Pediatric Surgery Practice Questions

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: 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

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 2

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 3

What is the investigation of choice for diagnosing Hirschsprung disease?

Accepted Answer

Biopsy

Answer

Manometry

Answer

Colonoscopy

Answer

Barium enema

Question 4

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 5

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 6

Orchidopexy for undescended testis is recommended at what age?

Accepted Answer

6 months

Answer

3 months

Answer

5 years

Answer

2 years

Question 7

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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