ABSITE – BILIARY QUESTIONS WITH
CORRECT ANSWERS 2025
A 37-year-
old woman with BMI 30kg/m2 presents with unremitting RUQ pain lasting several days. She has ex
perienced nausea and vomiting for the last two days. Vital signs are T 37.9°C, HR 105 bpm, BP 110
/80 mmHg, RR 20 breaths/min, 100% on RA. Labs reveal WBC 13,000 and total bilirubin 3 mg/dL.
On physical exam, there is no jaundice or scleral icterus, and palpation of the RUQMproduces guardi
ng and rebound. Ultrasound of the RUQ shows gallbladder wall thickness of 5 mm and mild perich
olecystic fluid. What is the diagnosis?
A. Acute cholecystitis
B. Cholelithiasis
C. Acute cholangitis
D. Chronic cholecystitis
E. Biliary dyskinesia - CORRECT ANSWER -Acute cholecystitis
Correct.
A) Acute cholecystitis is defined by pericholecystic fluid and gallbladder wall thickening > 4mm.
B) The ultrasound did not specify the presence of stones in the gallbladder.
C) Acute cholangitis requires the classic triad jaundice of the skin or sclera, fever and RUQMpain.
D) Chronic cholecystitis usually lasts longer than several days or has occurred on and off for some
time.
E) Biliary dyskinesia does not cause a SIRS response or pericholecystic fluid and gallbladder wall thi
ckening.
An 81-year-
old woman on POD #6 from open splenectomy for a grade 4 splenic laceration resulting from an
MVC develops a severe pneumonia, with persistent fever of 39°C, WBC 18,000, and high residuals
,on tube feedings. She has been unable to wean from the ventilator, and is on multiple inotropic a
gents to support her blood pressure which is currently 80/60 mmHg. On exam, she winces in pain
with palpation of the RUQ. RUQ US shows no stones in the gallbladder, pericholecystic fluid and a
wall thickness of 6 mm. Which of the following is the next best step in management?
A. CT scan of abdomen and pelvis
B. Percutaneous cholecystostomy tube placement
C. ERCP
D. Laparoscopic cholecystectomy
E. Open cholecystectomy - CORRECT ANSWER -Percutaneous cholecystostomy tube placement
Correct.
This patient has acalculous cholecystitis. She is not healthy enough for an elective cholecystectomy
at this time, so the appropriate treatment is percutaneous cholecystostomy tube placement. ERCP
would not help treat acalculous cholecystitis.
A 65-year-
old man presents to the ER with complaints of stabbing RUQ pain occurring for several days, and a
ccording to his family, has become increasingly aggravated and confused. His vitals are T 39°C, HR
115 bpm, BP 94/71 mmHg, RR 20 breaths/min, 100% on RA. He is jaundiced and exhibits a positiv
e Murphy's sign. Labs reveal elevated bilirubin, alkaline phosphatase, and WBC. His troponins are n
egative and EKG demonstrates normal sinus rhythm. His disease process is most likely caused by w
hich organism?
A. Staphylococcus aureus
B. Staphylococcus epididymis
C. Streptococcus pneumonia
D. Clostridium perfringens
E. Klebsiella pneumonia - CORRECT ANSWER -E. Klebsiella pneumoniae
Correct.
The patient is suffering from acute cholangitis, which is most commonly caused by E. coli, Klebsiell
a pneumoniae, enterococci, and Bacteroides fragilis.
,A 42-year-
old woman with BMI 42 kg/m2 presents with stabbing RUQ pain occurring after meals for the last
3 days, sometimes waking her from sleep. She had a myocardial infarction 2 months ago treated w
ith a stent. She is on clopidogrel. Her vitals are T 36.5°C, HR 75 bpm, BP 135/74 mmHg, RR 16 bre
aths/min, 100% on RA. She is jaundiced and has RUQ tenderness to deep palpation. Her total bilir
ubin is 4.0 mg/dL, direct bilirubin 3.2 mg/dL, and alkaline phosphatase 200 IU/L. Her WBC is norm
al and serum troponins are not elevated. EKG demonstrates normal sinus rhythm. An ultrasound of
the RUQMreveals stones in the gallbladder. What imaging study would you consider next?
A. CT scan without contrast
B. HIDA scan with administration of cholecystokinin
C. Plain radiograph of the abdomen
D. Magnetic resonance cholangiopancreatography (MRCP)
E. Endoscopic retrograde cholangiopancreatography (ERCP) - CORRECT ANSWER -
D. Magnetic resonance cholangiopancreatography (MRCP)
Correct.
This patient likely has choledocholithiasis given her elevated bilirubin and alkaline phosphatase. US
can only show stones in the CBD 10-
15% of the time. If clinically suspicious of choledocholithiasis, the next imaging study could be end
oscopic retrograde cholangiogram/endoscopic US (ERC/EUS) or MRCP. Since this patient recently ha
d an MI and is anticoagulated, she should undergo the least invasive procedure, an MRCP, and rule
out other causes of increased hepatic function panel before undergoing an invasive procedure suc
h as ERC/EUS.
MRCP can diagnose CBD stones with a sensitivity of 90%, a specificity of 100%, and an overall diag
nostic accuracy of 97%.
A) CT scan without contrast has great sensitivity and specificity for stones in the renal system. For
the gallbladder, calcified stones can only be visualized 50% of the time.
B) 99mTechnetium-labeled iminodiacetic acid derivatives (hepatic 2,6-dimethyl-
iminodiacetic acid [HIDA], diisopropyl-acetanilidoiminodiacetic acid, P-isopropylacetanilido-
imidodiacetic acid) scans with cholecystokinin administration should be used to identify biliary dyski
nesia.
, C) Plain x-
rays of the abdomen identify stones only 15% of the time and it would be impossible to differenti
ate a CBD stone from a gallbladder stone on x-ray.
D) Since this patient recently had an MI, she should undergo the least invasive procedure, an MRC
P, and rule out other causes of increased hepatic function panel before undergoing an invasive pro
cedure such as ERC/EUS.
E) Endoscopic retrograde cholangiogram/endoscopic US (ERC/EUS) is more invasive than MRCP; this
patient would be high risk for an invasive procedure.
A 55-year-
old male presents with RUQMpain over the last 24 hours. Ultrasound confirms acute cholecystitis, w
ith gallbladder wall thickening, pericholecystic fluid, and multiple stones. The CBD is not visualized
because of overlying bowel gas. His laboratory workup is as follows: WBC 17,000, total bilirubin 2.5
, AST/ALT 150/170, alkaline phosphatase 138. He is not febrile. His past surgical history includes a
Roux-en-
Y gastric bypass and a cerebral aneurysm repair. What is the best next step in his management?
A. Open cholecystectomy
B. Laparoscopic cholecystectomy with intraoperative cholangiogram
C. CT abdomen/pelvis
D. MRCP
E. ERCP - CORRECT ANSWER -B. Laparoscopic cholecystectomy with intraoperative cholangiogram
Correct.
This patient has cholecystitis with abnormal liver function tests. His CBD needs to be visualized pre
operatively or intraoperatively. Options generally include MRCP, ERCP, and/or intraoperative cholangi
ogram (IOC). Roux-en-
Y gastric bypass does not preclude laparoscopic cholecystectomy. Contraindications to MRCP include
older heart pacemakers, implanted metallic devices (insulin pumps, hearing aids, neurostimulators),
intracranial metal clips, and metallic bodies in the eye.
CORRECT ANSWERS 2025
A 37-year-
old woman with BMI 30kg/m2 presents with unremitting RUQ pain lasting several days. She has ex
perienced nausea and vomiting for the last two days. Vital signs are T 37.9°C, HR 105 bpm, BP 110
/80 mmHg, RR 20 breaths/min, 100% on RA. Labs reveal WBC 13,000 and total bilirubin 3 mg/dL.
On physical exam, there is no jaundice or scleral icterus, and palpation of the RUQMproduces guardi
ng and rebound. Ultrasound of the RUQ shows gallbladder wall thickness of 5 mm and mild perich
olecystic fluid. What is the diagnosis?
A. Acute cholecystitis
B. Cholelithiasis
C. Acute cholangitis
D. Chronic cholecystitis
E. Biliary dyskinesia - CORRECT ANSWER -Acute cholecystitis
Correct.
A) Acute cholecystitis is defined by pericholecystic fluid and gallbladder wall thickening > 4mm.
B) The ultrasound did not specify the presence of stones in the gallbladder.
C) Acute cholangitis requires the classic triad jaundice of the skin or sclera, fever and RUQMpain.
D) Chronic cholecystitis usually lasts longer than several days or has occurred on and off for some
time.
E) Biliary dyskinesia does not cause a SIRS response or pericholecystic fluid and gallbladder wall thi
ckening.
An 81-year-
old woman on POD #6 from open splenectomy for a grade 4 splenic laceration resulting from an
MVC develops a severe pneumonia, with persistent fever of 39°C, WBC 18,000, and high residuals
,on tube feedings. She has been unable to wean from the ventilator, and is on multiple inotropic a
gents to support her blood pressure which is currently 80/60 mmHg. On exam, she winces in pain
with palpation of the RUQ. RUQ US shows no stones in the gallbladder, pericholecystic fluid and a
wall thickness of 6 mm. Which of the following is the next best step in management?
A. CT scan of abdomen and pelvis
B. Percutaneous cholecystostomy tube placement
C. ERCP
D. Laparoscopic cholecystectomy
E. Open cholecystectomy - CORRECT ANSWER -Percutaneous cholecystostomy tube placement
Correct.
This patient has acalculous cholecystitis. She is not healthy enough for an elective cholecystectomy
at this time, so the appropriate treatment is percutaneous cholecystostomy tube placement. ERCP
would not help treat acalculous cholecystitis.
A 65-year-
old man presents to the ER with complaints of stabbing RUQ pain occurring for several days, and a
ccording to his family, has become increasingly aggravated and confused. His vitals are T 39°C, HR
115 bpm, BP 94/71 mmHg, RR 20 breaths/min, 100% on RA. He is jaundiced and exhibits a positiv
e Murphy's sign. Labs reveal elevated bilirubin, alkaline phosphatase, and WBC. His troponins are n
egative and EKG demonstrates normal sinus rhythm. His disease process is most likely caused by w
hich organism?
A. Staphylococcus aureus
B. Staphylococcus epididymis
C. Streptococcus pneumonia
D. Clostridium perfringens
E. Klebsiella pneumonia - CORRECT ANSWER -E. Klebsiella pneumoniae
Correct.
The patient is suffering from acute cholangitis, which is most commonly caused by E. coli, Klebsiell
a pneumoniae, enterococci, and Bacteroides fragilis.
,A 42-year-
old woman with BMI 42 kg/m2 presents with stabbing RUQ pain occurring after meals for the last
3 days, sometimes waking her from sleep. She had a myocardial infarction 2 months ago treated w
ith a stent. She is on clopidogrel. Her vitals are T 36.5°C, HR 75 bpm, BP 135/74 mmHg, RR 16 bre
aths/min, 100% on RA. She is jaundiced and has RUQ tenderness to deep palpation. Her total bilir
ubin is 4.0 mg/dL, direct bilirubin 3.2 mg/dL, and alkaline phosphatase 200 IU/L. Her WBC is norm
al and serum troponins are not elevated. EKG demonstrates normal sinus rhythm. An ultrasound of
the RUQMreveals stones in the gallbladder. What imaging study would you consider next?
A. CT scan without contrast
B. HIDA scan with administration of cholecystokinin
C. Plain radiograph of the abdomen
D. Magnetic resonance cholangiopancreatography (MRCP)
E. Endoscopic retrograde cholangiopancreatography (ERCP) - CORRECT ANSWER -
D. Magnetic resonance cholangiopancreatography (MRCP)
Correct.
This patient likely has choledocholithiasis given her elevated bilirubin and alkaline phosphatase. US
can only show stones in the CBD 10-
15% of the time. If clinically suspicious of choledocholithiasis, the next imaging study could be end
oscopic retrograde cholangiogram/endoscopic US (ERC/EUS) or MRCP. Since this patient recently ha
d an MI and is anticoagulated, she should undergo the least invasive procedure, an MRCP, and rule
out other causes of increased hepatic function panel before undergoing an invasive procedure suc
h as ERC/EUS.
MRCP can diagnose CBD stones with a sensitivity of 90%, a specificity of 100%, and an overall diag
nostic accuracy of 97%.
A) CT scan without contrast has great sensitivity and specificity for stones in the renal system. For
the gallbladder, calcified stones can only be visualized 50% of the time.
B) 99mTechnetium-labeled iminodiacetic acid derivatives (hepatic 2,6-dimethyl-
iminodiacetic acid [HIDA], diisopropyl-acetanilidoiminodiacetic acid, P-isopropylacetanilido-
imidodiacetic acid) scans with cholecystokinin administration should be used to identify biliary dyski
nesia.
, C) Plain x-
rays of the abdomen identify stones only 15% of the time and it would be impossible to differenti
ate a CBD stone from a gallbladder stone on x-ray.
D) Since this patient recently had an MI, she should undergo the least invasive procedure, an MRC
P, and rule out other causes of increased hepatic function panel before undergoing an invasive pro
cedure such as ERC/EUS.
E) Endoscopic retrograde cholangiogram/endoscopic US (ERC/EUS) is more invasive than MRCP; this
patient would be high risk for an invasive procedure.
A 55-year-
old male presents with RUQMpain over the last 24 hours. Ultrasound confirms acute cholecystitis, w
ith gallbladder wall thickening, pericholecystic fluid, and multiple stones. The CBD is not visualized
because of overlying bowel gas. His laboratory workup is as follows: WBC 17,000, total bilirubin 2.5
, AST/ALT 150/170, alkaline phosphatase 138. He is not febrile. His past surgical history includes a
Roux-en-
Y gastric bypass and a cerebral aneurysm repair. What is the best next step in his management?
A. Open cholecystectomy
B. Laparoscopic cholecystectomy with intraoperative cholangiogram
C. CT abdomen/pelvis
D. MRCP
E. ERCP - CORRECT ANSWER -B. Laparoscopic cholecystectomy with intraoperative cholangiogram
Correct.
This patient has cholecystitis with abnormal liver function tests. His CBD needs to be visualized pre
operatively or intraoperatively. Options generally include MRCP, ERCP, and/or intraoperative cholangi
ogram (IOC). Roux-en-
Y gastric bypass does not preclude laparoscopic cholecystectomy. Contraindications to MRCP include
older heart pacemakers, implanted metallic devices (insulin pumps, hearing aids, neurostimulators),
intracranial metal clips, and metallic bodies in the eye.
