Pediatric Surgery Practice Questions

Q: What are the primary criteria for considering operative treatment in Hirschsprung's disease?

Has failed to respond to conservative treatment. ***Has failed to respond to conservative treatment*** - Children with **Hirschsprung's disease** who do not respond to initial **conservative management**, such as bowel irrigation and laxatives, require surgical intervention to remove the aganglionic segment. - **Persistent symptoms** like severe constipation, abdominal distension, and failure to thrive despite medical therapy indicate the need for operative treatment. *Is 2 years of age* - Age itself is **not a primary criterion** for deciding operative treatment in Hirschsprung's disease; the decision is based on clinical presentation and response to treatment. - While many cases are diagnosed and treated surgically in infancy, some present later, and the timing of surgery depends on symptom severity and the child's overall condition. *Has no distension of abdomen* - The presence of **abdominal distension** is a common symptom in Hirschsprung's disease, and its absence would suggest **less severe disease** or effective conservative management, rather than an indication for surgery. - If a child has no distension, it implies that obstruction is not significant or is being managed, making operative intervention less urgent. *Is at least 8 kg in weight and thriving* - Being **at least 8 kg in weight and thriving** generally indicates a child is in good health and a suitable candidate for surgery, but these are **preconditions for safe surgery** rather than the primary criteria for deciding *if* surgery is needed. - The decision to operate is driven by the failure of conservative treatment and the persistence of disease-related symptoms, not solely by the child's weight or general thriving status.

Q: What is the most common surgical cause of abdominal pain in children?

Appendicitis. ***Appendicitis*** - **Appendicitis** is the most common surgical emergency in children, presenting with abdominal pain that often localizes to the right lower quadrant. - The pain is typically initially periumbilical, then migrates to the **right lower quadrant**, and may be accompanied by fever, nausea, vomiting, and anorexia. *Porphyria* - **Porphyria** is a rare metabolic disorder that can cause severe abdominal pain, but it is not a surgical condition and is not the most common cause of abdominal pain in children. - Abdominal pain in porphyria is often accompanied by neurological and psychiatric symptoms, which are distinct from the presentation of appendicitis. *Worm colic* - **Worm colic**, or intestinal obstruction due to a large burden of parasitic worms, can cause abdominal pain but is less common in developed countries and is not typically a surgical emergency requiring immediate intervention in the same way appendicitis is. - Diagnosis is usually made by identifying parasites in stool samples, and treatment involves anthelmintic medications rather than surgery. *Lead poisoning* - **Lead poisoning** can cause abdominal pain, often referred to as "lead colic," along with other systemic symptoms such as constipation, neurological issues, and anemia. - It is a medical condition managed with chelation therapy and environmental remediation, not a surgical cause of abdominal pain.

Q: An infant presents with colicky pain and vomiting, along with a sausage-shaped lump in the abdomen, and the diagnosis is:

Intussusception. ***Intussusception*** - This classic presentation of **colicky pain, vomiting, and a sausage-shaped abdominal lump** is highly indicative of intussusception, where one part of the intestine telescopes into another. - Most commonly occurs in **infants between 5-9 months of age**. - The symptoms are due to **bowel obstruction** and **ischemia**, which can progress to currant jelly stools. *Enterocolitis* - While enterocolitis can cause abdominal pain and vomiting, it typically presents with **diarrhea** and **fever**, and does not involve a palpable "sausage-shaped lump." - It involves **inflammation of the intestine** and colon, often due to infection. *Perforation of the abdomen* - Abdominal perforation would present with signs of **peritonitis**, severe acute pain, **abdominal distension**, and **rigidity**, often with signs of shock, and typically no palpable mass. - It is a severe condition that implies a hole in the gastrointestinal tract, leading to leakage of contents into the peritoneal cavity. *Acute appendicitis* - Though it causes abdominal pain and vomiting, acute appendicitis is **uncommon in infants** and typically localized to the **right lower quadrant**, not forming a "sausage-shaped lump." - Inflammation of the appendix is usually associated with **fever** and specific tenderness at **McBurney's point**.

Q: A 10-year-old female presents with pain in the right hypochondrium, fever, jaundice, and a palpable mass. The probable diagnosis is?

Choledochal cyst. ***Choledochal cyst*** - The classic triad of pain, jaundice, and a palpable abdominal mass in a child is highly suggestive of a **choledochal cyst**. - This condition involves congenital dilatation of the **bile ducts**, leading to bile stasis, potential infection, and obstruction. *Hepatitis* - While **jaundice** and **abdominal pain** can be present in hepatitis, a distinct palpable mass is not a typical feature unless there's severe hepatomegaly, and fever is also variable. - Hepatitis is primarily an inflammatory condition of the liver, not characterized by a mass resulting from ductal dilation. *Hepatoma* - **Hepatoma (liver cancer)** is rare in a 10-year-old and would more commonly present with a growing mass, weight loss, and possibly jaundice and pain, but the triad of symptoms strongly points away from it as the primary diagnosis. - While a mass would be present, the acute presentation with jaundice and fever is less typical for a primary liver tumor in this age group without other risk factors. *Mucocele gallbladder* - A **mucocele of the gallbladder** presents as a palpable mass due to gallbladder distension, but it is typically not associated with **jaundice** unless there is severe obstruction of the common bile duct, which is rarely primary. - The pain would be localized to the right hypochondrium, but the full triad including jaundice and fever (suggesting infection, e.g., cholangitis within the cyst) points away from a simple mucocele.

Q: The most common type of tracheoesophageal anomaly is

Esophageal atresia with fistula to the distal esophagus. ***Esophageal atresia with fistula to the distal esophagus*** - This is the **most common** presentation, accounting for approximately **85-90%** of all tracheoesophageal anomalies. - In this type, the **proximal esophagus** ends in a blind pouch, and the **distal esophagus** connects to the trachea via a fistula. *Esophageal atresia without fistula* - This is the **second most common** type, making up about 5-8% of cases. - Both the proximal and distal segments of the esophagus **end in blind pouches** without any connection to the trachea. *Esophageal atresia with fistula to the proximal esophagus* - This is an **uncommon configuration**, accounting for less than 1% of cases. - Here, the **proximal esophageal segment** connects to the trachea, while the distal segment ends in a blind pouch. *H-type fistula without esophageal atresia* - This type represents about 4% of tracheoesophageal anomalies and is characterized by a **fistula between the trachea and esophagus** without an interruption in the esophageal continuity. - It often presents with less severe symptoms and can be diagnosed later in life.

Q: What is the investigation of choice for diagnosing Hirschsprung disease?

Biopsy. ***Biopsy*** - **Rectal suction biopsy** is the **gold standard and most definitive diagnostic test** for Hirschsprung disease. - It demonstrates the **absence of ganglion cells** in the submucosal (Meissner's) and myenteric (Auerbach's) plexuses, establishing the definitive diagnosis of **aganglionosis** [1]. - This is the investigation of choice because it provides histological confirmation [1]. *Manometry* - **Anorectal manometry** is a useful screening tool that can show absence of the **rectoanal inhibitory reflex** due to absent ganglion cells. - However, it is not definitive, especially in neonates, and requires confirmation by biopsy. - It cannot replace histological diagnosis. *Colonoscopy* - **Colonoscopy** is not used for diagnosing Hirschsprung disease as it does not visualize ganglion cells or provide definitive diagnosis of aganglionosis. - It may be used to rule out other causes of constipation or manage complications, but not for initial diagnosis. *Barium enema* - **Barium enema** can suggest Hirschsprung disease by showing a **transition zone** (narrow aganglionic segment with dilated proximal colon). - While highly suggestive, it is not definitive and biopsy is still required for confirmation. - Useful for assessing the extent of disease preoperatively. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 759.

Q: In the management of prolonged intussusception with signs of shock, which of the following interventions is least appropriate?

Barium enema. ***Barium enema*** - A barium enema is used for the diagnosis and *non-operative reduction* of intussusception in hemodynamically stable children. - In a patient with **prolonged intussusception** and **signs of shock**, there is an increased risk of **bowel ischemia** or **perforation**, making a barium enema potentially dangerous and inappropriate. *IV fluid* - **Intravenous fluids** are crucial to correct **hypovolemia** and **electrolyte imbalances** resulting from poor oral intake, vomiting, and third-spacing associated with intussusception and shock. - They are vital for stabilizing the patient's **hemodynamics** prior to any definitive intervention. *Give O2* - Administering **oxygen** helps address **tissue hypoxia** that can occur in patients in shock due to poor perfusion. - It supports aerobic metabolism and may reduce the burden on the cardiovascular system. *Nasogastric tube* - A **nasogastric tube** is inserted to **decompress the stomach** and *prevent aspiration* in patients with intestinal obstruction and vomiting. - It also helps reduce further abdominal distension, making the patient more comfortable and potentially improving ventilation.

Q: Which electrolyte imbalance should be corrected before surgery in a patient with hypertrophic pyloric stenosis?

Chloride. ***Chloride*** - Patients with **pyloric stenosis** lose gastric acid (HCl) due to repeated vomiting, leading to **hypochloremic metabolic alkalosis**. - Correcting **hypochloremia** is crucial for resolving the metabolic alkalosis and ensuring safe anesthesia and surgery. *Potassium* - While **hypokalemia** can occur secondary to the metabolic alkalosis and fluid shifts, it is not the primary electrolyte imbalance requiring immediate correction before surgery. - Correcting **chloride** levels often facilitates the renal reabsorption of potassium, helping to resolve hypokalemia indirectly. *Bicarbonate (HCO3)* - Elevated **bicarbonate** is a feature of the metabolic alkalosis in pyloric stenosis, but directly correcting it with bicarbonate administration is generally contraindicated. - The goal is to correct the underlying cause (**chloride deficit**), which will allow the kidneys to excrete excess bicarbonate. *Sodium* - **Hyponatremia** can occur in cases of severe dehydration or if excessive free water is administered, but it is not the primary or most critical electrolyte imbalance directly caused by pyloric stenosis itself. - The focus is often on fluid resuscitation and correcting the **chloride deficit** to stabilize the patient.

Q: Orchidopexy for undescended testis is recommended at what age?

6 months. **6 months** - The recommended age for **orchidopexy** is between 6 and 12 months, ideally closer to 6 months. - Delaying beyond this period increases the risk of **infertility** and **testicular germ cell tumors**. *3 months* - While some descent can still occur naturally by 6 months, surgery at 3 months is generally **too early**. - This age doesn't allow for sufficient time for potential **spontaneous descent** to occur. *5 years* - Performing orchidopexy at 5 years is considered significantly **delayed**. - This delay substantially increases the risk of **testicular damage**, **infertility**, and **malignancy**. *2 years* - While more optimal than 5 years, 2 years is still on the **later side** of the recommended window for surgery. - Delaying until 2 years may still carry some increased risk for long-term complications compared to surgery between 6-12 months.

Q: A 12-year-old male is sent to your clinic from his new pediatrician's office for evaluation of left cryptorchidism. On examination, you cannot palpate a left testicle. You recommend which of the following options to the patient and his parents:

Surgical exploration and scrotal placement of the testicle. ***Surgical exploration and scrotal placement of the testicle*** - For **undescended testes**, especially after age 6-12 months, **surgical intervention** (orchiopexy) is the recommended management to prevent complications. - In a 12-year-old with a **non-palpable testis**, **laparoscopic exploration** is the preferred diagnostic and therapeutic approach. - This procedure aims to locate the testis and, if viable, bring it into the scrotum, reducing risks of **infertility** and **malignancy**. *Wait a few years to see if the testicle descends* - **Spontaneous descent** of cryptorchid testes rarely occurs after 6 months of age, and almost never after 1 year. - Delaying treatment beyond **6-12 months** increases the risks of infertility, malignancy, and testicular torsion. - At age 12, waiting is not appropriate management. *Orchiectomy* - **Orchiectomy** (removal of the testis) is typically reserved for cases where the testis is severely dysplastic, atrophic, or in certain situations where malignancy is highly suspected. - In a 12-year-old with **non-palpable undescended testis**, the primary goal is usually exploration first to assess viability before considering removal. *CT scan to look for the testicle* - **Imaging studies** such as CT or ultrasound are generally not recommended for localizing non-palpable testes because they are often unreliable and expose the child to unnecessary **radiation**. - **Laparoscopic exploration** is the preferred method for both diagnostic and therapeutic management of non-palpable testes.

Question 1

What are the primary criteria for considering operative treatment in Hirschsprung's disease?

Accepted Answer

Has failed to respond to conservative treatment

Answer

Is 2 years of age

Answer

Has no distension of abdomen

Answer

Is at least 8 kg in weight and thriving

Question 2

What is the most common surgical cause of abdominal pain in children?

Accepted Answer

Appendicitis

Answer

Porphyria

Answer

Worm colic

Answer

Lead poisoning

Question 3

An infant presents with colicky pain and vomiting, along with a sausage-shaped lump in the abdomen, and the diagnosis is:

Accepted Answer

Intussusception

Answer

Enterocolitis

Answer

Perforation of the abdomen

Answer

Acute appendicitis

Question 4

A 10-year-old female presents with pain in the right hypochondrium, fever, jaundice, and a palpable mass. The probable diagnosis is?

Accepted Answer

Choledochal cyst

Answer

Hepatitis

Answer

Hepatoma

Answer

Mucocele gallbladder

Question 5

The most common type of tracheoesophageal anomaly is

Accepted Answer

Esophageal atresia with fistula to the distal esophagus

Answer

Esophageal atresia without fistula

Answer

Esophageal atresia with fistula to the proximal esophagus

Answer

H-type fistula without esophageal atresia

Question 6

What is the investigation of choice for diagnosing Hirschsprung disease?

Accepted Answer

Biopsy

Answer

Manometry

Answer

Colonoscopy

Answer

Barium enema

Question 7

In the management of prolonged intussusception with signs of shock, which of the following interventions is least appropriate?

Accepted Answer

Barium enema

Answer

Nasogastric tube

Answer

IV fluid

Answer

Give O2

Question 8

Which electrolyte imbalance should be corrected before surgery in a patient with hypertrophic pyloric stenosis?

Accepted Answer

Chloride

Answer

Potassium

Answer

Bicarbonate (HCO3)

Answer

Sodium

Question 9

Orchidopexy for undescended testis is recommended at what age?

Accepted Answer

6 months

Answer

3 months

Answer

5 years

Answer

2 years

Question 10

A 12-year-old male is sent to your clinic from his new pediatrician's office for evaluation of left cryptorchidism. On examination, you cannot palpate a left testicle. You recommend which of the following options to the patient and his parents:

Accepted Answer

Surgical exploration and scrotal placement of the testicle

Answer

CT scan to look for the testicle

Answer

Orchiectomy

Answer

Wait a few years to see if the testicle descends

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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