Pediatric Surgery Practice Questions

Q: A child underwent surgery for a small intestine mass with intussusception. Histological examination of the resected tumor revealed the diagnosis. Which is the most likely tumor associated with this presentation?

Lymphoma. **Explanation:** **1. Why Lymphoma is the Correct Answer:** In the pediatric population, **Non-Hodgkin Lymphoma (specifically Burkitt Lymphoma)** is the most common primary malignancy of the small intestine. The terminal ileum is the most frequent site due to the abundance of Peyer’s patches. These tumors often act as a **pathological lead point**, causing the bowel to invaginate, leading to **intussusception**. While idiopathic intussusception is common in infants (6–24 months), intussusception in older children (typically >5 years) should highly raise suspicion of a secondary cause like Lymphoma. **2. Why Other Options are Incorrect:** * **Carcinoid:** While the most common tumor of the appendix in children, it is rare in the small intestine of pediatric patients compared to adults. * **Villous Adenoma:** These are premalignant epithelial tumors primarily found in the colon of older adults; they are virtually non-existent in the pediatric small bowel. * **Smooth Muscle Tumor (Leiomyoma/Leiomyosarcoma):** These are rare mesenchymal tumors in children. While they can cause bleeding or obstruction, they are significantly less common than Lymphoma in this age group. **3. Clinical Pearls for NEET-PG:** * **Lead Points:** In children, the most common pathological lead point for intussusception is a **Meckel’s Diverticulum**, but the most common **malignant** lead point is **Lymphoma**. * **Age Factor:** Idiopathic intussusception usually occurs under age 2. If a child presents with intussusception over the age of 5, always look for a pathological lead point (Lymphoma or Meckel’s). * **Triad of Intussusception:** Colicky abdominal pain, "currant jelly" stools, and a sausage-shaped mass. * **Diagnosis:** Ultrasound is the gold standard (Target/Donut sign).

Q: A neonate presents with a history of not passing meconium. Examination reveals an anal dimple but no anal opening. What is the investigation of choice?

Invertedogram. **Explanation:** The clinical presentation of a neonate failing to pass meconium with an absent anal opening is diagnostic of **Anorectal Malformation (ARM)**. **1. Why Invertedogram is the Correct Answer:** The **Invertedogram (Wangensteen-Rice technique)** is the traditional investigation of choice to determine the level of the lesion (High vs. Low). The infant is held upside down for 3–5 minutes to allow bowel gas to rise to the distal-most end of the rectal pouch. A radio-opaque marker is placed on the anal dimple. The distance between the gas bubble and the marker helps categorize the defect: * **Low anomaly:** Gas bubble is 1 cm from the skin. * *Note:* This must be performed only after **18–24 hours of life** to allow gas to reach the rectum. **2. Why Other Options are Incorrect:** * **A & B (X-ray Erect/Supine):** These are useful for identifying intestinal obstruction or pneumoperitoneum but cannot localize the distal rectal pouch relative to the perineum. * **C (Gastrograffin study):** Contrast studies are generally used for Hirschsprung’s disease or meconium ileus, not for the initial classification of ARM. **3. Clinical Pearls for NEET-PG:** * **Modern Shift:** While Invertedogram is the classic "textbook" answer, **Cross-table Prone Lateral X-ray** is now often preferred clinically as it is less stressful for the neonate. * **VACTERL Association:** Always screen for other anomalies (Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, Limb). * **Management:** Low anomalies usually require a **Primary Anoplasty**, while high anomalies require a **staged procedure** (Colostomy → PSARP/Pena’s procedure → Colostomy closure).

Q: What is the most sensitive investigation for the diagnosis of Meckel's diverticulum?

99m-Tc pertechnetate scan. **Explanation:** Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, resulting from the failure of the vitelline duct to obliterate. **Why the Correct Answer is Right:** The **99m-Tc pertechnetate scan (Meckel’s scan)** is the investigation of choice and the most sensitive test for diagnosing a symptomatic Meckel’s diverticulum. The underlying principle is that 99m-Tc pertechnetate has a high affinity for **gastric mucosa**. Since approximately 50-60% of symptomatic Meckel’s diverticula contain **ectopic gastric mucosa**, the isotope concentrates in the diverticulum, appearing as a "hot spot" on scintigraphy. Its sensitivity is further increased by using pharmacological adjuncts like H2 blockers (cimetidine), glucagon, or pentagastrin. **Why Other Options are Incorrect:** * **Ultrasonography (USG):** While useful for identifying complications like intussusception or inflammatory masses, it lacks the sensitivity to reliably visualize an uncomplicated Meckel’s diverticulum. * **CT Scan:** Often used in acute abdominal pain, it may show a "blind-ending pouch," but it is frequently non-specific and can miss the diverticulum unless it is inflamed (Meckel’s diverticulitis). * **Barium Enema:** This is primarily used for diagnosing large bowel pathologies or reducing intussusception. It rarely refluxes far enough into the ileum to visualize a Meckel’s diverticulum. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 2s:** 2% of the population, 2 inches long, 2 feet from the ileocecal valve, 2 types of ectopic tissue (Gastric > Pancreatic), and presents before age 2. * **Most common presentation:** Painless lower GI bleeding (hematochezia) in children; intestinal obstruction in adults. * **Treatment:** Surgical resection (diverticulectomy or wedge resection) is indicated for symptomatic cases.

Q: Exomphalos is a congenital condition involving which anatomical structure?

Abdominal wall. **Explanation:** **Exomphalos** (also known as **Omphalocele**) is a congenital **abdominal wall defect** occurring at the base of the umbilical cord. It results from the failure of the midgut to return to the abdominal cavity from the physiological herniation that occurs during the 6th to 10th weeks of gestation. The herniated viscera are covered by a three-layered sac consisting of amnion, Wharton’s jelly, and peritoneum. * **Why Option C is correct:** The defect is fundamentally a midline failure of the abdominal wall muscles and skin to close, allowing abdominal contents (bowel, and often the liver) to remain outside the body. * **Why Options A, B, and D are incorrect:** * **Umbilicus (A):** While the defect occurs *at* the umbilicus, it is classified as an abdominal wall defect. An umbilical hernia is a separate, less severe condition where the defect is covered by skin. * **Cervix (B):** This is part of the female reproductive system and is anatomically unrelated. * **Urinary bladder (D):** Bladder exstrophy is a different midline defect involving the lower abdominal wall and the bladder, but it is distinct from exomphalos. **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Exomphalos is frequently associated with chromosomal anomalies (Trisomy 13, 18, 21) and syndromes like **Beckwith-Wiedemann Syndrome** (macroglossia, gigantism, hypoglycemia). * **Diagnosis:** Elevated maternal serum alpha-fetoprotein (MSAFP) and prenatal ultrasound. * **Management:** Small defects (Exomphalos minor) can be closed primarily; large defects (Exomphalos major) may require staged closure using a "silo" or conservative management with escharotics (e.g., silver sulfadiazine) to allow epithelialization. * **Key Distinction:** Unlike Gastroschisis, Exomphalos is **midline**, has a **covering sac**, and the umbilical cord inserts **directly into the sac**.

Q: Which of the following statements regarding hypertrophic pyloric stenosis is TRUE?

Ultrasonography is the diagnostic test of choice.. ### Explanation **Hypertrophic Pyloric Stenosis (HPS)** is a common cause of gastric outlet obstruction in infants, characterized by hypertrophy of the circular muscle of the pylorus. **Why Option D is Correct:** **Ultrasonography (USG)** is the gold standard and diagnostic test of choice due to its high sensitivity and specificity. It is non-invasive and avoids radiation. Diagnostic criteria include a **pyloric muscle thickness >3 mm** and a **pyloric channel length >14 mm**. **Why the Other Options are Incorrect:** * **Option A:** Symptoms typically appear between **3 to 6 weeks of life**. It is rarely present at birth or within the first week, making "first week" clinically inaccurate. * **Option B:** While a "palpable olive-shaped mass" is a classic physical finding, it is **not always present** (palpable in about 60-80% of cases). Its absence does not rule out the diagnosis. * **Option C:** The surgical treatment of choice is **Ramstedt’s Pyloromyotomy** (longitudinal incision of the pylorus muscle while keeping the mucosa intact). Finney’s pyloroplasty is a reconstructive procedure used for different indications in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Non-bilious, projectile vomiting in a "hungry" infant. * **Metabolic Abnormality:** Hypochloremic, hypokalemic, metabolic alkalosis with **paradoxical aciduria** (a favorite MCQ topic). * **Radiology Sign:** On Barium swallow (if USG is inconclusive), look for the **"String sign"** or "Beak sign." * **Priority:** HPS is a **medical emergency**, not a surgical one. Electrolyte and fluid resuscitation (using Normal Saline) must be completed *before* the patient is taken to surgery.

Question 1

At what age should a patent vitello-intestinal duct preferably be operated on?

Accepted Answer

6 months of age

Answer

Birth

Answer

12 months of age

Answer

3 years of age

Question 2

A child underwent surgery for a small intestine mass with intussusception. Histological examination of the resected tumor revealed the diagnosis. Which is the most likely tumor associated with this presentation?

Accepted Answer

Lymphoma

Answer

Carcinoid

Answer

Villous adenoma

Answer

Smooth muscle tumor

Question 3

A neonate presents with a history of not passing meconium. Examination reveals an anal dimple but no anal opening. What is the investigation of choice?

Accepted Answer

Invertedogram

Answer

X-ray in erect posture

Answer

X-ray in supine posture

Answer

Gastrograffin study

Question 4

A newborn presents with discharge of urine from the umbilicus for 3 days. What is the most likely diagnosis?

Accepted Answer

Urachal fistula

Answer

Meckel's diverticulum

Answer

Mesenteric cysts

Answer

Omphalocele

Question 5

What is the most sensitive investigation for the diagnosis of Meckel's diverticulum?

Accepted Answer

99m-Tc pertechnetate scan

Answer

Ultrasonography (USG)

Answer

CT Scan

Answer

Barium enema

Question 6

A neonate presents with a smooth, transparent, fluctuating inguinal swelling that extends into the inguinal canal and receives an impulse when the child coughs or struggles. Congenital hydrocele is diagnosed after examination. What is the suggested treatment modality in this case?

Accepted Answer

Herniotomy

Answer

No treatment before 5 years

Answer

Herniorraphy

Answer

Eversion of sac

Question 7

Exomphalos is a congenital condition involving which anatomical structure?

Accepted Answer

Abdominal wall

Answer

Umbilicus

Answer

Cervix

Answer

Urinary bladder

Question 8

Which of the following statements is true regarding congenital hypertrophic pyloric stenosis?

Accepted Answer

A mass is palpated in the right upper quadrant when the patient is not feeding.

Answer

An olive mass is palpated in the epigastric region on feeding.

Answer

A mass is felt in the umbilical region.

Answer

A palpable mass is seen in the right iliac fossa.

Question 9

Which of the following statements regarding hypertrophic pyloric stenosis is TRUE?

Accepted Answer

Ultrasonography is the diagnostic test of choice.

Answer

Symptoms typically appear within the first week of life.

Answer

A palpable pyloric tumor is always present.

Answer

The treatment of choice is Finney's pyloroplasty.

Question 10

A meningomyelocele patient developed hydrocephalus after surgery. What is the most likely cause?

Accepted Answer

Arnold-Chiari malformation

Answer

Injury to the absorptive surface

Answer

Central canal injury

Answer

Arachnoidal block

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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