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Question 1
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A 14-year-old male was involved in a bicycle accident. He was brought to the emergency department with abdominal pain. On the CT scan of the abdomen, a hematoma was present beneath the capsule of the spleen. His BP and pulse were normal. What is the next step in his management?
Your Answer: Refer to surgeons for observation
Explanation:A surgeon will observe the patient and will decide which procedure he needs.
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This question is part of the following fields:
- Paediatric Surgery
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Question 2
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A 1-year old child is brought to the ER with abdominal distension and bilious vomiting. Radiological examination shows distended bowel loops and gas in the rectum. Her mother reveals that the baby had surgery at the two days of age for a twisted intestine. Blood gas analysis from a sample drawn from a capillary shows a pH of 7.34 and lactate of 2. Which of the following is the most appropriate management step?
Your Answer: Naso-gastric decompression, intra venous fluids and admit. The majority of adhesional obstruction resolves without need for surgery
Explanation:Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive aetiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.
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This question is part of the following fields:
- Paediatric Surgery
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Question 3
Correct
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A 14-month-old boy is brought to the paediatric clinic by his mother with complaints of vomiting, abdominal pain, and rectal bleeding. On examination, he is found to be dehydrated, and a palpable abdominal mass was felt. A Meckel's scan proved to be negative. However, the ultrasound scan did reveal a target sign.What is the most probable cause of the patient's complaints?
Your Answer: Intussusception
Explanation:The most probable cause for the patient’s symptoms is intussusception.Intussusception is a condition in which part of the intestine folds into the section next to it. It most commonly involves the small bowel and rarely the large bowel. Intussusception doesn’t usually require surgical correction. 80% of cases can be both confirmed and reduced using barium, water-soluble or air-contrast enema. However, up to 10% of cases can experience recurrence within 24 hours after reduction, warranting close monitoring during this period.Other options:- Enteric duplication: a duplication cyst could give all these features, although it may contain sufficient gastric epithelium to produce a positive Meckel’s scan. However, this is comparatively rare. – Meckel’s diverticulum: Scintigraphy has poor sensitivity making the possibility of a bleed from a Meckel’s diverticulum a genuine differential for this patient. However, considering the presence of features of bowel obstruction in the patient, a Meckel’s diverticulum bleeding and obstructing at the same time would be a rare phenomenon. – Midgut volvulus: It is also a plausible differential in this patient. However, for the given age group, a midgut volvulus is relatively uncommon compared to intussusception. – Acute appendicitis: While it is true that appendicitis can present acutely with a palpable mass and bowel obstruction, it rarely presents with rectal bleeding.
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This question is part of the following fields:
- Paediatric Surgery
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Question 4
Incorrect
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A 9-year-old boy was conservatively managed for an appendicular mass. The parents enquire whether to have an interval appendicectomy to prevent the chances of having appendicitis again. What percentage of patients with conservatively managed appendix mass are likely to develop recurrent appendicitis?
Your Answer: 60-80%
Correct Answer: 0-20%
Explanation:The chance of having appendicitis again after appendix mass is around 17% in children. While the traditional teachings by Hamilton Bailey recommend following the conservative Ochsner-Sherren regimen followed by an interval appendicectomy six weeks after the discharge of the patient, there remains a looming controversy whether to perform an interval appendicectomy or not.
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This question is part of the following fields:
- Paediatric Surgery
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Question 5
Incorrect
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A 16 year old boy was admitted with severe pain and swelling of his scrotum following a kick to the groin. What is the most appropriate management that can be done at this stage?
Your Answer: USG
Correct Answer: Exploratory surgery
Explanation:The most worrying condition is testicular torsion and to exclude it exploratory surgery is required.
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This question is part of the following fields:
- Paediatric Surgery
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Question 6
Correct
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A 1 day old baby girl is born with severe respiratory compromise. She is seen to have a scaphoid abdomen and an absent apex beat. Which anomaly does this baby have?
Your Answer: Bochdalek hernia
Explanation:Answer: Bochdalek herniaA Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5-10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications. Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:-anterior-more often right-sided (,90%)-small-rare (,2% of CDH)-at low risk of prolapseOnly ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or bothLate diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstructionCongenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunctionCongenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.
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This question is part of the following fields:
- Paediatric Surgery
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Question 7
Incorrect
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A 5 month old boy presents with a history of one episode of green vomiting. Upon clinical examination, doctors notice an acutely swollen mass located in the groin, extending to the scrotum. What is the most probable diagnosis and what's the most appropriate management?
Your Answer:
Correct Answer: Incarcerated indirect inguinal hernia, analgesia, sedation and attempt to reduce
Explanation:An incarcerated indirect inguinal hernia presents with abdominal pain, bloating, nausea, vomiting, and intestinal obstruction. It is characterized by the appearance of a tender mass in the inguinal area. Manual reduction in children requires analgesia and sedation.
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This question is part of the following fields:
- Paediatric Surgery
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Question 8
Incorrect
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A 7-year-old girl was brought to the hospital with complaints of fever. 5 days ago, she was taken to her GP with lower abdominal pain and leukocytes 3+ on urine dipstick. She was treated with trimethoprim. On examination, she is found to have a low-grade pyrexia, a CRP of 254 mg/L, and a palpable mass in the right iliac fossa. She is able to consume both solids and liquids. Based on the clinical scenario, what is the probable diagnosis and most appropriate management for this child?
Your Answer:
Correct Answer: This is an appendix mass and intravenous antibiotics where observation is the initial treatment
Explanation:The most appropriate diagnosis for this patient is appendicular mass. The initial treatment, according to the Ochsner-Sherren regimen recommended by Hamilton Bailey, would be the initiation of intravenous antibiotics.RationaleThe presentation is highly suggestive of appendicular mass. The correct management is broad-spectrum intravenous antibiotics such as co-amoxiclav and amikacin plus observation. Conservative management is the preferred treatment as surgical exploration at this stage can result in increased morbidity.The child should be allowed to eat and drink. If there are on-going temperature spikes, signs of obstruction or severe colicky abdominal pain, then surgery is required. The majority of patients respond to conservative management.Other options:- This is a partially treated appendicitis which has formed an appendix mass. Rather than planning appendectomy immediately; Hamilton Bailey recommended interval appendectomy after 6 weeks post-discharge. However, the need for interval appendectomy is still under debate.- Drainage via interventional radiology is not recommended in this patient as it can lead to swinging pyrexia secondary to peritonitis secondary to the collection.- The patient would have high-grade pyrexia and be constitutionally unwell if the patient was a patient of pyelonephritis. The presentation of the patient is more suggestive of appendicular mass.- The history would be more extended with symptoms of weight loss and altered bowel habit if the patient had Crohn’s disease.
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This question is part of the following fields:
- Paediatric Surgery
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Question 9
Incorrect
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A 15-year-old Afro-Caribbean boy presents with a temperature of 37.2C and acute abdominal pain. He has previously undergone a splenectomy secondary to sickle cell disease. Clinically he is jaundiced. An ultrasound scan demonstrates a common bile duct diameter of 10mm. What is the most likely diagnosis?
Your Answer:
Correct Answer: Impacted Gall Stone
Explanation:Based on the clinical scenario provided, this patient most probably has impacted gall stones. Gall stones in children can be caused by haematological diseases such as sickle cell anaemia and thalassemia. Cholesterol stones are also becoming more prevalent. A dilated common bile duct (> 10mm in adults) suggests gall stone impaction. The presence of pyrexia indicates cholecystitis.
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This question is part of the following fields:
- Paediatric Surgery
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Question 10
Incorrect
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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:
Correct Answer: Inflammatory bowel disease
Explanation:Answer: Inflammatory bowel diseaseThe 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.
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This question is part of the following fields:
- Paediatric Surgery
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