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  • Question 1 - A 2-day old neonate is developing increasing problems with feeding. On examination, she...

    Incorrect

    • A 2-day old neonate is developing increasing problems with feeding. On examination, she has a pan systolic murmur and her forearms have not developed properly. What is the most likely underlying problem?

      Your Answer: Duodenal atresia

      Correct Answer: Oesophageal atresia

      Explanation:

      The child has VACTERL
      Over 50% of infants with oesophageal atresia have one or more additional anomalies.
      The VATER association consists of a combination of anomalies including vertebral, anorectal, tracheooesophageal and renal or radial abnormalities. This association was later expanded as the VACTERL association to include cardiac and limb defects.
      Other associations which may include oesophageal atresia are the CHARGE association (coloboma, heart defects, atresia choanal, retarded growth and development, genital hypoplasia and ear deformities), POTTER’S syndrome (renal agenesis, pulmonary hypoplasia, typical dysmorphic facies) and SCHISIS association (omphalocele, cleft lip and/or palate, genital hypoplasia). Genetic defects associated with oesophageal atresia include Trisomy 21 and 18, and 13q deletion. Of the cardiac anomalies, the most common are ventricular septal defect and tetralogy of Fallot. Major cardiac malformations are one of the main causes of mortality in infants with oesophageal atresia.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      8.7
      Seconds
  • Question 2 - A 4 week old baby is taken to the clinic with bile stained...

    Correct

    • A 4 week old baby is taken to the clinic with bile stained vomiting. He had a congenital diaphragmatic hernia and an exomphalos. What is the most likely underlying condition?

      Your Answer: Intestinal malrotation

      Explanation:

      Answer: Intestinal malrotation

      During normal abdominal development, the 3 divisions of the GI tract (i.e., foregut, midgut, hindgut) herniate out from the abdominal cavity, where they then undergo a 270º counter clockwise rotation around the superior mesenteric vessels. Following this rotation, the bowels return to the abdominal cavity, with fixation of the duodenojejunal loop to the left of the midline and the cecum in the right lower quadrant.

      Intestinal malrotation refers to any variation in this rotation and fixation of the GI tract during development. Interruption of typical intestinal rotation and fixation during foetal development can occur at a wide range of locations; this leads to various acute and chronic presentations of disease. The most common type found in paediatric patients is incomplete rotation predisposing to midgut volvulus, requiring emergent operative intervention.

      Acute midgut volvulus

      Usually occurs during the first year of life

      Sudden onset of bilious emesis

      Diffuse abdominal pain out of proportion to physical examination

      Acute duodenal obstruction

      This anomaly is usually recognized in infants and is due to compression or kinking of the duodenum by peritoneal bands (Ladd bands).

      Patients present with forceful vomiting, which may or may not be bile-stained, depending on the location of the obstruction with respect to the entrance of the common bile duct (ampulla of Vater).

      Malrotation may occur as an isolated anomaly or in association with other congenital anomalies; 30-62% of children with malrotation have an associated congenital anomaly. All children with diaphragmatic hernia, gastroschisis, and omphalocele have intestinal malrotation by definition. Additionally, malrotation is seen in approximately 17% of patients with duodenal atresia and 33% of patients with jejunoileal atresia.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      2.6
      Seconds
  • Question 3 - A 5 year old boy is rushed to the A&E department after accidentally...

    Incorrect

    • A 5 year old boy is rushed to the A&E department after accidentally inhaling a Brazil nut. He is seen to be extremely distressed and cyanotic and imaging shows that it is lodged in the left main bronchus. Which of the following is the best course of action?

      Your Answer: Treat in emergency department under sedation

      Correct Answer: Arrange immediate transfer to theatre for bronchoscopy

      Explanation:

      A small number of foreign body aspirations are incidentally found after chest radiography or bronchoscopic inspection. Patients may be asymptomatic or may be undergoing testing for other diagnoses. If present, physical findings may include stridor, fixed wheeze, localized wheeze, or diminished breath sounds. If obstruction is severe, cyanosis may occur. Signs of consolidation can accompany post obstructive pneumonia.

      Bronchoscopy can be used diagnostically and therapeutically. Most aspirated foreign bodies are radiolucent. Radiologic procedures do not have extreme diagnostic accuracy, and aspiration events are not always detected. Rigid bronchoscopy usually requires heavy intravenous sedation or general anaesthesia. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. The paediatric flexible bronchoscope lacks a hollow working channel through which instruments may be inserted or blood and secretions may be aspirated.
      Unlike the flexible bronchoscope, the patient can be ventilated through the rigid scope; therefore, ventilation of the patient can be maintained. Rigid bronchoscopy is the procedure of choice for removing foreign bodies in children and in most adults. Success rates for extracting foreign bodies are reportedly more than 98%. Large solid and semisolid objects are best managed emergently in the operating room with a rigid bronchoscope and appropriate grasping instruments.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      3.8
      Seconds
  • Question 4 - A 13 year old girl presents to the clinic with weight loss and...

    Incorrect

    • A 13 year old girl presents to the clinic with weight loss and bloody diarrhoea. Examination of the abdomen is unremarkable. What is the most likely diagnosis?

      Your Answer: Colorectal cancer

      Correct Answer: Inflammatory bowel disease

      Explanation:

      Answer: Inflammatory bowel disease

      The inflammatory bowel diseases (IBDs), including ulcerative colitis and Crohn disease, are chronic inflammatory disorders of the gastrointestinal tract most often diagnosed in adolescence and young adulthood, with a rising incidence in paediatric populations. Inflammatory bowel disease is caused by a dysregulated mucosal immune response to the intestinal microflora in genetically predisposed hosts. Although children can present with the classic symptoms of weight loss, abdominal pain, and bloody diarrhoea, many present with nonclassical symptoms of isolated poor growth, anaemia, or other extraintestinal manifestations.

      Colorectal Carcinoma (CRC) is rare in patients less than 20 years of age.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      4
      Seconds
  • Question 5 - A 3 year old boy is awaiting surgery for a ruptured appendix and...

    Correct

    • A 3 year old boy is awaiting surgery for a ruptured appendix and the nurse wants to give him an infusion of intravenous fluid whilst waiting for theatre. Given that his electrolytes are normal, which of the following infusion fluid would be appropriate?

      Your Answer: 0.9% Saline solution

      Explanation:

      Indications for IV fluids include:
      – Resuscitation and circulatory support
      – Replacing on-going fluid losses
      – Maintenance fluids for children for whom oral fluids are not appropriate
      – Correction of electrolyte disturbances

      According to the NICE guidelines, if children and young people need IV fluid resuscitation, use glucose‑free crystalloids that contain sodium in the range 131–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre‑existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.

      All the others are contraindicated according to the guidelines as they are either made of glucose or are colloids.
      Gelofusine is a 4% w/v solution of succinylated gelatine (also known as modified fluid gelatine) used as an intravenous colloid, and behaves much like blood filled with albumins.
      Dextrose solution is a mixture of dextrose (glucose) and water. It is used to treat low blood sugar or water loss without electrolyte loss. Intravenous sugar solutions are in the crystalloid family of medications. They come in a number of strengths including 5%, 10%, and 50% dextrose.
      0.45% saline/ 5% glucose solution also contains glucose hence it is contraindicated.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      3.7
      Seconds
  • Question 6 - A 4-year-old boy inserts a crayon into his external auditory meatus. Attempts to...

    Correct

    • A 4-year-old boy inserts a crayon into his external auditory meatus. Attempts to remove it have not been successful. What is the best course of action?

      Your Answer: Operate on the next emergency operating list

      Explanation:

      The removal of foreign bodies from the ear is a common procedure in the emergency department.
      Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, oedema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign body from the ear may result in infection, perforation, or another morbidity.
      The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT consultation for removal by operative microscope and speculum.
      Local anaesthesia is invasive and is not generally used for uncomplicated ear foreign body removal because of the complex innervations of the external ear canal.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      2.6
      Seconds
  • Question 7 - A 5 year old boy is taken to the family doctor following a...

    Incorrect

    • A 5 year old boy is taken to the family doctor following a history of difficult, painful defecation with bright red rectal bleeding. Which of the following would be the diagnosis?

      Your Answer:

      Correct Answer: Anal fissure

      Explanation:

      An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. Anal fissures develop with equal frequency in both sexes; they tend to occur in younger and middle-aged persons.

      Treatment should include stool softeners and lifestyle advice. Failure of medical therapy is an indication for surgical therapy. Controversy mostly involves continued efforts to find a medical therapy for anal fissure that is as successful as the surgical therapy for the condition.
      Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.

      Children with intussceception usually present at a relatively young age with colicky abdominal pain, together with a mass on clinical examination. The often cited red current jelly type stool is a rare but classical feature.

      Juvenile polyps may occur as part of the familial polyposis coli syndromes. The lesions, which are hamartomas, are often cherry red if they protrude externally.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 8 - A 2-day old baby develops dyspnoea. A chest x-ray is performed and shows...

    Incorrect

    • A 2-day old baby develops dyspnoea. A chest x-ray is performed and shows a radio-opaque shadow with an air-fluid level in the chest. It is located immediately anterior to the 6th hemivertebra. Which of the following is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Bronchogenic cyst

      Explanation:

      Bronchogenic cysts, although relatively rare, represent the most common cystic lesion of the mediastinum.
      Bronchogenic cysts are the result of anomalous development of the ventral foregut; they are usually single but may be multiple and can be filled with fluid or mucus. They have been found all along the tracheoesophageal course, in perihilar or intraparenchymal sites, with a predilection for the area around the carina. Those in the mediastinum frequently attach to but do not communicate with the tracheobronchial tree. Bronchogenic cysts have also been described in more remote locations, including the interatrial septum, neck, abdomen, and retroperitoneal space.
      With the advent of improved antenatal diagnosis, many infants are identified before the development of symptoms:
      Chest pain and dysphagia are the most common symptoms in adults with bronchogenic cysts.
      Recurrent infections may be the clinical presentation in some children
      In infants, symptoms are most often produced as a result of airway or oesophageal compression.

      Oesophageal duplication cysts are rare inherited lesions usually diagnosed in early childhood. Most of them are found in the mediastinum and manifest themselves as separate masses along or in continuity with the native oesophagus

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 9 - A three week old baby is referred to surgery by his paediatrician because...

    Incorrect

    • A three week old baby is referred to surgery by his paediatrician because she has a painful area of macerated tissue at the site of the umbilicus. When he cries, a clear-yellowish fluid is seen to be draining from the umbilicus. Which of the following would be the correct diagnosis?

      Your Answer:

      Correct Answer: Patent urachus

      Explanation:

      A patent urachus is one of the spectrum of congenital urachal anomalies. It has occasionally been termed urachal fistula. In an open (or patent) urachus, there is an opening between the bladder and the belly button (navel). The urachus is a tube between the bladder and the belly button that is present before birth. In most cases, it closes along its full length before the baby is born. An open urachus occurs mostly in infants. A patent urachus is often diagnosed in neonates when urine is noted leaking from the umbilicus. The umbilicus may also have an abnormal appearance on physical exam.

      A patent urachus predisposes to infection. If the urachal disorder presents with an infection, the infection is treated first. This requires antibiotics, possible admission for intravenous antibiotics, and occasional surgical drainage of any infected cyst or poorly draining cavity. Once the infection is under control, excision of the urachus is usually performed. This can usually be done laparoscopically or with a small incision on the lower abdomen. Patients usually stay in the hospital 1-2 days after the surgery. The urachus can be excised because in normal development it usually obliterates anyway. The umbilicus is not removed.

      Omphalitis is an infection of the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period. Omphalitis is primarily a disease of the neonate and is characterized by tenderness, erythema, and induration of the umbilicus and surrounding tissues. Early on, patients may only have superficial cellulitis but, if untreated, this can progress to involve the entire abdominal wall. Patients may also have purulent drainage or be bleeding from the umbilical cord stump. Foul-smelling drainage should raise the suspicion of anaerobic infection.

      Patent vitellointestinal or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of population related with the embryonic yolk stalk. A persistent vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children.

      An umbilical granuloma is a moist, red lump of tissue that can form on a baby’s navel (belly button). It can be seen in the first few weeks of life, after the umbilical cord has dried and fallen off. It’s usually a minor problem that looks worse than it is. An umbilical granuloma does not cause pain. It may ooze a small amount of fluid that can make the skin around it red and irritated.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 10 - A 12 year old boy is shot in the abdomen with a pellet...

    Incorrect

    • A 12 year old boy is shot in the abdomen with a pellet gun. He hides the injury for over a week before he is taken to his doctor. CT scan shows that the pellet is lodged in his liver's left lobe. His abdomen is soft and non-tender on examination and he seems well. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Do not operate and review the patient several weeks later

      Explanation:

      Answer: Do not operate and review the patient several weeks later

      Air weapon injuries in children should be managed in the same way as any low velocity gun shot injury. Subcutaneous pellets are best removed. Urgent specialist referral is indicated for cranial, ocular, chest, abdominal, or vascular injuries as they may require emergency surgery. Cardiac injuries may be rapidly fatal. Penetrating abdominal injuries involving hollow viscera or major blood vessels need prompt exploration and repair. Intracranial air weapon pellets should be removed if possible. A pellet in lung parenchyma or muscle may be safely left in situ but there is a risk of infection. A pellet that has penetrated a joint or is associated with a fracture requires skilled orthopaedic management. A pellet lodged near a major blood vessel or nerve should ideally be removed. The possibility of intravascular embolism must be considered if the pellet is absent from a suspected entry site and there is no exit wound; numerous examples of arterial and venous embolism of an air weapon pellet in children have been described.

      In this case, the child seems well so there is no need to operate. He should be reviewed several weeks later.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 11 - A 6 week old baby who is developing well starts having profuse and...

    Incorrect

    • A 6 week old baby who is developing well starts having profuse and projectile vomiting after feeding. She has been losing weight and the vomit is non-bilious. Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Hypertrophy of the pyloric sphincter

      Explanation:

      Pyloric stenosis is a narrowing of the opening from the stomach to the first part of the small intestine (the pylorus). Symptoms include projectile vomiting without the presence of bile. This most often occurs after the baby is fed. The typical age that symptoms become obvious is two to twelve weeks old.

      The cause of pyloric stenosis is unclear. Risk factors in babies include birth by caesarean section, preterm birth, bottle feeding, and being first born. The diagnosis may be made by feeling an olive-shaped mass in the baby’s abdomen. This is often confirmed with ultrasound. It is four times more likely to occur in males, and is also more common in the first born. Rarely, infantile pyloric stenosis can occur as an autosomal dominant condition.

      It is uncertain whether it is a congenital anatomic narrowing or a functional hypertrophy of the pyloric sphincter muscle.
      Babies with this condition usually present any time in the first weeks to months of life with progressively worsening vomiting. The vomiting is often described as non-bile stained (non bilious) and projectile vomiting, because it is more forceful than the usual spitting up (gastroesophageal reflux) seen at this age. Some infants present with poor feeding and weight loss but others demonstrate normal weight gain. Dehydration may occur which causes a baby to cry without having tears and to produce less wet or dirty diapers due to not urinating for hours or for a few days. Symptoms usually begin between 3 to 12 weeks of age. Findings include epigastric fullness with visible peristalsis in the upper abdomen from the person’s left to right. Constant hunger, belching, and colic are other possible signs that the baby is unable to eat properly.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 12 - A 10 hour old baby who was born by emergency caesarean section, is...

    Incorrect

    • A 10 hour old baby who was born by emergency caesarean section, is being observed for foetal distress. She has a displaced apex beat and decreased air entry on the left side of her chest. A scaphoid abdomen is seen on abdominal examination but all else is unremarkable. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Congenital diaphragmatic hernia

      Explanation:

      Answer: Congenital diaphragmatic hernia

      Congenital diaphragmatic hernia (CDH) occurs when the diaphragm muscle — the muscle that separates the chest from the abdomen — fails to close during prenatal development, and the contents from the abdomen (stomach, intestines and/or liver) migrate into the chest through this hole.

      Examination in infants with congenital diaphragmatic hernias include the following findings:

      Scaphoid abdomen

      Barrel-shaped chest

      Respiratory distress (retractions, cyanosis, grunting respirations)

      In left-sided posterolateral hernia: Poor air entry on the left, with a shift of cardiac sounds over the right chest; in patients with severe defects, signs of pneumothorax (poor air entry, poor perfusion) may also be found

      Associated anomalies: Dysmorphisms such as craniofacial abnormalities, extremity abnormalities, or spinal dysraphism may suggest syndromic congenital diaphragmatic hernia

      Ileal atresia is a congenital abnormality where there is significant stenosis or complete absence of a portion of the ileum. There is an increased incidence in those with chromosomal abnormalities. Ileal atresia results from a vascular accident in utero that leads to decreased intestinal perfusion and subsequent ischemia a segment of bowel. This leads to narrowing, or in the most severe cases, complete obliteration of the intestinal lumen. In the postnatal period, an abdominal radiograph will show air in the dilated loops of proximal bowel. An ileal atresia is often discovered prenatally at a routine prenatal ultrasound scan or following the development of polyhydramnios. On ultrasound, there is frequently a proximal dilated intestinal segment.

      Meconium Ileus (MI) is a condition where the content of the baby’s bowel (meconium) is extremely sticky and causes the bowel to be blocked at birth. In most cases the bowel itself is complete and intact but it is just the inside that is blocked.

      In some cases there has been a twist of the bowel before birth, which has caused the bowel to be blind ending (an atresia). Most babies with meconium ileus (90%) have Cystic Fibrosis (CF) and it is this that has caused the sticky meconium. Meconium ileus is a rare condition affecting only 1 in 25,000 babies. There is normally a delay in your baby passing meconium (black sticky stool normally passed within 24 hours of delivery) and your baby may also be reluctant to feed and may vomit a green fluid called bile which would normally pass through the bowel.

      Your baby may be uncomfortable because of constipation and trapped air in the bowel and the abdomen (tummy) will become distended. Some babies present at delivery with a distended abdomen and may be unwell due to infection around the bowel.

      Pyloric stenosis is a problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It is the second most common problem requiring surgery in new-borns. The lower portion of the stomach that connects to the small intestine is known as the pylorus. In pyloric stenosis, the muscles in this part of the stomach enlarge, narrowing the opening of the pylorus and eventually preventing food from moving from the stomach to the intestine.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 13 - A 4-year-old boy is brought to the clinic with symptoms of urinary hesitancy...

    Incorrect

    • A 4-year-old boy is brought to the clinic with symptoms of urinary hesitancy and poor stream. Which of the following is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Posterior urethral valves

      Explanation:

      In children, more common causes of Urinary tract obstruction include the following:
      UPJ or UVJ obstruction
      Ectopic ureter
      Ureterocoele
      Megaureter
      Posterior urethral valves

      Posterior urethral valves:

      During the early stages of embryogenesis, the most caudal end of the wolffian duct is absorbed into the primitive cloaca at the site of the future verumontanum in the posterior urethra. In healthy males, the remnants of this process are the posterior urethral folds, called plicae colliculi. Histologic studies suggest that PUVs are formed at approximately 4 weeks’ gestation, as the wolffian duct fuses with the developing cloaca.
      Congenital obstructing posterior urethral membrane (COPUM) was first proposed by Dewan and Goh and was later supported by histologic studies by Baskin. This concept proposes that instead of a true valve, a persistent oblique membrane is ruptured by initial catheter placement and, secondary to rupture, forms a valve like configuration.
      Indicators of possible PUVs later in childhood include the following:
      Urinary tract infection (UTI)
      Diurnal enuresis in boys older than 5 years
      Secondary diurnal enuresis
      Voiding pain or dysfunction
      Abnormal urinary stream

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 14 - A 4-year-old boy is referred to the clinic with a scrotal swelling. On...

    Incorrect

    • A 4-year-old boy is referred to the clinic with a scrotal swelling. On examination, the mass does not transilluminate and it is impossible to palpate normal cord above it. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Indirect inguinal hernia

      Explanation:

      An inguinal hernia is a common condition requiring surgical repair in the paediatric age group.
      The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
      The swelling may or may not be associated with any pain or discomfort. More commonly, no pain is associated with a simple inguinal hernia in an infant. The parents may perceive the bulge as being painful when, in truth, it causes no discomfort to the patient.
      The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping.
      Indirect hernias are more common on the right side because of delayed descent of the right testicle. Hernias are present on the right side in 60% of patients, on the left is 30%, and bilaterally in 10% of patients.
      Physical examination of a child with an inguinal hernia typically reveals a palpable smooth mass originating from the external ring lateral to the pubic tubercle. The mass may only be noticeable after coughing or performing a Valsalva manoeuvre, and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle.
      In boys, differentiating between a hernia and a hydrocele is not always easy. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that is distended and fluid-filled in the scrotum of a young infant may also transilluminate. A rectal examination may be helpful if intestine can be felt descending through the internal ring.
      A femoral hernia can be very difficult to differentiate from an indirect inguinal hernia. Its location is below the inguinal canal, through the femoral canal. The differentiation is often made only at the time of operative repair, once the anatomy and relationship to the inguinal ligament are clearly visualized. The signs and symptoms for femoral hernias are essentially the same as those described for indirect inguinal hernias.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
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  • Question 15 - A 2-day-old baby presents with recurrent episodes of choking and cyanotic episodes. There...

    Incorrect

    • A 2-day-old baby presents with recurrent episodes of choking and cyanotic episodes. There is a history of polyhydramnios. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Oesophageal atresia

      Explanation:

      Oesophageal atresia encompasses a group of congenital anomalies comprising an interruption of the continuity of the oesophagus combined with or without a persistent communication with the trachea.
      The diagnosis of oesophageal atresia may be suspected prenatally by the finding of a small or absent fetal stomach bubble on an ultrasound scan performed after the 18th week of gestation. Overall the sensitivity of ultrasonography is 42% but in combination with polyhydramnios, the positive predictive value is 56%. Polyhydramnios alone is a poor indicator of oesophageal atresia (1% incidence).
      The newborn infant of a mother with polyhydramnios should always have a nasogastric tube passed soon after delivery to exclude oesophageal atresia. Infants with oesophageal atresia are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. At this stage, and certainly, before the first feed, a stiff wide-bore (10–12 French gauge) catheter should be passed through the mouth into the oesophagus. In oesophageal atresia, the catheter will not pass beyond 9–10 cm from the lower alveolar ridge. A plain X-ray of the chest and abdomen will show the tip of the catheter arrested in the superior mediastinum (T 2–4) while gas in the stomach and intestine signifies the presence of a distal tracheoesophageal fistula. The absence of gastrointestinal gas is indicative of isolated atresia. A fine bore catheter may curl up in the upper pouch giving the false impression of an intact oesophagus or rarely it may pass through the trachea and proceed distally into the oesophagus through the fistula. The X-ray may reveal additional anomalies such as a double bubble appearance of duodenal atresia, vertebral or rib abnormalities.
      Delaying the diagnosis until the infant presents with coughing and choking during the first feed is no longer acceptable in modern paediatric practice.

      Duodenal atresia is typically characterized by the onset of vomiting within hours of birth. While vomitus is most often bilious, it may be nonbilious because 15% of defects occur proximal to the ampulla of Vater.

      Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is the most common cause of intestinal obstruction in infancy. IHPS occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a functional gastric outlet obstruction.
      Classically, the infant with pyloric stenosis has nonbilious vomiting or regurgitation, which may become projectile (in as many as 70% of cases), after which the infant is still hungry.
      Emesis may be intermittent initially or occur after each feeding.
      Emesis should not be bilious as the obstruction is proximal to the common bile duct. The emesis may become brown or coffee colour due to blood secondary to gastritis or a Mallory-Weiss tear at the gastroesophageal junction.
      As the obstruction becomes more severe, the infant begins to show signs of dehydration and malnutrition, such as poor weight gain, weight loss, marasmus, decreased urinary output, lethargy, and shock.
      The infant may develop jaundice, which is corrected upon correction of the disease.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      0
      Seconds
  • Question 16 - A 3 month old infant is taken to the hospital after she is...

    Incorrect

    • A 3 month old infant is taken to the hospital after she is observed to have jaundice. Tests show an elevated conjugated bilirubin level. Diagnosis is confirmed by cholangiography during surgery. Which of the following is the best course of action?

      Your Answer:

      Correct Answer: Roux-en-Y portojejunostomy

      Explanation:

      In most cases of atresia, dissection into the porta hepatis and creation of a Roux-en-Y anastomosis with a 35 to 40-cm retro colic jejunal segment is the procedure of choice.
      In the unusual circumstance of distal patency of the common duct with acceptable proximal luminal calibre, a modified portoenterostomy may be considered in place of the traditional Kasai procedure. However, the clinician must be aware that progression of disease pathophysiology may occur.

      Biliary atresia is characterized by obliteration or discontinuity of the extrahepatic biliary system, resulting in obstruction to bile flow. Regardless of aetiology, the clinical presentation of neonatal cholestasis is remarkably similar in most infants.

      Typical symptoms include variable degrees of jaundice, dark urine, and light stools. In the case of biliary atresia, most infants are full-term, although a higher incidence of low birthweight may be observed. In most cases, acholic stools are not noted at birth but develop over the first few weeks of life. Appetite, growth, and weight gain may be normal.

      Physical findings do not identify all cases of biliary atresia. No findings are pathognomonic for the disorder. Infants with biliary atresia are typically full term and may manifest normal growth and weight gain during the first few weeks of life.

      Hepatomegaly may be present early, and the liver is often firm or hard to palpation. Splenomegaly is common, and an enlarging spleen suggests progressive cirrhosis with portal hypertension.

      Direct hyperbilirubinemia is always an abnormal finding and it is typically present from birth in the foetal/embryonic form. Consider biliary atresia in all neonates with direct hyperbilirubinemia.

      In the more common postnatal form, physiologic jaundice frequently merges into conjugated hyperbilirubinemia. The clinician must be aware that physiologic unconjugated hyperbilirubinemia rarely persists beyond 2 weeks. Infants with prolonged physiologic jaundice must be evaluated for other causes.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
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  • Question 17 - A 7 year old boy is taken to the doctor by his mother...

    Incorrect

    • A 7 year old boy is taken to the doctor by his mother after she observed a swelling in his right hemiscrotum. On examination, it transilluminates. What is the next best step in his management?

      Your Answer:

      Correct Answer: Division of the patent processus vaginalis via an inguinal approach

      Explanation:

      The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for paediatric hydroceles (typically, communicating). If a testicular tumour is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

      Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumours may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumours.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
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  • Question 18 - A 3 year old boy is taken to the doctor by his mother...

    Incorrect

    • A 3 year old boy is taken to the doctor by his mother who has noticed that he has been having rectal bleeding for a few months and a cherry red lesion appeared at the anal verge after defecation. Which of the following is most likely the diagnosis?

      Your Answer:

      Correct Answer: Juvenile polyp

      Explanation:

      Juvenile polyps are benign hamartomas with neoplastic potential that are the most frequent gastrointestinal polyp of childhood, with the peak incidence between 3 and 5 years of age.. The presence of multiple juvenile polyps may indicate a premalignant condition commonly named juvenile polyposis coli or juvenile polyposis syndrome (JPS). In contrast, single or solitary juvenile polyps generally are considered benign sporadic lesions that confer little to no future risk of malignancy. Most frequent presentation is painless rectal bleeding. Other features include a prolapsing rectal mass and abdominal pain.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
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  • Question 19 - A 11 month old baby develops periumbilical abdominal discomfort and diarrhoea after having...

    Incorrect

    • A 11 month old baby develops periumbilical abdominal discomfort and diarrhoea after having a sore throat and fever for a few days. He presents to the A&E department and an ultrasound is done which shows a 'target sign' on the right side of the abdomen. What is the best initial course of action?

      Your Answer:

      Correct Answer: Obtain intravenous access, administer fluids and antibiotics

      Explanation:

      Answer: Obtain intravenous access, administer fluids and antibiotics.

      Intussusception is a condition in which one segment of intestine telescopes inside of another, causing an intestinal obstruction (blockage). Although intussusception can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestines. The obstruction can cause swelling and inflammation that can lead to intestinal injury. The patient with intussusception is usually an infant, often one who has had an upper respiratory infection, who presents with the following symptoms:

      Vomiting: Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious

      Abdominal pain: Pain in intussusception is colicky, severe, and intermittent

      Passage of blood and mucus: Parents report the passage of stools, by affected children, that look like currant jelly; this is a mixture of mucus, sloughed mucosa, and shed blood; diarrhoea can also be an early sign of intussusception

      Lethargy: This can be the sole presenting symptom of intussusception, which makes the condition’s diagnosis challenging

      Palpable abdominal mass

      Diagnosis:
      Ultrasonography: Hallmarks of ultrasonography include the target and pseudo kidney signs.

      For all children, start intravenous fluid resuscitation and nasogastric decompression as soon as possible.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
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  • Question 20 - A 12 hour old baby is seen to be cyanotic whilst feeding and...

    Incorrect

    • A 12 hour old baby is seen to be cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected by the team of doctors. Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Transposition of the great arteries

      Explanation:

      Answer: Transposition of the great arteries

      Transposition of the great arteries (TGA) is the most common cyanotic congenital heart lesion that presents in neonates. The hallmark of transposition of the great arteries is ventriculoarterial discordance, in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle.

      Infants with transposition of the great arteries (TGA) are usually born at term, with cyanosis apparent within hours of birth.

      The clinical course and manifestations depend on the extent of intercirculatory mixing and the presence of associated anatomic lesions. Note the following:

      Transposition of the great arteries with intact ventricular septum: Prominent and progressive cyanosis within the first 24 hours of life is the usual finding in infants if no significant mixing at the atrial level is evident.

      Transposition of the great arteries with large ventricular septal defect: Infants may not initially manifest symptoms of heart disease, although mild cyanosis (particularly when crying) is often noted. Signs of congestive heart failure (tachypnoea, tachycardia, diaphoresis, and failure to gain weight) may become evident over the first 3-6 weeks as pulmonary blood flow increases.

      Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: Infants often present with extreme cyanosis at birth, proportional to the degree of left ventricular (pulmonary) outflow tract obstruction. The clinical history may be similar to that of an infant with tetralogy of Fallot.

      Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease: Progressively advancing pulmonary vascular obstructive disease can prevent this rare subgroup of patients from developing symptoms of congestive heart failure, despite a large ventricular septal defect. Most often, patients present with progressive cyanosis, despite an early successful palliative procedure.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
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Paediatric Surgery (2/6) 33%
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