For Pedia course 2nd

1. Common Pediatric Surgical
Problems
MCQ
Dr Yasmin Yousef MBBS, SSC-GS, SSC-PS
Consultant Pediatric Surgeon KAMC-Jd
Joint appointment Assistant Professor Pediatric Surgery KSAU-HS,
COM-J

2. Objectives
• To give an interactive summary in the format of single best
answer incorporating the pathophysiology, clinical
presentation and managements of these Pediatric surgical
conditions:
• Hernias, hydroceles and Acute Scrotum
• Abdominal wall defects (gastroschisis, omphalocele)
• Pyloric stenosis & duodenal atresia
• Intestinal atresia
• Malrotation and Volvulus

3. Hernias

4. Umbilical hernia

5. Q1What is the best age for repair
of umbilical hernia in pediatrics?
a) ASAP
b) Elective on the next available list
c) Elective at age of 3-4 years
d) Before the first birthday

6. Q2 What is the percentage of children
that present with strangulation of
umbilical hernia?
a) More than 10 %
b) Between 11-50 %
c) Umbilical hernia never strangulates
d) Between 51-75 %

7. Q3 Which of the following is the best
diagnostic modality for umbilical
hernia?
a) Abdominal ultrasound
b) Plain KUB xray
c) History and physical examination
d) Contrast study

8. Umbilical hernia
• Diagnosed by History and physical examination
• Caused by Delayed fusion of abdominal facial
plates
• Shows up after healing of umbilical stump
• never strangulates
• More than 80% close spontaneously
• Observe till age of 3-4 years then operate.

9. After
reduction

10. Q4 What is the main cause of
pediatric inguinal hernia?
a) Chronic cough
b) Severe constipation
c) Patent processuss vaginalis
d) Connective tissue disorders

11. Q5 What is the most common
groin hernia in females?
a) Femoral hernia
b) Indirect Inguinal hernia
c) Direct inguinal hernia
d) Combined direct and indirect
(Bantaloon hernia)

12. Q6 What is the organ that is
affected in strangulated inguinal
hernia?
a) The large bowel
b) The small bowel
c) The bladder
d) The small bowel and/or gonads

13. Q7 Which of the following images
represents a strangulated inguinal
hernia?
a) a
b) b
c) c
d) d
e) a and c

14. complications
a
b
c
d

15. Q8 Which is the best modality
of diagnosis of inguinal hernia?
a) Ultrasound
b) Plain xray
c) Physical examination
d) History and physical examination

16. Standard of management for
Inguinal hernia repair
• Premature babies have 30 % incidence of inguinal hernia vs 3 % in
term babies
• NICU patients before discharge
• Patients seen in the clinic next available
• Irreducible hernias should be reduced ASAP and hernia should be
repaired within 48 hours (for edema to subside)
• Due to risk to bowel and testis/ovary, strangulated Hernias should
be operated on as emergencies
• Emergency hernia repair carries higher risk of complications than
elective hernia repair
• Almost all childhood hernias are indirect except in patients with
connective tissue diseases
• Treatment is herniotomy

17. Hydroceles
Transillumination test

18. Q9 which hydrocele should be
repaired as soon as possible?
a) All hydroceles
b) Acute hydroceles
c) Communicating hydroceles
d) Tense hydroceles

19. Hydrocele
• Communicating hydroceles are treated as hernias
• Non communicating hydroceles are usually self limited
and resolve spontaneously in 90 % of cases
• If not resolved by age of 3-4 years operative
intervention is indicated
• Treatment is high ligation of PPV through inguinal
approach

20. The empty scrotum
Undescended testis

21. Possible Locations
ADAM

22. Q10 which of the following describes the
standard of care for management of
undescended testis?
a) Ultrasound abdomen and pelvis is a sensitive test for
location of an undescended testis
b) A groin ultrasound can differentiate between an
undescended testis and a retractile testis
c) Finding an undescended testis in the groin on examination
obviates the need for further imaging
d) The undescended testis should be operated upon at pre-
school age

23. Q11 A 6 month old male presents with bifid
scrotum and bilateral undescended testis and
hypospadias. Which of the following is
essential test prior to orchidopexy?
a) Groin ultrasound
b) Liver ultrasound
c) Ascending cystourethrogram
d) Chromosomal analysis

24. The Undescended Testis
• UDT are brought down by age of 9m-12m
• If palpable, no place for u/s in the dx.
• If not palpable, the best modality is diagnostic laparoscopy
• Bilateral UDT with abnormal external genetalia should
raise suspicion of intersex syndromes (Disorders Sex Development)
especially CAH

25. The empty scrotum
Retractile testis
• Parents give history of an empty scrotum on and off
• Well developed scrotum.
• Testis can be milked down to the base of the scrotum
• The testis stays in scrotum a little while.
• Caused by hyperactive cremasteric reflex.
• Self limited as testis grows and becomes heavier
• No indications for surgery

26. Q12 which of the following is the most
important diagnosis to rule out in an 8 y old
boy presentingwith red tender scrotum?
a) Epididemo-orchitis
b) Traumatic hydrocele
c) Torsion testis
d) Strangulated
inguinal hernia

27. Torsion testis
• Main differential (but not the most common)
• High testicular loss if more than 6 hours history
• Can occur at any age
• DON’T DELAY MANAGEMENT for specific imaging studies
. If suspected refer to surgery ASAP
• Contralateral fixation is usually indicated

28. Abdominal wall defects
(gastroschisis,
omphalocele)

29. Q13 which of the following is
accurate about a baby presenting
with omphalocele?
a) Isolated omphalocele has a bad prognosis
b) Survival rate depends on the severity of the
associated anomalies
c) Bowel abnormalities are the most common
anomalies
d) A ruptured omphalocele causes gastroschisis

30. Antenatal Diagnosis
• AFP level (maternal, amniotic)
• Antenatal us
– 75% sensitive for gastroschisis vs 77.3% for
omphalocele
– Associated anomalies (cardiac, genital, atresia,
CNS)
– Chromosomal analysis

31. Gastroschisis:
• Definition
– Herniation of the bowel through a right paraumbilical
full thickness defect
– Normal umbilical insertion
– No liver herniation
– No bowel coverings
• Etiology
– All theories:
• Premature interruption of the right omphalo-mesenteric artery,
resulting in ischemic injury to the anterior abdominal wall
• Abnormal involution of the right umbilical vein, resulting in rupture of
the anterior abdominal wall at a point of weakness.

32. Gastroschisis: Associated anomalies
• No congenital or chromosomal abnormalities (0-10% incidence
of anomalies)
• Associated with bowel atresia
• Malrotation
• Lack of fixation

33. Spring loaded self expanding Silo Gradual reduction

34. Omphalocele
• Midline defect at the base of the umbilicus where
herniated bowel, organs are covered with a
membrane composed of parietal peritoneum and
amnion
• Etiology: failure of fusion of the abd wall
components

35. Giant omphalocele: liver is
outside
Liver

36. Omphalocele: Associated anomalies
• 80 % of babies have associated anomalies
• Renal, Cardiac
• Trisomies 13,18,21
• Beckwith-Wiedemann syndrome (hypoglycemia,
omphalocele, macroglosia)
• Pentalogy of Cantrell (epigastric omphalocele,
bifid sternum, diaphragmatic defect, pericardium
defect (ectopia cordis), intracardiac anomalies)
• Malrotation

37. • Which of the following is the first investigation
needed for a 3 years old boy with penoscrotal
hypospadias, small phallus, bifid scrotum and
bilateral undescended testis:
a) Ultrasound abdomen
b) MRI pelvis
c) Testosterone level
d) Chromosomal analysis

38. Pyloric Stenosis and
Duodenal atresia/web

39. Q14which of the folling is the most
prevalent electrolyte disturbance in
HPS?
a) Compensated metabolic acidosis
b) Hyperchloremic hypokalemic metabolic
acidosis
c) Hypochloremic, hypokalemic metabolic
alkalosis
d) Paradoxical alkalurea

40. Q15 what is the best time
to operate on HPS?
a) Upon diagnosis
b) After rapid correction of electrolytes
c) After gradual correction of
electrolytes
d) After failure of atropine therapy

41. Infantile Hypertrophic Pyloric Stenosis
• 3-5/1000 live births in Caucasians
• 0.5-1/1000 live births in non-Caucasians
• 4:1 male to female ratio
• Genetics and environmental factors involved

42. Infantile Hypertrophic Pyloric
Stenosis
• Non bilious vomiting starting on 3rd week of life
• Progressive, projectile
• Infant is hungry right after vomiting
• Examination:
– dehydrated, palpable olive, visible peristalsis
• Electrolyte imbalance and dehydration
– hypokalemic, hypochloremic metabolic alkalosis with
paradoxic acidurea

43. Pyloric stenosis

45. Infantile Hypertrophic Pyloric
stenosis
• Cause: abnormal thickening of circular muscle
• Medical emergency rather than surgical
• Diagnosis:
– US thickness >4mm, length >15mm
– UGI contrast study if inexperienced US
• Treatment:
– rehydration and correction of electrolytes (24- 72 hours)
– Ramstedt Pyloromyotomy is Rx of choice (open, lap)
– Medical treatment also available (atropine)

46. What is this sign?

47. Q16 What is the most common
chromosomal anomaly associated with
Duodenal atresia?
a) Trisomy 18
b) Trisomy 21
c) Infant of Diabetic mother
d) BWS

48. Duodenal atresia and webs
• A spectrum of congenital anomalies of the duodenum caused
by aberrant recanalization in utero
• Complete atresia to a perforated diaphragm with all grades
in between
• 8 times more common in Trisomy 21 infants
• Can be diagnosed in utero by antenatal ultrasound
• Can present at birth (atresia) or later in life (Stenosis)
What is this study?
What does it show?

50. Duodenal atresia and web
• Vomiting can be bilious (85%) or non bilious (15%)
• Double bubble sign on plain xray, abdominal US
• Double bubble can also be seen on antenatal US
• Rx is DuodenoDuodenostomy (excision of the web
can sometimes be done)
• Post op prolonged ileus with need for TPN due to
discrepancy in lumen sizes (up to 3 weeks)

51. Q17 What is the charachteristic
xray sign in ileal atresia
a) Double bubble
b) Corkscrew
c) Reverse Recto/sigmoid ratio
d) Triple bubble sign

52. Q18 Which of the following
conditions can be associated with
ileal, ileojujenal atresia
a) Trisomy 18
b) Cystic fibrosis
c) Hirschsprung disease
d) Goldenhar syndrome

53. Intestinal atresia
• Jujenal, jujenoilial or ilial
• Triple bubble on plain xray
• Cause : thought to be ischemic vascular
insult to area/ areas of mesentery
• Hyperbilirubinemia is common.
• Intestinal obstruction increases the
enterohepatic circulation of bile and often
results in jaundice.
• About 10% of infants with jejunal or ileal
atresia have cystic fibrosis and meconium
ileus.

54. Q19 A full term 1 month old baby boy presented
to the ER with yellow green vomiting for one
day. No significant findings on examination.
What is the best management to be offered to
this baby?
a) Change milk to AR formula
b) US abdomen to rule out HPS
c) Reassure mother and instruct to decrease feed
amount
d) Upper GI contrast study

55. What is Malrotation/
malfixation?
• During fetal development the midgut elongates
more than the capacity of the fetal abdominal
cavity, so it herniates outside the abdomen.
• While it comes back, around the 12th week of
gestation it undergoes two processes rotation and
fixation
• If this process does not occur properly, a spectrum
of anomalies of the mid gut result.

56. Normal rotation and fixation

57. Typical malrotation

58. How does it present?
• Bilious vomiting (beware of the full term infant
with bilious vomiting)
• Volvulus
• Intermittent vomiting with intolerance of feed
(chronic volvulus)
• Intermittent abdominal pain
• Asymptomatic

59. When does it present?
• Anytime, at any age but:
• 50-60% present in neonatal period, 20-30%
present during the first year of life
• Usual presentation at this age is acute volvulus
with bilious vomiting in a previously healthy
infant
• Rapid deterioration with bowel ischemia follows

60. No distal gas Corkscrew appearance

62. Diagnosis
• High index of suspicion
• Upper GI contrast study (gold standard)
• Ultrasound and or CT scan (position of SMA in
relation to the SMV)

63. Management
• Stabilize
• Ladd’s procedure (open/laparoscopic)
– Derotate the volvulus counterclockwise
– Division of Ladd’s bands
– Widen the mesentery
– +/- appendectomy
– Return small bowel on RT and large bowel on Lt

64. After surgical correction (Ladd’s procedure),
is there still a risk of volvulus?
a) Yes.
b) No.