Pediatric Surgery — MCQs

A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?

Q275

What is the most common complication occurring in tracheostomy in children? (March 2004)

Q276

A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

Q277

The commonest cause of intestinal obstruction in children is –

Q278

A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

Q279

The ideal timing of radiotherapy for Wilms tumour after surgery is:

Q280

A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 271: A child presented with intermittent episodes of left sided flank pain. Ultrasonography reveals large hydronephrosis with dilated renal pelvis and cortical thinning with a normal ureter. Kidney differential function was observed to be 19%. Which of the following is the best management?

A. Endopylostomy
B. Nephrectomy
C. Pyeloplasty (Correct Answer)
D. External drainage

Explanation: ***Pyeloplasty*** - **Pyeloplasty** is the gold standard for treating **ureteropelvic junction (UPJ) obstruction**, which is indicated by hydronephrosis, a dilated renal pelvis, and a normal ureter. - While **19% differential function** is in the borderline range, pyeloplasty is still preferred in **pediatric patients** because: - There is potential for **functional recovery** after relieving obstruction, especially in children - The kidney retains some salvageable function (generally >15% warrants preservation) - The **cortical thinning** suggests chronic obstruction, but intermittent symptoms indicate acute-on-chronic component with potential for improvement - Preserving renal mass is particularly important in children for long-term renal reserve - **Nephrectomy would only be considered if function was <10-15%** or if there were complications like recurrent infections or symptomatic non-functioning kidney. *Endopylostomy* - **Endopylostomy** (endoscopic pyelotomy) is a minimally invasive procedure for UPJ obstruction, but it has a **lower success rate** (70-85%) compared to open or laparoscopic pyeloplasty (>95%). - It is typically considered for **less severe obstructions** or as a secondary option, not for cases with significant hydronephrosis and cortical thinning where a more definitive repair is needed. - The anatomical distortion from severe hydronephrosis makes endoscopic approach less ideal. *Nephrectomy* - **Nephrectomy** (kidney removal) would be considered if the kidney function was **minimal (<10-15%)** or if the kidney was clearly non-salvageable with persistent complications. - With **19% differential function**, there is still meaningful functional reserve worth preserving, especially in a child who may benefit from improved function post-decompression. - Removing a kidney with nearly 20% function would be overly aggressive and deprive the child of potential renal reserve. *External drainage* - **External drainage** (e.g., nephrostomy tube) is a **temporary measure** primarily used for acute decompression of a severely obstructed kidney or to assess renal recovery potential before definitive repair. - It does not address the underlying anatomical obstruction and is not a long-term solution for UPJ obstruction. - While it could be used as a temporizing measure, definitive surgical correction (pyeloplasty) is the appropriate next step.

Question 272: What is the definitive treatment for Tetralogy of Fallot (TOF)?

A. Modified Blalock-Taussig shunt
B. Fontan procedure
C. Glenn shunt
D. Complete repair (Correct Answer)

Explanation: ***Complete repair*** - **Complete repair** is the definitive treatment for TOF, addressing all four anatomical defects. This typically involves closing the **ventricular septal defect (VSD)** and relieving the **right ventricular outflow tract (RVOT) obstruction**. - This procedure usually occurs between 3 to 6 months of age, or earlier if the child experiences severe cyanosis or hypercyanotic spells. *Modified Blalock-Taussig shunt* - The **Modified Blalock-Taussig shunt** is a palliative procedure, not a definitive one. It creates a connection between a systemic artery (often the subclavian) and the pulmonary artery. - This shunt increases **pulmonary blood flow** in infants with severe cyanosis, bridging them to a time when definitive repair can be safely performed. *Fontan procedure* - The **Fontan procedure** is a surgical intervention used for complex congenital heart defects with a **single functional ventricle**, such as hypoplastic left heart syndrome. - It reroutes systemic venous return directly to the pulmonary arteries, bypassing the non-functional ventricle, which is not the primary issue in TOF. *Glenn shunt* - The **Glenn shunt** (or superior cavopulmonary connection) is another palliative procedure, typically performed as the second stage in single-ventricle repair strategies. - It connects the **superior vena cava** to the **pulmonary artery**, diverting upper body venous blood directly to the lungs, and allowing the single ventricle to pump only systemic blood. This is not applicable as a definitive solution for TOF.

Question 273: All are features of congenital megacolon except:

A. Pseudodiarrhoea
B. Tight anal ring
C. Large bulky stools (Correct Answer)
D. Failure to thrive

Explanation: ***Large bulky stools*** - Patients with **congenital megacolon** (Hirschsprung disease) typically have difficulty passing stool, leading to small, pellet-like stools or significant constipation, not large bulky stools. - The absence of **ganglion cells** in the affected segment prevents proper relaxation and propulsion, resulting in stool retention and a narrow, spastic segment. *Pseudodiarrhoea* - **Pseudodiarrhoea** can occur in congenital megacolon when liquid stool bypasses the impaction, leading to overflow incontinence. - This symptom is often mistaken for true diarrhea but is characteristic of severe constipation. *Tight anal ring* - A **tight anal ring** on digital rectal examination is a classic finding in Hirschsprung disease due to the spastic, aganglionic segment extending down to the internal anal sphincter. - This spasticity prevents normal relaxation of the internal anal sphincter. *Failure to thrive* - **Failure to thrive** is a common complication of congenital megacolon due to chronic constipation, poor nutrient absorption secondary to bowel stasis, and recurrent enterocolitis. - Chronic poor feeding and malabsorption contribute to inadequate weight gain and growth.

Question 274: A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?

A. Narcotic analgesics
B. Rapid streptococcal screen
C. Trial of oral penicillin V
D. Surgical consultation for incision and drainage under general anesthesia (Correct Answer)

Explanation: ***Surgical consultation for incision and drainage under general anesthesia*** - The clinical presentation, including the abrupt onset of high fever, difficulty swallowing, poor handling of secretions, marked worsening of sore throat, and a **fluctuant bulge in the posterior pharyngeal wall**, is highly suggestive of a **retropharyngeal abscess**. - The soft tissue radiograph of the neck would likely show **widening of the prevertebral space** (as hinted by the image showing significant soft tissue swelling anterior to the cervical vertebrae), which confirms the diagnosis and necessitates urgent surgical consultation for **incision and drainage** to prevent airway compromise and spread of infection. *Narcotic analgesics* - While **pain management** is important, narcotic analgesics alone do not address the underlying life-threatening infection and potential for **airway obstruction**. - Providing only analgesia without treating the abscess would allow the condition to worsen, potentially leading to **sepsis** or **respiratory arrest**. *Rapid streptococcal screen* - Though an initial URI might suggest a bacterial infection like **streptococcal pharyngitis**, the abrupt worsening of symptoms, high fever, and particularly the **fluctuant pharyngeal bulge** are not typical for uncomplicated strep throat. - A rapid strep test would be insufficient as it doesn't rule out or address the critical complication of a **retropharyngeal abscess**, which requires more urgent intervention. *Trial of oral penicillin V* - Broad-spectrum antibiotics are necessary for a retropharyngeal abscess, but **oral penicillin V** is inadequate for a severe, likely advanced infection like this, which often involves multiple bacterial species and requires **intravenous antibiotics**. - More importantly, antibiotics alone are **insufficient** for a mature abscess; **surgical drainage** is the definitive treatment to remove pus and prevent further complications.

Question 275: What is the most common complication occurring in tracheostomy in children? (March 2004)

A. Infection (Correct Answer)
B. Difficult decannulation
C. Difficult weaning
D. Stenosis

Explanation: ***Infection*** - **Infection** is among the most frequent complications in pediatric tracheostomy, occurring in the immediate postoperative period and throughout the tracheostomy course. - Can manifest as **stoma infections** (cellulitis, wound breakdown), **tracheitis**, **pneumonia**, or **mediastinitis**. - The constant presence of an open wound, bypassed upper airway defenses, and need for frequent suctioning create ongoing infection risk. - **Clinical significance**: While some studies cite difficult decannulation as more common, infection remains the most clinically significant early complication requiring active management. *Difficult decannulation* - A very common complication in pediatric tracheostomy, with some studies suggesting it may be the **most frequent** long-term issue. - Children's airways are more prone to **granulation tissue formation**, **suprastomal collapse**, and **tracheomalacia**. - Occurs in **prolonged tracheostomy** cases, often requiring multiple attempts or surgical intervention. - Frequency varies by underlying indication and duration of cannulation. *Difficult weaning* - Refers to challenges in **ventilator weaning** rather than a direct tracheostomy complication. - More related to the **underlying respiratory or neurological condition** necessitating tracheostomy. - A management challenge rather than a procedural complication. *Stenosis* - **Tracheal or subglottic stenosis** is a serious **late complication** occurring in 10-15% of pediatric cases. - Results from **chronic irritation**, **granulation tissue**, cartilage injury, or improper tube size. - While severe when it occurs, its overall incidence is **lower than infection or decannulation issues**.

Question 276: A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

A. Peritoneal drainage (Correct Answer)
B. Resection and anastomosis
C. Conservative treatment
D. Stabilization with membrane oxygenator and defer surgery

Explanation: ***Peritoneal drainage*** - In a newborn with **perforated necrotizing enterocolitis (NEC)** and **poor general condition**, peritoneal drainage is the preferred initial surgical approach to address sepsis while avoiding major abdominal surgery. - This procedure involves draining accumulated fluid and pus from the peritoneal cavity, reducing intra-abdominal pressure and systemic inflammation in a medically unstable patient. *Resection and anastomosis* - **Resection and primary anastomosis** is a more extensive surgical procedure that carries higher risks in a globally unstable neonate. - This surgery is typically reserved for more stable patients or as a secondary procedure once the patient's condition has improved following initial decompression. *Conservative treatment* - **Conservative treatment** alone is insufficient and inappropriate for **perforated necrotizing enterocolitis**, as perforation implies the need for surgical intervention to address peritonitis and sepsis. - Delaying surgical management in perforation can lead to rapid deterioration, severe sepsis, and increased mortality. *Stabilization with membrane oxygenator and defer surgery* - While an **extracorporeal membrane oxygenator (ECMO)** might be used for respiratory or cardiovascular support in severe cases, it does not address the underlying **perforation and peritonitis**. - **Deferring surgery** for perforation is not an option as surgical source control is necessary to manage the acute peritonitis and sepsis, even if the patient is on ECMO.

Question 277: The commonest cause of intestinal obstruction in children is –

A. Adhesions
B. Intussusception (Correct Answer)
C. Hernia
D. Volvulus

Explanation: ***Intussusception*** - **Intussusception** is the most common cause of intestinal obstruction in children, especially in infants between 6 months and 3 years of age. - It occurs when one segment of the intestine telescopes into an adjacent segment, leading to obstruction and potentially compromising blood supply. *Adhesions* - **Adhesions** are bands of scar tissue that can form after abdominal surgery and are a common cause of intestinal obstruction in adults. - While they can occur in children, they are generally less common as a primary cause of obstruction compared to intussusception, especially in infants. *Hernia* - **Hernias**, particularly incarcerated inguinal hernias, can cause intestinal obstruction in children. - Although common, hernias are not the single most frequent cause of intestinal obstruction across all pediatric age groups compared to intussusception. *Volvulus* - **Volvulus** refers to the twisting of a loop of intestine around its mesentery, often associated with intestinal malrotation. - It is a serious cause of intestinal obstruction in children and infants, but less common than intussusception, though it carries a higher risk of intestinal ischemia.

Question 278: A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

A. Ileal (Meckel) diverticulum (Correct Answer)
B. External hemorrhoids
C. Internal hemorrhoids
D. Diverticulosis

Explanation: ***Ileal (Meckel) diverticulum*** - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract, present in approximately 2% of the population. - It is the **most common cause of painless, profuse rectal bleeding** in the pediatric age group, typically presenting with brick-red or maroon stools. - The bleeding results from **peptic ulceration of the ileal mucosa** adjacent to ectopic (heterotopic) gastric mucosa within the diverticulum, which secretes acid. - Diagnosis is often confirmed with a **Technetium-99m pertechnetate scan** (Meckel's scan), which detects ectopic gastric mucosa. *External hemorrhoids* - External hemorrhoids typically present with **pain, itching, and a palpable perianal lump**, especially when thrombosed. - While they can cause bleeding, it is usually **minimal and bright red**, not the profuse rectal bleeding described in this case. - Hemorrhoids are **uncommon in children** and usually associated with chronic constipation or straining. *Internal hemorrhoids* - Internal hemorrhoids can cause **painless bleeding**, but this typically manifests as bright red blood coating the stool or dripping into the toilet bowl. - The bleeding is usually **minor and intermittent**, not profuse or life-threatening. - They are **much less common in the pediatric population** compared to adults and are not a typical cause of significant hemorrhage in children. *Diverticulosis* - Colonic diverticulosis is predominantly a **disease of older adults** (typically >40 years of age) related to dietary factors and increased intraluminal pressure. - It is **extremely rare in the pediatric age group** and would not be a primary consideration in a 12-year-old. - While diverticulosis can cause significant painless bleeding in adults, its occurrence in children is highly unlikely.

Question 279: The ideal timing of radiotherapy for Wilms tumour after surgery is:

A. Any time after surgery
B. Within 2 weeks
C. Within 3 weeks
D. Within 10 days (Correct Answer)

Explanation: ***Within 10 days*** - For patients with **Wilms tumour** requiring adjuvant radiotherapy, treatment should ideally commence within **10 days following surgery**. - This prompt initiation minimizes the time for any residual microscopic disease to proliferate and potentially spread, optimizing local control and overall outcome. *Any time after surgery* - This timing is too broad and does not adhere to the recommended protocol for Wilms tumour, which emphasizes early post-operative radiotherapy. - Delaying radiotherapy beyond the recommended window can increase the risk of tumour recurrence and negatively impact prognosis. *Within 2 weeks* - While 2 weeks is a relatively short timeframe, **10 days** is the more precise and **ideal window** for initiating radiotherapy according to established protocols for Wilms tumour. - Waiting up to 2 weeks (14 days) might still introduce an unnecessary delay compared to the optimal 10-day goal. *Within 3 weeks* - A delay of up to **3 weeks** is considered suboptimal and potentially risky, as it allows a longer period for any remaining tumour cells to regrow. - This interval significantly deviates from the **evidence-based guidelines** for timely adjuvant therapy in Wilms tumour management.

Question 280: A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

A. Herniation at the lumbar triangle (of Petit) (Correct Answer)
B. Indirect inguinal hernia
C. Tumor of the external abdominal oblique muscle
D. Direct inguinal hernia

Explanation: ***Herniation at the lumbar triangle (of Petit)*** - This hernia occurs through the **lumbar triangle of Petit**, which is bounded by the **latissimus dorsi**, **external oblique**, and **iliac crest**. - Its location just **superior to the iliac crest** and unilateral presentation align with the description of a lumbar hernia, often presenting as a soft, pliable lump. *Indirect inguinal hernia* - This type of hernia protrudes through the **deep inguinal ring** and often descends into the scrotum or labia, a location not consistent with a lump above the buttocks. - It is typically associated with a **patent processus vaginalis**, more common in infants and young children, but the described location differs significantly. *Tumor of the external abdominal oblique muscle* - While possible, a **tumor** would likely present with different characteristics, such as being firm, fixed, and potentially painful, rather than a soft, pliable protrusion. - The described soft and pliable characteristics are more indicative of a hernia involving abdominal contents rather than a solid muscle mass. *Direct inguinal hernia* - A direct inguinal hernia protrudes through the **Hesselbach's triangle** and appears medially to the inferior epigastric vessels, typically presenting as a bulge in the groin area. - Its location in the **anterior abdominal wall**, near the pubic tubercle, makes it inconsistent with a lump found superior to the iliac crest.

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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