Pediatric Surgery Practice Questions

Q: What does the 'Signe de Dance' refer to?

Empty right iliac fossa in intussusception. **Explanation** **Signe de Dance** (Dance’s Sign) is a classic clinical finding in **intussusception**, most commonly seen in the ileocolic variety. It refers to a palpable **emptiness in the right iliac fossa (RIF)**. This occurs because the cecum and the ileum invaginate (telescope) into the ascending and transverse colon, physically migrating out of their normal anatomical position in the RIF. **Analysis of Options:** * **Option A (Correct):** As the intussusceptum moves distally along the colon, the RIF feels "empty" on palpation. This is often accompanied by a sausage-shaped mass felt in the right hypochondrium or epigastrium. * **Option B (Incorrect):** A "pincer-shaped" or "claw appearance" is a **radiological** finding seen on a barium enema, not a clinical sign. * **Option C (Incorrect):** Tenderness at McBurney’s point is the hallmark of **acute appendicitis**, caused by inflammation of the appendix. * **Option D (Incorrect):** Passing large quantities of urine after the relief of loin pain is known as **Dietl’s crisis**, seen in intermittent hydronephrosis (often due to PUJ obstruction). **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Intussusception:** Intermittent abdominal pain (screaming episodes), sausage-shaped mass, and **"red currant jelly" stools**. * **Target/Donut Sign:** The classic appearance on Ultrasonography (the investigation of choice). * **Treatment:** Non-operative reduction using **hydrostatic (saline) or pneumatic (air) enema** is the first-line treatment in stable patients. * **Lead Point:** In children, it is usually idiopathic (hypertrophied Peyer’s patches); in adults, it is usually a malignancy.

Q: What is the most common cause of hydronephrosis in children?

Congenital PUJ obstruction. **Explanation:** **Congenital Pelvi-Ureteric Junction (PUJ) Obstruction** is the most common cause of hydronephrosis in children and the most frequent cause of an abdominal mass in neonates. It occurs due to an anatomical or functional impairment of urine flow from the renal pelvis into the ureter. The most common underlying mechanism is an **aperistaltic segment** at the PUJ, though extrinsic compression by an accessory (aberrant) lower pole renal artery is also a significant cause. **Analysis of Options:** * **Ureterocoele (Option A):** This is a cystic dilatation of the distal intramural ureter. While it can cause hydroureteronephrosis, it is far less common than PUJ obstruction. * **Ureteric stricture (Option B):** These are usually acquired (post-inflammatory or post-surgical) and are rare in the pediatric population compared to congenital anomalies. * **Watermelon prostate (Option C):** This is a distractor term. "Watermelon stomach" (GAVE) is a clinical entity, but there is no such standard term for the prostate. Furthermore, prostatic pathologies typically cause bilateral hydronephrosis due to bladder outlet obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Most cases are now detected on **antenatal ultrasound**. Postnatally, it may present as a palpable flank mass or episodic loin pain (Dietl’s crisis) after increased fluid intake. * **Investigation of Choice:** **DTPA or MAG-3 scan** (Diuretic renogram) is used to assess the functional severity and drainage pattern. * **Surgical Gold Standard:** **Anderson-Hynes Dismembered Pyeloplasty** (can be open, laparoscopic, or robotic). * **Key Association:** If hydronephrosis is **bilateral** in a male infant, always suspect **Posterior Urethral Valves (PUV)** first.

Q: Which of the following is NOT a feature of ectopia vesicae?

X-linked dominant inheritance. **Explanation:** **Ectopia vesicae (Bladder Exstrophy)** is a complex congenital malformation resulting from the failure of the infraumbilical anterior abdominal wall and bladder neck to fuse. **Why Option D is the correct answer:** Ectopia vesicae is **not** an X-linked dominant disorder. Most cases occur **sporadically** with no clear inheritance pattern. While there is a slightly higher risk in siblings (approx. 1 in 100), it does not follow Mendelian genetics. The etiology is primarily attributed to the failure of mesenchymal migration between the ectoderm and endoderm of the cloacal membrane. **Analysis of incorrect options (Features of Ectopia Vesicae):** * **Epispadias (Option A):** This is a hallmark feature. In males, the urethra opens on the dorsal aspect of the penis. The penis is typically short and broad with a dorsal chordee. * **Bifid Clitoris (Option B):** In females, the clitoris is bifid (split), the labia are widely separated, and the vaginal orifice is displaced anteriorly. * **Undescended Testis (Option C):** Cryptorchidism and inguinal hernias are frequently associated with bladder exstrophy due to the widening of the bony pelvis and defects in the inguinal canal. **High-Yield Clinical Pearls for NEET-PG:** * **Bony Defect:** Widening of the **symphysis pubis** (diastasis) is a classic radiological finding. * **Associated Malignancy:** Patients have a significantly increased risk (up to 400-fold) of developing **Adenocarcinoma** of the bladder due to chronic irritation and glandular metaplasia of the exposed mucosa. * **Umbilicus:** The umbilicus is typically low-set, immediately above the exstrophied bladder. * **Management:** The primary goal is functional closure of the bladder, reconstruction of the bladder neck for continence, and repair of the epispadias.

Q: Which of the following is true about Hirschsprung's disease?

The aganglionic segment is contracted, not dilated.. **Explanation:** **Hirschsprung’s Disease (Congenital Aganglionic Megacolon)** is caused by the failure of neural crest cells to migrate cranio-caudally, resulting in an absence of Meissner’s and Auerbach’s plexuses in the distal bowel. 1. **Why Option A is Correct:** In Hirschsprung’s, the **aganglionic segment** lacks the inhibitory signals required for smooth muscle relaxation. Consequently, this segment remains in a state of **tonic contraction**. The proximal ganglionic bowel undergoes massive compensatory hypertrophy and **dilation** (megacolon) as it attempts to push stool past the distal obstruction. Thus, the pathology lies in the contracted segment, while the dilation is a secondary effect. 2. **Why Other Options are Incorrect:** * **Option B:** The most common site is the **Rectosigmoid region** (80% of cases), not the descending colon. * **Option C:** While a Barium enema is a useful screening tool (showing a "transition zone"), it is **not diagnostic**. The **Gold Standard** for diagnosis is a **Rectal Suction Biopsy**, which demonstrates the absence of ganglion cells and increased acetylcholinesterase staining. * **Option D:** Barium enema shows a transition zone and delayed evacuation of contrast; it does **not** show calcification. (Calcification is more characteristic of Meconium Peritonitis). **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Delayed passage of meconium (>48 hours), abdominal distension, and bilious vomiting. * **Physical Exam:** "Blast sign" or "Squirt sign" (explosive release of stool/gas on digital rectal exam). * **Associated Condition:** Strongly associated with **Down Syndrome** (Trisomy 21). * **Radiology:** Look for an "inverted cone" appearance on Barium enema. * **Management:** Definitive treatment involves surgical pull-through procedures (e.g., Duhamel, Soave, or Swenson).

Q: What is the treatment of choice for cystic hygroma?

Surgical excision. **Explanation:** **Cystic Hygroma** (Cystic Lymphangioma) is a congenital malformation of the lymphatic system, most commonly occurring in the posterior triangle of the neck. **Why Surgical Excision is the Correct Answer:** The treatment of choice is **complete surgical excision**. The primary goal is to remove the entire cyst wall while preserving vital neurovascular structures (such as the facial nerve or carotid sheath). Because these lesions are benign but infiltrative, "en bloc" resection is often impossible without damaging critical structures; therefore, meticulous dissection and excision are preferred. **Analysis of Incorrect Options:** * **A. Percutaneous aspiration:** This is only a temporary measure. The cyst invariably refills with lymph, and there is a high risk of introducing infection (which makes subsequent surgery much harder). * **B. Intralesional sclerosant injection:** Agents like OK-432 (Picibanil) or Bleomycin are used primarily for **macrocystic** lesions or in cases where surgery is contraindicated (e.g., high surgical risk or extensive infiltration). However, surgery remains the gold standard. * **C. En bloc resection:** While total removal is ideal, "en bloc" implies removing the lesion along with a margin of normal tissue. In the neck, this is avoided to prevent sacrificing essential nerves and vessels. **High-Yield Clinical Pearls for NEET-PG:** * **Transillumination:** Cystic hygromas are characteristically **brilliantly transilluminant** (unlike hemangiomas). * **Association:** Often associated with chromosomal abnormalities like **Turner syndrome** and Down syndrome. * **Complications:** Sudden increase in size usually indicates **intracystic hemorrhage** or infection. * **Timing of Surgery:** Usually performed around 2 years of age unless there is respiratory distress due to compression.

Question 1

What does the 'Signe de Dance' refer to?

Accepted Answer

Empty right iliac fossa in intussusception

Answer

Pincer shaped appearance in barium enema in intussusception

Answer

Tenderness at McBurney's Point

Answer

Passing of large quantities of urine in hydronephrosis

Question 2

What is the most common cause of hydronephrosis in children?

Accepted Answer

Congenital PUJ obstruction

Answer

Ureterocoele

Answer

Ureteric stricture

Answer

Watermelon prostate

Question 3

What is the optimal management of bilateral undescended testicles in an infant?

Accepted Answer

Chorionic gonadotropin therapy for 1 month; operative placement into the scrotum before age 1 if descent has not occurred

Answer

Immediate surgical placement into the scrotum

Answer

Observation until the child is 2 years old because delayed descent is common

Answer

Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school

Question 4

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 5

Which of the following is NOT a feature of ectopia vesicae?

Accepted Answer

X-linked dominant inheritance

Answer

Epispadias

Answer

Bifid clitoris

Answer

Undescended testis

Question 6

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 7

Which of the following is true about Hirschsprung's disease?

Accepted Answer

The aganglionic segment is contracted, not dilated.

Answer

The descending colon is the most common site.

Answer

Barium enema is diagnostic.

Answer

Barium enema shows calcification.

Question 8

What is the treatment of choice for cystic hygroma?

Accepted Answer

Surgical excision

Answer

Percutaneous aspiration

Answer

Intralesional sclerosant injection

Answer

En bloc resection

Question 9

A 9-month-old girl presents with rectal bleeding, vomiting, a palpable mass, and colicky pain in the right lumbar region, accompanied by diminished liver dullness. The child is in shock. What is the initial management?

Accepted Answer

Insert nasogastric tube and administer IV fluids

Answer

Administer oxygen

Answer

Perform barium enema

Answer

Attempt saline reduction

Question 10

Regarding neonatal circumcision, which of the following statements is true?

Accepted Answer

General anesthesia should be administered to neonates for circumcision as they perceive pain similarly to adults.

Answer

It should be performed without anesthesia, as it is hazardous to administer anesthesia.

Answer

It should be performed without anesthesia, as neonates do not perceive pain like adults.

Answer

It should be performed under local anesthesia only.

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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