25 Best Choice Questions (BCQs) for Pediatric Surgery Postgraduate Trainees
The following 25 BCQs with clinical scenarios cover various topics in pediatric surgery, designed to test the knowledge and clinical reasoning of postgraduate trainees.
BCQ 1: Bilious Vomiting in a Neonate
A 2-day-old term neonate presents with bilious vomiting, abdominal distension, and failure to pass meconium. Abdominal X-ray shows dilated loops of bowel. Which of the following is the most appropriate next step in management?
a) Immediate laparotomy b) Upper GI contrast study c) Contrast enema followed by rectal suction biopsy d) CT scan of abdomen e) Nasogastric decompression and observation for 24 hours
Answer: c) Contrast enema followed by rectal suction biopsy 1
BCQ 2: Necrotizing Enterocolitis
A 32-week preterm infant develops abdominal distension, erythema of the abdominal wall, and feeding intolerance on day 10 of life. X-ray shows pneumatosis intestinalis. The infant's condition deteriorates with signs of perforation. What is the most appropriate surgical management?
a) Conservative management with antibiotics only b) Peritoneal drain placement c) Laparotomy, resection of necrotic bowel, and primary anastomosis d) Laparotomy, resection of necrotic bowel, and stoma creation e) Laparoscopic exploration and lavage
Answer: d) Laparotomy, resection of necrotic bowel, and stoma creation 1
BCQ 3: Intussusception
A 9-month-old infant presents with intermittent abdominal pain, drawing up of legs, and currant jelly stools. On examination, a sausage-shaped mass is palpable in the right abdomen. What is the first-line management?
a) Immediate surgical exploration b) Hydrostatic or pneumatic reduction c) Observation and pain management d) CT scan of abdomen e) Exploratory laparoscopy
Answer: b) Hydrostatic or pneumatic reduction 1
BCQ 4: Appendicitis Diagnosis
A 10-year-old child presents with right lower quadrant pain, anorexia, and fever for 24 hours. Physical examination reveals localized tenderness at McBurney's point. Laboratory studies show WBC of 16,000/μL. What is the most appropriate initial imaging study?
a) CT scan with contrast b) Plain abdominal X-ray c) Ultrasound d) MRI abdomen e) No imaging needed, proceed to surgery
Answer: c) Ultrasound 1
BCQ 5: Esophageal Atresia
A term neonate presents with excessive salivation and respiratory distress. Attempts to pass a nasogastric tube are unsuccessful. Chest X-ray with contrast shows a blind-ending esophageal pouch. Which associated anomaly should be specifically evaluated before surgical repair?
a) Renal anomalies b) Cardiac defects c) Skeletal anomalies d) Anorectal malformations e) Cerebral malformations
Answer: b) Cardiac defects 1
BCQ 6: Congenital Pulmonary Airway Malformation
An infant with recurrent pneumonia in the right lower lobe undergoes CT chest showing a cystic lesion with air-fluid level. What is the most appropriate management?
a) Observation with antibiotic prophylaxis b) Bronchoscopy and lavage c) Surgical resection of the affected lobe d) Percutaneous drainage e) Bronchial artery embolization
Answer: c) Surgical resection of the affected lobe 1
BCQ 7: Inguinal Hernia in Infants
A 6-month-old male infant presents with a right-sided inguinal swelling that appears during crying and reduces spontaneously. What is the most appropriate management?
a) Observation until 2 years of age b) Elective surgical repair c) Immediate emergency repair d) Compression bandage application e) Hernia reduction and watchful waiting
Answer: b) Elective surgical repair 2
BCQ 8: Hypertrophic Pyloric Stenosis
A 4-week-old male infant presents with non-bilious projectile vomiting after feeds and failure to gain weight. On examination, an olive-shaped mass is palpable in the epigastrium. Laboratory studies show hypochloremic, hypokalemic metabolic alkalosis. What is the most appropriate pre-operative management?
a) Immediate surgical correction b) Fluid resuscitation and electrolyte correction c) Trial of medical management with proton pump inhibitors d) Endoscopic pyloric dilation e) Nasogastric tube placement and observation
Answer: b) Fluid resuscitation and electrolyte correction 1
BCQ 9: Imperforate Anus
A newborn male is noted to have no visible anal opening on physical examination. What is the most important initial investigation to determine the type of anomaly?
a) MRI of the pelvis b) Invertogram after 24 hours of life c) Contrast enema d) Abdominal ultrasound e) Perineal ultrasound
Answer: b) Invertogram after 24 hours of life 1
BCQ 10: Malrotation with Midgut Volvulus
A 2-week-old infant presents with sudden onset bilious vomiting and abdominal distension. What is the most appropriate initial diagnostic study?
a) Plain abdominal X-ray b) Upper GI contrast study c) Abdominal ultrasound with Doppler d) CT scan of abdomen e) Diagnostic laparoscopy
Answer: b) Upper GI contrast study 1
BCQ 11: Pediatric Trauma Assessment
A 7-year-old child is brought to the emergency department after being struck by a car. The child is conscious but tachycardic with abdominal tenderness and bruising. FAST scan is positive for free fluid. What is the most appropriate next step in management?
a) Immediate laparotomy b) CT scan of abdomen and pelvis c) Diagnostic peritoneal lavage d) Observation with serial abdominal examinations e) Angioembolization
Answer: b) CT scan of abdomen and pelvis 1
BCQ 12: Undescended Testis
An 18-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 in management?
a) Observation until puberty b) Hormonal therapy with hCG c) Diagnostic laparoscopy d) MRI of the abdomen and pelvis e) Open inguinal exploration
Answer: c) Diagnostic laparoscopy 1
BCQ 13: Pediatric Airway Foreign Body
A 2-year-old child presents with sudden onset coughing and wheezing after playing with small toys. Chest X-ray shows hyperinflation of the right lung. What is the most appropriate management?
a) Observation with bronchodilators b) Chest physiotherapy c) Rigid bronchoscopy under general anesthesia d) Flexible bronchoscopy under sedation e) Antibiotics for presumed pneumonia
Answer: c) Rigid bronchoscopy under general anesthesia 1
BCQ 14: Gastroschisis
A fetus is diagnosed with gastroschisis on prenatal ultrasound. What is the most appropriate mode and timing of delivery?
a) Vaginal delivery at term b) Elective cesarean section at 34 weeks c) Planned vaginal delivery at 36-37 weeks d) Emergency cesarean section when labor begins e) Cesarean section at term
Answer: c) Planned vaginal delivery at 36-37 weeks 1
BCQ 15: Biliary Atresia
A 6-week-old infant presents with persistent jaundice, acholic stools, and dark urine. Laboratory studies show conjugated hyperbilirubinemia. Ultrasound shows a contracted gallbladder. What is the most appropriate next step in management?
a) MRCP (Magnetic Resonance Cholangiopancreatography) b) ERCP (Endoscopic Retrograde Cholangiopancreatography) c) Liver biopsy d) HIDA scan e) Exploratory laparotomy with intraoperative cholangiogram
Answer: e) Exploratory laparotomy with intraoperative cholangiogram 1
BCQ 16: Pediatric Burns
A 5-year-old child sustains a scald burn to the anterior chest and abdomen. The burn appears deep partial thickness and covers approximately 15% of the total body surface area. What is the most appropriate initial fluid resuscitation formula?
a) 2 mL/kg/%TBSA of Lactated Ringer's over 24 hours b) 3 mL/kg/%TBSA of Lactated Ringer's over 24 hours c) 4 mL/kg/%TBSA of Lactated Ringer's over 24 hours d) 2 mL/kg/hour regardless of burn size e) No fluid resuscitation needed for burns <20% TBSA
Answer: c) 4 mL/kg/%TBSA of Lactated Ringer's over 24 hours 1
BCQ 17: 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?
a) Immediate surgical repair b) ECMO (Extracorporeal Membrane Oxygenation) c) Endotracheal intubation and gastric decompression d) High-frequency oscillatory ventilation e) Nitric oxide therapy
Answer: c) Endotracheal intubation and gastric decompression 3
BCQ 18: Wilms Tumor
A 3-year-old child presents with a palpable abdominal mass. Ultrasound and CT scan show a 10 cm heterogeneous mass arising from the left kidney. What is the most appropriate initial management?
a) Percutaneous biopsy b) Neoadjuvant chemotherapy c) Primary surgical resection d) Radiation therapy e) Observation with serial imaging
Answer: c) Primary surgical resection 1
BCQ 19: Pediatric Intestinal Obstruction
A 4-year-old child with a history of previous abdominal surgery presents with abdominal pain, bilious vomiting, and constipation. X-ray shows dilated bowel loops with air-fluid levels. What is the most appropriate initial management?
a) Immediate laparotomy b) Gastrografin follow-through study c) Nasogastric decompression, IV fluids, and observation d) CT scan of abdomen e) Colonoscopy
Answer: c) Nasogastric decompression, IV fluids, and observation 1
BCQ 20: Pediatric Minimal Access Surgery
A 10-year-old child requires an appendectomy for non-perforated appendicitis. Which of the following is the most appropriate surgical approach?
a) Open appendectomy through McBurney's incision b) Laparoscopic appendectomy c) Single-incision laparoscopic surgery (SILS) d) Robotic-assisted appendectomy e) Natural orifice transluminal endoscopic surgery (NOTES)
Answer: b) Laparoscopic appendectomy 1, 2
BCQ 21: Hirschsprung's Disease
A 3-month-old infant presents with chronic constipation since birth, abdominal distension, and failure to thrive. Contrast enema shows a transition zone at the rectosigmoid junction. Rectal suction biopsy confirms the absence of ganglion cells. What is the most appropriate surgical management?
a) Transanal endorectal pull-through b) Duhamel procedure c) Soave procedure d) Swenson procedure e) Temporary colostomy followed by definitive surgery at 1 year of age
Answer: a) Transanal endorectal pull-through 1
BCQ 22: Pediatric Surgical Oncology
A 2-year-old child is diagnosed with a stage III neuroblastoma arising from the left adrenal gland with encasement of major vessels. What is the most appropriate initial management?
a) Complete surgical resection b) Neoadjuvant chemotherapy followed by delayed surgery c) Radiation therapy d) Immunotherapy e) Observation with serial imaging
Answer: b) Neoadjuvant chemotherapy followed by delayed surgery 1
BCQ 23: Pediatric Trauma - Splenic Injury
A 9-year-old child sustains a grade III splenic laceration in a bicycle accident. The child is hemodynamically stable. What is the most appropriate management?
a) Immediate splenectomy b) Splenic artery embolization c) Non-operative management with bed rest and observation d) Partial splenectomy e) Exploratory laparotomy with splenorrhaphy
Answer: c) Non-operative management with bed rest and observation 1
BCQ 24: Tracheoesophageal Fistula
A newborn with esophageal atresia and distal tracheoesophageal fistula develops respiratory distress and pneumonia prior to surgical repair. What is the most appropriate management?
a) Immediate surgical repair b) Gastrostomy tube placement followed by delayed repair c) Endoscopic fistula occlusion d) ECMO support followed by repair e) Bronchoscopic evaluation followed by surgical repair
Answer: e) Bronchoscopic evaluation followed by surgical repair 3
BCQ 25: COVID-19 and Pediatric Surgery
A 7-year-old child requires surgery for acute appendicitis during the COVID-19 pandemic. The child has no symptoms of COVID-19. What is the most appropriate surgical approach?
a) Open appendectomy to minimize aerosolization risk b) Laparoscopic appendectomy with precautions to minimize aerosolization c) Conservative management with antibiotics only d) Delay surgery until COVID-19 testing results are available e) Percutaneous drainage followed by interval appendectomy
Answer: b) Laparoscopic appendectomy with precautions to minimize aerosolization 1, 4