 Welcome back to our question of the day. Let's get started We're going to start again with the answer choices hidden and we always start with the last sentence or the question of the vignette Before we read through so we know what this question is going to be asking us What is the probable source of this child's condition a 19-month-old child is brought to the emergency department after his parents found blood in his stool They state that he has not had any acute distress and although he now displays some tenderness to abdominal pressure Other than this tenderness there are no significant findings on physical examination After performing radionucleotide imaging using the technician 99 the doctor makes a diagnosis and recommends surgery to correct the problem What is the probable source of this child's condition? so I'm thinking through what I know that this is a blood and stool of a child The technician 99 kind of gave me a bit of a buzzword That's used very often in one particular type of thing, but let's go ahead and look at our answer choices and see What options we might have that that might fit in with this particular situation? a Blockage of the intestine due to folding of the distal ilium into the proximal colon B Breakdown of the stomach mucosal barrier with erosion of the underlying mucosa C Damage the intestinal epithelium due to ingestion of coins D ectopic gastric epithelium in a persistent umphalo mesenteric duct or E incomplete bowel rotation resulting in obstruction of the superior mesenteric artery Take a minute come up with your answer and write your answer in the comments below All right, let's first start off that last one e incomplete bowel rotation So this is something that happens in fetal growth and fetal life. So if something presents With this we're gonna see this in the first few weeks of life. So at a 19 month old I'm not seeing a lot of reason why we would have any type of bowel rotation Also an occlusion of an artery is going to cause some severe pain and this patient is showing Very little significant findings on physical examination. So that automatically takes e out of the running Let's go back up and start with a blockage of the intestine due to folding the distal ilium into the proximal colon That's another way of saying uh into seception While we can get some Blood in the stool into seception. I don't think that we're going to have No other symptoms. We usually have a lot of pain and it can be pretty pretty bad along Alongside of vomiting diarrhea and that kind of thing. So into the seption Doesn't seem to fit this case B break down a stomach mucosal barrier with erosion of underlying mucosa You know, are we talking about a peptic ulcer? Maybe in this case, you know, I think that's what b describes I don't think that's what we're seeing with just some blood in the stool with no other symptoms A lot of times in peptic ulcers, I'm going to have, you know, some abdominal pain That that that is really Going to be quite significant. Uh, and they're not really showing much of an issue So I'm going to take b out of the running here C damage to the intestinal epithelium due to the ingestion of coins while ingestion of foreign bodies is very very common, uh with Infants and toddlers as they like to put things in their mouth That's going to be causing more of a mechanical damage to the intestinal lining and not just a A little bit of bowel and or blood in the stool And we don't also use the technician many nine scan For those type of things trying to find foreign objects in the abdomen. So To me, that's going to be not a good answer. So that just leaves me with d ectopic gastric epithelium in a persistent umfala mesenteric duct That will be my answer. I believe that is a Meckles diverticulum And that fits the vignette and my answer choice. So d is my answer And d is the correct answer is a Meckles diverticulum. So this patient is presenting with the persistent umfala mesenteric duct or the vitiline duct That comes just inside of the belly button The mescal diverticulum, it's going to be typically found in the mid to the distal ileum And that can end blindly or it can connect to the umbilicus And one thing to remember with our Meckles diverticulum is the rule of twos And remember the rule twos is two percent of the population Within two feet of the ileocecal valve It's two inches in length two types of mucosa are involved both gastric and pancreatic mucosa and it often presents before the age of two So those are our rule of twos associated with our Meckles diverticulum, which is the correct answer for this question