A 4-week-old infant is brought to the emergency department by his parents with violent vomiting. It started about 3 days ago and has slowly gotten worse. He vomits after most feedings but seems to keep some formula down. His mother notes that he is eager to feed between episodes and seems to be putting on weight. Other than an uncomplicated course of chlamydia conjunctivitis, the infant has been healthy. He was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. The physical exam is significant for a palpable mass in the right upper quadrant. What is the first-line confirmatory diagnostic test and associated finding?
Q2
A 7-month-old boy is brought to the ED by his mother because of abdominal pain. Two weeks ago, she noticed he had a fever and looser stools, but both resolved after a few days. One week ago, he began to experience periodic episodes during which he would curl up into a ball, scream, and cry. The episodes lasted a few minutes, and were occasionally followed by vomiting. Between events, he was completely normal. She says the episodes have become more frequent over time, and this morning, she noticed blood in his diaper. In the ED, his vitals are within normal ranges, and his physical exam is normal. After confirming the diagnosis with an abdominal ultrasound, what is the next step in management?
Q3
A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
Q4
An institutionalized 65-year-old man is brought to the emergency department because of abdominal pain and distension for 12 hours. The pain was acute in onset and is a cramping-type pain associated with nausea, vomiting, and constipation. He has a history of chronic constipation and has used laxatives for years. There is no history of inflammatory bowel disease in his family. He has not been hospitalized recently. There is no recent history of weight loss or change in bowel habits. On physical examination, the patient appears ill. The abdomen is distended with tenderness mainly in the left lower quadrant and is tympanic on percussion. The blood pressure is 110/79 mm Hg, heart rate is 100/min, the respiratory rate is 20/min, and the temperature is 37.2°C (99.0°F). The CBC shows an elevated white blood cell count. The plain abdominal X-ray is shown in the accompanying image. What is the most likely cause of his condition?
Q5
A 68-year-old man is brought to the emergency department because of fever, progressive weakness, and cough for the past five days. He experienced a similar episode 2 months ago, for which he was hospitalized for 10 days while visiting his son in Russia. He states that he has never fully recovered from that episode. He felt much better after being treated with antibiotics, but he still coughs often during meals. He sometimes also coughs up undigested food after eating. For the last 5 days, his coughing has become more frequent and productive of yellowish-green sputum. He takes hydrochlorothiazide for hypertension and pantoprazole for the retrosternal discomfort that he often experiences while eating. He has smoked half a pack of cigarettes daily for the last 30 years and drinks one shot of vodka every day. The patient appears thin. His temperature is 40.1°C (104.2°F), pulse is 118/min, respirations are 22/min, and blood pressure is 125/90 mm Hg. Auscultation of the lungs shows right basal crackles. There is dullness on percussion at the right lung base. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15.4 g/dL
Leukocyte count 17,000/mm3
Platelet count 350,000/mm3
Na+ 139 mEq/L
K+
4.6 mEq/L
Cl- 102 mEq/L
HCO3- 25 mEq/L
Urea Nitrogen 16 mg/dL
Creatinine 1.3 mg/dL
An x-ray of the chest shows a right lower lobe infiltrate. Which of the following is the most likely explanation for this patient's symptoms?
Q6
A 63-year-old man presents to the ambulatory medical clinic with symptoms of dysphagia and ‘heartburn’, which he states have become more troublesome over the past year. Past medical history is significant for primary hypertension. On physical exam, he is somewhat tender to palpation over his upper abdomen. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Barium swallow fluoroscopy demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax. Given the following options, what is the most appropriate next step in the management of this patient’s underlying condition?
Neonatal surgical emergencies US Medical PG Practice Questions and MCQs
Question 1: A 4-week-old infant is brought to the emergency department by his parents with violent vomiting. It started about 3 days ago and has slowly gotten worse. He vomits after most feedings but seems to keep some formula down. His mother notes that he is eager to feed between episodes and seems to be putting on weight. Other than an uncomplicated course of chlamydia conjunctivitis, the infant has been healthy. He was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. The physical exam is significant for a palpable mass in the right upper quadrant. What is the first-line confirmatory diagnostic test and associated finding?
A. Abdominal ultrasound; elongated pyloric channel and muscle hypertrophy (Correct Answer)
B. Barium upper GI series; GE junction and portion of the stomach in thorax
C. Air enema; filling defect and coil spring sign
D. Barium upper GI series; bird beak sign and corkscrewing
E. Abdominal X-ray; ‘double bubble’ sign
Explanation: ***Abdominal ultrasound; elongated pyloric channel and muscle hypertrophy***
- The clinical picture of **projectile vomiting** in a 4-week-old infant, **eagerness to feed** ("hungry vomiter"), and **palpable olive-shaped mass** in the right upper quadrant is classic for **pyloric stenosis**.
- **Abdominal ultrasonography** is the gold standard for diagnosis, revealing an **elongated pyloric channel** (>16mm) and thickened pyloric muscle (>3-4mm).
- Pyloric stenosis typically presents between 3-6 weeks of age with progressive non-bilious vomiting.
*Barium upper GI series; GE junction and portion of the stomach in thorax*
- A **barium upper GI series** showing the **GE junction and stomach in the thorax** would indicate a **hiatal hernia**, which is not consistent with the palpable mass or "hungry vomiter" presentation.
- While hiatal hernias can cause vomiting and reflux, they typically don't present with this specific type of projectile vomiting or a palpable abdominal mass.
*Air enema; filling defect and coil spring sign*
- An **air enema** showing a **filling defect** and **coil spring sign** is characteristic of **intussusception**, which usually presents with sudden onset of **crampy abdominal pain**, **currant jelly stools**, and a palpable mass in the right lower quadrant.
- The clinical presentation does not fit intussusception, which typically occurs in older infants (6-36 months) and has a more acute presentation.
*Barium upper GI series; bird beak sign and corkscrewing*
- A **barium upper GI series** showing a **bird beak sign** and **corkscrewing** is pathognomonic for **midgut volvulus**, a surgical emergency.
- While volvulus can cause bilious vomiting and abdominal distension, the presentation of non-bilious vomiting with a palpable pyloric mass is more typical of pyloric stenosis.
*Abdominal X-ray; 'double bubble' sign*
- An **abdominal X-ray** revealing a **'double bubble' sign** is indicative of **duodenal atresia** or **annular pancreas**, leading to complete duodenal obstruction.
- This condition typically presents with **bilious vomiting** shortly after birth (within first day of life) and does not involve a palpable hypertrophied pylorus.
Question 2: A 7-month-old boy is brought to the ED by his mother because of abdominal pain. Two weeks ago, she noticed he had a fever and looser stools, but both resolved after a few days. One week ago, he began to experience periodic episodes during which he would curl up into a ball, scream, and cry. The episodes lasted a few minutes, and were occasionally followed by vomiting. Between events, he was completely normal. She says the episodes have become more frequent over time, and this morning, she noticed blood in his diaper. In the ED, his vitals are within normal ranges, and his physical exam is normal. After confirming the diagnosis with an abdominal ultrasound, what is the next step in management?
A. Supportive care
B. Broad-spectrum antibiotics
C. Air contrast enema (Correct Answer)
D. Abdominal laparotomy
E. Abdominal CT scan
Explanation: ***Air contrast enema***
- An **air contrast enema** is both diagnostic and therapeutic for **intussusception**, which is strongly suggested by the patient's symptoms (colicky abdominal pain, drawing legs to chest, currant jelly stools).
- It uses air pressure to **reduce the intussusception**, avoiding surgery if successful and the bowel is not compromised.
*Supportive care*
- While supportive care (IV fluids, pain control) is important, it does not address the underlying mechanical issue of **intussusception** and would not resolve the condition.
- Delaying definitive treatment for intussusception can lead to **bowel ischemia, necrosis, and perforation**, which are life-threatening.
*Broad-spectrum antibiotics*
- Antibiotics are not the primary treatment for **intussusception**, as it is a mechanical obstruction, not typically a primary infection.
- They might be considered if there are signs of **perforation or peritonitis**, but the immediate goal is reduction.
*Abdominal laparotomy*
- An **abdominal laparotomy** is a surgical intervention reserved for cases where **non-operative reduction** (like an air enema) fails or if there are signs of **bowel perforation or gangrene**.
- It is not the *first-line* next step after diagnosis, especially if non-invasive options remain viable.
*Abdominal CT scan*
- An **abdominal CT scan** can diagnose intussusception but is typically not the preferred initial imaging because it involves **radiation exposure** and **does not offer therapeutic benefit**, unlike an air contrast enema.
- Abdominal ultrasound is usually sufficient for diagnosis and safer for pediatric patients.
Question 3: A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
A. Traumatic urethral injury
B. Seminoma
C. Appendicitis
D. Epididymitis
E. Testicular torsion (Correct Answer)
Explanation: ***Testicular torsion***
- The sudden onset of **unilateral scrotal pain** in an adolescent, accompanied by an **elevated testicle** with a **horizontal lie**, is highly suggestive of testicular torsion. The absence of scrotal swelling or discoloration in the early stages is also consistent.
- Testicular torsion is a **surgical emergency** requiring prompt intervention to preserve testicular viability.
*Traumatic urethral injury*
- This would typically present with **dysuria**, **hematuria**, inability to void, and potentially **blood at the urethral meatus**, none of which are described.
- A traumatic urethral injury often results from falls, straddle injuries, or pelvic fractures, not typically from playing football without direct trauma to the perineum.
*Seminoma*
- Seminoma is a type of **testicular cancer** that typically presents as a **painless testicular mass**.
- It would not cause sudden, acute abdominal pain and would not manifest with an acutely elevated testicle and horizontal lie.
*Appendicitis*
- Although appendicitis can cause abdominal pain, the **non-tender abdomen** on examination and the specific findings on **testicular examination** (elevated testicle, horizontal lie) make appendicitis unlikely.
- Appendicitis pain typically localizes to the right lower quadrant, often associated with fever, nausea, and vomiting.
*Epididymitis*
- Epididymitis causes **scrotal pain** and **swelling**, often with fever and **dysuria**, usually developing over days, not hours.
- It is often associated with the **Prehn's sign** (pain relief with elevation of the testicle), which is usually absent or negative in torsion. The patient's sexual history might suggest an STI, but the acute presentation and examination findings point away from epididymitis.
Question 4: An institutionalized 65-year-old man is brought to the emergency department because of abdominal pain and distension for 12 hours. The pain was acute in onset and is a cramping-type pain associated with nausea, vomiting, and constipation. He has a history of chronic constipation and has used laxatives for years. There is no history of inflammatory bowel disease in his family. He has not been hospitalized recently. There is no recent history of weight loss or change in bowel habits. On physical examination, the patient appears ill. The abdomen is distended with tenderness mainly in the left lower quadrant and is tympanic on percussion. The blood pressure is 110/79 mm Hg, heart rate is 100/min, the respiratory rate is 20/min, and the temperature is 37.2°C (99.0°F). The CBC shows an elevated white blood cell count. The plain abdominal X-ray is shown in the accompanying image. What is the most likely cause of his condition?
A. Sigmoid volvulus (Correct Answer)
B. Intussusception
C. Acute diverticulitis
D. Toxic megacolon
E. Colon cancer
Explanation: ***Sigmoid volvulus***
- The patient’s symptoms of acute **abdominal pain**, distension, and cramping strongly indicate **sigmoid volvulus**, often seen in chronic constipation and institutionalized patients.
- Physical examination revealing **tenderness in the left lower quadrant** and a tympanic abdomen supports the diagnosis of bowel obstruction typically caused by **volvulus**.
*Intussusception*
- Generally presents with **currant jelly stools** and is more common in children; the acute symptoms here are less typical.
- It often involves a **lead point** or associated conditions like **polyps** or tumors, which are not indicated in this case.
*Acute diverticulitis*
- Usually associated with **localized pain** in the left lower quadrant but would present with fever and changes in bowel habits, which the patient lacks.
- Typically shows **peritoneal signs** and may have complications like abscess or perforation, not indicated here.
*Toxic megacolon*
- Commonly associated with underlying **inflammatory bowel disease** or infections, not indicated in this patient with no recent history of **IBD**.
- Symptoms would include severe **diarrhea** and abdominal pain, which do not fit the current acute cramping and constipation pattern.
*Colon cancer*
- While it can cause abdominal symptoms, it presents more insidiously with **weight loss** or **change in bowel habits**, none of which are reported here.
- The acute presentation and findings do not align with a malignancy, which would often be chronic in nature.
Question 5: A 68-year-old man is brought to the emergency department because of fever, progressive weakness, and cough for the past five days. He experienced a similar episode 2 months ago, for which he was hospitalized for 10 days while visiting his son in Russia. He states that he has never fully recovered from that episode. He felt much better after being treated with antibiotics, but he still coughs often during meals. He sometimes also coughs up undigested food after eating. For the last 5 days, his coughing has become more frequent and productive of yellowish-green sputum. He takes hydrochlorothiazide for hypertension and pantoprazole for the retrosternal discomfort that he often experiences while eating. He has smoked half a pack of cigarettes daily for the last 30 years and drinks one shot of vodka every day. The patient appears thin. His temperature is 40.1°C (104.2°F), pulse is 118/min, respirations are 22/min, and blood pressure is 125/90 mm Hg. Auscultation of the lungs shows right basal crackles. There is dullness on percussion at the right lung base. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15.4 g/dL
Leukocyte count 17,000/mm3
Platelet count 350,000/mm3
Na+ 139 mEq/L
K+
4.6 mEq/L
Cl- 102 mEq/L
HCO3- 25 mEq/L
Urea Nitrogen 16 mg/dL
Creatinine 1.3 mg/dL
An x-ray of the chest shows a right lower lobe infiltrate. Which of the following is the most likely explanation for this patient's symptoms?
A. Weak tone of the lower esophageal sphincter
B. Unrestricted growth of pneumocytes with invasion of the surrounding tissue
C. Uncoordinated contractions of the esophagus
D. Formation of a tissue cavity containing necrotic debris
E. Outpouching of the hypopharynx (Correct Answer)
Explanation: ***Outpouching of the hypopharynx***
- The patient's history of coughing up undigested food and coughing during meals suggests **dysphagia** and potential **aspiration**, which can be caused by a **Zenker's diverticulum** (an outpouching of the hypopharynx).
- This condition creates a pouch that can trap food, leading to regurgitation and repeated aspiration pneumonia, as evidenced by his recurrent pneumonia and current symptoms.
- Zenker's diverticulum is the **underlying explanation** that accounts for *all* of this patient's symptoms: the regurgitation of undigested food, dysphagia, and recurrent aspiration pneumonia.
*Weak tone of the lower esophageal sphincter*
- A weak lower esophageal sphincter (LES) primarily causes **gastroesophageal reflux disease (GERD)**, often associated with heartburn and regurgitation of stomach contents, not undigested food.
- While GERD can cause aspiration, the coughing up of *undigested food* is more indicative of a proximal esophageal issue or pharyngeal problem.
*Unrestricted growth of pneumocytes with invasion of the surrounding tissue*
- This describes **lung cancer**, which can present with cough, weight loss, and recurrent pneumonia due to bronchial obstruction.
- However, the symptom of coughing up *undigested food* is not typical of primary lung malignancy, and the history strongly points to a swallowing disorder.
*Uncoordinated contractions of the esophagus*
- This refers to esophageal motility disorders like **achalasia** or **diffuse esophageal spasm**, which can cause dysphagia and regurgitation.
- While these can lead to aspiration, the specific complaint of coughing up *undigested food* *after eating* is more characteristic of a pharyngeal pouch (Zenker's diverticulum) rather than general esophageal dysmotility.
*Formation of a tissue cavity containing necrotic debris*
- This describes a **lung abscess**, which is a possible *complication* of aspiration pneumonia, accounting for the fever, productive cough, and infiltrate.
- However, the question asks for the **most likely explanation** for this patient's symptoms—a lung abscess is a *sequela* of aspiration, not the *underlying cause* of the repeated aspiration events.
- It does not explain the pathognomonic finding of coughing up undigested food after eating, which points to Zenker's diverticulum as the root cause.
Question 6: A 63-year-old man presents to the ambulatory medical clinic with symptoms of dysphagia and ‘heartburn’, which he states have become more troublesome over the past year. Past medical history is significant for primary hypertension. On physical exam, he is somewhat tender to palpation over his upper abdomen. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Barium swallow fluoroscopy demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax. Given the following options, what is the most appropriate next step in the management of this patient’s underlying condition?
A. Lifestyle modification
B. Antacid therapy
C. Cimetidine
D. Surgical gastropexy (Correct Answer)
E. Omeprazole
Explanation: ***Surgical gastropexy***
- This patient has a **paraesophageal hiatal hernia** (Type II or III), evidenced by the barium swallow showing a **subdiaphragmatic gastroesophageal junction** with **herniation of the gastric fundus into the left hemithorax**.
- In paraesophageal hernias, the GE junction remains in relatively normal position while the gastric fundus herniates through the diaphragmatic hiatus alongside the esophagus.
- **Symptomatic paraesophageal hernias** warrant **surgical repair** (fundoplication with hernia reduction and hiatal repair) due to significant risk of complications including **gastric volvulus, strangulation, incarceration**, and **ischemia**.
- The patient's progressive dysphagia and year-long symptoms indicate this is not an incidental finding but a symptomatic hernia requiring definitive surgical management.
*Omeprazole*
- **Proton pump inhibitors** are first-line medical therapy for **sliding hiatal hernias (Type I)** where the GE junction migrates above the diaphragm, causing GERD symptoms.
- In **paraesophageal hernias**, the primary pathophysiology is **mechanical** (herniation and potential obstruction/strangulation), not acid-related, so PPIs address symptoms but not the underlying structural problem.
- While PPIs may provide some symptomatic relief, they do **not prevent the serious mechanical complications** of paraesophageal hernias and are insufficient as definitive management.
*Lifestyle modification*
- **Lifestyle modifications** are appropriate adjunctive measures for GERD and sliding hiatal hernias but do not address the mechanical nature and complication risk of paraesophageal hernias.
- They cannot prevent gastric volvulus or strangulation, which are life-threatening complications unique to paraesophageal hernias.
*Antacid therapy*
- **Antacids** provide temporary symptom relief but have no role in managing the structural abnormality or preventing complications of paraesophageal hernia.
- They are even less effective than PPIs for acid suppression and similarly fail to address the mechanical problem.
*Cimetidine*
- **H2-receptor antagonists** like cimetidine reduce gastric acid production but are less potent than PPIs.
- Like PPIs, they may provide some symptomatic relief but do not address the **mechanical herniation** or prevent the serious complications that make surgical repair necessary for paraesophageal hernias.
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