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free120/Block 2/Question#32 (15.6 difficulty score)
A 27-year-old man comes to the emergency ...
gastric mucosaπŸ”,πŸ“Ί
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 +3 
submitted by thisquestionsucks(9),

Got this one wrong too. Add it to the count. Decided not to pick gastric mucosa, because I was under the impression that Meckel's diverticulum isn't something you would see in a grown man?




 +2 
submitted by lpp06(32),

I think this is actually just a complication of a Meckel's Diverticulum - Acute Meckel's Diverticulitis - which would be consistent with his presentation of acute abdomen + tarry black stools + CT/gross findings. It can be described as a mimic of appendicitis (as seen here).

I think if they wanted us to think this was Crohn's + Meckel they would have given us a more classical Crohn's presentation (skip lesions, insidious onset, non bloody stool)

cheesetouch  2 by 2xm bulge is a hint for meckels too (FA 'rule of 2's) +  
topgunber  Antimesenteric border is a big sign of meckels because its a true diverticulum +  
ih8payingfordis  I don't want to be that guy but rule of 2 in FA refers to 2 inches. Question stem is cm, which is a pretty significant difference. +  



 +2 
submitted by formii27(2),

As per page 378 in FA 2019, this appears to be a classic presentation for Meckels.

-They say its a bulge (I usually associate that with some type of diverticulum)

-"May contain ectopic acid secreting gastric mucosa and/or pancreatic tissue". This is consistent with the inflamed small bowel

-Can cause hematochezia/melena and RLQ abd pain

-Can cause obstruction near the terminal ileum

I originally got this question wrong because for some reason I just associated the fat stranding with Crohns and was just kind of thrown off. Overthinking can really lead to your detriment. Be kind to yourself and know that even if you dont outright know it, your subconscious definitely knows it haha

Good luck everyone!

tekkenman101  Crohn's is not even an answer option? +  
cbrazell92  "Be kind to yourself and know that even if you dont outright know it, your subconscious definitely knows it haha" >>> This is a pearl for all step takers. Stay calm. You have likely done thousands of questions and seen in somewhere +  



 +1 
submitted by screwprometric5(1),

I was thinking Crohns with the multiple episodes over the last year, fat stranding, terminal ileum involvement which would then maybe be describing a false diverticulum involving the mucosa.

barbados  i think you are right. according to this article, CD can lead to meckels d/t transmural inflammation: https://journals.lww.com/ajg/Fulltext/2011/10002/Association_of_Meckel_s_Diverticulum_with_Crohn_s.974.aspx +  
amy  In case anyone is wondering: Fat stranding: "Fat stranding refers to an abnormally increased attenuation in fat. Acute conditions that cause fat stranding include peritonitis; inflammation, infection, or ischemia of the bowel; perforation of colon cancer; inflammation associated with pancreatitis or cholecystitis; trauma; and surgery. Creeping fat (the one associate with Crohn disease): mesenteric fat wrap around the bowel wall, causing it to thicken +  



 +0 
submitted by icedcoffeeislyfe(49),

I think this is a Meckel diverticulum presentation!

alinton  Agreed-Confused b/c Meckel Diverticulum is legit the classic example of a choristoma (p. 221 FA 2019) Maybe they're thinking gastric mucosa is a more specific answer? Idk +4  
step7777  I had the same thought that Meckel's = choristoma = gastric mucosa in the small intestine... +