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.
Az 65-year-
oldz manz presentsz toz thez ERz withz complaintsz ofz stabbingz RUQz painz occurringz forz severalz days,z andz
a
ccording
1 z to
15z bpm, z his
z BP z family,
z 94/71 z hasz become
z mmHg, increasinglyzzaggravated
z RRz 20zzbreaths/min, and
100%z onz zRA. z confused.
z He z Hisz zvitals
z isz jaundiced arez Tz 39°C,
andzzexhibits z HR
z az positi
v
ez Murphy'sz sign.z Labsz revealz elevatedz bilirubin,z alkalinez phosphatase,z andz WBC.z Hisz troponinsz arez n
egativez andz EKGz demonstratesz normalz sinusz rhythm.z Hisz diseasez processz isz mostz likelyz causedz byz w
hichz organism?
A.z Staphylococcusz aureus
B.z Staphylococcusz epididymis
C.z Streptococcusz pneumonia
D.z Clostridiumz perfringens
E.z Klebsiellaz pneumoniaz -z CORRECTz ANSWERz -E.z Klebsiellaz pneumoniae
Correct.
Thez patientz isz sufferingz fromz acutez cholangitis,z whichz isz mostz commonlyz causedz byz E.z coli,z Klebsiell
az pneumoniae,z enterococci,z andz Bacteroidesz fragilis.
,z
Az 42-year-
oldz womanz withz BMIz 42z kg/m2z presentsz withz stabbingz RUQz painz occurringz aſterz mealsz forz thez las
t3 days,z sometimesz wakingz herz fromz sleep.z Shez hadz az myocardialz infarctionz 2z monthsz agoz treatedz
ithw
z az stent.z Shez isz onz clopidogrel.z Herz vitalsz arez Tz 36.5°C,z HRz 75z bpm,z BPz 135/74z mmHg,z RRz 16z br
e
aths/min,z 100%z onz RA.z Shez isz jaundicedz andz hasz RUQz tendernessz toz deepz palpation.z Herz totalz bilir
ubinz isz 4.0z mg/dL,z directz bilirubinz 3.2z mg/dL,z andz alkalinez phosphatasez 200z IU/L.z Herz WBCz isz norm
alz andz serumz troponinsz arez notz elevated.z EKGz demonstratesz normalz sinusz rhythm.z Anz ultrasoundz of
thez RUQz revealsz stonesz inz thez gallbladder.z Whatz imagingz studyz wouldz youz considerz next?
A.z CTz scanz withoutz contrast
B.z HIDAz scanz withz administrationz ofz cholecystokinin
C.z Plainz radiographz ofz thez abdomen
D.z Magneticz resonancez cholangiopancreatographyz (MRCP)
E.z Endoscopicz retrogradez cholangiopancreatographyz (ERCP)z -z CORRECTz ANSWERz -
D.z Magneticz resonancez cholangiopancreatographyz (MRCP)
Correct.
Thisz patientz likelyz hasz choledocholithiasisz givenz herz elevatedz bilirubinz andz alkalinez phosphatase.z US
canz onlyz showz stonesz inz thez CBDz 10-
15%z ofz thez time.z Ifz clinicallyz suspiciousz ofz choledocholithiasis,z thez nextz imagingz studyz couldz bez en
d
oscopic z retrogradez cholangiogram/endoscopicz USz (ERC/EUS)z orz MRCP.z Sincez thisz patientz recentlyz ha
dz anz MIz andz isz anticoagulated,z shez shouldz undergoz thez leastz invasivez procedure,z anz MRCP,z andz rul
e
outz otherz causesz ofz increasedz hepaticz functionz panelz beforez undergoingz anz invasivez procedurez suc
hz asz ERC/EUS.
MRCPz canz diagnosez CBDz stonesz withz az sensitivityz ofz 90%,z az specificityz ofz 100%,z andz anz overallz dia
g
nosticz accuracyz ofz 97%.
A)z CTz scanz withoutz contrastz hasz greatz sensitivityz andz specificityz forz stonesz inz thez renalz system.z Fo
r
thez gallbladder,z calcifiedz stonesz canz onlyz bez visualizedz 50%z ofz thez time.
B)z 99mTechnetium-labeledz iminodiaceticz acidz derivativesz (hepaticz 2,6-dimethyl-
iminodiaceticz acidz [HIDA],z diisopropyl-acetanilidoiminodiaceticz acid,z P-isopropylacetanilido-
imidodiaceticz acid)z scansz withz cholecystokininz administrationz shouldz bez usedz toz identifyz biliaryz dyski
nesia.
,z
C)z Plainz x-
raysz ofz thez abdomenz identifyz stonesz onlyz 15%z ofz thez timez andz itz wouldz bez impossiblez toz different
i
atez az CBDz stonez fromz az gallbladderz stonez onz x-ray.
D)z Sincez thisz patientz recentlyz hadz anz MI,z shez shouldz undergoz thez leastz invasivez procedure,z anz MR
C
P,andz rulez outz otherz causesz ofz increasedz hepaticz functionz panelz beforez undergoingz anz invasivez pro
cedurez suchz asz ERC/EUS.
E)z Endoscopicz retrogradez cholangiogram/endoscopicz USz (ERC/EUS)z isz morez invasivez thanz MRCP;z this
patientz wouldz bez highz riskz forz anz invasivez procedure.
Az 55-year-
oldz malez presentsz withz RUQz painz overz thez lastz 24z hours.z Ultrasoundz confirmsz acutez cholecystitis,z w
ithz gallbladderz wallz thickening,z pericholecysticz fluid,z andz multiplez stones.z Thez CBDz isz notz visualized
becausez ofz overlyingz bowelz gas.z Hisz laboratoryz workupz isz asz follows:z WBCz 17,000,z totalz bilirubinz 2.
5
, AST/ALTz 150/170,z alkalinez phosphatasez 138.z Hez isz notz febrile.z Hisz pastz surgicalz historyz includesz a
Roux-en-
Yz gastricz bypassz andz az cerebralz aneurysmz repair.z Whatz isz thez bestz nextz stepz inz hisz management
?
A.z Openz cholecystectomy
B.z Laparoscopicz cholecystectomyz withz intraoperativez cholangiogram
C.z CTz abdomen/pelvis
D.z MRCP
E.z ERCPz -z CORRECTz ANSWERz -B.z Laparoscopicz cholecystectomyz withz intraoperativez cholangiogram
Correct.
Thisz patientz hasz cholecystitisz withz abnormalz liverz functionz tests.z Hisz CBDz needsz toz bez visualizedz pre
operativelyz orz intraoperatively.z Optionsz generallyz includez MRCP,z ERCP,z and/orz intraoperativez cholangi
ogramz (IOC).z Roux-en-
Yz gastricz bypassz doesz notz precludez laparoscopicz cholecystectomy.z Contraindicationsz toz MRCPz include
olderz heartz pacemakers,z implantedz metallicz devicesz (insulinz pumps,z hearingz aids,z neurostimulators),
intracranialz metalz clips,z andz metallicz bodiesz inz thez 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.
Az 65-year-
oldz manz presentsz toz thez ERz withz complaintsz ofz stabbingz RUQz painz occurringz forz severalz days,z andz
a
ccording
1 z to
15z bpm, z his
z BP z family,
z 94/71 z hasz become
z mmHg, increasinglyzzaggravated
z RRz 20zzbreaths/min, and
100%z onz zRA. z confused.
z He z Hisz zvitals
z isz jaundiced arez Tz 39°C,
andzzexhibits z HR
z az positi
v
ez Murphy'sz sign.z Labsz revealz elevatedz bilirubin,z alkalinez phosphatase,z andz WBC.z Hisz troponinsz arez n
egativez andz EKGz demonstratesz normalz sinusz rhythm.z Hisz diseasez processz isz mostz likelyz causedz byz w
hichz organism?
A.z Staphylococcusz aureus
B.z Staphylococcusz epididymis
C.z Streptococcusz pneumonia
D.z Clostridiumz perfringens
E.z Klebsiellaz pneumoniaz -z CORRECTz ANSWERz -E.z Klebsiellaz pneumoniae
Correct.
Thez patientz isz sufferingz fromz acutez cholangitis,z whichz isz mostz commonlyz causedz byz E.z coli,z Klebsiell
az pneumoniae,z enterococci,z andz Bacteroidesz fragilis.
,z
Az 42-year-
oldz womanz withz BMIz 42z kg/m2z presentsz withz stabbingz RUQz painz occurringz aſterz mealsz forz thez las
t3 days,z sometimesz wakingz herz fromz sleep.z Shez hadz az myocardialz infarctionz 2z monthsz agoz treatedz
ithw
z az stent.z Shez isz onz clopidogrel.z Herz vitalsz arez Tz 36.5°C,z HRz 75z bpm,z BPz 135/74z mmHg,z RRz 16z br
e
aths/min,z 100%z onz RA.z Shez isz jaundicedz andz hasz RUQz tendernessz toz deepz palpation.z Herz totalz bilir
ubinz isz 4.0z mg/dL,z directz bilirubinz 3.2z mg/dL,z andz alkalinez phosphatasez 200z IU/L.z Herz WBCz isz norm
alz andz serumz troponinsz arez notz elevated.z EKGz demonstratesz normalz sinusz rhythm.z Anz ultrasoundz of
thez RUQz revealsz stonesz inz thez gallbladder.z Whatz imagingz studyz wouldz youz considerz next?
A.z CTz scanz withoutz contrast
B.z HIDAz scanz withz administrationz ofz cholecystokinin
C.z Plainz radiographz ofz thez abdomen
D.z Magneticz resonancez cholangiopancreatographyz (MRCP)
E.z Endoscopicz retrogradez cholangiopancreatographyz (ERCP)z -z CORRECTz ANSWERz -
D.z Magneticz resonancez cholangiopancreatographyz (MRCP)
Correct.
Thisz patientz likelyz hasz choledocholithiasisz givenz herz elevatedz bilirubinz andz alkalinez phosphatase.z US
canz onlyz showz stonesz inz thez CBDz 10-
15%z ofz thez time.z Ifz clinicallyz suspiciousz ofz choledocholithiasis,z thez nextz imagingz studyz couldz bez en
d
oscopic z retrogradez cholangiogram/endoscopicz USz (ERC/EUS)z orz MRCP.z Sincez thisz patientz recentlyz ha
dz anz MIz andz isz anticoagulated,z shez shouldz undergoz thez leastz invasivez procedure,z anz MRCP,z andz rul
e
outz otherz causesz ofz increasedz hepaticz functionz panelz beforez undergoingz anz invasivez procedurez suc
hz asz ERC/EUS.
MRCPz canz diagnosez CBDz stonesz withz az sensitivityz ofz 90%,z az specificityz ofz 100%,z andz anz overallz dia
g
nosticz accuracyz ofz 97%.
A)z CTz scanz withoutz contrastz hasz greatz sensitivityz andz specificityz forz stonesz inz thez renalz system.z Fo
r
thez gallbladder,z calcifiedz stonesz canz onlyz bez visualizedz 50%z ofz thez time.
B)z 99mTechnetium-labeledz iminodiaceticz acidz derivativesz (hepaticz 2,6-dimethyl-
iminodiaceticz acidz [HIDA],z diisopropyl-acetanilidoiminodiaceticz acid,z P-isopropylacetanilido-
imidodiaceticz acid)z scansz withz cholecystokininz administrationz shouldz bez usedz toz identifyz biliaryz dyski
nesia.
,z
C)z Plainz x-
raysz ofz thez abdomenz identifyz stonesz onlyz 15%z ofz thez timez andz itz wouldz bez impossiblez toz different
i
atez az CBDz stonez fromz az gallbladderz stonez onz x-ray.
D)z Sincez thisz patientz recentlyz hadz anz MI,z shez shouldz undergoz thez leastz invasivez procedure,z anz MR
C
P,andz rulez outz otherz causesz ofz increasedz hepaticz functionz panelz beforez undergoingz anz invasivez pro
cedurez suchz asz ERC/EUS.
E)z Endoscopicz retrogradez cholangiogram/endoscopicz USz (ERC/EUS)z isz morez invasivez thanz MRCP;z this
patientz wouldz bez highz riskz forz anz invasivez procedure.
Az 55-year-
oldz malez presentsz withz RUQz painz overz thez lastz 24z hours.z Ultrasoundz confirmsz acutez cholecystitis,z w
ithz gallbladderz wallz thickening,z pericholecysticz fluid,z andz multiplez stones.z Thez CBDz isz notz visualized
becausez ofz overlyingz bowelz gas.z Hisz laboratoryz workupz isz asz follows:z WBCz 17,000,z totalz bilirubinz 2.
5
, AST/ALTz 150/170,z alkalinez phosphatasez 138.z Hez isz notz febrile.z Hisz pastz surgicalz historyz includesz a
Roux-en-
Yz gastricz bypassz andz az cerebralz aneurysmz repair.z Whatz isz thez bestz nextz stepz inz hisz management
?
A.z Openz cholecystectomy
B.z Laparoscopicz cholecystectomyz withz intraoperativez cholangiogram
C.z CTz abdomen/pelvis
D.z MRCP
E.z ERCPz -z CORRECTz ANSWERz -B.z Laparoscopicz cholecystectomyz withz intraoperativez cholangiogram
Correct.
Thisz patientz hasz cholecystitisz withz abnormalz liverz functionz tests.z Hisz CBDz needsz toz bez visualizedz pre
operativelyz orz intraoperatively.z Optionsz generallyz includez MRCP,z ERCP,z and/orz intraoperativez cholangi
ogramz (IOC).z Roux-en-
Yz gastricz bypassz doesz notz precludez laparoscopicz cholecystectomy.z Contraindicationsz toz MRCPz include
olderz heartz pacemakers,z implantedz metallicz devicesz (insulinz pumps,z hearingz aids,z neurostimulators),
intracranialz metalz clips,z andz metallicz bodiesz inz thez eye.
