Pediatric Surgery — MCQs

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 241: Failure of migration of neural crest cells is seen in which of the following conditions?

A. Albinism
B. Congenital megacolon (Correct Answer)
C. Odontomes
D. Adrenal tumour

Explanation: **Explanation:** The correct answer is **Congenital megacolon**, also known as **Hirschsprung disease**. **1. Why Congenital Megacolon is correct:** Hirschsprung disease is a developmental disorder characterized by the absence of ganglion cells in the myenteric (Auerbach’s) and submucosal (Meissner’s) plexuses of the distal bowel. This occurs due to the **failure of craniocaudal migration of neural crest cells** (precursors of the enteric nervous system) during the 5th to 12th weeks of gestation. The resulting "aganglionic segment" remains in a state of tonic contraction, leading to functional proximal obstruction and massive dilation of the normal colon (megacolon). **2. Why other options are incorrect:** * **Albinism:** This is a genetic disorder of **melanin synthesis** (usually a defect in the enzyme tyrosinase). While melanocytes are derived from neural crest cells, albinism is a failure of pigment production, not a failure of cell migration. * **Odontomes:** These are benign tumors (hamartomas) of dental origin involving epithelial and mesenchymal dental tissues. They are not primarily characterized by neural crest migration failure. * **Adrenal Tumour:** While the adrenal medulla is derived from neural crest cells (e.g., Pheochromocytoma), most adrenal tumors (like cortical adenomas) arise from the mesoderm or are sporadic growths not defined by migratory failure. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Full-thickness rectal biopsy showing absence of ganglion cells and presence of hypertrophied nerve bundles. * **Histochemistry:** Increased **Acetylcholinesterase (AChE)** staining is a classic diagnostic marker. * **Clinical Presentation:** Delayed passage of meconium (>48 hours), abdominal distension, and "blast sign" (explosive release of stool) on digital rectal exam. * **Associated Condition:** Strongly associated with **Down Syndrome** (Trisomy 21) in approximately 10% of cases. * **Common Site:** Most commonly affects the **rectosigmoid region** (short-segment disease).

Question 242: The Duhamel procedure is primarily indicated for which condition?

A. Hirschsprung's disease (Correct Answer)
B. Hepatic portal systemic shunt (HPSS)
C. Meckel's diverticulum
D. Intestinal volvulus

Explanation: **Explanation:** **Hirschsprung’s Disease (Correct Answer):** Hirschsprung’s disease is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses, leading to a functional bowel obstruction. The **Duhamel procedure** (Retrorectal Pull-through) is one of the classic definitive surgeries for this condition. In this technique, the ganglionic proximal bowel is pulled down behind the aganglionic rectum into the retrorectal space. A side-to-side anastomosis is then performed, creating a "neorectum" that combines the sensory benefits of the original rectum with the motor function of the ganglionic bowel. **Incorrect Options:** * **Hepatic Portal Systemic Shunt (HPSS):** This is a vascular anomaly. Management involves surgical ligation or radiological embolization (e.g., using coils), not a pull-through procedure. * **Meckel’s Diverticulum:** This is a remnant of the vitellointestinal duct. Treatment is typically a wedge resection or formal segmental bowel resection (diverticulectomy). * **Intestinal Volvulus:** This is a surgical emergency requiring detorsion (untwisting) and, if the bowel is viable, a Ladd’s procedure (for malrotation) or resection if gangrenous. **High-Yield Clinical Pearls for NEET-PG:** * **Other Surgeries for Hirschsprung’s:** Swenson (original pull-through), Soave (endorectal pull-through), and the modern gold standard—Transanal Endorectal Pull-through (TEPT). * **Diagnosis:** The gold standard is a **Rectal Suction Biopsy** showing absence of ganglion cells and hypertrophied nerve bundles (increased Acetylcholinesterase staining). * **Classic Presentation:** Delayed passage of meconium (>48 hours), abdominal distension, and "blast sign" on digital rectal examination.

Question 243: Identify the pathology in the child.

A. Inguinal Hernia
B. Umbilical Hernia (Correct Answer)
C. Femoral Hernia
D. Spigelian Hernia

Explanation: ***Umbilical Hernia*** - This is a protrusion of abdominal contents through a weak spot at the **umbilicus** (belly button), which is clearly depicted in the image. It occurs due to the incomplete closure of the umbilical ring after birth. - Umbilical hernias are very common in infants, particularly those born prematurely, and most resolve spontaneously without intervention by the age of 4-5 years. *Spigelian Hernia* - A Spigelian hernia occurs through the **Spigelian fascia**, located at the lateral edge of the rectus abdominis muscle, typically below the umbilicus. The bulge in the image is midline, not lateral. - This type of hernia is rare, especially in the pediatric population, and presents as a palpable mass on the side of the lower abdomen. *Inguinal Hernia* - An inguinal hernia involves the protrusion of abdominal contents through the **inguinal canal**, resulting in a bulge in the groin or scrotum. The location in the image is the umbilicus, not the groin. - While common in children, inguinal hernias are anatomically distinct and are located inferior and lateral to the umbilicus. *Femoral Hernia* - A femoral hernia occurs through the **femoral canal**, presenting as a bulge in the upper thigh, just below the inguinal ligament. This location is significantly different from the periumbilical bulge shown. - These hernias are rare in children and are more commonly seen in adult females due to the wider pelvis.

Question 244: A neonate has intestines protruding from the abdomen without any external covering. What will be your next line of management?

A. Surgical correction
B. Cover the content with a Silo bag and wait (Correct Answer)
C. Cover with NS-soaked gauze
D. Conservative management with higher antibiotics

Explanation: ***Cover the content with a Silo bag and wait*** - This presentation, where intestines protrude without a covering sac, is **gastroschisis**. The primary management for gastroschisis usually involves a **staged reduction** using a pre-formed **silo bag** (or pouch). - The silo allows the edematous bowel to gradually return into the abdominal cavity by gravity over several days, minimizing the risk of **abdominal compartment syndrome** and visceral ischemia that can occur with forced primary closure. *Surgical correction* - Immediate primary surgical closure is often difficult in gastroschisis because the infant's abdominal cavity is relatively small (**abdominal paucity**). - Forcing closure when the volume is too large can significantly elevate intra-abdominal pressure, potentially leading to **intestinal ischemia** or respiratory compromise. *Conservative management with higher antibiotics* - Gastroschisis is a surgical emergency requiring definitive intervention (closure or staged reduction); simple conservative management or antibiotics alone is insufficient. - While **antibiotics** are a necessary supportive measure to prevent infection of the exposed bowel, they do not address the underlying anatomical defect or the risk of desiccation and mechanical injury. *Cover with NS-soaked gauze* - Covering the exposed bowel with warm, **NS-soaked gauze** is an essential immediate stabilization step during resuscitation and transport, protecting the viscera and minimizing fluid and heat loss. - However, the **silo bag** is considered the definitive method for long-term protection and **staged reduction** in cases where primary surgical repair is not feasible, making it the superior choice for the next line of management.

Question 245: A 2-month-old male infant presents with a scrotal swelling that has been present since birth. Now, the swelling has become suddenly painful, red, and irreducible. What is the most likely diagnosis?

A. Incarcerated inguinal hernia
B. Strangulated inguinal hernia (Correct Answer)
C. Acute epididymo-orchitis
D. Testicular torsion

Explanation: **Strangulated inguinal hernia** - The presence of a scrotal swelling since birth strongly suggests an underlying indirect inguinal hernia, common due to a **patent processus vaginalis** in infants. - Sudden onset of severe pain, marked **irreducibility**, and **erythema** (redness) indicates vascular compromise of the contents (often bowel), classifying it as a surgical emergency (strangulation). *Acute epididymo-orchitis* - This condition is exceedingly rare in 2-month-old infants unless associated with underlying **urinary tract anomalies** or sepsis, and typically presents acutely without a long-standing mass. - The pain and swelling would usually involve the testicle/epididymis itself, accompanied by fever, and is less likely to present with the history of a mass existing **since birth**. *Testicular torsion* - Torsion usually presents with an extremely rapid onset of severe testicular pain without a history of a chronic mass, and often occurs due to inadequate fixation (**bell-clapper deformity**). - While painful, torsion involves the testicle and is generally diagnosed by absence of flow on **Doppler ultrasound**, unlike a hernia mass. *Incarcerated inguinal hernia* - An incarcerated hernia is irreducible because the contents are trapped, but the key differentiating factor is the lack of **vascular compromise**. - The presence of severe pain, tenderness, and redness (erythema) indicates progression beyond simple incarceration to **strangulation**, necessitating immediate intervention.

Question 246: A 4-year-old boy was brought to the emergency department with complaints of melena and acute intermittent pain in the right iliac region. On surgical exploration, a diverticulum containing gastric mucosa was found. What is the diagnosis? ![img-71.jpeg](img-71.jpeg)

A. Appendicular lump
B. Obstructed bowel loops
C. Meckel's diverticulum (Correct Answer)
D. Carcinoid

Explanation: ***Meckel's diverticulum*** - This is a remnant of the **vitelline duct** and is the most common congenital anomaly of the gastrointestinal tract, classically presenting with painless rectal bleeding in a young child. - The symptoms of **melena** and right iliac fossa pain are due to ulceration caused by acid secretion from ectopic **gastric mucosa**, which is found in about 50% of symptomatic cases. *Appendicular lump* - An appendicular lump is an inflammatory mass formed by the inflamed appendix and adjacent structures, typically presenting with fever, pain, and a palpable mass in the right iliac fossa. - It does not contain ectopic gastric mucosa and would not be the primary cause of melena; the image shows a distinct diverticulum, not an inflammatory phlegmon. *Carcinoid* - A carcinoid is a **neuroendocrine tumor** that can occur in the GI tract, but it appears as a solid, yellowish tumor, which is different from the structure shown in the image. - While it can cause bleeding or obstruction, the classic history of bleeding from ectopic gastric mucosa is not associated with carcinoid tumors. *Obstructed bowel loops* - This is a clinical finding rather than a specific diagnosis. While a Meckel's diverticulum can cause bowel obstruction (e.g., through **intussusception** or volvulus), the image and history point to the diverticulum as the primary pathology. - The image shows a specific anatomical structure (the diverticulum), not the general appearance of dilated, obstructed bowel loops proximal to a blockage.

Question 247: A 3-year-old child presented with multiple burn injuries involving the entire head, neck & one upper limb. What is the percentage of burn?

A. 5-10%
B. 25-30% (Correct Answer)
C. 40-44%
D. 18-20%

Explanation: ***Correct Answer: 25-30%*** Using the **Modified Rule of Nines for Pediatric Burns** (for children aged 1-4 years): **Calculation:** - **Head & Neck:** ~18% (children have proportionally larger heads compared to adults) - **One Upper Limb:** ~9% - **Total TBSA (Total Body Surface Area):** 18% + 9% = **27%** This falls within the range of **25-30%**, making this the correct answer. **Why Other Options are Incorrect:** *Incorrect: 5-10%* - This significantly underestimates the burn area. Head and neck alone account for ~18% in young children. *Incorrect: 18-20%* - This would represent only the head and neck, failing to account for the upper limb involvement. *Incorrect: 40-44%* - This overestimates the burn area. Even if both upper limbs were involved (18%), the total would be ~36%, not 40-44%. **Clinical Pearl:** In pediatric burns, remember that children have different body surface area proportions than adults - the head is proportionally larger (18% vs 9% in adults), while the lower limbs are proportionally smaller. Always use age-appropriate burn assessment charts.

Question 248: A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

A. Bronchoscopy
B. Esophagoscopy (Correct Answer)
C. Heimlich's manoeuvre
D. Tracheostomy

Explanation: ***Esophagoscopy*** - The X-ray shows a circular radiopaque object, the classic **"coin sign"** on an anteroposterior view, which is characteristic of a foreign body lodged in the **esophagus**. - **Esophagoscopy** is the definitive procedure for both visualizing and safely removing the foreign object, especially important if it is a button battery which can cause rapid mucosal injury. *Bronchoscopy* - This procedure is indicated for the removal of foreign bodies from the **airways** (trachea or bronchi), not the esophagus. - A tracheal foreign body would typically present with **respiratory distress** (stridor, wheezing) and would appear as a thin line on an AP X-ray because it would be oriented in the sagittal plane. *Tracheostomy* - A tracheostomy is a surgical procedure to create an alternative airway and is reserved for severe **upper airway obstruction** or the need for long-term mechanical ventilation. - This patient's primary problem is **dysphagia** (difficulty swallowing) due to an esophageal obstruction, not an airway emergency requiring a surgical airway. *Heimlich's manoeuvre* - This is an emergency first-aid procedure used for acute **choking** caused by a foreign body obstructing the airway, leading to an inability to breathe or speak. - The patient is not described as actively choking and has a stable airway; therefore, this maneuver is inappropriate and could cause harm.

Question 249: A 3-year-old child was brought to OPD with complaint of dysuria and ballooning on micturition and examination as given below, what is the diagnosis?

A. Recurrent balanoposthitis
B. Balanitis xerotica obliterans
C. Recurrent urinary tract infections
D. True phimosis (Correct Answer)

Explanation: ***True phimosis*** - The image shows a severely narrowed, pinhole-like preputial opening, coupled with **dysuria** and **ballooning on micturition**, which are hallmark symptoms of symptomatic or **pathological phimosis**. - **Ballooning** occurs because the tight foreskin traps urine before it can exit, confirming significant distal urinary outflow obstruction. *Balanitis xerotica obliterans* - Although BXO is a leading cause of pathological phimosis, this diagnosis is reserved for cases showing characteristic **sclerotic, white, atrophic skin changes** around the meatus, which are absent in the image. - BXO typically develops secondary to a chronic inflammatory process and is often considered when the phimosis is **acquired** rather than purely developmental. *Recurrent balanoposthitis* - Balanoposthitis is an inflammation of the glans and prepuce, typically presenting with **erythema, swelling, and discharge**. - While repeated episodes can lead to **scarring and acquired phimosis**, the primary and most concerning diagnosis here is the resulting anatomical obstruction (phimosis) that is causing symptoms. *Recurrent urinary tract infections* - **Recurrent UTIs** are a potential complication of significant true phimosis, resulting from urine stasis and poor hygiene. - However, the symptoms described, especially **ballooning on micturition**, directly indicate the presence of urethral **outflow obstruction**, which is the diagnosis.

Question 250: Which of the following statements are correct regarding Inguinal hernias in children? I. It is more common in premature boys. II. It should be repaired promptly. III. It is always indirect. IV. It may frequently be transilluminant. Select the answer using the code given below :

A. II and III
B. I, III and IV
C. I, II and IV
D. I, II and III (Correct Answer)

Explanation: ***I, II and III*** - **Statement I is correct**: Inguinal hernias are significantly **more common in premature boys**, with an incidence of up to **30% in preterm infants** compared to 3-5% in term infants. Male predominance is marked (6-10:1 ratio). - **Statement II is correct**: Pediatric inguinal hernias should be **repaired promptly** (elective basis) due to the high risk of **incarceration and strangulation**, especially in infants under 1 year where the risk can be as high as 31%. - **Statement III is correct**: All inguinal hernias in children are **indirect hernias**, occurring through a **patent processus vaginalis**. Direct hernias are extremely rare in the pediatric population and represent adult pathology. - **Statement IV is incorrect**: Inguinal hernias are typically **NOT transilluminant** because they contain solid abdominal contents like bowel or omentum. **Transillumination** is a characteristic feature of **hydroceles** (fluid-filled), not hernias. *II and III* - While statements II and III are correct, this option is **incomplete** as it omits Statement I, which is also factually correct regarding the increased incidence in premature boys. *I, III and IV* - Statements I and III are correct, but **Statement IV is false**. Inguinal hernias do **not transilluminate** because they contain bowel or omentum, not fluid. Transillumination distinguishes hydroceles from hernias. *I, II and IV* - Statements I and II are correct, but **Statement IV is false** (hernias are not transilluminant), and Statement III is omitted despite being a fundamental characteristic of pediatric inguinal hernias (always indirect).

Practice by Chapter

Neonatal Physiology

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Congenital Anomalies Overview

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Neonatal Intestinal Obstruction

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Necrotizing Enterocolitis

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Hirschsprung's Disease

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Anorectal Malformations

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Pediatric Hernias

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Pyloric Stenosis

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Biliary Atresia

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Pediatric Tumors

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Congenital Diaphragmatic Hernia

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Pediatric Trauma

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