Pediatric Surgery Practice Questions

Q: A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?

Intussusception. ***Intussusception*** - This condition is characterized by a "telescoping" of one segment of the intestine into another, which can lead to **abdominal pain**, **rectal bleeding** (often described as "currant jelly" stools), and a **palpable sausage-shaped mass** on examination. - A barium study (specifically a **barium enema**) is often diagnostic and can also be therapeutic for intussusception, revealing a **coiled spring appearance** or an obstruction. *Volvulus* - Volvulus involves the **twisting of a loop of bowel** around its mesentery, often presenting with sudden onset, severe **abdominal pain**, vomiting, and constipation. - While it can cause an obstruction and pain, a palpable mass and bloody stools are less common initial findings compared to intussusception. *Meckel's Diverticulum* - Meckel's diverticulum is a **congenital outpouching** of the small intestine that can be asymptomatic or cause complications like **gastrointestinal bleeding** (due to ectopic gastric mucosa), obstruction, or diverticulitis. - While it can cause painless rectal bleeding, a palpable mass and acute, intermittent abdominal pain are not typical primary presentations for an uncomplicated Meckel’s diverticulum. *Diverticulitis* - Diverticulitis is the **inflammation of diverticula** (small pouches in the colon), typically presenting with **left lower quadrant abdominal pain**, fever, and changes in bowel habits. - While it can cause bleeding, a palpable mass is less common unless there's an abscess, and the clinical picture does not align as strongly with the "currant jelly stool" and classic palpable mass of intussusception.

Q: A 4-year-old child was brought to the hospital with right impalpable testis. During diagnostic laparoscopy for undescended testis, there are blind testicular vessels. What should be done next?

Nothing is to be done. ***Nothing is to be done*** - The presence of **blind-ending testicular vessels** on diagnostic laparoscopy is diagnostic of **vanishing testis syndrome** (testicular regression syndrome). - This finding indicates that the testis underwent **atrophy and resorption** during fetal development or early infancy, and **no viable testicular tissue remains**. - The blind vessels represent **remnant vascular structures** where the testis once existed, confirming absence of testicular tissue beyond that point. - **No further surgical exploration is required** as the laparoscopy has already provided definitive diagnosis - the testis is absent, not located elsewhere. - This completes the diagnostic and therapeutic management for this condition. *Inguinal exploration* - This would be indicated if the testicular vessels were seen **entering the internal inguinal ring**, suggesting an inguinal or high scrotal location. - With **blind-ending vessels**, the testis is confirmed absent, making inguinal exploration unnecessary and futile. - Inguinal exploration would find no testicular tissue and subject the child to unnecessary additional surgery. *Abdominal exploration* - This is not needed as **diagnostic laparoscopy has already visualized the abdomen** and identified blind vessels. - If vessels were patent and leading to an intra-abdominal testis, orchidopexy would be performed laparoscopically. - Blind vessels rule out intra-abdominal testis location. *Scrotal exploration* - This approach is only appropriate for **palpable undescended testes** in the superficial inguinal pouch or high scrotum. - The testis is **impalpable** and laparoscopy shows **no testicular tissue exists**, making scrotal exploration illogical and non-contributory.

Q: A 10 year old child came to the OPD with pain and mass in right lumbar region with no fever, with right hip flexed. The pain increased on extension and X ray showed spine changes. Most probable diagnosis is:

Psoas abscess. ***Psoas abscess*** - A **psoas abscess** can present as a lumbar mass with pain, and the classic **psoas sign** (pain on hip extension) occurs because the inflamed psoas muscle is stretched. Spine changes on X-ray suggest a potential vertebral source, such as **spinal tuberculosis (Pott's disease)**, which is a common cause of psoas abscess in children. - The absence of fever does not rule out chronic infections like tuberculosis, and the **flexed hip posture** is a common compensatory mechanism to relieve tension on the inflamed psoas muscle. *Appendicular lump in retrocecal position* - While a retrocecal appendicular lump can cause a right lumbar mass, the pain would typically worsen with hip flexion, not extension, and it is less likely to be associated with **spine changes** on X-ray. - Appendicular lumps are usually accompanied by a history of appendicitis with pain that is often more diffuse in the right lower quadrant, and may be associated with **fever and leukocytosis**. *Pyonephrosis* - **Pyonephrosis** (pus in the kidney) would typically present with significant systemic symptoms of infection, such as **fever, chills, and flank pain**. - While it can cause a flank mass, the characteristic **hip flexion and pain on extension (psoas sign)**, along with spine changes, are not typical features. *Torsion of Right undescended testis* - **Testicular torsion** presents with sudden, severe scrotal pain (or inguinal/pelvic pain if undescended) and swelling, not a lumbar mass or psoas signs. - It would also not be associated with **spine changes** on an X-ray.

Q: A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?

Thyroglossal duct cyst. ***Thyroglossal duct cyst*** - A **midline neck swelling** that is **painless** and **moves with swallowing** or protrusion of the tongue is a classic presentation of a thyroglossal duct cyst. - This cyst develops from the **remnant of the embryonic thyroglossal duct**, connecting the thyroid gland to the tongue base. *Branchial cyst* - Typically presents as a **lateral neck mass**, usually anterior to the sternocleidomastoid muscle, not midline. - They are remnants of the **branchial arches** and are less likely to move with swallowing. *Dermoid cyst* - While dermoid cysts can occur in the neck and be midline, they are generally **not mobile with swallowing** because they are not attached to the hyoid bone or tongue. - They are congenital cysts formed from trapped skin elements. *Thyroid nodule* - A thyroid nodule would be located in the **lower anterior neck** over the thyroid gland, typically not as high as a thyroglossal duct cyst. - While it might move with swallowing, it is often firmer and may be associated with thyroid dysfunction or a history of radiation exposure, which is not mentioned here.

Q: In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Pneumatic reduction under fluoroscopy. ***Pneumatic reduction under fluoroscopy*** - This is the **first-line therapeutic procedure** for intussusception in hemodynamically stable children without peritoneal signs. - Uses air pressure to un-telescope the bowel segments, with success rates of **70-90%** in appropriately selected cases. - Performed under fluoroscopic or **ultrasound guidance** (ultrasound preferred in many centers to avoid radiation). - Contraindications include peritonitis, perforation, and shock. *Exploratory laparotomy* - Reserved as **second-line treatment** when pneumatic reduction fails (occurs in 10-30% of cases). - Also indicated when there are contraindications to reduction: **peritonitis, perforation, bowel necrosis**, or hemodynamic instability. - Allows manual reduction or bowel resection if necrotic segments are present. *Observation and supportive care* - Supportive measures (IV fluids, NG decompression, antibiotics) are **adjunctive** but not definitive treatment. - Intussusception requires **prompt intervention** as it can rapidly progress to bowel ischemia, necrosis, and perforation. - Observation alone is inadequate and risks serious complications. *Abdominal ultrasound only* - Ultrasound is the **gold standard for diagnosis**, showing the characteristic "target sign" or "pseudokidney sign." - However, it is **diagnostic only** and does not treat the intussusception. - Diagnosis must be followed by therapeutic intervention (reduction or surgery).

Q: A child presents with acute abdominal pain, vomiting, and currant jelly stools. The attending physician suspects intussusception. What is the definitive diagnostic and therapeutic procedure for this condition?

Air enema (pneumatic reduction). ***Air enema (pneumatic reduction)*** - An **air enema** is both diagnostic, by confirming the characteristic "telescoping" on imaging, and therapeutic, as the injected air pressure can **reduce the intussusception**. - It is a **first-line treatment** for uncomplicated intussusception in children, avoiding the need for surgery in most cases. *Abdominal ultrasound* - An **abdominal ultrasound** is often the initial diagnostic tool, revealing the **"target sign"** or **"donut sign"**, indicative of intussusception. - While diagnostic, it is **not therapeutic** and does not resolve the intussusception itself. *CT scan of the abdomen* - A **CT scan** can confirm intussusception with high accuracy but exposes the child to **radiation** and is generally not the preferred first-line diagnostic method for this condition in children. - It is **not therapeutic** and is typically reserved for cases where ultrasound is inconclusive or complications are suspected. *Exploratory laparotomy* - An **exploratory laparotomy** is a surgical procedure that is reserved for cases where **non-operative reduction (e.g., air enema)** fails or when there are signs of bowel perforation or peritonitis. - While it can definitively treat intussusception, it is an **invasive procedure** with associated risks, making it a last resort.

Q: A 6-year-old child presents with fever, abdominal pain, and a positive McBurney's sign. What is the most likely diagnosis?

Acute appendicitis. ***Acute appendicitis*** - The classic presentation of **fever, abdominal pain**, and a **positive McBurney's sign** in a child strongly indicates acute appendicitis. - **McBurney's sign** refers to tenderness at McBurney's point, which is 2/3 of the way from the umbilicus to the anterior superior iliac spine, a hallmark of appendiceal inflammation. *Gastroenteritis* - While it can cause fever and abdominal pain, **gastroenteritis** is typically associated with **vomiting and diarrhea**, which are not mentioned here. - It does not present with a localized sign like **McBurney's tenderness**. *Meckel's diverticulitis* - **Meckel's diverticulitis** can mimic appendicitis but typically presents with **painless rectal bleeding** due to ectopic gastric mucosa or occasionally with periumbilical pain. - It is less commonly associated with a distinct McBurney's sign. *Intussusception* - **Intussusception** is characterized by sudden onset of intermittent, severe **colicky abdominal pain**, often with **currant jelly stools** (blood and mucus) and a palpable sausage-shaped mass, not typically McBurney's sign. - It is also more common in infants and toddlers, though it can occur in older children.

Q: An infant presents with intermittent abdominal pain and currant jelly stools. An ultrasound suggests intussusception. What is the best next step in management?

Pneumatic or hydrostatic enema reduction. ***Pneumatic or hydrostatic enema reduction*** - **Air enema (pneumatic) or saline enema (hydrostatic)** is the **first-line treatment** for uncomplicated intussusception in hemodynamically stable infants. It can both diagnose and therapeutically reduce the intussusception. - The classic symptoms of **intermittent abdominal pain** and **currant jelly stools** are highly suggestive of intussusception, and an ultrasound confirming the diagnosis makes non-operative enema reduction the appropriate next step. - Success rates are **70-90%** for uncomplicated cases. Air enema is preferred over barium as it has lower risk of peritonitis if perforation occurs. *Exploratory laparotomy* - This is a surgical intervention and is typically reserved for cases where **pneumatic or hydrostatic reduction fails**, or when there are signs of **peritonitis, bowel perforation, or hemodynamic instability**. - While surgery may ultimately be necessary, it is not the initial best step given the high success rate of non-operative reduction. *CT scan of the abdomen* - An ultrasound has already confirmed the diagnosis of intussusception; a **CT scan is not usually necessary** and would expose the infant to unnecessary radiation. - The priority after diagnosis is reduction, not further imaging, unless complications are suspected. *Observation and follow-up* - Intussusception is a **medical emergency** that can lead to bowel ischemia, necrosis, and perforation if not treated promptly. - **Observation is not appropriate** as it delays definitive treatment and increases the risk of serious complications including bowel necrosis within 24 hours.

Question 1

A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?

Accepted Answer

Intussusception

Answer

Volvulus

Answer

Meckel's Diverticulum

Answer

Diverticulitis

Question 2

A 4-year-old child was brought to the hospital with right impalpable testis. During diagnostic laparoscopy for undescended testis, there are blind testicular vessels. What should be done next?

Accepted Answer

Nothing is to be done

Answer

Abdominal exploration

Answer

Inguinal exploration

Answer

Scrotal exploration

Question 3

A 10 year old child came to the OPD with pain and mass in right lumbar region with no fever, with right hip flexed. The pain increased on extension and X ray showed spine changes. Most probable diagnosis is:

Accepted Answer

Psoas abscess

Answer

Appendicular lump in retrocecal position

Answer

Pyonephrosis

Answer

Torsion of Right undescended testis

Question 4

A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?

Accepted Answer

Thyroglossal duct cyst

Answer

Branchial cyst

Answer

Dermoid cyst

Answer

Thyroid nodule

Question 5

In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Accepted Answer

Pneumatic reduction under fluoroscopy

Answer

Exploratory laparotomy

Answer

Observation and supportive care

Answer

Abdominal ultrasound only

Question 6

A neonate presented with fever, lethargy, abdominal distension, vomiting, and constipation. What is the most likely diagnosis?

Accepted Answer

Hirschsprung disease

Answer

Volvulus neonatorum

Answer

Intestinal atresia

Answer

Necrotizing enterocolitis

Question 7

A child presents with acute abdominal pain, vomiting, and currant jelly stools. The attending physician suspects intussusception. What is the definitive diagnostic and therapeutic procedure for this condition?

Accepted Answer

Air enema (pneumatic reduction)

Answer

Abdominal ultrasound

Answer

CT scan of the abdomen

Answer

Exploratory laparotomy

Question 8

A 6-year-old child presents with fever, abdominal pain, and a positive McBurney's sign. What is the most likely diagnosis?

Accepted Answer

Acute appendicitis

Answer

Gastroenteritis

Answer

Meckel's diverticulitis

Answer

Intussusception

Question 9

An infant presents with intermittent abdominal pain and currant jelly stools. An ultrasound suggests intussusception. What is the best next step in management?

Accepted Answer

Pneumatic or hydrostatic enema reduction

Answer

CT scan of the abdomen

Answer

Observation and follow-up

Answer

Exploratory laparotomy

Question 10

All are true about sacrococcygeal teratoma except which of the following?

Accepted Answer

Not associated with increased serum markers

Answer

If associated with hydrops, should be resected antenatally

Answer

Most common tumor of fetus

Answer

In most cases, it is visible externally.

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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