ABSITE – BILIARY QUESTIONS WITH
CORRECT ANSWERS 2026/2027
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 RUQ produces 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 RUQ pain.
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.
Ac 65-year-
oldc manc presentsc toc thec ERc withc complaintsc ofc stabbingc RUQc painc occurringc forc severalc days,c andc
a
ccording
1 c to
15c bpm, c his
c BP c family,
c 94/71 c hasc become
c mmHg, increasinglyccaggravated
c RRc 20ccbreaths/min, and
100%c onc cRA. c confused.
c He c Hisc cvitals
c isc jaundiced arec Tc 39°C,
andccexhibits c HR
c ac positi
v
ec Murphy'sc sign.c Labsc revealc elevatedc bilirubin,c alkalinec phosphatase,c andc WBC.c Hisc troponinsc arec n
egativec andc EKGc demonstratesc normalc sinusc rhythm.c Hisc diseasec processc isc mostc likelyc causedc byc w
hichc organism?
A.c Staphylococcusc aureus
B.c Staphylococcusc epididymis
C.c Streptococcusc pneumonia
D.c Clostridiumc perfringens
E.c Klebsiellac pneumoniac -c CORRECTc ANSWERc -E.c Klebsiellac pneumoniae
Correct.
Thec patientc isc sufferingc fromc acutec cholangitis,c whichc isc mostc commonlyc causedc byc E.c coli,c Klebsiell
ac pneumoniae,c enterococci,c andc Bacteroidesc fragilis.
,c
Ac 42-year-
oldc womanc withc BMIc 42c kg/m2c presentsc withc stabbingc RUQc painc occurringc aſterc mealsc forc thec las
t3 days,c sometimesc wakingc herc fromc sleep.c Shec hadc ac myocardialc infarctionc 2c monthsc agoc treatedc
ithw
c ac stent.c Shec isc onc clopidogrel.c Herc vitalsc arec Tc 36.5°C,c HRc 75c bpm,c BPc 135/74c mmHg,c RRc 16c br
e
aths/min,c 100%c onc RA.c Shec isc jaundicedc andc hasc RUQc tendernessc toc deepc palpation.c Herc totalc bilir
ubinc isc 4.0c mg/dL,c directc bilirubinc 3.2c mg/dL,c andc alkalinec phosphatasec 200c IU/L.c Herc WBCc isc norm
alc andc serumc troponinsc arec notc elevated.c EKGc demonstratesc normalc sinusc rhythm.c Anc ultrasoundc of
thec RUQc revealsc stonesc inc thec gallbladder.c Whatc imagingc studyc wouldc youc considerc next?
A.c CTc scanc withoutc contrast
B.c HIDAc scanc withc administrationc ofc cholecystokinin
C.c Plainc radiographc ofc thec abdomen
D.c Magneticc resonancec cholangiopancreatographyc (MRCP)
E.c Endoscopicc retrogradec cholangiopancreatographyc (ERCP)c -c CORRECTc ANSWERc -
D.c Magneticc resonancec cholangiopancreatographyc (MRCP)
Correct.
Thisc patientc likelyc hasc choledocholithiasisc givenc herc elevatedc bilirubinc andc alkalinec phosphatase.c US
canc onlyc showc stonesc inc thec CBDc 10-
15%c ofc thec time.c Ifc clinicallyc suspiciousc ofc choledocholithiasis,c thec nextc imagingc studyc couldc bec en
d
oscopic c retrogradec cholangiogram/endoscopicc USc (ERC/EUS)c orc MRCP.c Sincec thisc patientc recentlyc ha
dc anc MIc andc isc anticoagulated,c shec shouldc undergoc thec leastc invasivec procedure,c anc MRCP,c andc rul
e
outc otherc causesc ofc increasedc hepaticc functionc panelc beforec undergoingc anc invasivec procedurec suc
hc asc ERC/EUS.
MRCPc canc diagnosec CBDc stonesc withc ac sensitivityc ofc 90%,c ac specificityc ofc 100%,c andc anc overallc dia
g
nosticc accuracyc ofc 97%.
A)c CTc scanc withoutc contrastc hasc greatc sensitivityc andc specificityc forc stonesc inc thec renalc system.c Fo
r
thec gallbladder,c calcifiedc stonesc canc onlyc bec visualizedc 50%c ofc thec time.
B)c 99mTechnetium-labeledc iminodiaceticc acidc derivativesc (hepaticc 2,6-dimethyl-
iminodiaceticc acidc [HIDA],c diisopropyl-acetanilidoiminodiaceticc acid,c P-isopropylacetanilido-
imidodiaceticc acid)c scansc withc cholecystokininc administrationc shouldc bec usedc toc identifyc biliaryc dyski
nesia.
,c
C)c Plainc x-
raysc ofc thec abdomenc identifyc stonesc onlyc 15%c ofc thec timec andc itc wouldc bec impossiblec toc different
i
atec ac CBDc stonec fromc ac gallbladderc stonec onc x-ray.
D)c Sincec thisc patientc recentlyc hadc anc MI,c shec shouldc undergoc thec leastc invasivec procedure,c anc MR
C
P,andc rulec outc otherc causesc ofc increasedc hepaticc functionc panelc beforec undergoingc anc invasivec pro
cedurec suchc asc ERC/EUS.
E)c Endoscopicc retrogradec cholangiogram/endoscopicc USc (ERC/EUS)c isc morec invasivec thanc MRCP;c this
patientc wouldc bec highc riskc forc anc invasivec procedure.
Ac 55-year-
oldc malec presentsc withc RUQc painc overc thec lastc 24c hours.c Ultrasoundc confirmsc acutec cholecystitis,c w
ithc gallbladderc wallc thickening,c pericholecysticc fluid,c andc multiplec stones.c Thec CBDc isc notc visualized
becausec ofc overlyingc bowelc gas.c Hisc laboratoryc workupc isc asc follows:c WBCc 17,000,c totalc bilirubinc 2.
5
, AST/ALTc 150/170,c alkalinec phosphatasec 138.c Hec isc notc febrile.c Hisc pastc surgicalc historyc includesc a
Roux-en-
Yc gastricc bypassc andc ac cerebralc aneurysmc repair.c Whatc isc thec bestc nextc stepc inc hisc management
?
A.c Openc cholecystectomy
B.c Laparoscopicc cholecystectomyc withc intraoperativec cholangiogram
C.c CTc abdomen/pelvis
D.c MRCP
E.c ERCPc -c CORRECTc ANSWERc -B.c Laparoscopicc cholecystectomyc withc intraoperativec cholangiogram
Correct.
Thisc patientc hasc cholecystitisc withc abnormalc liverc functionc tests.c Hisc CBDc needsc toc bec visualizedc pre
operativelyc orc intraoperatively.c Optionsc generallyc includec MRCP,c ERCP,c and/orc intraoperativec cholangi
ogramc (IOC).c Roux-en-
Yc gastricc bypassc doesc notc precludec laparoscopicc cholecystectomy.c Contraindicationsc toc MRCPc include
olderc heartc pacemakers,c implantedc metallicc devicesc (insulinc pumps,c hearingc aids,c neurostimulators),
intracranialc metalc clips,c andc metallicc bodiesc inc thec eye.
CORRECT ANSWERS 2026/2027
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 RUQ produces 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 RUQ pain.
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.
Ac 65-year-
oldc manc presentsc toc thec ERc withc complaintsc ofc stabbingc RUQc painc occurringc forc severalc days,c andc
a
ccording
1 c to
15c bpm, c his
c BP c family,
c 94/71 c hasc become
c mmHg, increasinglyccaggravated
c RRc 20ccbreaths/min, and
100%c onc cRA. c confused.
c He c Hisc cvitals
c isc jaundiced arec Tc 39°C,
andccexhibits c HR
c ac positi
v
ec Murphy'sc sign.c Labsc revealc elevatedc bilirubin,c alkalinec phosphatase,c andc WBC.c Hisc troponinsc arec n
egativec andc EKGc demonstratesc normalc sinusc rhythm.c Hisc diseasec processc isc mostc likelyc causedc byc w
hichc organism?
A.c Staphylococcusc aureus
B.c Staphylococcusc epididymis
C.c Streptococcusc pneumonia
D.c Clostridiumc perfringens
E.c Klebsiellac pneumoniac -c CORRECTc ANSWERc -E.c Klebsiellac pneumoniae
Correct.
Thec patientc isc sufferingc fromc acutec cholangitis,c whichc isc mostc commonlyc causedc byc E.c coli,c Klebsiell
ac pneumoniae,c enterococci,c andc Bacteroidesc fragilis.
,c
Ac 42-year-
oldc womanc withc BMIc 42c kg/m2c presentsc withc stabbingc RUQc painc occurringc aſterc mealsc forc thec las
t3 days,c sometimesc wakingc herc fromc sleep.c Shec hadc ac myocardialc infarctionc 2c monthsc agoc treatedc
ithw
c ac stent.c Shec isc onc clopidogrel.c Herc vitalsc arec Tc 36.5°C,c HRc 75c bpm,c BPc 135/74c mmHg,c RRc 16c br
e
aths/min,c 100%c onc RA.c Shec isc jaundicedc andc hasc RUQc tendernessc toc deepc palpation.c Herc totalc bilir
ubinc isc 4.0c mg/dL,c directc bilirubinc 3.2c mg/dL,c andc alkalinec phosphatasec 200c IU/L.c Herc WBCc isc norm
alc andc serumc troponinsc arec notc elevated.c EKGc demonstratesc normalc sinusc rhythm.c Anc ultrasoundc of
thec RUQc revealsc stonesc inc thec gallbladder.c Whatc imagingc studyc wouldc youc considerc next?
A.c CTc scanc withoutc contrast
B.c HIDAc scanc withc administrationc ofc cholecystokinin
C.c Plainc radiographc ofc thec abdomen
D.c Magneticc resonancec cholangiopancreatographyc (MRCP)
E.c Endoscopicc retrogradec cholangiopancreatographyc (ERCP)c -c CORRECTc ANSWERc -
D.c Magneticc resonancec cholangiopancreatographyc (MRCP)
Correct.
Thisc patientc likelyc hasc choledocholithiasisc givenc herc elevatedc bilirubinc andc alkalinec phosphatase.c US
canc onlyc showc stonesc inc thec CBDc 10-
15%c ofc thec time.c Ifc clinicallyc suspiciousc ofc choledocholithiasis,c thec nextc imagingc studyc couldc bec en
d
oscopic c retrogradec cholangiogram/endoscopicc USc (ERC/EUS)c orc MRCP.c Sincec thisc patientc recentlyc ha
dc anc MIc andc isc anticoagulated,c shec shouldc undergoc thec leastc invasivec procedure,c anc MRCP,c andc rul
e
outc otherc causesc ofc increasedc hepaticc functionc panelc beforec undergoingc anc invasivec procedurec suc
hc asc ERC/EUS.
MRCPc canc diagnosec CBDc stonesc withc ac sensitivityc ofc 90%,c ac specificityc ofc 100%,c andc anc overallc dia
g
nosticc accuracyc ofc 97%.
A)c CTc scanc withoutc contrastc hasc greatc sensitivityc andc specificityc forc stonesc inc thec renalc system.c Fo
r
thec gallbladder,c calcifiedc stonesc canc onlyc bec visualizedc 50%c ofc thec time.
B)c 99mTechnetium-labeledc iminodiaceticc acidc derivativesc (hepaticc 2,6-dimethyl-
iminodiaceticc acidc [HIDA],c diisopropyl-acetanilidoiminodiaceticc acid,c P-isopropylacetanilido-
imidodiaceticc acid)c scansc withc cholecystokininc administrationc shouldc bec usedc toc identifyc biliaryc dyski
nesia.
,c
C)c Plainc x-
raysc ofc thec abdomenc identifyc stonesc onlyc 15%c ofc thec timec andc itc wouldc bec impossiblec toc different
i
atec ac CBDc stonec fromc ac gallbladderc stonec onc x-ray.
D)c Sincec thisc patientc recentlyc hadc anc MI,c shec shouldc undergoc thec leastc invasivec procedure,c anc MR
C
P,andc rulec outc otherc causesc ofc increasedc hepaticc functionc panelc beforec undergoingc anc invasivec pro
cedurec suchc asc ERC/EUS.
E)c Endoscopicc retrogradec cholangiogram/endoscopicc USc (ERC/EUS)c isc morec invasivec thanc MRCP;c this
patientc wouldc bec highc riskc forc anc invasivec procedure.
Ac 55-year-
oldc malec presentsc withc RUQc painc overc thec lastc 24c hours.c Ultrasoundc confirmsc acutec cholecystitis,c w
ithc gallbladderc wallc thickening,c pericholecysticc fluid,c andc multiplec stones.c Thec CBDc isc notc visualized
becausec ofc overlyingc bowelc gas.c Hisc laboratoryc workupc isc asc follows:c WBCc 17,000,c totalc bilirubinc 2.
5
, AST/ALTc 150/170,c alkalinec phosphatasec 138.c Hec isc notc febrile.c Hisc pastc surgicalc historyc includesc a
Roux-en-
Yc gastricc bypassc andc ac cerebralc aneurysmc repair.c Whatc isc thec bestc nextc stepc inc hisc management
?
A.c Openc cholecystectomy
B.c Laparoscopicc cholecystectomyc withc intraoperativec cholangiogram
C.c CTc abdomen/pelvis
D.c MRCP
E.c ERCPc -c CORRECTc ANSWERc -B.c Laparoscopicc cholecystectomyc withc intraoperativec cholangiogram
Correct.
Thisc patientc hasc cholecystitisc withc abnormalc liverc functionc tests.c Hisc CBDc needsc toc bec visualizedc pre
operativelyc orc intraoperatively.c Optionsc generallyc includec MRCP,c ERCP,c and/orc intraoperativec cholangi
ogramc (IOC).c Roux-en-
Yc gastricc bypassc doesc notc precludec laparoscopicc cholecystectomy.c Contraindicationsc toc MRCPc include
olderc heartc pacemakers,c implantedc metallicc devicesc (insulinc pumps,c hearingc aids,c neurostimulators),
intracranialc metalc clips,c andc metallicc bodiesc inc thec eye.
