THEME: GASTROINTESTINAL DISORDERS IN NEONATES

A Infantile hypertrophic pyloric. stenosis

B Intestinal atresia
C Meckel’s diverticulum
D Tracheo-oesophageal fistula
E Intussusception
F Hirschsprung’s disease
G Anorectal atresia
H Mid-gut malrotation
I Meconium ileus
J Necrotising enterocolitis
K Volvulus neonatorum

For each of the case descriptions below, select the most appropriate diagnosis
from the list above. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
An 8-month-old baby boy presents with intermittent episodes of inconsolable crying and
vomiting. The parents say that the baby’s stools are mixed with blood. On examination, a mass is
palpable over the right side of the abdomen.

E Correct answer

Intussusception is caused by invagination of a segment of bowel into its adjoining lower

segment. It is more common in boys and usually occurs under the age of 1 year. Eighty-five
percent are idiopathic. This condition may be associated with Henoch–Schönlein purpura,
submucous lipomas and gastrointestinal lymphomas. Clinical features of intussusception include
severe colicky abdominal pain (classically causing intermittent inconsolable cries with the child
drawing up the legs) and vomiting. Between attacks, the infant may appear in good health. The
stools may have an appearance resembling redcurrant jelly. A sausage-shaped mass may be
palpable on abdominal examination. Rectal examination may reveal blood.

Scenario 2

Incorrect
A newborn baby girl with cystic fibrosis presents with gross abdominal distension and bilious
vomiting. Her abdominal X-ray shows distended coils of bowel, but no fluid levels. Per-rectal
examination reveals an empty rectum.
I Correct answer

Meconium ileus is seen in 1 in 15 000 newborns. This is caused by distal small bowel
obstruction secondary to an abnormally bulky and viscid meconium. Ninety percent of these
infants will have cystic fibrosis, and the viscid meconium is the result of deficient intestinal
secretions. The condition presents during the very early days of life with gross abdominal
distension and bilious vomiting. The rectum is empty. X-ray of the abdomen shows distended
coils of bowel and a typical mottled ‘ground-glass’ appearance; fluid levels are scarce, as the
meconium is viscid.

Scenario 3

Incorrect
A premature infant (28-weeks’ gestation) presents with bloody diarrhoea and a distended and
tense abdomen. On examination, there is erythema over the anterior abdominal wall. The infant
is also manifesting signs of sepsis.

J Correct answer

Necrotising enterocolitis is more common in premature infants. The terminal ileum, the caecum
and the distal colon are the commonly affected sites. The abdomen is distended and tense, and
the infant passes blood and mucus per rectum. Mesenteric ischaemia causes bacterial invasion of
the mucosa, leading to sepsis. Erythema of the anterior abdominal wall suggests full-thickness
necrosis of the bowel with peritonitis. X-rays of the abdomen show distended loops of intestine,
and gas bubbles may be seen in the bowel wall.

Scenario 4

Incorrect
A newborn baby boy presents with mild abdominal distension, bilious vomiting and failure to
pass meconium after 24 hours. Plain abdominal X-ray reveals dilated loops of bowel with fluid
levels, and barium enema demonstrates a segment of the colon with a conical appearance.

F Correct answer

Hirschsprung’s disease, occurring in 1 in every 5000 live births, is also called congenital
megacolon or congenital intestinal aganglionosis. It is due to the absence of ganglion cells in the
neural plexus of the intestinal wall. Hirschsprung’s disease is more common in boys. The
delayed passage of meconium, together with distension of the abdomen following feeds and
bilious vomiting, are the usual clinical features. Plain abdominal X-ray may demonstrate dilated
loops of bowel with fluid levels. Barium enema reveals the affected part of the bowel to have a
conical appearance. This is due to the dilatation of the proximal ganglionic colon and the failure
of the distal aganglionic part to distend. Biopsy of the affected part and anorectal manometric
studies may be needed to confirm the diagnosis.

Theme: Paediatric surgical disorders

A Acute appendicitis
B Duodenal atresia
C Duplication
D Hirschsprung’s disease
E Imperforate anus
F Inguinal hernia
G Intestinal volvulus
H Intussusception
I Malrotation
J Meconeum ileus
K Necrotising enterocolitis
L Pyloric stenosis
M Septicaemia
N Testicular torsion

The following are descriptions of paediatric surgical disorders. Please select the
most appropriate diagnosis from the above list. The items may be used once, more
than once or not at all.

Scenario 1

Incorrect
A 1-day-old full-term infant presents with a 1-day history of abdominal distension and clear
green vomiting; a sweat test reveals sodium and chloride levels >60 mmol/litre. Examination
demonstrates upper abdominal distension. Plain abdominal radiograph shows a ‘soap bubble’
appearance in the right lower quadrant of the abdomen.

M Your answer

J Correct answer
J – Meconeum ileus

The sweat test provides a definitive diagnosis of cystic fibrosis, although this can be confirmed
by gene probe which demonstrates the mutation on the long arm of chromosome 7. Around 10–
15% of affected infants present at birth with meconium ileus. Obstruction is caused by thick,
sticky meconium within the distal ileum lumen. Diagnosis is suspected on plain abdominal
radiograph, which shows dilated loops of bowel, absence of air-fluid levels and a ‘soap bubble’
appearance in the right lower quadrant. If uncomplicated, the obstruction may be relieved by a
therapeutic gastrograffin enema (hyperosmolar and emulsifying action); the success rate is
approximately 55%. If unsuccessful, infants require an enterotomy and mechanical washout.

Scenario 2

Incorrect
A 1-week-old pre-term infant presents with abdominal distension, green-stained vomit and
bleeding per rectum. Examination demonstrates upper abdominal distension. Plain abdominal
radiograph shows intramural intestinal gas.

K Correct answer

K – Necrotising enterocolitis

This predominantly affects pre-term infants, and is one of the commonest surgical emergencies
in the neonatal period. Pathogenesis involves intestinal ischaemia, bacterial colonisation and
translocation, and presence of milk formula in the intestinal lumen. The radiological finding of
intramural gas, (pneumatosis intestinalis), is pathognomonic. Management involves nasogastric
decompression, broad-spectrum antibiotics, fluid resuscitation and parenteral nutrition; it is
successful in 70–80% of cases.

Scenario 3

Incorrect
A 9-month-old full-term infant presents with intermittent episodes of apparent abdominal pain,
associated with vomiting and the passage of blood per rectum. Abdominal examination reveals a
palpable sausage-shaped mass.

B Your answer

H Correct answer

H – Intussusception
This is the most common cause of abdominal emergency in infants between 3 and 24 months,
with incidence peaking at 6–9 months. Most cases are idiopathic, the intussusceptum being an
enlarged Peyer’s patch secondary to a viral infection. The intussusceptum invaginates into
neighbouring bowel, (the intussuscipiens), causing subacute intestinal obstruction and venous
compression of the intussusceptum. The diagnosis may be made on the classical clinical findings
of intermittent, recurrent attacks of screaming and the infant drawing up its knees, passage of
blood per rectum and a palpable sausage-shaped mass. Diagnosis may be confirmed by contrast
enema or ultrasound scan. Reduction, by air or contrast enema under fluoroscopic or ultrasound
control, can be successful in up to 90% of infants.

Scenario 4

Incorrect
A 5-week-old full-term infant presents with a 1-day history of abdominal distension and clear
projectile vomiting. Examination demonstrates a palpable ‘olive-shaped’ mass in the right upper
quadrant.

H Your answer

L Correct answer

L – Pyloric stenosis

This occurs most commonly at 4–6 weeks of age and typically presents with projectile non-
bilious vomiting. Diagnosis is usually made by palpation of an ‘olive-shaped’ mass in the right
hypochondrium. If in doubt, ultrasound is the investigation of choice. Management involves
fluid resuscitation and a pyloromyotomy, which can be performed as open surgery or
laparoscopically.

Theme: Paediatric investigations

A A‘cone’ on contrast enema

B A ‘double-bubble sign’ on plain abdominal X-ray (AXR)
C A ‘target’ lesion on abdominal ultrasound
D A type-II curve on a diuretic renogram
E Air-filled cysts in the left chest
F Clubbed renal calyces on a micturating cystogram
G Hypochloraemic metabolic alkalosis
H Intramural gas on plain AXR
For each of the clinical scenarios below, select the most appropriate feature on investigation from
the above list. Each option may be used once, more than once, or not at all.

Scenario 1

Correct
A 10-hour-old term baby presents with persistent bile-stained vomiting.

B Correct answer

B – A ‘double-bubble sign’ on plain AXR

Persistent bile-stained vomiting (if the atresia is distal to the second part where the common bile
duct enters the duodenum) in a newborn infant may indicate a diagnosis of duodenal atresia. The
typical radiological feature is the ‘double-bubble’ seen on plain AXR (an air-filled dilated
stomach and first part of duodenum, creating two discrete air shadows).

Scenario 2

Incorrect
A 10-day-old baby, born at 30 weeks, presents with bile-stained vomiting and bloody diarrhoea.

H Correct answer

H – Intramural gas on plain AXR

A premature baby presenting with bile-stained vomiting and rectal bleeding is at high risk of
suffering from necrotising enterocolitis. The typical radiological feature of this condition is gas
within the bowel wall on plain AXR. It may be associated with gas in the portal system and/or
free air in the abdomen when the disease progresses to intestinal perforation.

Scenario 3

Incorrect
An 8-month-old infant presents with colicky abdominal pain and bleeding per rectum.

D Your answer

C Correct answer
C – A ‘target’ lesion on abdominal ultrasound

An 8-month-old infant with colicky abdominal pain and rectal bleeding is likely to have
intussusception, which may be diagnosed on abdominal ultrasound by the presence of a ‘target
lesion’ or by gastrografin enema. The ‘target’ lesion represents the layers of the bowel, one
invaginated inside the other, seen in transverse section.

Scenario 4

Incorrect
A 2-day-old baby presents with abdominal distension, bile-stained vomiting and failure to pass
meconium.

A Correct answer

A – A ‘cone’ on contrast enema

Hirschsprung’s disease typically presents in the first few days of life with abdominal distension,
bile-stained vomiting and failure to pass meconium. The diagnosis can easily be made by the
presence of a cone between collapsed distal (usually rectum) and proximal dilated bowel on a
contrast enema. The cone represents the transition zone between normal proximal ganglionated
bowel and distal aganglionic bowel. Confirmation of Hirschsprung’s disease, however, can only
be made on histological biopsy.

Theme: Paediatric conditions

A Intussusception
B Meckel’s diverticulum
C Pyloric stenosis
D Replicated bowel

For each of the patients described below, select the most likely diagnosis from the
list of options above. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 2-year-old presents with bilious vomiting, bleeding per rectum and a sausage-shaped mass in
the abdomen.

A Correct answer

A – Intussusception

A sausage-shaped mass may be seen in intussusception or pyloric stenosis. However, bilious

vomiting is not a feature of pyloric stenosis. Rectal bleeding with the production of ‘redcurrant
jelly’ stools is seen in intussusception.

Scenario 2

Incorrect
A 2-month-old presents with non-bilious projectile vomiting after feeds.

C Correct answer

C – Pyloric stenosis

The patient in question has typical features of pyloric stenosis.

Scenario 3

Incorrect
A 5-year-old presents with bilious vomiting and bleeding per rectum.

B Correct answer

B – Meckel’s diverticulum

Meckel’s diverticulum may give rise to rectal bleeding as 5% of cases have ectopic gastric
mucosa.

Theme: Neonatal surgical diagnoses

A Duodenal atresia
B Exomphalos
C Gastroschisis
D Hirschsprung’s disease
E Imperforate anus
F Mid-gut volvulus
G Necrotising enterocolitis (NEC)
H Oesophageal atresia
I Tracheo-oesophageal fistula

For each of the clinical scenarios given below, select the most likely diagnosis
from the above list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A male infant with trisomy 21, born at term, presents with abdominal distension, bile-stained
vomiting and collapse. There has been no passage of meconium.

D Correct answer

D – Hirschsprung’s disease

Hirschsprung’s disease usually presents in the neonatal period with a history of delayed passage
of meconium, abdominal distension and bilestained vomiting. The infant may be shocked with
impending enterocolitis. Hirschsprung’s disease is more common in children with Down’s
syndrome (trisomy 21). It can be differentiated postnatally from duodenal atresia in which there
is passage of meconium, even in complete atresia.

Scenario 2

Incorrect
An antenatal observation of intestine and liver outside the fetal abdomen.

B Correct answer

B – Exomphalos

Both gastroschisis and exomphalos are frequently diagnosed antenatally. In exomphalos, the
liver is frequently outside the abdomen and the herniated organs are covered by an identifiable
membrane.

Scenario 3
 Incorrect
A previously well male infant, 6 weeks old and born at 35 weeks gestation, presents with bile-
stained vomiting.

F Correct answer

F – Mid-gut volvulus

Bile-stained vomiting in a previously well infant should raise the suspicion of a mid-gut
volvulus.

Scenario 4

Incorrect
A 4-hour-old female infant noted to be ‘frothy’, was born to a mother with polyhydramnios
during pregnancy.

H Correct answer

H – Oesophageal atresia

A baby with oesophageal atresia is frequently born to a mother with polyhydramnios. At birth the
infant is unable to swallow even saliva, which froths through the mouth and nose.

Scenario 5

Incorrect
An 8-day-old female infant presents with respiratory distress at each oral feed.

I Correct answer

I – Tracheo-oesophageal fistula

Oesophageal atresia can occur with or without a tracheo-oesophageal fistula, which itself can
occur in isolation. When an infant feeds, there may be aspiration of milk through the fistula into
the lungs. Occasionally, the infant may be several months old before the diagnosis is made.
Theme: Paediatric newborn gastrointestinal disorders

A Biliary atresia
B Duodenal atresia
C Hirschsprung’s disease
D Intussusception
E Meconium ileus
F Necrotising enterocolitis
G Pyloric stenosis

For each of the patients described below, select the most likely diagnosis from the
list of options above. Each option may be used once, more than once, or not at all.

A child with a scaphoid abdomen and bilious vomiting should be suspected of

having duodenal atresia. Symptoms usually occur in the first few hours of life. The
diagnosis may be made by injecting 30 ml of air via a nasogastric tube and taking a
radiograph. This is not to be confused with the persistent vomiting of hypertrophic
pyloric stenosis, which is not bile stained and presents at 6 weeks.

A child with an abdominal mass, distension, passing meconium for 3 days and now
passing blood, should be suspected of having an intussusception. It is only late in
the disease that bleeding per rectum becomes a feature, suggesting mucosal
necrosis.

Meconium ileus tends to present with a distended abdomen and bilious vomiting
with no passage of meconium. The rectum is characteristically empty. Distal small
bowel obstruction, secondary to abnormally bulky viscid meconium is seen in 1 :
15 000 newborns. Ninety per cent of these infants will have cystic fibrosis.

Hirschsprung’s disease is the most common cause of intestinal obstruction in a

newborn and affects 1 : 5000 children. Typically, there is delay in passing
meconium beyond the first 24 hours of life with abdominal distension and bilious
vomiting. Patients with Hirschsprung’s disease may present after the neonatal
period with chronic constipation or partial large bowel obstruction.

Scenario 1

Incorrect
A 3-day-old child presents with a scaphoid abdomen, and is unable to feed with bilious vomiting.

B Correct answer

B – Duodenal atresia
Scenario 2

Correct
A 10-day-old child presents with a right abdominal mass and distension, with a history of passing
meconium for only three days with the help of suppositories. He is now passing blood per
rectum.

D Correct answer

D – Intussusception

Scenario 3

Incorrect
A baby presents needing enemas to open its bowels owing to a 24-hour delay in passing
meconium.

C Correct answer

C – Hirschsprung’s disease

Theme: Gastrointestinal disorders in neonates

A Ano-rectal atresia
B Hirschsprung’s disease
C Infantile hypertrophicPyloric stenosis
D Intestinal atresia
E Intussusception
F Meckel’s diverticulum
G Meconium ileus
H Mid-gut malrotation
I Necrotising enterocolitis
J Tracheo-oesophageal fistula
K Volvulus neonatorum

For each of the following situations, select the most appropriate cause of
diarrhoea/vomiting from the above list. Each option may be used once, more than
once, or not at all.
Scenario 1

Incorrect
An 8-month-old male baby with haemophilia presents with intermittent episodes of inconsolable
crying and vomiting. The parents say the baby’s stools are mixed with blood. On examination, a
mass is palpable over the right side of abdomen.

D Your answer

E Correct answer

E – Intussusception

Intussusception is caused by invagination of a segment of bowel into its adjoining lower

segment. It is more common in boys and usually occurs under 1 year. Intussusception is
associated with haemophilia, Henoch–Schonlein purpura, haemangiomas and GI lymphomas.
Clinical features include severe colicky abdominal pain (causing intermittent inconsolable cries
with the child drawing up the legs) and vomiting. Between attacks, the infant may appear in good
health. The infant may pass ‘redcurrant jelly’ stools and a sausage-shaped mass is palpable on
abdominal examination. Rectal examination may reveal blood.

Scenario 2

Incorrect
A new-born baby girl with cystic fibrosis presents with gross abdominal distension and bilious
vomiting. Abdominal X-ray shows distended coils of bowel, but no fluid levels. Rectal
examination reveals an empty rectum.

G Correct answer

G – Meconium ileus

Meconium ileus is seen in 1 in 15 000 newborns. This is due to distal small bowel obstruction
secondary to abnormally bulky and viscid meconium. Ninety per cent of these infants will have
cystic fibrosis and the viscid meconium is the result of deficient intestinal secretions. The
condition presents during the very early days of life with gross abdominal distension and bilious
vomiting. X-ray of the abdomen shows distended coils of bowel and a typical mottled ‘ground
glass appearance’. Fluid levels are scarce, as the meconium is viscid.

Scenario 3
 Incorrect
A premature infant (30-week gestation) presents with bloody diarrhoea, and a distended and
tense abdomen. On examination, there is erythema over the anterior abdominal wall. The infant
also manifests signs of sepsis.

H Your answer

I Correct answer

I – Necrotising enterocolitis

Necrotising enterocolitis is more common in premature infants. Terminal ileum, caecum and the
distal colon are the commonly affected sites. The abdomen is distended and tense, and the infant
passes blood and mucus per rectum. Mesenteric ischaemia causes bacterial invasion of the
mucosa leading to sepsis. Erythema of the anterior abdominal wall suggests full-thickness
necrosis of the bowel with peritonitis. X-rays of the abdomen shows distended loops of intestine
and gas bubbles may be seen in the bowel wall.

Scenario 4

Incorrect
A newborn baby boy presents with mild abdominal distension, bilious vomiting, and failure to
pass meconium after 24 hours. Plain abdominal X-ray reveals dilated loops of bowel with fluid
levels and barium enema demonstrates a ‘conical appearance’ in a segment of the colon.

A Your answer

B Correct answer

B – Hirschsprung’s disease

Hirschsprung’s disease is an absence of ganglion cells in the neural plexus of the intestinal wall.
It is more common in males. The delayed passage of meconium together with distension of the
abdomen following feeds and bilious vomiting are the usual clinical features. Plain abdominal X-
ray may demonstrate dilated loops of bowel with fluid levels. Barium enema demonstrates a
‘conical appearance’ in the affected part as a result of the dilated ganglionic proximal colon and
the distal aganglionic bowel failing to distend.
Theme: Paediatrics

A Pyloric stenosis
B Replicated bowel
C Meckel's diverticulum
D Intussusception

For each of the clinical scenarios choose the most likely diagnosis. Each option
may be used once, more than once, or not at all.

A sausage-shaped mass may be seen in intussusception or pyloric stenosis.

However, bilious vomiting is not a feature of pyloric stenosis. Rectal bleeding with
the production of something that looks like red currant jelly is seen in
intussusception. The patient in case 2 has the classic features of pyloric stenosis.
Meckel’s diverticulum may give rise to rectal bleeding because 5% cases have
ectopic gastric mucosa.

Scenario 1

Incorrect
A 2-year-old child with bilious vomiting, per rectum (PR) bleeding and sausage-shaped mass.

D Correct answer

Scenario 2

Incorrect
A 2-month-old girl with non-bilious projectile vomiting after feeds.

A Correct answer

Scenario 3

Incorrect
A 5-year-old child with bilious vomiting and PR bleeding.

C Correct answer
Theme: Paediatric newborn gastrointestinal disorders

A Hirschsprung's disease
B Intussusception
C Meconium ileus
D Duodenal atresia
E Necrotising enterocolitis
F Pyloric stenosis
G Biliary atresia

For each of the patients described below, select the most likely diagnosis from the
list of options above. Each option may be used once, more than once or not at all.
You may believe that more than one diagnosis is possible but you should choose
the ONE most likely diagnosis.

Scenario 1

Incorrect
A one-day-old baby presents with scaphoid abdomen, bilious vomiting and unable to feed.

D Correct answer

Duodenal atresia should be suspected in a child with a scaphoid abdomen and bilious vomiting.
Vomiting and duodenal atresia may occur in the first few hours of life. The diagnosis may be
confirmed by injecting 30 ml of air via a nasogastric tube and taking a radiograph.

Scenario 2

Incorrect
A 10-day-old baby is brought to the emergency department with right abdominal mass and
distension. The child passed meconium for 3 days with the help of suppository and is now
passing blood per rectum (PR).

D Your answer

B Correct answer

Intussusception should be suspected in a child with an abdominal mass, distension, passing

meconium for three days and now passing blood. This is a fairly classical history. It is only late
on in the progression of the disease that per recum bleeding become a feature; this is suggestive
of mucosal necrosis.

Scenario 3

Incorrect
An one-week old baby is brought to the emergency department with unremitting cry, distended
abdomen and bilious vomiting. The child has not passed meconium since birth. Per rectal
examination reveals an empty rectum.

A Your answer

C Correct answer

Meconium ileus tends to present with a distended abdomen and bilious vomiting with no passage
of meconium. The rectum is characteristically empty; 1:15000 new-borns have a distal small
bowel obstruction secondary to abnormally bulky viscid meconium. Ninety per cent of these
infants will have cystic fibrosis.

Scenario 4

Incorrect
A three-day old baby needs enema to open bowels due to delay in passing meconium for greater
than 24 h.

F Your answer

A Correct answer

Hirschsprung’s disease is the most common cause of intestinal obstruction in a new-born and
affects 1:5000 children. Typically there is delay in passing meconium beyond the first 24 h of
life, with abdominal distension and bilious vomiting. Individuals affected with Hirschsprung’s
disease may also present in their adult life with chronic constipation or subtotal large bowel
obstruction.

Theme: Paediatrics
A Oesophageal atresia with tracheo-oesophageal fistula
B Oesophageal atresia without tracheo-oesophageal fistula
C Diaphragmatic hernia - congenital
D Malrotation of the gut

For each of the patients described below, select the most likely diagnosis from the
list of options above. Each option may be used once, more than once or not at all.
You may believe that more than one diagnosis is possible but you should choose
the ONE most likely diagnosis.

Scenario 1

Incorrect
A 10-day-old baby presents with displaced apex beat and bowel sounds heard on auscultation of
chest.

C Correct answer

Diaphragmatic hernia occurs on the left side in 85% of cases. Half of these babies will have
associated congenital defects. The apex beat of the heart is obviously shifted and can be felt
to the right of the midline.

Scenario 2

Incorrect
A 5-day-old baby presents with inability to feed and vomiting. It is not possible to pass a
nasogastric tube beyond T3. Gas bubble seen is seen in the stomach.

A Correct answer

Scenario 3

Incorrect
An 1-day-old baby presents with scaphoid abdomen and profuse vomiting. X-ray shows no
gastric bubble.

B Correct answer

Oesophageal atresia should be suspected antenatally if the fetal stomach is consistently

empty on ultrasound scan. However, the presence of a distal tracheo-oesophageal fistula
usually allows enough amniotic fluid to be swallowed and reach the stomach. Typically, it is
unable to pass a nasogastric tube beyond thesecond or third thoracic vertebral body. Gas in
the stomach indicates a distal tracheo-oesophageal fistula.

Theme: Paediatric gastro-intestinal disorders

A Hypertrophic pyloric stenosis

B Intussusception
C Gastro-oesophageal reflux
D Mid-gut volvulus
E Meckel's diverticulum

For each of the patients described below, select the single most likely diagnosis
from the options listed above. Each option may be used once, more than once or
not at all.

Scenario 1

Incorrect
A boy aged 6 months presents with colicky abdominal pain, two episodes of bilious vomiting and
rectal bleeding. On examination the abdomen is tender in the right hypochondrium and there is a
sausage-shaped palpable mass.

B Correct answer

This is typical of intussusception where the child presents with colicky abdominal pain,
vomiting, lethargy, palpable abdominal mass and rectal bleeding. Enema reduction may be
successful and where that fails or there are signs of peritonism then surgery is needed

Scenario 2

Incorrect
A 1-week-old baby presents with profuse bilious vomiting and a tender abdomen. There is no
palpable mass.
D Correct answer

A mid-gut volvulus must be excluded. Malrotation with volvulus usually presents in the first
week of life but may occur at any age. The vomiting is bile stained. An

urgent barium meal will diagnose malrotation. If volvulus goes unrecognised the entire mid-gut
may become ischaemic.

Scenario 3

Incorrect
A girl aged 2 years presents with dark red rectal bleeding and pallor. There has been no vomiting
and abdominal examination is unremarkable.

E Correct answer

Meckel’s diverticulum occurs in approximately 2% of the population and in a small proportion of

these there is ectopic gastric mucosa. Acid produced causes ulceration of the adjacent small
bowel. Bleeding usually presents as painless ‘brick red’ stools with anaemia.

Scenario 4

Incorrect
A 4-week-old girl presents with copious non-bilious vomiting after all her feeds for 1 week. She
has lost weight and the serum bicarbonate is 34 mmol/l.

A Correct answer

Pyloric stenosis affects approximately 1 in 450 infants. It presents with vomiting after feeds, is
practically never bile stained and usually projectile. The child will eventually become dehydrated
and loose weight. On examination there is the classical ‘olive’ pyloric tumour.

Theme: Kidney swellings in children

A Hypernephroma
B Wilms' tumour
C Hepatoma
D Hydronephrosis
E Duplication cyst
F Polycystic kidney disease

For each of the patients described below, select the single most likely diagnosis
from the options listed above. Each option may be used once, more than once or
not at all.

Scenario 1

Incorrect
A 4-year-old with solid right-sided mass.

B Correct answer

Commonest renal tumour is a nephroblastoma (Wilms’ tumour). It presents most commonly from
birth to 5 years of age. Ten per cent are bilateral. Presentation is in 90% of cases with a hard
lateral abdominal mass. Ten per cent present with fever, poor appetite, loss of weight and/or
haematuria.

Scenario 2

Incorrect
An 8-month-old boy, with right renal angle mass. Ultrasound shows multiple cysts in both
kidneys and liver.

B Your answer

F Correct answer

Infantile Polycystic kidney disease is an autosomal recessive disease affecting the kidneys and
the liver. The kidney enlargement (bilateral) is conspicuous at birth or early infancy.

THEME: PAEDATRIC GASTROINTESTINAL DISORDERS

A Hypertrophic pyloric stenosis
B Intussusception
C Gastrooesophageal reflux
D Mid-gut volvulus
E Meckel's diverticulum

For each of the patients described below, select the single most likely diagnosis
from the options listed above. Each option may be used once, more than once, or
not at all.

Scenario 1

Incorrect
A 6-month-old boy presents with colicky abdominal pain, two episodes of bilious vomiting and
rectal bleeding. On examination, the abdomen is tender in the right hypochondrium and there is a
sausage-shaped palpable mass.

B Correct answer

These symptoms are typical of intussusception, where the child presents with colicky abdominal
pain, vomiting, lethargy, palpable abdominal mass and rectal bleeding. Enema reduction may be
successful, and where that fails, or there are signs of peritonism, then surgery is needed.

Scenario 2

Incorrect
A 1-week-old baby presents with profuse bilious vomiting and a tender abdomen. There is no
palpable mass.

D Correct answer

A mid-gut volvulus must be excluded. Malrotation with volvulus usually presents in the first
week of life but may occur at any age. The vomiting is bile stained. An urgent barium meal will
diagnose malrotation. If volvulus goes unrecognised the entire mid gut may become ischaemic.

Scenario 3

Incorrect
A 2-year-old girl presents with dark red rectal bleeding and pallor. There has been no vomiting
and an abdominal examination is unremarkable.
E Correct answer

Meckel’s diverticulum occurs in approximately 2% of the population, and in a small proportion

of these there is ectopic gastric mucosa. The acid produced causes ulceration of the adjacent
small bowel. Bleeding usually presents as painless ‘brick red’ stools with anaemia.

Scenario 4

Incorrect
A 4-week-old girl presents with copious non-bilious vomiting after all her feeds for 1 week. She
has lost weight and the serum bicarbonate is 34 mmol/l.

A Correct answer

Pyloric stenosis affects approximately 1 in 450 infants. It presents with vomiting after feeds, is
practically never bile stained and is usually projectile. The child will eventually become
dehydrated and lose weight. On examination, there is the classical ‘olive’ pyloric tumour.

THEME: KIDNEY SWELLINGS IN CHILDREN

A Hypernephroma
B Wilm's tumour
C Hepatoma
D Hydronephrosis
E Duplication cyst
F Polycystic kidney disease

For each of the patients described below, select the single most likely diagnosis
from the options listed above. Each option may be used once, more than once, or
not at all.

Scenario 1

Incorrect
A 4-year-old child presents with a solid right-sided mass.
B Correct answer

The most common renal tumour is a nephroblastoma (Wilm’s tumour). It presents most
commonly from birth to 5 years of age. 10% are bilateral. Presentation in 90% of cases is with a
hard lateral abdominal mass. 10% of patients present with fever, poor appetite, loss of weight
and/or haematuria.

Scenario 2

Incorrect
An 8-month-old boy presents with right renal angle mass. An ultrasound shows multiple cysts in
both kidneys and liver.

F Correct answer

Infantile polycystic kidney disease is an autosomal recessive disease affecting the kidneys and
the liver. The kidney enlargement (usually bilateral) is conspicuous at birth or in early infancy.