

Atresia of the third part of the duodenum. **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).

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

It is typically seen on the right side.. **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.

Q: What is the recommended treatment for annular pancreas?

Duodenoduodenostomy. **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.

Question 1

What is the commonest type of tracheo-esophageal fistula?

Accepted Answer

Proximal end blind; distal end communicating with the trachea

Answer

Distal end blind; proximal end communicating with the trachea

Answer

Both ends blind

Answer

Both ends open

Question 2

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

Accepted Answer

Seen more frequently in children with Down's syndrome than in the general population.

Answer

Inherited in an autosomal recessive fashion.

Answer

Caused by unopposed parasympathetic activity in the affected segment of the bowel.

Answer

Has an equal incidence in girls and boys.

Question 3

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

Accepted Answer

Cystic hygroma

Answer

Branchial cyst

Answer

Thyroglossal cyst

Answer

Dermoid cyst

Question 4

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

Accepted Answer

Length of pyloric canal < 14 mm

Answer

Alkalosis

Answer

Non-bilious vomiting

Answer

Visible peristalsis

Question 5

What is the most common type of anorectal malformation?

Accepted Answer

Anorectal agenesis

Answer

Imperforate anus

Answer

Anal agenesis

Answer

Rectal atresia

Question 6

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

Accepted Answer

It is more common on the right side.

Answer

The defect is posterolateral.

Answer

It may lead to pulmonary hypoplasia and respiratory distress.

Answer

It can be diagnosed prenatally.

Question 7

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

Accepted Answer

Modified Blalock-Taussig shunt

Answer

Blalock-Taussig shunt

Answer

Waterston shunt

Answer

Pott shunt operation

Question 8

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

Accepted Answer

Atresia of the third part of the duodenum

Answer

Esophageal atresia

Answer

Congenital pyloric stenosis

Answer

Gastric outlet obstruction

Question 9

Which of the following is NOT true about Bochdalek hernia?

Accepted Answer

It is typically seen on the right side.

Answer

It is associated with hypoplasia of the lung.

Answer

It is associated with a hiatus hernia.

Answer

A pericardial cyst is a differential diagnosis.

Question 10

What is the recommended treatment for annular pancreas?

Accepted Answer

Duodenoduodenostomy

Answer

Conservative management

Answer

Gastrojejunostomy

Answer

Surgical resection of the affected pancreatic segment

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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