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 Utube Ufeedings. UShe Uhas Ubeen Uunable Uto Uwean Ufrom Uthe Uventilator, Uand Uis Uon Umultiple
Uinotropic Ua U gents U to U support U her U blood U pressure U which U is U currently U 80/60 U mmHg. U On
U exam, U she U winces U in U pain Uwith U palpation U of U the U RUQ. U RUQ U US U shows U no U stones U in
U the U gallbladder, U pericholecystic U fluid U and U a Uwall U thickness U of U 6 U mm. U Which U of U the
U following U is U the U next U best U step U in U management?
A. CT U scan U of U abdomen U and U pelvis
B. Percutaneous U cholecystostomy U tube U placement
C. ERCP
D. Laparoscopic U cholecystectomy
E. Open U cholecystectomy U - U CORRECT U ANSWER U -Percutaneous U cholecystostomy U tube
U placement UCorrect.
This U patient U has U acalculous U cholecystitis. U She U is U not U healthy U enough U for U an U elective
U cholecystectomy Uat U this U time, U so U the U appropriate U treatment U is U percutaneous
U cholecystostomy U tube U placement. U ERCP Uwould U not U help U treat U acalculous U cholecystitis.
A U 65-year-
old U man U presents U to U the U ER U with U complaints U of U stabbing U RUQ U pain U occurring U for U several
U days, U and U a Uccording U to U his U family, U has U become U increasingly U aggravated U and U confused.
U His U vitals U are U T U 39°C, U HR U115 U bpm, U BP U 94/71 U mmHg, U RR U 20 U breaths/min, U 100% U on
U RA. U He U is U jaundiced U and U exhibits U a U positiv Ue U Murphy's U sign. U Labs U reveal U elevated
U bilirubin, U alkaline U phosphatase, U and U WBC. U His U troponins U are U n Uegative U and U EKG
U demonstrates U normal U sinus U rhythm. U His U disease U process U is U most U likely U caused U by U w Uhich
U organism?
A. Staphylococcus U aureus
B. Staphylococcus U epididymis
C. Streptococcus U pneumonia
D. Clostridium U perfringens
E. Klebsiella U pneumonia U - U CORRECT U ANSWER U -E. U Klebsiella
U pneumoniae UCorrect.
The U patient U is U suffering U from U acute U cholangitis, U which U is U most U commonly U caused U by U E.
U coli, U Klebsiell Ua U pneumoniae, U enterococci, U and U Bacteroides U fragilis.
,A U 42-year-
old U woman U with U BMI U 42 U kg/m2 U presents U with U stabbing U RUQ U pain U occurring U after U meals
U for U the U last U3 U days, U sometimes U waking U her U from U sleep. U She U had U a U myocardial U infarction
U 2 U months U ago U treated U w Uith U a U stent. U She U is U on U clopidogrel. U Her U vitals U are U T U 36.5°C,
U HR U 75 U bpm, U BP U 135/74 U mmHg, U RR U 16 U bre Uaths/min, U 100% U on U RA. U She U is U jaundiced
U and U has U RUQ U tenderness U to U deep U palpation. U Her U total U bilir Uubin U is U 4.0 U mg/dL, U direct
U bilirubin U 3.2 U mg/dL, U and U alkaline U phosphatase U 200 U IU/L. U Her U WBC U is U norm Ual U and
U serum U troponins U are U not U elevated. U EKG U demonstrates U normal U sinus U rhythm. U An
U ultrasound U of Uthe U RUQMreveals U stones U in U the U gallbladder. U What U imaging U study U would
U you U consider U next?
A. CT U scan U without U contrast
B. HIDA U scan U with U administration U of U cholecystokinin
C. Plain U radiograph U of U the U abdomen
D. Magnetic U resonance U cholangiopancreatography U (MRCP)
E. Endoscopic U retrograde U cholangiopancreatography U (ERCP) U - U CORRECT U ANSWER U -
D. U Magnetic U resonance U cholangiopancreatography U (MRCP)
Correct.
U
This Upatient Ulikely Uhas Ucholedocholithiasis Ugiven Uher Uelevated Ubilirubin Uand Ualkaline Uphosphatase.
UUS U can U only U show U stones U in U the U CBD U 10-
15% Uof Uthe Utime. UIf Uclinically Ususpicious Uof Ucholedocholithiasis, Uthe Unext Uimaging Ustudy Ucould Ube
Uend Uoscopic U retrograde U cholangiogram/endoscopic U US U (ERC/EUS) U or U MRCP. U Since U this
U patient U recently U ha Ud U an U MI U and U is U anticoagulated, U she U should U undergo U the U least
U invasive U procedure, U an U MRCP, U and U rule Uout U other U causes U of U increased U hepatic U function
U panel U before U undergoing U an U invasive U procedure U suc Uh U as U ERC/EUS.
MRCP U can U diagnose U CBD U stones U with U a U sensitivity U of U 90%, U a U specificity U of U 100%, U and U an
U overall U diag Unostic U accuracy U of U 97%.
A) CT U scan U without U contrast U has U great U sensitivity U and U specificity U for U stones U in U the U renal
U system. U For Uthe U gallbladder, U calcified U stones U can U only U be U visualized U 50% U of U the U time.
B) 99mTechnetium-labeled U iminodiacetic U acid U derivatives U (hepatic U 2,6-dimethyl-
iminodiacetic U acid U [HIDA], U diisopropyl-acetanilidoiminodiacetic U acid, U P-isopropylacetanilido-
imidodiacetic U acid) U scans U with U cholecystokinin U administration U should U be U used U to U identify U biliary
U dyski Unesia.
, C) Plain U x-
rays U of U the U abdomen U identify U stones U only U 15% U of U the U time U and U it U would U be U impossible
U to U differenti Uate U a U CBD U stone U from U a U gallbladder U stone U on U x-ray.
D) Since U this U patient U recently U had U an U MI, U she U should U undergo U the U least U invasive
U procedure, U an U MRC UP, Uand Urule Uout Uother Ucauses Uof Uincreased Uhepatic Ufunction Upanel Ubefore
Uundergoing Uan Uinvasive Upro Ucedure U such U as U ERC/EUS.
E) Endoscopic Uretrograde Ucholangiogram/endoscopic UUS U(ERC/EUS) Uis Umore Uinvasive Uthan UMRCP;
Uthis Upatient U would U be U high U risk U for U an U invasive U procedure.
A U 55-year-
old U male U presents U with U RUQMpain U over U the U last U 24 U hours. U Ultrasound U confirms U acute
U cholecystitis, U w Uith U gallbladder U wall U thickening, U pericholecystic U fluid, U and U multiple U stones.
U The U CBD U is U not U visualized Ubecause U of U overlying U bowel U gas. U His U laboratory U workup U is U as
U follows: U WBC U 17,000, U total U bilirubin U 2.5
, U AST/ALT U 150/170, U alkaline U phosphatase U 138. U He U is U not U febrile. U His U past U surgical
U history U includes U a URoux-en-
Y U gastric U bypass U and U a U cerebral U aneurysm U repair. U What U is U the U best U next U step U in U his
U management?
A. Open U cholecystectomy
B. Laparoscopic U cholecystectomy U with U intraoperative U cholangiogram
C. CT U abdomen/pelvis
D. MRCP
E. ERCP U- CORRECT
U U ANSWER -B.
U ULaparoscopic Ucholecystectomy with
U intraoperative
U
cholangiogram UCorrect.
U
This Upatient Uhas Ucholecystitis Uwith Uabnormal Uliver Ufunction Utests. UHis UCBD Uneeds Uto Ube Uvisualized
Upre Uoperatively Uor Uintraoperatively. UOptions Ugenerally Uinclude UMRCP, UERCP, Uand/or Uintraoperative
Ucholangi Uogram U (IOC). U Roux-en-
Y Ugastric Ubypass Udoes Unot Upreclude Ulaparoscopic Ucholecystectomy. UContraindications Uto UMRCP
Uinclude Uolder Uheart Upacemakers, Uimplanted Umetallic Udevices U(insulin Upumps, Uhearing Uaids,
Uneurostimulators), Uintracranial U metal U clips, U and U metallic U bodies U in U the U 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 Utube Ufeedings. UShe Uhas Ubeen Uunable Uto Uwean Ufrom Uthe Uventilator, Uand Uis Uon Umultiple
Uinotropic Ua U gents U to U support U her U blood U pressure U which U is U currently U 80/60 U mmHg. U On
U exam, U she U winces U in U pain Uwith U palpation U of U the U RUQ. U RUQ U US U shows U no U stones U in
U the U gallbladder, U pericholecystic U fluid U and U a Uwall U thickness U of U 6 U mm. U Which U of U the
U following U is U the U next U best U step U in U management?
A. CT U scan U of U abdomen U and U pelvis
B. Percutaneous U cholecystostomy U tube U placement
C. ERCP
D. Laparoscopic U cholecystectomy
E. Open U cholecystectomy U - U CORRECT U ANSWER U -Percutaneous U cholecystostomy U tube
U placement UCorrect.
This U patient U has U acalculous U cholecystitis. U She U is U not U healthy U enough U for U an U elective
U cholecystectomy Uat U this U time, U so U the U appropriate U treatment U is U percutaneous
U cholecystostomy U tube U placement. U ERCP Uwould U not U help U treat U acalculous U cholecystitis.
A U 65-year-
old U man U presents U to U the U ER U with U complaints U of U stabbing U RUQ U pain U occurring U for U several
U days, U and U a Uccording U to U his U family, U has U become U increasingly U aggravated U and U confused.
U His U vitals U are U T U 39°C, U HR U115 U bpm, U BP U 94/71 U mmHg, U RR U 20 U breaths/min, U 100% U on
U RA. U He U is U jaundiced U and U exhibits U a U positiv Ue U Murphy's U sign. U Labs U reveal U elevated
U bilirubin, U alkaline U phosphatase, U and U WBC. U His U troponins U are U n Uegative U and U EKG
U demonstrates U normal U sinus U rhythm. U His U disease U process U is U most U likely U caused U by U w Uhich
U organism?
A. Staphylococcus U aureus
B. Staphylococcus U epididymis
C. Streptococcus U pneumonia
D. Clostridium U perfringens
E. Klebsiella U pneumonia U - U CORRECT U ANSWER U -E. U Klebsiella
U pneumoniae UCorrect.
The U patient U is U suffering U from U acute U cholangitis, U which U is U most U commonly U caused U by U E.
U coli, U Klebsiell Ua U pneumoniae, U enterococci, U and U Bacteroides U fragilis.
,A U 42-year-
old U woman U with U BMI U 42 U kg/m2 U presents U with U stabbing U RUQ U pain U occurring U after U meals
U for U the U last U3 U days, U sometimes U waking U her U from U sleep. U She U had U a U myocardial U infarction
U 2 U months U ago U treated U w Uith U a U stent. U She U is U on U clopidogrel. U Her U vitals U are U T U 36.5°C,
U HR U 75 U bpm, U BP U 135/74 U mmHg, U RR U 16 U bre Uaths/min, U 100% U on U RA. U She U is U jaundiced
U and U has U RUQ U tenderness U to U deep U palpation. U Her U total U bilir Uubin U is U 4.0 U mg/dL, U direct
U bilirubin U 3.2 U mg/dL, U and U alkaline U phosphatase U 200 U IU/L. U Her U WBC U is U norm Ual U and
U serum U troponins U are U not U elevated. U EKG U demonstrates U normal U sinus U rhythm. U An
U ultrasound U of Uthe U RUQMreveals U stones U in U the U gallbladder. U What U imaging U study U would
U you U consider U next?
A. CT U scan U without U contrast
B. HIDA U scan U with U administration U of U cholecystokinin
C. Plain U radiograph U of U the U abdomen
D. Magnetic U resonance U cholangiopancreatography U (MRCP)
E. Endoscopic U retrograde U cholangiopancreatography U (ERCP) U - U CORRECT U ANSWER U -
D. U Magnetic U resonance U cholangiopancreatography U (MRCP)
Correct.
U
This Upatient Ulikely Uhas Ucholedocholithiasis Ugiven Uher Uelevated Ubilirubin Uand Ualkaline Uphosphatase.
UUS U can U only U show U stones U in U the U CBD U 10-
15% Uof Uthe Utime. UIf Uclinically Ususpicious Uof Ucholedocholithiasis, Uthe Unext Uimaging Ustudy Ucould Ube
Uend Uoscopic U retrograde U cholangiogram/endoscopic U US U (ERC/EUS) U or U MRCP. U Since U this
U patient U recently U ha Ud U an U MI U and U is U anticoagulated, U she U should U undergo U the U least
U invasive U procedure, U an U MRCP, U and U rule Uout U other U causes U of U increased U hepatic U function
U panel U before U undergoing U an U invasive U procedure U suc Uh U as U ERC/EUS.
MRCP U can U diagnose U CBD U stones U with U a U sensitivity U of U 90%, U a U specificity U of U 100%, U and U an
U overall U diag Unostic U accuracy U of U 97%.
A) CT U scan U without U contrast U has U great U sensitivity U and U specificity U for U stones U in U the U renal
U system. U For Uthe U gallbladder, U calcified U stones U can U only U be U visualized U 50% U of U the U time.
B) 99mTechnetium-labeled U iminodiacetic U acid U derivatives U (hepatic U 2,6-dimethyl-
iminodiacetic U acid U [HIDA], U diisopropyl-acetanilidoiminodiacetic U acid, U P-isopropylacetanilido-
imidodiacetic U acid) U scans U with U cholecystokinin U administration U should U be U used U to U identify U biliary
U dyski Unesia.
, C) Plain U x-
rays U of U the U abdomen U identify U stones U only U 15% U of U the U time U and U it U would U be U impossible
U to U differenti Uate U a U CBD U stone U from U a U gallbladder U stone U on U x-ray.
D) Since U this U patient U recently U had U an U MI, U she U should U undergo U the U least U invasive
U procedure, U an U MRC UP, Uand Urule Uout Uother Ucauses Uof Uincreased Uhepatic Ufunction Upanel Ubefore
Uundergoing Uan Uinvasive Upro Ucedure U such U as U ERC/EUS.
E) Endoscopic Uretrograde Ucholangiogram/endoscopic UUS U(ERC/EUS) Uis Umore Uinvasive Uthan UMRCP;
Uthis Upatient U would U be U high U risk U for U an U invasive U procedure.
A U 55-year-
old U male U presents U with U RUQMpain U over U the U last U 24 U hours. U Ultrasound U confirms U acute
U cholecystitis, U w Uith U gallbladder U wall U thickening, U pericholecystic U fluid, U and U multiple U stones.
U The U CBD U is U not U visualized Ubecause U of U overlying U bowel U gas. U His U laboratory U workup U is U as
U follows: U WBC U 17,000, U total U bilirubin U 2.5
, U AST/ALT U 150/170, U alkaline U phosphatase U 138. U He U is U not U febrile. U His U past U surgical
U history U includes U a URoux-en-
Y U gastric U bypass U and U a U cerebral U aneurysm U repair. U What U is U the U best U next U step U in U his
U management?
A. Open U cholecystectomy
B. Laparoscopic U cholecystectomy U with U intraoperative U cholangiogram
C. CT U abdomen/pelvis
D. MRCP
E. ERCP U- CORRECT
U U ANSWER -B.
U ULaparoscopic Ucholecystectomy with
U intraoperative
U
cholangiogram UCorrect.
U
This Upatient Uhas Ucholecystitis Uwith Uabnormal Uliver Ufunction Utests. UHis UCBD Uneeds Uto Ube Uvisualized
Upre Uoperatively Uor Uintraoperatively. UOptions Ugenerally Uinclude UMRCP, UERCP, Uand/or Uintraoperative
Ucholangi Uogram U (IOC). U Roux-en-
Y Ugastric Ubypass Udoes Unot Upreclude Ulaparoscopic Ucholecystectomy. UContraindications Uto UMRCP
Uinclude Uolder Uheart Upacemakers, Uimplanted Umetallic Udevices U(insulin Upumps, Uhearing Uaids,
Uneurostimulators), Uintracranial U metal U clips, U and U metallic U bodies U in U the U eye.
