Pediatric Surgery Practice Questions

Q: Kasai procedure is used in the treatment of which condition?

Congenital Biliary Atresia. ### Explanation **Correct Answer: A. Congenital Biliary Atresia** **Congenital Biliary Atresia (CBA)** is a progressive fibro-inflammatory obliteration of the extrahepatic biliary tree, leading to obstructive jaundice in neonates. The **Kasai procedure**, also known as **Hepatoportoenterostomy**, is the standard initial surgical treatment. In this procedure, the obliterated extrahepatic biliary remnants are excised, and a Roux-en-Y loop of the jejunum is anastomosed directly to the transected fibrous stroma at the porta hepatis. This allows bile to drain from the microscopic patent intrahepatic ducts directly into the intestine. **Why other options are incorrect:** * **Primary Sclerosing Cholangitis (B):** This is a chronic cholestatic liver disease characterized by inflammation and fibrosis of both intra- and extrahepatic bile ducts. Management is primarily medical (UDCA) or liver transplantation; the Kasai procedure has no role here. * **Cholangiocarcinoma (C):** This is a malignancy of the bile ducts. Treatment involves radical surgical resection (like Whipple’s procedure or hemihepatectomy) or palliative stenting, depending on the location (Klatskin tumor). * **Carcinoma of the Gallbladder (D):** Treatment typically involves radical cholecystectomy (including liver wedge resection and lymphadenectomy), not portoenterostomy. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** The Kasai procedure is most successful when performed early, ideally **before 60 days of life**. Success rates drop significantly after 90 days. * **Diagnosis:** The "Gold Standard" for diagnosis is **Intraoperative Cholangiography (IOC)**. On ultrasound, the **"Triangular Cord Sign"** is a classic finding. * **Prognosis:** While Kasai can delay the need for surgery, Biliary Atresia remains the **most common indication for liver transplantation in the pediatric age group**.

Q: Which condition is treated with a Bishop-Koop operation?

Meconium ileus. **Explanation:** **Meconium Ileus** is the correct answer. It is a common presentation of Cystic Fibrosis where thick, inspissated meconium causes distal small bowel obstruction. The **Bishop-Koop procedure** (a distal chimney enterostomy) is a specialized surgical technique used when simple irrigation fails. In this procedure, the proximal end of the divided bowel is anastomosed to the side of the distal limb, leaving the distal end as a venting stoma. This allows for the forward passage of intestinal contents while providing a port for postoperative irrigation with N-acetylcysteine to dissolve the remaining meconium. **Analysis of Incorrect Options:** * **Intussusception:** Primarily managed via non-operative hydrostatic or pneumatic reduction. If surgery is required, it involves manual reduction (Hutchinson’s maneuver) or bowel resection with primary anastomosis. * **Midgut Volvulus:** The definitive treatment is **Ladd’s Procedure**, which involves counter-clockwise detorsion, widening the mesenteric base, and performing an appendectomy. * **Duodenal Atresia:** Treated with a **Duodenoduodenostomy** (Kimura’s "diamond-shaped" anastomosis). **NEET-PG High-Yield Pearls:** * **Bishop-Koop vs. Santulli:** In Bishop-Koop, the *distal* limb is the stoma (chimney). In the Santulli procedure, the *proximal* limb is the stoma. * **Radiology:** Meconium ileus often shows a "ground glass" or "soap bubble" appearance (Neuhauser sign) on X-ray due to air mixing with meconium. * **Association:** 90% of infants with meconium ileus have Cystic Fibrosis.

Q: What is your diagnosis in this neonate with visible bowel loops at birth?

Gastroschisis. ***Gastroschisis*** - **Visible bowel loops at birth** without a **membranous covering**, typically protruding through a **right paraumbilical** abdominal wall defect. - The exposed bowel appears **matted and thickened** due to direct contact with **amniotic fluid** during fetal development. *Omphalocele* - Features a **membranous sac covering** the protruding abdominal contents, which is absent in this case. - The defect occurs **centrally at the umbilical cord insertion** and is associated with other **congenital anomalies** in 50-70% of cases. *Congenital Diaphragmatic Hernia* - Presents with **respiratory distress** and **bowel sounds in the chest**, not visible bowel loops on the abdominal surface. - Diagnosed by **chest X-ray** showing bowel loops in the **thoracic cavity** and **mediastinal shift**. *Bladder exstrophy* - Involves exposure of the **bladder mucosa** on the lower abdominal wall, not bowel loops. - Associated with **epispadias** and **wide pubic diastasis**, presenting as a red mucosal surface below the umbilicus.

Q: Which one of the following is not a feature of congenital hypertrophic pyloric stenosis?

Diarrhea. **Explanation:** **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is characterized by the hypertrophy of the circular muscle fibers of the pylorus, leading to a functional gastric outlet obstruction. **Why Diarrhea is the Correct Answer:** In CHPS, there is a physical obstruction at the pylorus that prevents gastric contents from entering the duodenum. Because the food cannot pass into the intestines, the patient typically presents with **constipation** (due to lack of stool bulk) rather than diarrhea. If any stool is passed, it is often small, dry "ribbon-like" stools. **Analysis of Other Options:** * **A. More common in males:** This is a classic feature. CHPS has a strong male predilection, typically affecting **first-born males** with a ratio of approximately 4:1. * **B. Projectile vomiting:** This is the hallmark clinical presentation. The vomiting is **non-bilious** (as the obstruction is proximal to the ampulla of Vater) and occurs with increasing force shortly after feeding. * **C. Malnutrition:** Due to persistent vomiting and the inability to retain feeds, infants rapidly develop dehydration, weight loss, and features of malnutrition if not treated promptly. **High-Yield Clinical Pearls for NEET-PG:** * **Metabolic Profile:** The classic derangement is **Hypochloremic, Hypokalemic, Metabolic Alkalosis** with **Paradoxical Aciduria**. * **Physical Exam:** A palpable, olive-shaped mass in the epigastrium (best felt after vomiting or during a "test feed") and visible gastric peristalsis. * **Diagnosis:** Ultrasound is the investigation of choice (Pyloric thickness >4mm, length >14-16mm). * **Treatment:** Initial management is resuscitation with **0.45% or 0.9% Normal Saline with Potassium**. The definitive surgery is **Ramstedt’s Pyloromyotomy**.

Question 1

Kasai procedure is used in the treatment of which condition?

Accepted Answer

Congenital Biliary Atresia

Answer

Primary Sclerosing Cholangitis

Answer

Cholangiocarcinoma

Answer

Carcinoma of the gallbladder

Question 2

Two days after birth, a child developed respiratory distress and had a scaphoid abdomen. Breath sounds were decreased on the left side. After bag and mask ventilation, an endotracheal tube was inserted, and the maximal cardiac impulse shifted to the right side. What should be the next step in management?

Accepted Answer

Confirm the position of the endotracheal tube

Answer

Emergency surgery

Answer

Nasogastric tube insertion

Answer

Chest X-ray to confirm the position of the endotracheal tube

Question 3

Which condition is treated with a Bishop-Koop operation?

Accepted Answer

Meconium ileus

Answer

Intussusception

Answer

Midgut volvulus

Answer

Duodenal atresia

Question 4

Regarding Gastroschisis and omphalocele, which of the following statements is false?

Accepted Answer

Gastroschisis is frequently associated with multiple anomalies.

Answer

Intestinal obstruction is common in Gastroschisis.

Answer

Liver is typically an intra-abdominal organ in Omphalocele.

Answer

The umbilical cord is attached to the Omphalocele sac.

Question 5

Cleft palate is ideally repaired at what age?

Accepted Answer

1 year of age

Answer

5 months of age

Answer

Before going to school

Answer

6 to 8 years of age

Question 6

What is your diagnosis in this neonate with visible bowel loops at birth?

Accepted Answer

Gastroschisis

Answer

Omphalocele

Answer

Congenital Diaphragmatic Hernia

Answer

Bladder exstrophy

Question 7

Which of the following statements regarding gastroschisis is TRUE?

Accepted Answer

Herniation occurs to the right of the umbilical cord due to obliteration of the right umbilical vein.

Answer

Herniation occurs through the umbilical cord.

Answer

The herniated contents are covered with an amniotic sac.

Answer

It is associated with multiple anomalies.

Question 8

Which one of the following is not a feature of congenital hypertrophic pyloric stenosis?

Accepted Answer

Diarrhea

Answer

More common in males

Answer

Projectile vomiting

Answer

Malnutrition

Question 9

True about intussusceptions in children?

Accepted Answer

Most common variety is ileocolic.

Answer

Associated with a pathological lead point.

Answer

May be seen after viral infection.

Answer

Can be relieved by barium enema.

Question 10

What is the approximate incidence of anastomotic leak following repair of esophageal atresia?

Accepted Answer

10-20%

Answer

<5%

Answer

5-10%

Answer

25-30%

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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