An immediate surgical opinion within 48 hours is required for a neonate withwhich of the

following?

Correct
Talipes equinovarus True False

Incorrect
Covered myelomeningocoele True False

Correct
Inguinal hernia True False

Correct
Difficulty swallowing True False

Correct
Gastroschisis True False

Herniae will only need immediate surgical attention if incarcerated, etc. Swallowing
difficulties may be due to oesophageal atresia. Gastroschisis is a complete defect through
all layers of the anterior abdominal wall extending up to about 3 cm in length and usually
lying to the right of a normally attached umbilical cord. If possible, delivery should be in a
perinatal center close to the regional pediatric surgical center. Secondary postnatal injury
may occur with myelomeningoceles and although immediate operation at birth does not
reverse neurological deficit, a surgical opinion should be sought.

Next question

Which of the following are true regarding intussusception?

Correct
It is more common in patients with Henoch Schonlein purpura True False

Incorrect
Recurrence occurs in about 20% of patients True False

Correct
It is more common in under 2 months of age True False

Correct
Barium enema is contraindicated True False

Correct
A cause can be identified in more than 50% of patients True False

Intussusception most commonly occurs at the terminal ileum (ie, ileocolic). The telescoping
proximal portion of bowel (ie, intussusceptum) invaginates into the adjacent distal bowel
(ie, intussuscipiens).

The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel
wall quickly leads to obstruction. Venous engorgement and ischemia of the intestinal
mucosa cause bleeding and an outpouring of mucous, which results in the classic
description of "redcurrant jelly" stool.

Most cases (90%) are idiopathic, with no identifiable lesion acting as the lead point or
pathological apex of the intussusceptum.

Intussusception is the predominate cause of intestinal obstruction in persons aged 3 months

to 6 years. Recurrence is observed in 3-11% of cases.

Conservative treatment with barium (or air or saline) enema is effective in up to 80% of
children presenting with intussusception unless diagnosis and treatment is delayed. There
are few reported complications although recurrence occurs in approximately 10% of
patients.
Next question

Which of the following are true regarding anal fissures?

Correct
They can cause constipation True False

Correct
They can cause megacolon True False

Correct
They commonly present with anaemia True False
 Correct
Does not occur in the neonatal period
True False

Incorrect
They are associated with ulcerative colitis
True False

Pain from anal fissures can result in constipation and megacolon. Fissures are a cause of
rectal bleeding at any age. UC is associated with fissures although it is not normally the
cause of simple fissures.
Next question

Which of the following is/are likely causes of tender scrotal swelling in a one day old male
infant?
Correct
Inguinal hernia True False

Incorrect
Breech delivery True False

Correct
Normal response to maternal hormones True False

Incorrect
Torsion of testis True False

Correct
Congenital adrenal hyperplasia True False

Torsion in neonates is rare.

Next question

Indications for tonsillectomy include which of the following?

Correct
Recurrent ear infections True False
 Correct
Sleep apnoea True False

Correct
Mouth breathing True False

Correct
Blocked nasal passages True False

Correct
Recurrent URTIs True False

Absolute indications: Enlarged tonsils that cause upper airway obstruction, severe
dysphagia, sleep disorders, or cardiopulmonary complications; peritonsillar abscess
unresponsive to medical management and drainage; tonsillitis resulting in febrile
convulsions; tonsils requiring biopsy to define tissue pathology
Relative indications: Three or more tonsil infections per year despite adequate medical
therapy; persistent foul taste or breath due to chronic tonsillitis; chronic or recurrent
tonsillitis.

Next question

A three-month-old infant presented with bilious vomiting. Which of the following may
explain the symptoms?
Incorrect
Intestinal atresias True False

Correct
Pyloric stenosis True False

Correct
Physiological jaundice in a healthy neonate True False
 Correct
Gastro-oesophageal reflux True False

Correct
Biliary atresias True False

Bilious vomiting, especially in a young infant, should be considered to be an indication of a

high bowel obstruction such as midgut volvulus, which warrants immediate surgical
consultation.

Next question

Bilious vomiting is seen in

Correct
Gastro-oesophageal reflux True False

Correct
Duodenal atresia True False

Correct
Cystic fibrosis True False

Correct
Hirschprungs disease True False

Correct
Simple inguinal hernia True False

Bile stained vomiting occurs due to bowel obstruction distal to the ampulla of vater. Causes
include duodenal or jejunal atresia, strangulated hernia, meconium ileus secondary to
cystic fibrosis, Hirschprungs disease and malrotation of the gut with volvulus. Gastro-
oesophageal reflux is not a recognised cause of bile stained vomiting.

Which of the following are causes of bile stained vomiting?

 Correct
Hirschsprung's disease True False

Correct
Volvulus True False

Correct
Meconium ileus True False

Correct
Pyloric stenosis True False

Correct
Malrotation True False

Intraluminal causes of intestinal obstruction resulting in bile stained vomiting in the

neonate include meconium ileus, milk curd obstruction and meconium plug syndrome.
Extraluminal causes include malrotation and volvulus.
Complete duodenal obstruction presents with vomiting within 24 h after birth. The vomitus
may or may not be bile stained, depending on whether the obstruction is proximal or distal
to the ampulla of Vater.
Failure to pass meconium within the first 24 h, abdominal distention, bile stained vomiting
and reluctance to feed are the main symptoms of Hirschsprung's enterocolitis
Necrotising enterocolitis presents with abdominal distention and bile stained vomiting.

Which of the following biochemical parameters are consistent with a diagnosis of pyloric
stenosis?

Correct
Hyperchloraemia True False

Correct
Alkalosis True False

Correct
True False
Low PaCO2

Correct
Raised haematocrit True False

Correct
True False
Low total body volume

In pyloric stenosis, volume depletion and H+/Cl- loss occur.

Loss of H+ stimulates more carbonic anhydrase activity to attempt to replace the lost H +
which results in more HCO3- as well. If dudodenal secretion and renal excretion of
bicarbonate are not able to correct this rise in plasma HCO3- then hypochloraemic alkalosis
develops.

Next question

Oesophageal atresia is associated with

Incorrect
Low birth weight True False

Correct
Cardiac defects True False

Correct
Oligohydramnios True False

Correct
Renal abnormalities True False

Correct
Autosomal recessive inheritance True False

Oesophageal atresia is linked to the VACTERL association- Vertebral, Anorectal, Cardiac,

TracheoEsophageal fistula, Renal and Limb abnormalities. Polyhydramnios is a recognised
feature. A tracheo-oesophageal fistula accompanies at least 96% of cases of oesophageal
Next question
atresia.

Which of the following are true Percentage correct: 36%

regarding pyloric stenosis:? Questions correct: 4
Questions completed: 11
Correct
Responses Percentage
85%
correct:
Metabolic alkalosis is due to Responses correct: 47
vomiting Responses incorrect: 8
Responses completed: 55
True
False
Correct
It may present in children
aged 3-4 months

True
False
Incorrect
Barium meal is needed for
diagnosis

True
False
Correct
It is inherited by sex-linked
pattern
 True
False
Correct
It results in bile-stained
vomit
True
False

Pyloric stenosis has a male to

female preponderance of 4:
1. The cause of the condition
is unclear although a
reduced number of cases
occur in babies with blood
group A and there is also a
strong familial pattern of
inheritance. A thickening of
the pyloric muscle results in
gastric outlet obstruction
with resulting vomiting.

Symptoms of projectile
vomiting occurring 10-20 min
after a feed develop between
the second and fourth week
of life, although they can
occasionally occur either
sooner or at up to 4 months
of age. With progressive
vomiting the infants loose
weight and may eventually
become dehydrated and
alkalotic. On clinical
examination gastric
peristaltic activity may be
seen, and palpation of the
right upper quadrant of the
abdomen during a test feed
will reveal the pyloric
tumour in most cases. If the
mass cannot be felt diagnosis
can be aided by a barium
meal by ultrasound.

(12411)
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Intussusception
Correct
Can reduce spontaneously True False

Correct
Can be recurrent True False

Correct
Is not associated with the passage of blood stained stools True False

Correct
Most commonly occurs after the age of 1 year True False

Correct
Always requires surgical intervention True False

Intussusception most commonly occurs between the ages of 6-9 months and can be
recurrent. It classically presents with abdominal pain, pallor, and drawing up of the legs
and the passage of blood stained redcurrant mucous stools. Barium or air enemas can be
used to attempt reduction of the intussusception, however care must be taken if
perforation of the bowel is suspected. It can reduce spontaneously and can often be
treated with air enema reduction rather than surgical laparotomy.

Next question

Which of the following require urgent surgical intervention?

Correct
Umbilical hernia in a 12-month-old True False

Correct
Inguinal hernia in a 3-month-old True False
 Correct
A non-retractile foreskin in a 3-year-old True False

Correct
Tongue-tie in a 3-year-old True False

Correct
A child with large tonsils True False

Inguinal herniae should be corrected in infants although urgent treatment is not required
unless it is complicated by obstruction or ischaemia.

Next question

Which of the following are true in intussussception?

Correct
Barium enema is contraindicated True False

Correct
It is associated with HSP
True False

Correct
It cannot be diagnosed without the presence of altered blood True False

Correct
It presents with constant abdominal pain True False

Correct
It is most common in children >3 years True False
The peak incidence is in infants 3-9 months of age. In infants the lead point is presumed to
be an enlarged Peyer's patch; In older children the lead point may be an invaginated
Meckel's diverticulum, a polyp, an enteric cyst, or haemorrhage into the bowel wall in
Henoch-Schnlein purpura or leukaemia.

The presentation is with a painful cry, intermittent colicky pain and vomiting. The passage
of redcurrant jelly stools is frequent but often late. On examination, between attacks of
colic, an abdominal mass is usually palpable. This is typically sausage shaped and commonly
palpable in the ascending or transverse colon.

Ultrasound can identify a 'target sign' corresponding to the layers of the intussusception.
Occasionally a barium enema may be used diagnostically in frankly obstructed cases. It may
also be used as a therapeutic technique and is frequently successful. Recently air has been
used for reduction rather than barium.

Next question

cute appendicitis
Correct
Can lead to death if untreated True False

Correct
Urinary frequency is not a recognised feature True False

Correct
Ultrasound scanning is a very reliable method for diagnosis True False

Correct
Is largely a clinical diagnosis True False

Correct
Prolonged treatment with IV antibiotics may be required True False

Acute appendicitis can lead to death if untreated. The inflamed appendix undergoes
necrosis and the bowel can perforate leading to peritonitis. The inflamed appendix may lie
next to the bladder and irritate it, leading to increased urinary frequency. Ultrasound
scanning is more useful for detecting an appendix abscess or mass, the diagnosis of an
acute appendicitis itself is still largely made on clinical grounds.
Next question

Exomphalos
 Correct
Is associated with Edwards syndrome True False

Correct
Co-existant abnormalities occur in approximately 40% of cases True False

Incorrect
Has an incidence of 1 in 10,000 True False

Correct
Is associated with Sturge Weber syndrome True False

Correct
Can contain major organs such as the liver and spleen True False

Exomphalos occurs when the contents of the gut herniate into the umbilical cord. The
incidence of exomphalos is approximately 1 in 5000 in the UK. It is associated with
Edwards syndrome, Pataus syndrome and Beckwith-Wiedemann syndrome. Associated
abnormalities occur in up to 40% of cases.

Next question

Congenital hypertrophic pyloric stenosis is associated with

Correct
Characteristic findings on ultrasound True False

Correct
Occurs commonly in girls True False

Correct
Bilious vomiting True False

Correct
Metabolic Acidosis True False
 Correct
Oesophageal atresia True False

Projectile vomiting is associated with congenital hypertrophic pyloric stenosis. Persistent

vomiting leads to a hypochloraemic hypokalaemic alkalosis with a paradoxical aciduria, due
to the kidney excreting hydrogen ions in exchange for sodium ions. A small olive-shaped
mass may be palpable in the upper abdomen, just to the right of the midline, especially
during a test feed. Bile stained vomiting is not seen, as the obstruction is at the pylorus-
Next question
proximal to the ampulla of vater.

Which of the following are true regarding acute appendicitis in preschool children?
Correct
Perforation will not have occurred if temperature is normal True False

Correct
Perforation is more likely than in adolescents True False

Correct
Vomiting is not an early feature True False

Correct
The mortality rate is 5-10% True False

Incorrect
The child is likely to writhe around to relieve the pain True False

Appendicitis is the most common condition for which emergency abdominal surgery is
required in childhood. Its symptomatology and management are similar to those in adults
although in the very young child there may be difficulty in making the appropriate
diagnosis. Classically the condition presents with pain, vomiting and fever. In the preschool
child the diagnosis is also difficult and a high perforation rate is encountered. The
preschool child may present with anorexia, listlessness, fever, vomiting and diarrhoea. The
mortality rate for children with appendicitis ranges from 0.1-1%. A child with appendicitis
typically prefers to lie still due to peritoneal irritation.
Next question
Indications for adeno-tonsillectomy include:

Correct
Obstructive sleep apnoea True False

Correct
Parental desire for the operation to be performed True False

Correct
Repeated episodes of tonsillitis resulting in failure to thrive True False

Correct
Recurrent otitis media True False

Correct
Enlarged tonsils True False

Indications for adeno-tonsillectomy include obstructive sleep apnoea and

repeated episodes of tonsillitis resulting in failure to thrive or time lost from school.
Recurrent ear infections with middle ear effusion would be an indication for
adenoidectomy but there would be no indication for the tonsils to also be removed.
Next question