Diverticular Disease — MCQs
A 28-year-old previously healthy woman arrives in the emergency room complaining of 24 hours of anorexia and nausea, and lower abdominal pain that is more intense in the right lower quadrant than elsewhere. On examination, she has peritoneal signs in the right lower quadrant and a rectal temperature of 38.38°C (101.8°F). At exploration through an incision in the right lower quadrant, she is found to have a small, contained perforation of a cecal diverticulum. Which of the following statements regarding cecal diverticula is true?
What is the treatment of choice for a 70-year-old male patient who presents with peritonitis secondary to ruptured diverticulitis?
A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?
Which extra-intestinal symptom of inflammatory bowel disease worsens with exacerbation of disease activity?
Massive bleeding per rectum in an elderly patient is due to.
A patient presented with diarrhea, poor appetite and malabsoption. His duodenal biopsy was taken which showed crypt hyperplasia, villous atrophy and infiltration of CD8+ T cells in the epithelium. What is the likely diagnosis of the patient?
All of the following are pathological features associated with Crohn's disease except which of the following?
Which histological feature is more characteristic of ulcerative colitis than Crohn's disease?
The histopathological image shows a section of colon. What histological feature seen in the image is more characteristic of Ulcerative Colitis than Crohn's Disease?
Which of the following is a histological feature of Whipple's disease -
Diverticular Disease Indian Medical PG Practice Questions and MCQs
Question 1: A 28-year-old previously healthy woman arrives in the emergency room complaining of 24 hours of anorexia and nausea, and lower abdominal pain that is more intense in the right lower quadrant than elsewhere. On examination, she has peritoneal signs in the right lower quadrant and a rectal temperature of 38.38°C (101.8°F). At exploration through an incision in the right lower quadrant, she is found to have a small, contained perforation of a cecal diverticulum. Which of the following statements regarding cecal diverticula is true?
- A. Diverticulectomy, closure of the cecal defect, and appendectomy may be indicated. (Correct Answer)
- B. Cecal diverticula are often solitary but rarely require surgical intervention.
- C. Cecal diverticula are typically acquired pseudodiverticula like sigmoid diverticula.
- D. Cecal diverticula are pseudodiverticula that commonly present with perforation.
Explanation: **Diverticulectomy, closure of the cecal defect, and appendectomy may be indicated.** - In cases of **perforated cecal diverticulitis**, surgical management often involves **diverticulectomy** to remove the inflamed diverticulum. - **Closure of the cecal defect** is necessary to prevent further leakage, and **appendectomy** is frequently performed concurrently to eliminate potential future diagnostic confusion given the similar presentation with appendicitis. - This is the **correct management** for the clinical scenario of a contained perforation. *Cecal diverticula are often solitary but rarely require surgical intervention.* - While cecal diverticula are often **solitary**, they frequently require surgical intervention when symptomatic or perforated as seen in this clinical scenario. - Symptomatic cecal diverticula, particularly those with **inflammation or perforation**, demand surgical management due to risks of complications like peritonitis. *Cecal diverticula are typically acquired pseudodiverticula like sigmoid diverticula.* - This is **incorrect**. Cecal diverticula are typically **congenital true diverticula** involving all layers of the bowel wall (mucosa, submucosa, and muscularis propria). - In contrast, sigmoid/colonic diverticula are **acquired pseudodiverticula** that contain only mucosa and submucosa herniating through the muscle layer. *Cecal diverticula are pseudodiverticula that commonly present with perforation.* - This is **incorrect**. Cecal diverticula are **true diverticula**, not pseudodiverticula, containing all layers of the intestinal wall. - While perforation can occur (as in this case), it is not a **common** presentation; most remain asymptomatic or present with inflammation mimicking appendicitis.
Question 2: What is the treatment of choice for a 70-year-old male patient who presents with peritonitis secondary to ruptured diverticulitis?
- A. Conservative
- B. Primary resection and anastomosis
- C. Whipple procedure
- D. Hartmann's procedure (Correct Answer)
Explanation: ***Hartmann's procedure*** - For **peritonitis secondary to ruptured diverticulitis** in an elderly patient, a Hartmann's procedure is often the safest choice, involving resection of the diseased bowel and creation of an **end colostomy**. - This procedure avoids a primary anastomosis in the presence of **sepsis** and inflammation, reducing the risk of anastomotic leak in a high-risk patient. *Conservative* - **Conservative management** with antibiotics is typically reserved for **uncomplicated diverticulitis** (i.e., no perforation or generalized peritonitis). - Given the presence of **peritonitis**, a surgical intervention is necessary to address the source of infection and contamination. *Primary resection and anastomosis* - While possible in select, hemodynamically stable patients with localized contamination, **primary anastomosis** carries a higher risk of **anastomotic leak** in the setting of diffuse peritonitis and inflammation. - This approach is generally avoided in elderly patients with significant contamination due to increased morbidity and mortality risks. *Whipple procedure* - The **Whipple procedure**, or pancreaticoduodenectomy, is a complex surgical operation to remove the **head of the pancreas**, duodenum, gallbladder, and part of the bile duct. - It is used to treat **pancreatic cancer** and other tumors of the periampullary region, and is completely unrelated to diverticular disease or peritonitis.
Question 3: A patient presents with abdominal pain, blood in stools and a palpable mass on examination. A Barium Study was performed, probable diagnosis is?
- A. Volvulus
- B. Meckel's Diverticulum
- C. Diverticulitis
- D. Intussusception (Correct Answer)
Explanation: ***Intussusception*** - This condition is characterized by a "telescoping" of one segment of the intestine into another, which can lead to **abdominal pain**, **rectal bleeding** (often described as "currant jelly" stools), and a **palpable sausage-shaped mass** on examination. - A barium study (specifically a **barium enema**) is often diagnostic and can also be therapeutic for intussusception, revealing a **coiled spring appearance** or an obstruction. *Volvulus* - Volvulus involves the **twisting of a loop of bowel** around its mesentery, often presenting with sudden onset, severe **abdominal pain**, vomiting, and constipation. - While it can cause an obstruction and pain, a palpable mass and bloody stools are less common initial findings compared to intussusception. *Meckel's Diverticulum* - Meckel's diverticulum is a **congenital outpouching** of the small intestine that can be asymptomatic or cause complications like **gastrointestinal bleeding** (due to ectopic gastric mucosa), obstruction, or diverticulitis. - While it can cause painless rectal bleeding, a palpable mass and acute, intermittent abdominal pain are not typical primary presentations for an uncomplicated Meckel’s diverticulum. *Diverticulitis* - Diverticulitis is the **inflammation of diverticula** (small pouches in the colon), typically presenting with **left lower quadrant abdominal pain**, fever, and changes in bowel habits. - While it can cause bleeding, a palpable mass is less common unless there's an abscess, and the clinical picture does not align as strongly with the "currant jelly stool" and classic palpable mass of intussusception.
Question 4: Which extra-intestinal symptom of inflammatory bowel disease worsens with exacerbation of disease activity?
- A. Primary sclerosing cholangitis
- B. Uveitis
- C. Arthritis (Correct Answer)
- D. Erythema nodosum
Explanation: ***Arthritis*** - **Peripheral arthritis** associated with inflammatory bowel disease (IBD) often **worsens with intestinal disease exacerbations** and improves with resolution of flares [1]. - This type of arthritis typically affects larger joints and is **non-deforming and asymmetric**. *Erythema nodosum* - **Erythema nodosum**, a skin manifestation, is generally **correlated with IBD activity** and usually improves as the bowel disease is treated [1]. - It presents as **tender, red nodules** on the shins and is not consistently one of the symptoms that *worsens* with exacerbation, but rather is *present* during active disease. *Primary sclerosing cholangitis* - **Primary sclerosing cholangitis (PSC)** is a chronic liver condition that is **associated with IBD**, particularly ulcerative colitis. - However, the progression of PSC is largely **independent of the intestinal disease activity** and does not necessarily worsen during IBD exacerbations. *Uveitis* - **Uveitis**, an inflammation of the eye's middle layer, is an extra-intestinal manifestation of IBD that can occur **independently of intestinal disease activity**. - It does not consistently worsen during IBD exacerbations and may require separate focused treatment.
Question 5: Massive bleeding per rectum in an elderly patient is due to.
- A. Colitis
- B. Diverticulosis (Correct Answer)
- C. Peptic ulcer disease
- D. Colorectal cancer
Explanation: ***Diverticulosis*** - **Diverticular bleeding** is the most common cause of **massive lower gastrointestinal bleeding** in elderly patients. - Bleeding occurs when a small artery at the base of a diverticulum is eroded, leading to significant, often **painless, rectal bleeding**. *Colitis* - While colitis can cause rectal bleeding, it is typically associated with **diarrhea, abdominal pain**, and often **bloody stools** rather than massive, isolated rectal bleeding. - Inflammatory conditions like ulcerative colitis can cause bleeding, but a single episode of massive hemorrhage is less characteristic. *Colorectal cancer* - **Colorectal cancer** can cause rectal bleeding, but it is typically **chronic, intermittent, and low-volume**, often presenting as blood mixed with stool or on the surface of the stool. - It rarely presents as a sudden, **massive hemorrhage** that fills the toilet bowl. *Peptic ulcer disease* - **Peptic ulcer disease** is a cause of **upper gastrointestinal bleeding**, presenting as **hematemesis** (vomiting blood) or **melena** (black, tarry stools) [1]. - It would not cause **massive bleeding per rectum** unless there is a very rapid transit of blood through the entire gastrointestinal tract, which is uncommon.
Question 6: A patient presented with diarrhea, poor appetite and malabsoption. His duodenal biopsy was taken which showed crypt hyperplasia, villous atrophy and infiltration of CD8+ T cells in the epithelium. What is the likely diagnosis of the patient?
- A. Celiac disease (Correct Answer)
- B. Pancreatitis
- C. Whipple disease
- D. Environmental enteropathy
Explanation: ***Celiac disease*** - The combination of **diarrhea, poor appetite, malabsorption**, and a duodenal biopsy showing **crypt hyperplasia, villous atrophy, and increased intraepithelial CD8+ T cells** is pathognomonic for celiac disease [1]. - Celiac disease is an **autoimmune reaction to gluten** that leads to inflammation and damage of the small intestinal lining, specifically flattening of the villi [1], [2]. *Pancreatitis* - While chronic pancreatitis can cause malabsorption due to **enzyme deficiency**, it primarily presents with **abdominal pain** and does not involve specific duodenal biopsy findings like villous atrophy or crypt hyperplasia. - The biopsy findings described are **not characteristic of pancreatitis**. *Whipple disease* - Whipple disease is caused by the bacterium *Tropheryma whipplei* and is characterized by malabsorption, **arthralgias, fever, and lymphadenopathy** [3]. - Duodenal biopsy typically shows **macrophages containing PAS-positive material**, not increased CD8+ T cells or isolated villous atrophy and crypt hyperplasia as the primary findings [3]. *Environmental enteropathy* - Also known as tropical enteropathy or tropical sprue, it involves villous atrophy and crypt hyperplasia similar to celiac disease, but it is typically seen in individuals living in **poor hygienic conditions** and responds to antibiotics [4]. - The key differentiating factor here is the specific mention of **CD8+ T cell infiltration**, which is a hallmark of celiac disease [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 789-790. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 360-361. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 798-799. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 790-791.
Question 7: All of the following are pathological features associated with Crohn's disease except which of the following?
- A. Toxic megacolon (Correct Answer)
- B. Skip lesions
- C. Non-caseating granulomas
- D. Cobblestone appearance
Explanation: ***Toxic megacolon*** - Toxic megacolon is primarily associated with **ulcerative colitis**, not Crohn's disease, making it the exception among the listed features. - Crohn's disease typically does not lead to the **massive colonic dilation** seen in toxic megacolon. *Non caseating granulomas* - Found in Crohn's disease, these **granulomas** help in supporting the diagnosis and are characteristic features [1][2]. - They are also observed in other conditions like **sarcoidosis**, but are a definitive feature of Crohn's [1]. *Cobblestone appearance* - This refers to the **mucosal pattern** seen in Crohn's disease due to **transmural inflammation** and ulceration [2]. - It is a classic pathological finding and helps differentiate Crohn's from other gastrointestinal diseases [2]. *Skip lesions* - Skip lesions are segments of normal bowel found between inflamed areas in Crohn's disease, illustrating its **patchy distribution** [2]. - This feature is instrumental in diagnosing and understanding the nature of Crohn's disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-367.
Question 8: Which histological feature is more characteristic of ulcerative colitis than Crohn's disease?
- A. Crypt abscess (Correct Answer)
- B. Mucosal edema
- C. Diffuse distribution of pseudopolyps
- D. Lymphoid aggregates in the mucosa
Explanation: ***Crypt abscess*** - **Crypt abscesses** are formed by neutrophils infiltrating and accumulating within glandular crypts, a hallmark of acute mucosal inflammation [1]. - While crypt abscesses **can occur in both ulcerative colitis and Crohn's disease**, they are **far more characteristic and frequent in ulcerative colitis** due to the diffuse, continuous mucosal involvement [1]. - In UC, crypt abscesses are seen in the acute phase and reflect the superficial mucosal inflammation pattern. - **Note:** The true distinguishing features of Crohn's disease include **transmural inflammation** [2], **non-caseating granulomas** (50% of cases) [3], and **skip lesions** [4], none of which are present in UC [5]. *Mucosal edema* - **Mucosal edema** is a non-specific inflammatory change present in both ulcerative colitis and Crohn's disease. - It occurs in many inflammatory bowel conditions and does not help differentiate between UC and CD. *Diffuse distribution of pseudopolyps* - **Pseudopolyps** (inflammatory polyps) result from repeated cycles of mucosal ulceration and regeneration. - While more common in **chronic ulcerative colitis**, they can also occur in Crohn's disease. - This is primarily a **macroscopic/endoscopic feature** rather than a microscopic histological finding [1]. *Lymphoid aggregates in the mucosa* - **Lymphoid aggregates** represent chronic immune activation and are found in **both UC and CD** [2]. - They reflect the underlying chronic inflammatory process but are not specific to either disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 809. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 366-367. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-366. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 367-368.
Question 9: The histopathological image shows a section of colon. What histological feature seen in the image is more characteristic of Ulcerative Colitis than Crohn's Disease?
- A. Presence of pseudopolyps
- B. Mucosal edema present
- C. Presence of crypt abscesses (Correct Answer)
- D. Lymphoid aggregates in the mucosa present
Explanation: ***Crypt abscess*** - **Crypt abscesses** are a hallmark of ulcerative colitis, where there is **inflammation and necrosis** within the intestinal crypts [1]. - This feature is distinct from Crohn's disease, which does not typically present with crypt abscesses but rather with **transmural inflammation** [2,3]. *Diffuse distribution of pseudopolyps* - While pseudopolyps can occur in ulcerative colitis, they are not a **distinct histological feature** that differentiates it from Crohn's. - Pseudopolyps are **proliferative tissue islands** due to mucosal regeneration, and their presence is not exclusive to either condition. *Mucosal edema* - Mucosal edema is a common feature in various forms of colitis but is **not specific** to differentiate ulcerative colitis from Crohn's disease. - Both conditions can exhibit **mucosal edema**, making it insufficient for definitive diagnosis. *Lymphoid aggregates in the mucosa* - Lymphoid aggregates can be found in Crohn's disease, particularly in the **intestinal lymphoid tissue** [2], but they are **not a defining feature** of ulcerative colitis. - Ulcerative colitis primarily involves **continuous mucosal inflammation** without these prominent aggregates [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 809. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-368. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807.
Question 10: Which of the following is a histological feature of Whipple's disease -
- A. Eosinophils in the lamina propria
- B. Infiltration of histocytes in the lamina propria
- C. Macrophages with PAS (+) material inside the lamina propria (Correct Answer)
- D. Granuloma in the lamina propria
Explanation: ***Macrophages with PAS (+) material inside the lamina propria*** - **Whipple's disease** is characterized by the presence of **foamy macrophages** (histiocytes) that are heavily laden with **Tropheryma whipplei** bacteria in the lamina propria of the small intestine [1]. - These macrophages stain positive with **periodic acid-Schiff (PAS) stain** due to the glycolipid and polysaccharide components of the bacterial cell walls within their cytoplasm [1]. *Granuloma in the lamina* - **Granulomas** are a feature of various inflammatory conditions like Crohn's disease [3] or tuberculosis [2], but they are not the characteristic histological finding in Whipple's disease. - Whipple's disease involves a macrophagic infiltration, not the formation of organized granulomas with epithelioid cells and giant cells [1]. *Eosinophils in the lamina propria* - An increase in **eosinophils** in the lamina propria may indicate conditions such as allergic gastroenteropathy, parasitic infections, or celiac disease, but it is not a defining feature of Whipple's disease. - The hallmark of Whipple's disease involves a specific type of macrophage. *Infiltration of histocytes in the lamina propria* - While there is an **infiltration of histiocytes (macrophages)**, this option is less specific than the correct answer [1]. - The crucial differentiating feature for Whipple's disease is that these histiocytes contain **PAS-positive material**, reflecting the intracellular bacteria [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 798-799. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 363-364. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 366-367.
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