pathology 4 Irritable bowel syndrome-Appendicitis-Diverticula of the GI tract- Zenker diverticulum Meckel diverticulum Malrotation Volvulus Intussusception

Question 1

• Irritable bowel syndrome is diagnosed if at least two of what three criteria are met?

Answer 1

Recurrent abdominal pain that improves after defecation, change in stool frequency, and change in the appearance of stool

Question 2

• A 40-y/o woman has irregular bowel movements and pain that subsides after defecation. She asks if these symptoms are likely to be chronic.

Answer 2

Yes (the patient likely has irritable bowel syndrome, which has chronic symptoms)

Question 3

• What is the treatment for irritable bowel syndrome?

Answer 3

Since the symptoms fluctuate, it is important to reassess the patient’s chief complaint and treat the current symptoms

Question 4

A 13-year-old boy has sharp pain that started at the umbilicus and then migrated toward the right. What test can confirm the diagnosis?

Answer 4

Ultrasound can confirm appendicitis, but cannot not rule it out if clinical suspicion is high (the painful spot is the McBurney point)

Question 5

A boy has 2 days of fever, vomiting, and severe abdominal pain. On work-up, the RLQ is tender and WBC count elevated. What is the treatment?

Answer 5

Surgery (appendectomy for appendicitis)

Question 6

A 21-year-old woman presents with diffuse periumbilical pain and nausea. Other than appendicitis, what condition should be ruled out?

Answer 6

Ectopic pregnancy (ruled out by a β-human chorionic gonadotropin test)

Question 7

A 7-year-old boy is transferred to your ED for suspected appendicitis. What signs would you check for on your physical exam?

Answer 7

Psoas, obturator, and Rovsing signs, & may see pain at the McBurney point, guarding, and rebound tenderness

Question 8

In children, what causes appendicitis?

Answer 8

Obstruction by lymphoid hyperplasia (as opposed to fecaliths in adults)

Question 9

What is a diverticulum?

Answer 9

A blind pouch leading off of the alimentary tract that communicates with the lumen of the tract

Question 10

What is the difference between a true diverticulum and a false diverticulum?

Answer 10

True diverticulum contains three layers (mucosa, submucosa, serosa), whereas false diverticulum contains only two layers (mucosa, submucosa)

Question 11

A 62-year-old man with known diverticulosis has a screening colonoscopy. Where would you most expect to observe a diverticulum?

Answer 11

The sigmoid colon

Question 12

What is the etiology of diverticulosis?

Answer 12

Increased intraluminal pressure combined with focal weakness of the colonic wall

Question 13

A patient is concerned about her likelihood of developing diverticulosis. What dietary change do you suggest?

Answer 13

Increase the amount of dietary fiber

Question 14

A 57-year-old woman presents with vague abdominal discomfort and painless rectal bleeding. What is the most likely diagnosis?

Answer 14

Diverticulosis

Question 15

Diverticulitis classically causes pain in what region of the abdomen?

Answer 15

The left lower quadrant (most commonly occurs in the sigmoid colon)

Question 16

A man with fevers and rectal bleeding is found to have diverticulitis. What are the four most common potential complications?

Answer 16

Perforation, peritonitis, abscess formation, and bowel stenosis

Question 17

A 73-y/o man admitted for LLQ pain and rectal bleeding develops pneumaturia on day 4 of hospitalization. What complication has occurred?

Answer 17

Colovesical fistula (one of the more common complications of diverticulitis)

Question 18

After being diagnosed with diverticulitis, your patient asks about the mainstay of treatment. What do you respond?

Answer 18

Antibiotics, although surgery may be required

Question 19

A patient’s vasa recta perforate the muscularis externa. What is the diagnosis?

Answer 19

Pseudodiverticulum or false diverticulum

Question 20

An 80-year-old woman has vague GI discomfort and hematochezia, along with many people her age. She will most likely have what diagnosis?

Answer 20

Diverticulosis

Question 21

A patient has symptoms similar to appendicitis but instead has the pain on the left side. What is highest on your differential?

Answer 21

Diverticulitis (left-sided appendicitis)

Question 22

What is a Zenker diverticulum?

Answer 22

Herniation of mucosal tissue at Killian triangle, between the thyropharyngeal/cricopharyngeal parts of the inferior pharyngeal constrictor

Question 23

Is Zenker diverticulum a true or false diverticulum?

Answer 23

False diverticulum (it contains only the mucosa and submucosa—a true diverticulum involves all three layers)

Question 24

A patient presents with halitosis and decreased oral intake due to discomfort on swallowing. What is the most likely diagnosis?

Answer 24

Zenker diverticulum

Question 25

In what age and gender group is Zenker diverticulum most common?

Answer 25

Elderly men

Question 26

What is the most common congenital anomaly of the gastrointestinal tract?

Answer 26

Meckel diverticulum

Question 27

A 19-month-old boy has a congenital anomaly causing melena and RLQ pain. What are some potential complications?

Answer 27

Intussusception, volvulus, colonic obstruction (this is a Meckel diverticulum

Question 28

Approximately what size is a typical Meckel diverticulum?

Answer 28

2 inches (the five 2’s: 2 inches long, 2 feet from ileocecal valve, 2% of population, first 2 years of life, 2 epithelial types)

Question 29

How far are Meckel diverticula typically located from the ileocecal valve?

Answer 29

2 feet (the five 2’s: 2 inches long, 2 feet from ileocecal valve, 2% of population, first 2 years of life, 2 epithelial types)

Question 30

In approximately what percentage of the population can Meckel diverticula be found?

Answer 30

2% (the five 2s: 2 inches long, 2 feet from ileocecal valve, 2% of population, first 2 years of life, 2 epithelial types)

Question 31

When in life do Meckel diverticula typically present?

Answer 31

First 2 years (the five 2s: 2 inches long, 2 feet from ileocecal valve, 2% of population, first 2 years of life, 2 epithelial types)

Question 32

A 16-month-old girl has had melena for the past 7 weeks, and sometimes clutches her RLQ. What test can confirm the most likely diagnosis?

Answer 32

Pertechnetate uptake by ectopic gastric mucosa to confirm Meckel diverticulum (in some cases, appendicitis may need to be ruled out)

Question 33

A patient with a Meckel diverticulum has significant pain. What is most likely to be causing it?

Answer 33

Gastric acid secretion from ectopic tissue growth (gastric and/or pancreatic)

Question 34

A newborn has a cystic dilation of the vitelline duct found on exam. Do you need to perform a pertechnetate study?

Answer 34

No, as this finding is more consistent with an omphalomesenteric cyst rather than a Meckel diverticulum

Question 35

An infant is born with an atypical bowel position and Ladd bands on plain film. What is a potential complication of this condition?

Answer 35

Volvulus, duodenal obstruction (this is malrotation in which Ladd bands are peritoneal bands that can obstruct the colon)

Question 36

Malrotation of the gut is due to improper rotation of what fetal structure during development?

Answer 36

The midgut

Question 37

An infant has twisting of a portion of the bowels around its mesentery. Where is this twisting likely to occur?

Answer 37

Midgut (this is volvulus)

Question 38

A 3-year-old presents with loose stools and severe but intermittent lower abdominal pain. What section of the GI tract is likely affected?

Answer 38

The ileocecal junction (this is intussusception, which often presents with classic “currant jelly” stools)

Question 39

Is intussusception found more commonly in adults or infants?

Answer 39

Infants

Question 40

An adult with telescoping bowel on imaging should receive a colonoscopy for what associated condition?

Answer 40

Colon cancer (this is intussusception, which may be a presenting sign of colon cancer in adults)

Question 41

A young child presents with abdominal pain. Abdominal ultrasound shows a “bull’s eye” appearance to a loop of bowel. Do you call surgery?

Answer 41

Yes, as this finding is classically associated with intussusception, which is an abdominal emergency