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Pediatric Surgery ( 7)
Q1. A child presented with bilious vomiting and unstable vitals- abdomen xray showed double bubble sign-
A. Malrotation
B. Malrotation with volvulus
C Esophageal atresia
D Diaphragmatic hernia
Ans b
Malrotation with volvulus. This condition can lead to a duodenal obstruction (mimicking the "double bubble" appearance due to air-fluid levels in the stomach and proximal duodenum) and is a medical emergency, aligning with the unstable vital signs. While duodenal atresia (not listed) is the classic cause of the "double bubble" sign, malrotation with volvulus is the best match from the provided choices.
A. Malrotation – Malrotation alone may present with intermittent symptoms but does not always cause volvulus or instability.
C. Esophageal atresia – Presents with excessive drooling and inability to pass an NG tube, not bilious vomiting.
D. Diaphragmatic hernia – Typically causes respiratory distress due to lung compression, rather than bilious vomiting.
Q2) A new born presented with drooling of saliva and respiratory complaints. Unable to pass Ng to stomach. on cxr there was ng upto chest. What ll be the diagnosis-
A) H shape Tracheo esophageal fistula
B Esophageal pouch proximal and distal
c) Proximal esophageal pouch with abnormal connection of distal esophagus to trachea
d) None
Ans c
The diagnosis of TEF is considered in an infant with excessivesalivation along with coughing or choking experienced at first oral feeding. In addition, curling of the orogastric tube at the level of
thoracic inlet is pathognomonic for esophageal atresia
Five anatomic variants of esophageal atresia. In the most common type
(C lesion), a proximal esophageal atresia with distal TEF
Q3) TOC for a Child with Submucous Cleft Palate with VPI
a) Von Langenbeck
b) furlow z plasty
c) Bardach
d)
Ans b
Submucous cleft palate (SMCP), a type of cleft palate, can lead to velopharyngeal insufficiency (VPI), where the soft palate and pharyngeal wall don't seal properly during speech, causing hypernasal speech and other issues.
VPI occurs when the velopharyngeal port (the opening between the nasal and oral cavities) doesn't close completely during speech, leading to air escaping through the nose.
This can result in hypernasal speech (a voice that sounds like it's coming from the nose) and other speech problems.
Other issues associated with VPI include nasal air emission, nasal regurgitation, and difficulty with certain speech sounds.
Surgical options are
Furlow double opposing Z-plasty:A technique used to reposition the levator muscles of the palate.
Pharyngoplasty:Surgery to improve velopharyngeal closure.
Why not other options
Von Langenbeck – A basic palatal repair technique, but does not lengthen the soft palate, making it less effective for VP Bardach (Two-flap Palatoplasty) – Primarily used for overt cleft palate repair, not ideal for submucous cleft with VPI.
T.I.P. urethroplasty is the most commonly used single-stage technique for distal and midshaft hypospadias.
It involves incising the urethral plate and tubularizing it, leading to a neourethra with good cosmetic and functional outcomes.
Has a low complication rate compared to other techniques.
Why not the others?
Bracka – A two-stage repair, typically used for severe/proximal hypospadias.
Asopa II – A modification of onlay urethroplasty, more commonly used in cases with a narrow urethral plate or proximal hypospadias.
Q5) At what time does primordial germ cells migrate and form genital ridge?
A) 3rd week
b) 5 week
c) 7 week
d) 9 week
B) 5th week
Primordial germ cells (PGCs) originate from the yolk sac endoderm and begin migrating towards the developing gonadal ridge around the 4th to 5th week of embryonic development. They complete their migration by the end of the 5th week, forming the genital ridge, which later differentiates into testes or ovaries depending on genetic and hormonal influences.
Q6. A 3-year-old child presents with intermittent abdominal pain, vomiting, and a palpable right lower quadrant mass. Ultrasound of the abdomen shows a pseudo-kidney sign. What is the most likely diagnosis?
A) Hypertrophic pyloric stenosis B) Intussusception C) Wilms tumor D) Appendicular abscess
B) Intussusception
Explanation: The pseudo-kidney sign on ultrasound represents the bowel wall thickening and layering seen in intussusception. This condition commonly presents in children with colicky abdominal pain, red currant jelly stools, and a palpable mass. Early diagnosis and management with an air or contrast enema can prevent complications.
Q7 The classic Ramstedt pyloromyotomy involves:
A. Circular full-thickness resection of the pylorus B. Longitudinal incision of the serosa and muscle down to the mucosa C. Excision of the hypertrophied antral tissue D. Transverse splitting of the pyloric mucosa
Answer b
Ramstedt pyloromyotomy, first described by Dr. Conrad Ramstedt in 1912, is the standard surgical treatment for infantile hypertrophic pyloric stenosis (IHPS) — a condition characterized by thickening and hypertrophy of the circular muscle fibers of the pylorus, leading to gastric outlet obstruction.
The goal is to split the hypertrophied pyloric muscle so that the underlying mucosa bulges outward, relieving the obstruction without entering the lumen.
The surgeon makes a longitudinal incision through:
The serosa (outer layer)
The hypertrophied circular muscle fibers
This incision extends from the gastric antrum across the pylorus and stops at the duodenal end, just short of the duodenal bulb.
What is not done?
The mucosa is not incised (as in option D). If the mucosa is cut, it’s a complication requiring repair.
There is no excision or resection of muscle or tissue (unlike options A and C).
The pylorus is not removed, but rather relieved by cutting through the constricting muscle fibers.
Key Objective of the Technique:
To open the pyloric channel by splitting the hypertrophied muscle so that food can pass freely from the stomach to the duodenum, preserving the integrity of the mucosal lining
Thyroid
Q8)A 35-year-old woman presents with a 2-week history of painful anterior neck swelling, low-grade fever, and fatigue. Labs show suppressed TSH, elevated free T4, and elevated ESR. A radioactive iodine uptake scan shows diffusely low uptake. She is clinically thyrotoxic with a heart rate of 110 bpm and neck tenderness. What is the most appropriate initial treatment?
A) Carbimazole and propranolol B) Prednisone and levothyroxine C) NSAIDs and propranolol D) Total thyroidectomy
C) NSAIDs and propranolol
Explanation:
This is classic De Quervain’s (subacute) thyroiditis: painful thyroid, thyrotoxicosis, elevated ESR, and low RAIU.
First-line treatment is NSAIDs to reduce pain/inflammation.
Propranolol is used to control adrenergic symptoms of thyrotoxicosis.
Antithyroid drugs (A, E) are not effective because hormone excess is from release, not increased synthesis.
Steroids (B) are used only if NSAIDs fail or pain is severe.
Surgery (D) is not indicated in typical, self-limiting cases.
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