NBME 21 Diverticulitis (NBME Answers)

NBME 21 Answers

nbme21/Block 2/Question#12 (reveal difficulty score)
A 66-year-old woman comes to the physician ...
Diverticulitis 🔍 / 📺 / 🌳 / 📖
tags:

+7 upvote downvote
submitted by nuts4med(8)

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I was thinking Chron’s because of the narrowing of the lumen and the picture seemed like there was creeping fat. Now that I think about it though, the LLQ and constipation should have led towards diverticulitis pretty quickly.

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suckitnbme Also agree the narrowing of the lumen plus the pic is pointing towards Crohn's. The acute systemic sx of fever and chills is what made me go with diverticulitis (along with the hx of increasing constipation). +2

pg32 Why does the question say there is NARROWING OF THE LUMEN? Does that happen in diverticulitis? I went with Chron's at the last second against my better judgment because Chron's can cause strictures/narrowing of the lumen. +2

lola915 FA 2020 pg.383 Most common area for Diverticulosis to take place is the sigmoid colon and diverticulitis can cause obstruction (inflammatory stenosis). The key here is recognizing the risk factors (>60, chronic constipation) and signs of acute inflammation (fever, chills and LLQ pain). +4

+6 upvote downvote
submitted by ∗imgdoc(183)

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The clinical presentation is that of lower abdominal pain, fever, and chills. This alone made me think it was an inflammatory process. Also the question says there are 3 separate poorly delimited regions of narrow lumen. As far as ulcerative colitis is concerned, there are no skip lesions, it is continuous wherever it is. This coupled with the history of constipation makes diverticulitis the best answer choice.

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lovebug I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +2

trazobone Granulomatous colitis is Chron’s, which also doesn’t fit bc it presents commonly in the terminal ileum and does not usually present with fever as it is an inflammatory pathology rather an infectious one. While it does present with string sign (“narrowing of the lumen”), anything can cause a narrowing of the lumen, so this doesn’t necessarily mean that it’s string sign +3

+5 upvote downvote
submitted by ∗an_improved_me(91)

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I would have easily chosen granulomatous colitis... had i known it is the same thing as Crohns. Shout out to ignorance and its bliss.

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+4 upvote downvote
submitted by ∗usmleuser007(464)

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Don't this is UC or Crohns. For this question you have to have noticed the age (66 year-old). Lower left quadrant = diverticulitis of elderly & Lower right quadrant = angiodysplasia of elderly (think these were mentioned in Pathoma)

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pfebo Also, the patient has fever +

+1 upvote downvote
submitted by logical_champion(1)

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I think it is good to note the demographics. The patient is female and old. That, along with the constipation, made me lean more towards diverticulitis. IBD usually develops in younger persons.

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privatejoker Does the obviously darkened area not point at all towards ischemia of any kind? Maybe I am blind, but I don't see anything that remotely looks like an obstructive diverticulum in this picture. I feel like I would have gotten this question correct if no picture had been provided at all because the symptoms described absolutely pointed towards diverticulitis otherwise. I actually changed my answer because of the image lol +24

sahusema Picture is a bullshit distractor +2

lola915 From what I've seen on practice tests and advice i've gotten is that often if the picture is given along with an already complete clinical picture it's often a distractor. I also was going between ischemia and diverticulitis but then remembered that clinical signs in the vignette trump everything else. +2

alimd they dont give a fuck about pictures +

+1 upvote downvote
submitted by egghead(1)

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What is with the picture? I just would never pick diverticulitis without seeing a diverticulum...

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quaper I spent so long looking at that picture and thinking what the heck are they trying to show me here. I couldn't see any diverticuli, didn't see any cobblestoning, figured the dark patch in between the white patches was necrosis in the end. +10

step1soon https://www.google.com/search?q=diverticulitis+gross+pathology&sxsrf=ACYBGNQOIbK7_DEYAoCCjRy2MZ18h_kY6g:1569188132803&source=lnms&tbm=isch&sa=X&ved=0ahUKEwig_PapseXkAhXUbsAKHSEhDMsQ_AUIEygB&biw=1920&bih=969#imgrc=1GGMCNmDeXv5kM: Check our the gross pathology → makes sense now +1

+1 upvote downvote
submitted by ∗burak(71)

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What does 3 narrowin means? Is that a cause of diverticulary diseases or the result?? And what is that photo means :/

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lola915 Yes, diverticulitis causes inflammatory stenosis (obstruction) +

+0 upvote downvote
submitted by ∗angelaq11(83)

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I first chose diverticulitis because of the history, but then I saw the picture, and honestly I wish I hadn't. I didn't see ANY diverticulum, so I thought...hmmm, they're want to "trick" me into choosing diverticulitis, but it's actually "something else"... :'( :'(

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+0 upvote downvote
submitted by ∗chandlerbas(118)

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remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

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chandlerbas one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +

chandlerbas wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2

-1 upvote downvote
submitted by ∗vonhippelindau(21)

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I picked Crohn’s too. I think the severe constipation over 5 years distracted me.

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haliburton i think it is critical to remember that constipation is what caused the diverticulosis. +3

lola915 Crohn's presents with +/- bloody diarrhea, not constipation +

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