Pediatric Surgery Practice Questions

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.

Q: A child presents with a scrotal swelling that disappears when lying down and reappears when standing or crying. What is the most likely diagnosis?

Indirect inguinal hernia. ***Indirect inguinal hernia*** - This presentation, where a **scrotal swelling disappears upon lying down** and reappears with increased intra-abdominal pressure (standing, crying), is classic for an **indirect inguinal hernia**. - The hernia sac passes through the **patent processus vaginalis**, allowing abdominal contents to descend into the scrotum. - The **reducibility** of the swelling is the key diagnostic feature. *Congenital hydrocele* - A **congenital hydrocele** is typically a collection of **peritoneal fluid** within the processus vaginalis that does not usually reduce spontaneously. - While it can be transilluminable, its size does not typically fluctuate as dramatically with position or straining. - Hydroceles are **non-reducible** and **painless**. *Varicocele* - A **varicocele** is an abnormal dilation of the **pampiniform plexus veins** within the scrotum. - It usually feels like a "bag of worms" and **enlarges with standing** or Valsalva maneuver, but does not typically reduce completely when lying down in the same way an indirect hernia does. - More common in **adolescents**, typically on the **left side**. *Testicular torsion* - **Testicular torsion** presents with **acute onset** severe scrotal pain and swelling, not a chronic reducible swelling. - The affected testis is typically **tender**, **elevated**, and has an **abnormal lie** (horizontal orientation). - This is a **surgical emergency** requiring immediate intervention, unlike the gradual, painless, reducible presentation described.

Q: A 10-year-old male presents with a smooth swelling near superficial inguinal ring, which moves downwards when the testicle is pulled downwards. Diagnosis -

Encysted hydrocele of the cord. ***Encysted hydrocele of the cord*** - An **encysted hydrocele of the cord** manifests as a smooth swelling near the superficial inguinal ring, which is connected to the testicle and thus moves downwards when the testicle is pulled. - This condition arises from the **incomplete obliteration of the processus vaginalis**, leading to a localized fluid collection along the spermatic cord. *Inguinal hernia* - An **inguinal hernia** usually presents with a swelling that can be *reduced* (pushed back into the abdomen) and typically has a **cough impulse**. - While it can be near the inguinal ring, its connection to the testicle is less direct, and pulling the testicle would not typically move the swelling downwards in the same manner. *Congenital hydrocele* - A **congenital hydrocele** involves fluid surrounding the testicle within the tunica vaginalis, often communicating with the peritoneal cavity, causing the scrotum to swell. - It would typically cause a *generalized scrotal swelling* rather than a localized swelling near the superficial inguinal ring that moves with testicular traction. *Varicocele* - A **varicocele** is characterized by a "bag of worms" sensation due to dilated veins in the pampiniform plexus. - It typically appears as a swelling *above the testicle* and does not move downwards when the testicle is pulled, nor is it a smooth, fluid-filled swelling.

Q: What is the best treatment for cystic hygroma?

Surgical excision. ***Surgical excision*** - **Complete surgical excision** is the **gold standard and definitive treatment** for cystic hygroma, offering the best chance of cure and lowest recurrence rate. - Surgery aims for **complete removal** of the lesion while preserving vital structures like nerves and blood vessels in the neck region. - **Timing**: Ideally performed between **18-24 months of age** or earlier if causing airway compromise or rapid growth. - Modern microsurgical techniques have significantly reduced complications like nerve injury. *Sclerotherapy* - **Sclerotherapy** (using agents like OK-432, doxycycline, or bleomycin) is a **second-line or adjunct treatment**, particularly useful for **macrocystic lesions**. - It is considered when complete surgical excision is difficult, for residual disease post-surgery, or in poor surgical candidates. - Has **variable success rates** (60-100% for macrocystic, lower for microcystic) and **higher recurrence** compared to complete excision. *Radiotherapy* - **Radiotherapy has NO role** in the treatment of cystic hygroma as these are benign lymphatic malformations. - Risk of **radiation-induced malignancies** and tissue damage in pediatric patients makes it contraindicated. *Chemotherapy* - **Chemotherapy is NOT indicated** for cystic hygroma as these are **benign congenital lymphatic malformations**, not malignant tumors. - Chemotherapy targets rapidly dividing malignant cells and has no effect on lymphatic malformations.

Q: Treatment of congenital hydrocephalus is -

Ventriculoperitoneal shunt. ***Ventriculoperitoneal shunt*** - A **ventriculoperitoneal shunt** is the most common and effective treatment for congenital hydrocephalus, diverting excess **cerebrospinal fluid (CSF)** from the ventricles to the peritoneal cavity for absorption. - This surgical procedure aims to reduce **intracranial pressure** and prevent further brain damage caused by CSF accumulation. *Stereotactic radiosurgery* - This minimally invasive technique primarily treats **tumors** or **vascular malformations** in the brain, delivering high-dose radiation precisely. - It does not address the underlying **CSF flow obstruction** or **absorption issues** characteristic of hydrocephalus. *Diuretics* - Diuretics like **acetazolamide** can reduce CSF production, offering temporary or adjunctive treatment for certain forms of hydrocephalus, but they are generally **insufficient** as a primary treatment for congenital hydrocephalus. - They do not address the large-volume fluid accumulation or **obstruction** that typically requires surgical intervention in congenital cases. *Radiotherapy* - **Radiotherapy** uses radiation to destroy cancer cells and is primarily used in the treatment of **brain tumors**. - It is not a treatment for **congenital hydrocephalus**, as it does not resolve the issues of CSF accumulation or reabsorption.

Q: What is the most appropriate surgical treatment for a large omphalocele?

Silo placement with gradual reduction. ***Silo placement with gradual reduction*** - For **large/giant omphaloceles**, **silo placement** (spring-loaded silo or Silastic pouch) with **gradual reduction** is the most appropriate modern approach when primary closure is not feasible. - The silo allows for **progressive reduction of the visceral contents** back into the abdominal cavity over several days to weeks, allowing the abdominal domain to expand gradually. - This technique **minimizes intra-abdominal pressure**, reduces risk of **abdominal compartment syndrome**, and avoids respiratory and cardiovascular compromise. - The silo is progressively tightened, and once contents are reduced, definitive fascial and skin closure is performed. *Staged closure using PTFE mesh* - **PTFE mesh** or prosthetic patch repair is an alternative for large omphaloceles but is typically a **secondary option**. - It is used when silo reduction fails or for complex cases requiring reinforcement of the abdominal wall. - Mesh may be associated with complications like infection, adhesions, and need for future hernia repair. *Primary closure of the defect* - **Primary closure** is reserved for **small omphaloceles** (typically <5 cm) where the abdominal contents can be reduced and the fascial defect closed without tension. - Attempting primary closure in a **large omphalocele** can lead to **abdominal compartment syndrome** with increased intra-abdominal pressure, causing respiratory distress, renal failure, and bowel ischemia. *None of the options* - This option is incorrect as silo placement with gradual reduction is a well-established and appropriate surgical treatment for large omphaloceles.

Q: Which one of the following is the most clinically significant consequence of undescended testis?

Has a higher incidence of malignancy. ***Has a higher incidence of malignancy*** - **Undescended testes** (cryptorchidism) are associated with a significantly increased risk of developing **germ cell tumors**, particularly seminomas. - While other complications exist, the lifelong risk of **testicular cancer** represents the most serious clinical consequence. *Usually does not descend spontaneously at puberty.* - Spontaneous descent is most likely to occur by **6 months of age**; descent after this period, and particularly at puberty, is rare. - Waiting until puberty for descent is an outdated and potentially harmful approach due to the **increased risk of malignancy** and impaired fertility. *Orchidopexy should be performed if no descent occurs by 6 months of age.* - While early intervention is crucial, the current recommendation is to perform **orchidopexy if spontaneous descent does not occur by 6-12 months of age**. - Performing surgery earlier than 6 months is generally not recommended, as some testes may still descend spontaneously within this timeframe. *Leads to impaired sperm production due to higher internal body temperature.* - The higher temperature within the abdominal cavity or inguinal canal does indeed **impair spermatogenesis**, leading to reduced fertility. - However, while significant, **infertility** is generally considered a less immediate and life-threatening concern compared to the risk of **testicular malignancy**.

Q: Commonest site of hypospadias is:

Glanular/Coronal. ***Glanular/Coronal*** - The most common location for the ectopic urethral opening in hypospadias is **glanular** or **coronal** (distal type). - This accounts for approximately **65-70%** of all hypospadias cases. - The urethral meatus opens on or just proximal to the glans penis. *Scrotum* - This represents a more **severe form** of hypospadias, where the urethral opening is located on the scrotum. - While it occurs, it is far **less common** than the distal forms. - Classified as **proximal hypospadias**. *Perineum* - **Perineal hypospadias** is the **most severe** form, with the urethral opening located in the perineum (between the scrotum and anus). - This is a **rare occurrence** and often associated with other urogenital anomalies. - Also classified as **proximal hypospadias**. *Mid-penile* - **Mid-shaft hypospadias** involves the urethral opening being located along the mid-portion of the penile shaft. - While more common than scrotal or perineal, it is **less frequent** than the distal (glanular/coronal) types. - Classified as **middle hypospadias**.

Question 1

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 2

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 3

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.

Question 4

A child presents with a scrotal swelling that disappears when lying down and reappears when standing or crying. What is the most likely diagnosis?

Accepted Answer

Indirect inguinal hernia

Answer

Testicular torsion

Answer

Varicocele

Answer

Congenital hydrocele

Question 5

A 10-year-old male presents with a smooth swelling near superficial inguinal ring, which moves downwards when the testicle is pulled downwards. Diagnosis -

Accepted Answer

Encysted hydrocele of the cord

Answer

Inguinal hernia

Answer

Congenital hydrocele

Answer

Varicocele

Question 6

What is the best treatment for cystic hygroma?

Accepted Answer

Surgical excision

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Sclerotherapy

Question 7

Treatment of congenital hydrocephalus is -

Accepted Answer

Ventriculoperitoneal shunt

Answer

Diuretics

Answer

Radiotherapy

Answer

Stereotactic radiosurgery

Question 8

What is the most appropriate surgical treatment for a large omphalocele?

Accepted Answer

Silo placement with gradual reduction

Answer

Staged closure using PTFE mesh

Answer

Primary closure of the defect

Answer

None of the options

Question 9

Which one of the following is the most clinically significant consequence of undescended testis?

Accepted Answer

Has a higher incidence of malignancy

Answer

Usually does not descend spontaneously at puberty

Answer

Orchidopexy should be performed if no descent occurs by 6 months of age

Answer

Leads to impaired sperm production due to higher internal body temperature.

Question 10

Commonest site of hypospadias is:

Accepted Answer

Glanular/Coronal

Answer

Scrotum

Answer

Perineum

Answer

Mid-penile

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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