What are some sample Best Choice Questions (BCQs) with clinical scenarios for postgraduate trainees in pediatric surgery?

25 Best Choice Questions (BCQs) for Pediatric Surgery Postgraduate Trainees

Congenital Anomalies

BCQ 1: Biliary Atresia

A 6-week-old infant presents with persistent jaundice since birth. Physical examination reveals hepatomegaly and acholic stools. Laboratory tests show direct hyperbilirubinemia with elevated liver enzymes. Ultrasound shows an absent gallbladder.

What is the most appropriate next step in management?

1. Magnetic resonance cholangiopancreatography (MRCP)
2. Percutaneous liver biopsy
3. Hepatobiliary iminodiacetic acid (HIDA) scan
4. Kasai portoenterostomy
5. Liver transplantation

Answer: 4. Kasai portoenterostomy

Reference: Pediatric Surgical Care Guidelines 1

BCQ 2: Duodenal Atresia

A newborn presents with bilious vomiting within the first 24 hours of life. Abdominal X-ray shows a "double bubble" sign without distal gas.

Which of the following is the most likely associated condition?

1. Hirschsprung disease
2. Down syndrome
3. Cystic fibrosis
4. Meconium ileus
5. Necrotizing enterocolitis

Answer: 2. Down syndrome

Reference: Pediatric Surgical Care Guidelines 1

BCQ 3: Anorectal Malformation

A male newborn is noted to have no visible anal opening. There is meconium in the urine.

Which of the following is the most appropriate initial management?

1. Immediate colostomy
2. Posterior sagittal anorectoplasty
3. Anal dilatation
4. Observation for 24 hours
5. Perineal anoplasty

Answer: 1. Immediate colostomy

Reference: Pediatric Surgical Care Guidelines 1

Pediatric Trauma

BCQ 4: Blunt Abdominal Trauma

A 7-year-old boy presents to the emergency department after falling from a bicycle. He has abdominal pain and tenderness in the left upper quadrant. His vital signs are stable, and hemoglobin is 9.5 g/dL.

What is the most appropriate initial imaging study?

1. Abdominal X-ray
2. Focused assessment with sonography for trauma (FAST)
3. Contrast-enhanced CT scan
4. MRI abdomen
5. Diagnostic peritoneal lavage

Answer: 2. Focused assessment with sonography for trauma (FAST)

Reference: Pediatric Surgical Care Guidelines 1

BCQ 5: Pediatric Head Trauma

An 8-year-old child presents with a Glasgow Coma Scale score of 13 after falling from a tree. There is no loss of consciousness, but the child has vomited twice.

What is the most appropriate management?

1. Immediate craniotomy
2. CT scan of the head
3. Observation for 6 hours
4. Discharge home with head injury instructions
5. MRI of the brain

Answer: 2. CT scan of the head

Reference: Pediatric Surgical Care Guidelines 1

Neonatal Surgical Emergencies

BCQ 6: Necrotizing Enterocolitis

A premature infant (32 weeks gestation) on day 10 of life develops abdominal distension, bloody stools, and feeding intolerance. Abdominal X-ray shows pneumatosis intestinalis.

What is the most appropriate initial management?

1. Immediate laparotomy
2. Bowel rest, antibiotics, and nasogastric decompression
3. Peritoneal drainage
4. Contrast enema
5. Probiotics administration

Answer: 2. Bowel rest, antibiotics, and nasogastric decompression

Reference: Pediatric Surgical Care Guidelines 1

BCQ 7: Congenital Diaphragmatic Hernia

A newborn presents with respiratory distress immediately after birth. Chest X-ray shows bowel loops in the left hemithorax with mediastinal shift to the right.

What is the most important initial management step?

1. Immediate surgical repair
2. Endotracheal intubation and ventilatory support
3. Chest tube placement
4. Extracorporeal membrane oxygenation (ECMO)
5. Nitric oxide therapy

Answer: 2. Endotracheal intubation and ventilatory support

Reference: ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2

Pediatric Oncology

BCQ 8: Wilms Tumor

A 3-year-old child presents with a palpable abdominal mass. Ultrasound reveals a 7 cm solid mass arising from the left kidney.

What is the most appropriate next step?

1. Percutaneous biopsy
2. CT scan of chest and abdomen
3. Immediate nephrectomy
4. Neoadjuvant chemotherapy
5. Radiation therapy

Answer: 2. CT scan of chest and abdomen

Reference: Pediatric Surgical Care Guidelines 1

BCQ 9: Neuroblastoma

A 2-year-old presents with a firm, irregular abdominal mass crossing the midline. CT scan shows a retroperitoneal mass with calcifications encasing major vessels.

Which of the following is the most important prognostic factor?

1. Age at diagnosis
2. Tumor size
3. MYCN amplification
4. Presence of calcifications
5. Vanillylmandelic acid levels

Answer: 3. MYCN amplification

Reference: Pediatric Surgical Care Guidelines 1

Pediatric Urology

BCQ 10: Hypospadias

A 6-month-old boy is noted to have the urethral meatus on the ventral surface of the penis at the junction of the glans and shaft.

What is the optimal timing for surgical repair?

1. Immediately
2. Between 6-12 months of age
3. Between 2-3 years of age
4. Before school entry
5. After puberty

Answer: 2. Between 6-12 months of age

Reference: Pediatric Surgical Care Guidelines 1

BCQ 11: Undescended Testis

A 10-month-old boy has a non-palpable right testis. Ultrasound fails to identify the testis in the inguinal canal.

What is the most appropriate next step?

1. Observation until puberty
2. Hormonal therapy with hCG
3. Diagnostic laparoscopy
4. Open inguinal exploration
5. MRI of the abdomen and pelvis

Answer: 3. Diagnostic laparoscopy

Reference: Pediatric Surgical Care Guidelines 1

Thoracic Surgery

BCQ 12: Congenital Lobar Emphysema

A 2-month-old infant presents with progressive respiratory distress. Chest X-ray shows hyperinflation of the left upper lobe with mediastinal shift.

What is the most appropriate management?

1. Bronchoscopy
2. Chest tube placement
3. Lobectomy
4. Antibiotics and observation
5. Bronchodilator therapy

Answer: 3. Lobectomy

Reference: Pediatric Surgical Care Guidelines 1

BCQ 13: Esophageal Atresia

A newborn has excessive oral secretions and inability to pass a nasogastric tube. Chest X-ray shows the tube coiled in the upper esophagus with a gasless abdomen.

Which type of esophageal atresia is most likely present?

1. Type A (pure esophageal atresia)
2. Type B (proximal TEF)
3. Type C (distal TEF)
4. Type D (proximal and distal TEF)
5. Type E (H-type TEF)

Answer: 1. Type A (pure esophageal atresia)

Reference: Pediatric Surgical Care Guidelines 1

Gastrointestinal Disorders

BCQ 14: Intussusception

A 9-month-old infant presents with intermittent colicky abdominal pain, vomiting, and currant jelly stools. Abdominal ultrasound confirms intussusception.

What is the most appropriate initial management?

1. Immediate laparotomy
2. Laparoscopic reduction
3. Air or hydrostatic enema reduction
4. Observation for spontaneous reduction
5. Antibiotics and bowel rest

Answer: 3. Air or hydrostatic enema reduction

Reference: Pediatric Surgical Care Guidelines 1

BCQ 15: Malrotation with Midgut Volvulus

A 2-week-old infant presents with bilious vomiting and abdominal distension. Upper GI series shows the duodenojejunal junction to the right of the spine.

What is the most appropriate management?

1. Immediate laparotomy and Ladd's procedure
2. Nasogastric decompression and observation
3. Contrast enema
4. Endoscopic reduction
5. Antibiotics and bowel rest

Answer: 1. Immediate laparotomy and Ladd's procedure

Reference: Pediatric Surgical Care Guidelines 1

Hepatobiliary Disorders

BCQ 16: Choledochal Cyst

A 4-year-old girl presents with recurrent abdominal pain, jaundice, and a palpable right upper quadrant mass. MRCP shows a type I choledochal cyst.

What is the most appropriate surgical management?

1. Percutaneous drainage
2. Internal drainage with cystoduodenostomy
3. Complete excision with Roux-en-Y hepaticojejunostomy
4. Liver transplantation
5. ERCP with stent placement

Answer: 3. Complete excision with Roux-en-Y hepaticojejunostomy

Reference: Pediatric Surgical Care Guidelines 1

BCQ 17: Portal Hypertension

A 6-year-old child with known extrahepatic portal vein thrombosis presents with hematemesis. Endoscopy confirms bleeding esophageal varices.

What is the most appropriate long-term management after initial stabilization?

1. Propranolol therapy
2. Repeated endoscopic band ligation
3. Transjugular intrahepatic portosystemic shunt (TIPS)
4. Mesocaval shunt
5. Splenectomy

Answer: 4. Mesocaval shunt

Reference: Pediatric Surgical Care Guidelines 1

Pediatric Surgical Critical Care

BCQ 18: Postoperative Junctional Ectopic Tachycardia

A 2-year-old child develops heart rate of 180-200 bpm with narrow QRS complexes and AV dissociation 6 hours after tetralogy of Fallot repair.

What is the most appropriate initial management?

1. Adenosine administration
2. Synchronized cardioversion
3. Core cooling to 34-35°C
4. Digoxin administration
5. Overdrive atrial pacing

Answer: 3. Core cooling to 34-35°C

Reference: ACCF/AHA/AAP Recommendations for Training in Pediatric Cardiology 2

BCQ 19: Postoperative Fluid Management

A 10 kg child undergoes abdominal surgery. What is the appropriate maintenance intravenous fluid rate in the first 24 hours postoperatively?

1. 40 mL/hr of D5 1/2NS
2. 30 mL/hr of D5 1/4NS
3. 20 mL/hr of D10 1/4NS
4. 10 mL/hr of D5NS
5. 50 mL/hr of D5 1/4NS

Answer: 2. 30 mL/hr of D5 1/4NS

Reference: An Overview of Perioperative Care for Pediatric Patients 3

Minimally Invasive Surgery

BCQ 20: Laparoscopic Appendectomy

A 10-year-old child with acute appendicitis is undergoing laparoscopic appendectomy. During the procedure, a fecalith is noted at the base of the appendix with localized perforation.

What is the most appropriate management?

1. Convert to open appendectomy
2. Continue laparoscopic appendectomy with copious irrigation
3. Place a drain and complete the procedure
4. Perform ileocecectomy
5. Administer intraperitoneal antibiotics only

Answer: 2. Continue laparoscopic appendectomy with copious irrigation

Reference: Pediatric Surgical Care Guidelines 1

BCQ 21: Pneumothorax during Laparoscopy

During a laparoscopic fundoplication in a 2-year-old, the anesthesiologist notes decreased breath sounds on the right side, increased airway pressures, and oxygen desaturation.

What is the most appropriate immediate management?

1. Terminate the procedure immediately
2. Decrease insufflation pressure
3. Release pneumoperitoneum and place a needle thoracostomy
4. Administer 100% oxygen and continue the procedure
5. Convert to open procedure

Answer: 3. Release pneumoperitoneum and place a needle thoracostomy

Reference: An Overview of Perioperative Care for Pediatric Patients 3

Vascular Access

BCQ 22: Central Venous Access

A 3-year-old child with short bowel syndrome requires long-term parenteral nutrition. Which of the following is the most appropriate long-term venous access?

1. Peripherally inserted central catheter (PICC)
2. Tunneled central venous catheter
3. Non-tunneled central venous catheter
4. Implanted port
5. Peripheral venous catheter

Answer: 2. Tunneled central venous catheter

Reference: Pediatric Surgical Care Guidelines 1

BCQ 23: Difficult Intravenous Access

A 2-year-old child requires intravenous antibiotics but has difficult peripheral venous access after multiple attempts.

What is the most appropriate next step?

1. Intraosseous access
2. Cut-down technique
3. Ultrasound-guided peripheral IV placement
4. Central venous catheter placement
5. Intramuscular antibiotics

Answer: 3. Ultrasound-guided peripheral IV placement

Reference: An Overview of Perioperative Care for Pediatric Patients 3

Pediatric Surgical Training

BCQ 24: Pediatric Surgical Competency

A general surgery resident rotating through pediatric surgery is expected to achieve competency in which of the following procedures?

1. Kasai portoenterostomy
2. Repair of congenital diaphragmatic hernia
3. Inguinal hernia repair in infants
4. Pull-through procedure for Hirschsprung disease
5. Repair of esophageal atresia

Answer: 3. Inguinal hernia repair in infants

Reference: Training general surgery residents in pediatric surgery: A Canadian survey 4

BCQ 25: Pediatric Surgical Critical Care Training

A pediatric surgery fellow is completing training in pediatric surgical critical care. Which of the following best describes the recommended primary training experience?

1. Observation of critical care management
2. Consultation service for surgical patients
3. Primary patient management responsibilities
4. Research in critical care outcomes
5. Simulation-based training only

Answer: 3. Primary patient management responsibilities

Reference: A National Assessment of Pediatric Surgical Critical Care Fellowship Structure 5