Snapshot A 2-year-old boy with no significant past medical history presents with bright red blood per rectum in his diaper. His parents were immediately concerned and called the pediatrician. The patient is not in much pain but cries when the RLQ is palpated. A technetium-99m scan comes back positive for Meckel’s diverticulum. Introduction Congenital diverticulum presenting in childhood note, is a “true” diverticulum, with all 3 layers of the gut wall outpouched note, distinct from diverticulosis (false diverticula) and diverticulitis (inflammation of diverticula) Pathogenesis persistence of vitelline (omphalomesenteric) duct in small intestine may have ectopic acid-secreting gastric or pancreatic tissue Epidemiology most common congenital anomaly of gastrointestinal tract Rule of 2’s affects 2% of population 2 feet from ileocecal valve 2 inches long 2 types of epithelia tissue: gastric and pancreatic male:female ratio 2:1 patients < 2 years old 2% symptomatic Presentation Symptoms painless rectal bleeding due to gastric acid secretion causing damage to small bowel tissue RLQ pain may serve as lead point for intussusception small bowel obstruction Evaluation Most commonly discovered as incidental finding on laparotomy Technetium-99m scan aka Meckel scan most accurate test technetium-99m pertechnetate radioisotope is taken up by ectopic gastric mucosa Upper GI series with small bowel follow-through can also detect Differential Diagnosis Intussusception Appendicitis Hirschsprung’s disease Treatment Surgical removal Prognosis, Prevention, and Complications Complications hemorrhage (most common) SBO diverticulitis perforation
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M1.GI.4740) A mother brings her 2-year-old son to the pediatrician following an episode of abdominal pain and bloody stool. The child has otherwise been healthy and growing normally. On physical exam, the patient is irritable with guarding of the right lower quadrant of the abdomen. Based on clinical suspicion, pertechnetate scintigraphy demonstrates increased uptake in the right lower abdomen. Which of the following embryologic structures is associated with this patient’s condition? Review Topic QID: 108653 1 Metanephric mesenchyme 6% (13/212) 2 Ductus arteriosus 3% (6/212) 3 Vitelline duct 68% (145/212) 4 Paramesonephric duct 8% (16/212) 5 Allantois 12% (26/212) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.GI.64) A concerned father brings his 2 year-old son to the clinic for evaluation. In the past 24 hours, the child has had multiple episodes of painless bloody stools. On physical examination, the child's vital signs are within normal limits. There is mild generalized discomfort on palpation of the abdomen but no rebound or guarding. A technetium-99m (99mTc) pertechnetate scan indicates increased activity in two locations within the abdomen. Cells originating in which organ account for the increased radionucleotide activity? Review Topic QID: 106459 1 Stomach 56% (10/18) 2 Pancreas 11% (2/18) 3 Small intestine 28% (5/18) 4 Gallbladder 0% (0/18) 5 Liver 0% (0/18) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M1.GI.43) A 2-year-old female with abdominal pain undergoes laparoscopic surgery. An outpouching of tissue is excised from the ileum and sent to the laboratory for evaluation. The pathologist notes inflammation and the presence of mucosa, submucosa, and muscle in the walls of the specimen. Which of the following is the most likely diagnosis? Review Topic QID: 101937 1 Hirschprung's disease 5% (7/152) 2 Crohn's disease 9% (13/152) 3 Meckel's diverticulum 83% (126/152) 4 Appendicitis 3% (4/152) 5 Henoch-Schonlein purpura 0% (0/152) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.GI.70) A 1-year-old previously healthy male presents to the emergency department with 3 hours of intermittent abdominal pain, vomiting, and one episode of dark red stools. On exam, his abdomen is tender to palpation and there are decreased bowel sounds. A CT scan reveals air fluid levels and a cystic mass in the ileum. Gross specimen histology reveals gastric tissue. What is the cause of this patient's problems? Review Topic QID: 106478 1 Obstruction of the lumen of the appendix by a fecalith 7% (1/14) 2 Abnormal closure of the vitilline duct 57% (8/14) 3 Twisting of the midgut secondary to malrotation 36% (5/14) 4 Hypertrophy of the pylorus 0% (0/14) 5 Ingestion of contaminated water 0% (0/14) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.GI.33) An 8-month-old boy is brought to the emergency room by his mother who notes that the child has not been passing stool regularly. Palpation and radiographic imaging of the umbilical region reveal the presence of fecal material in an abnormal out-pocketing of bowel. Which of the following is a common complication seen in this condition? Review Topic QID: 101927 1 Enlarged rugal folds 12% (9/78) 2 Dysplasia 3% (2/78) 3 Ulceration 36% (28/78) 4 Megacolon 42% (33/78) 5 Paneth cell metaplasia 5% (4/78) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.GI.2) A 2-year-old male is brought to his pediatrician by his mother because of abdominal pain and blood in the stool. Scintigraphy reveals uptake in the right lower quadrant of the abdomen. Persistence of which of the following structures is the most likely cause of this patient's symptoms? Review Topic QID: 101896 1 Urachus 5% (2/38) 2 Omphalomesenteric duct 63% (24/38) 3 Paramesonephric duct 5% (2/38) 4 Allantois 13% (5/38) 5 Ureteric bud 0% (0/38) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2