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.
Ax 65-year-
oldx manx presentsx tox thex ERx withx complaintsx ofx stabbingx RUQx painx occurringx forx severalx days,x and
xa
ccording
1 x to
15x bpm, x his
x BP x family,
x 94/71 x hasx become
x mmHg, increasinglyxxaggravated
x RRx 20xxbreaths/min, and
100%x onxxRA. confused.
x xHe x Hisx vitals
x isx jaundiced arex Tx 39°C,
x andx exhibits x HR
x ax posi
tiv
ex Murphy'sx sign.x Labsx revealx elevatedx bilirubin,x alkalinex phosphatase,x andx WBC.x Hisx troponinsx arex
n
egativex andx EKGx demonstratesx normalx sinusx rhythm.x Hisx diseasex processx isx mostx likelyx causedx byx
w
hichx organism?
A.x Staphylococcusx aureus
B.x Staphylococcusx epididymis
C.x Streptococcusx pneumonia
D.x Clostridiumx perfringens
E.x Klebsiellax pneumoniax -x CORRECTx ANSWERx -E.x Klebsiellax pneumoniae
Correct.
Thex patientx isx sufferingx fromx acutex cholangitis,x whichx isx mostx commonlyx causedx byx E.x coli,x Klebsi
ell
ax pneumoniae,x enterococci,x andx Bacteroidesx fragilis.
,x
Ax 42-year-
oldx womanx withx BMIx 42x kg/m2x presentsx withx stabbingx RUQx painx occurringx aſterx mealsx forx thex la
st
3 days,x sometimesx wakingx herx fromx sleep.x Shex hadx ax myocardialx infarctionx 2x monthsx agox treatedx
ithwx ax stent.x Shex isx onx clopidogrel.x Herx vitalsx arex Tx 36.5°C,x HRx 75x bpm,x BPx 135/74x mmHg,x RRx 16x
bre
aths/min,x 100%x onx RA.x Shex isx jaundicedx andx hasx RUQx tendernessx tox deepx palpation.x Herx totalx bili
r
ubinx isx 4.0x mg/dL,x directx bilirubinx 3.2x mg/dL,x andx alkalinex phosphatasex 200x IU/L.x Herx WBCx isx nor
m
alx andx serumx troponinsx arex notx elevated.x EKGx demonstratesx normalx sinusx rhythm.x Anx ultrasoundx
of
A.the x RUQx revealsx stonesx inx thex gallbladder.x Whatx imagingx studyx wouldx youx considerx next?
x CTx scanx withoutx contrast
B.x HIDAx scanx withx administrationx ofx cholecystokinin
C.x Plainx radiographx ofx thex abdomen
D.x Magneticx resonancex cholangiopancreatographyx (MRCP)
E.x Endoscopicx retrogradex cholangiopancreatographyx (ERCP)x -x CORRECTx ANSWERx -
D.x Magneticx resonancex cholangiopancreatographyx (MRCP)
Correct.
Thisx patientx likelyx hasx choledocholithiasisx givenx herx elevatedx bilirubinx andx alkalinex phosphatase.x U
S
can
1 5%xxonly x show
ofx the x stones
x time. x inx thex suspicious
x Ifx clinically CBDx 10- x ofx choledocholithiasis,x thex nextx imagingx studyx couldx bex e
nd
oscopicx retrogradex cholangiogram/endoscopicx USx (ERC/EUS)x orx MRCP.x Sincex thisx patientx recentlyx ha
dx anx MIx andx isx anticoagulated,x shex shouldx undergox thex leastx invasivex procedure,x anx MRCP,x andx r
ule
outx otherx causesx ofx increasedx hepaticx functionx panelx beforex undergoingx anx invasivex procedurex su
c
hx asx ERC/EUS.
MRCPx canx diagnosex CBDx stonesx withx ax sensitivityx ofx 90%,x ax specificityx ofx 100%,x andx anx overallx di
ag
nosticx accuracyx ofx 97%.
A)x CTx scanx withoutx contrastx hasx greatx sensitivityx andx specificityx forx stonesx inx thex renalx system.x F
or
thex gallbladder,x calcifiedx stonesx canx onlyx bex visualizedx 50%x ofx thex time.
B)x 99mTechnetium-labeledx iminodiaceticx acidx derivativesx (hepaticx 2,6-dimethyl-
iminodiaceticx acidx [HIDA],x diisopropyl-acetanilidoiminodiaceticx acid,x P-isopropylacetanilido-
imidodiaceticx acid)x scansx withx cholecystokininx administrationx shouldx bex usedx tox identifyx biliaryx dys
ki
nesia.
,x
C)x Plainx x-
raysx ofx thex abdomenx identifyx stonesx onlyx 15%x ofx thex timex andx itx wouldx bex impossiblex tox differe
nti
atex ax CBDx stonex fromx ax gallbladderx stonex onx x-ray.
D)x Sincex thisx patientx recentlyx hadx anx MI,x shex shouldx undergox thex leastx invasivex procedure,x anx M
RC
P,andx rulex outx otherx causesx ofx increasedx hepaticx functionx panelx beforex undergoingx anx invasivex pr
o
cedurex suchx asx ERC/EUS.
E)x Endoscopicx retrogradex cholangiogram/endoscopicx USx (ERC/EUS)x isx morex invasivex thanx MRCP;x thi
s
patientx wouldx bex highx riskx forx anx invasivex procedure.
Ax 55-year-
oldx malex presentsx withx RUQx painx overx thex lastx 24x hours.x Ultrasoundx confirmsx acutex cholecystitis,x
w
ithx gallbladderx wallx thickening,x pericholecysticx fluid,x andx multiplex stones.x Thex CBDx isx notx visualized
because
, AST/ALT x of x overlying
x 150/170, x bowelxxphosphatase
x alkaline gas.x Hisx laboratory x workup
x 138.x He x isx notxxis x asx follows:
febrile. x WBC
x Hisx past x 17,000,
x surgical x totalxx includes
x history bilirubinxx 2
.5a
Roux-en-
Yx gastricx bypassx andx ax cerebralx aneurysmx repair.x Whatx isx thex bestx nextx stepx inx hisx managemen
t?
A.x Openx cholecystectomy
B.x Laparoscopicx cholecystectomyx withx intraoperativex cholangiogram
C.x CTx abdomen/pelvis
D.x MRCP
E.x ERCPx -x CORRECTx ANSWERx -
B.x Laparoscopicx cholecystectomyx withx intraoperativex cholangiogram
Correct.
Thisx patientx hasx cholecystitisx withx abnormalx liverx functionx tests.x Hisx CBDx needsx tox bex visualizedx pr
e
operativelyx orx intraoperatively.x Optionsx generallyx includex MRCP,x ERCP,x and/orx intraoperativex cholang
i
ogramx (IOC).x Roux-en-
Yx gastricx bypassx doesx notx precludex laparoscopicx cholecystectomy.x Contraindicationsx tox MRCPx includ
e
olderx heartx pacemakers,x implantedx metallicx devicesx (insulinx pumps,x hearingx aids,x neurostimulators)
,
intracranialx metalx clips,x andx metallicx bodiesx inx thex 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.
Ax 65-year-
oldx manx presentsx tox thex ERx withx complaintsx ofx stabbingx RUQx painx occurringx forx severalx days,x and
xa
ccording
1 x to
15x bpm, x his
x BP x family,
x 94/71 x hasx become
x mmHg, increasinglyxxaggravated
x RRx 20xxbreaths/min, and
100%x onxxRA. confused.
x xHe x Hisx vitals
x isx jaundiced arex Tx 39°C,
x andx exhibits x HR
x ax posi
tiv
ex Murphy'sx sign.x Labsx revealx elevatedx bilirubin,x alkalinex phosphatase,x andx WBC.x Hisx troponinsx arex
n
egativex andx EKGx demonstratesx normalx sinusx rhythm.x Hisx diseasex processx isx mostx likelyx causedx byx
w
hichx organism?
A.x Staphylococcusx aureus
B.x Staphylococcusx epididymis
C.x Streptococcusx pneumonia
D.x Clostridiumx perfringens
E.x Klebsiellax pneumoniax -x CORRECTx ANSWERx -E.x Klebsiellax pneumoniae
Correct.
Thex patientx isx sufferingx fromx acutex cholangitis,x whichx isx mostx commonlyx causedx byx E.x coli,x Klebsi
ell
ax pneumoniae,x enterococci,x andx Bacteroidesx fragilis.
,x
Ax 42-year-
oldx womanx withx BMIx 42x kg/m2x presentsx withx stabbingx RUQx painx occurringx aſterx mealsx forx thex la
st
3 days,x sometimesx wakingx herx fromx sleep.x Shex hadx ax myocardialx infarctionx 2x monthsx agox treatedx
ithwx ax stent.x Shex isx onx clopidogrel.x Herx vitalsx arex Tx 36.5°C,x HRx 75x bpm,x BPx 135/74x mmHg,x RRx 16x
bre
aths/min,x 100%x onx RA.x Shex isx jaundicedx andx hasx RUQx tendernessx tox deepx palpation.x Herx totalx bili
r
ubinx isx 4.0x mg/dL,x directx bilirubinx 3.2x mg/dL,x andx alkalinex phosphatasex 200x IU/L.x Herx WBCx isx nor
m
alx andx serumx troponinsx arex notx elevated.x EKGx demonstratesx normalx sinusx rhythm.x Anx ultrasoundx
of
A.the x RUQx revealsx stonesx inx thex gallbladder.x Whatx imagingx studyx wouldx youx considerx next?
x CTx scanx withoutx contrast
B.x HIDAx scanx withx administrationx ofx cholecystokinin
C.x Plainx radiographx ofx thex abdomen
D.x Magneticx resonancex cholangiopancreatographyx (MRCP)
E.x Endoscopicx retrogradex cholangiopancreatographyx (ERCP)x -x CORRECTx ANSWERx -
D.x Magneticx resonancex cholangiopancreatographyx (MRCP)
Correct.
Thisx patientx likelyx hasx choledocholithiasisx givenx herx elevatedx bilirubinx andx alkalinex phosphatase.x U
S
can
1 5%xxonly x show
ofx the x stones
x time. x inx thex suspicious
x Ifx clinically CBDx 10- x ofx choledocholithiasis,x thex nextx imagingx studyx couldx bex e
nd
oscopicx retrogradex cholangiogram/endoscopicx USx (ERC/EUS)x orx MRCP.x Sincex thisx patientx recentlyx ha
dx anx MIx andx isx anticoagulated,x shex shouldx undergox thex leastx invasivex procedure,x anx MRCP,x andx r
ule
outx otherx causesx ofx increasedx hepaticx functionx panelx beforex undergoingx anx invasivex procedurex su
c
hx asx ERC/EUS.
MRCPx canx diagnosex CBDx stonesx withx ax sensitivityx ofx 90%,x ax specificityx ofx 100%,x andx anx overallx di
ag
nosticx accuracyx ofx 97%.
A)x CTx scanx withoutx contrastx hasx greatx sensitivityx andx specificityx forx stonesx inx thex renalx system.x F
or
thex gallbladder,x calcifiedx stonesx canx onlyx bex visualizedx 50%x ofx thex time.
B)x 99mTechnetium-labeledx iminodiaceticx acidx derivativesx (hepaticx 2,6-dimethyl-
iminodiaceticx acidx [HIDA],x diisopropyl-acetanilidoiminodiaceticx acid,x P-isopropylacetanilido-
imidodiaceticx acid)x scansx withx cholecystokininx administrationx shouldx bex usedx tox identifyx biliaryx dys
ki
nesia.
,x
C)x Plainx x-
raysx ofx thex abdomenx identifyx stonesx onlyx 15%x ofx thex timex andx itx wouldx bex impossiblex tox differe
nti
atex ax CBDx stonex fromx ax gallbladderx stonex onx x-ray.
D)x Sincex thisx patientx recentlyx hadx anx MI,x shex shouldx undergox thex leastx invasivex procedure,x anx M
RC
P,andx rulex outx otherx causesx ofx increasedx hepaticx functionx panelx beforex undergoingx anx invasivex pr
o
cedurex suchx asx ERC/EUS.
E)x Endoscopicx retrogradex cholangiogram/endoscopicx USx (ERC/EUS)x isx morex invasivex thanx MRCP;x thi
s
patientx wouldx bex highx riskx forx anx invasivex procedure.
Ax 55-year-
oldx malex presentsx withx RUQx painx overx thex lastx 24x hours.x Ultrasoundx confirmsx acutex cholecystitis,x
w
ithx gallbladderx wallx thickening,x pericholecysticx fluid,x andx multiplex stones.x Thex CBDx isx notx visualized
because
, AST/ALT x of x overlying
x 150/170, x bowelxxphosphatase
x alkaline gas.x Hisx laboratory x workup
x 138.x He x isx notxxis x asx follows:
febrile. x WBC
x Hisx past x 17,000,
x surgical x totalxx includes
x history bilirubinxx 2
.5a
Roux-en-
Yx gastricx bypassx andx ax cerebralx aneurysmx repair.x Whatx isx thex bestx nextx stepx inx hisx managemen
t?
A.x Openx cholecystectomy
B.x Laparoscopicx cholecystectomyx withx intraoperativex cholangiogram
C.x CTx abdomen/pelvis
D.x MRCP
E.x ERCPx -x CORRECTx ANSWERx -
B.x Laparoscopicx cholecystectomyx withx intraoperativex cholangiogram
Correct.
Thisx patientx hasx cholecystitisx withx abnormalx liverx functionx tests.x Hisx CBDx needsx tox bex visualizedx pr
e
operativelyx orx intraoperatively.x Optionsx generallyx includex MRCP,x ERCP,x and/orx intraoperativex cholang
i
ogramx (IOC).x Roux-en-
Yx gastricx bypassx doesx notx precludex laparoscopicx cholecystectomy.x Contraindicationsx tox MRCPx includ
e
olderx heartx pacemakers,x implantedx metallicx devicesx (insulinx pumps,x hearingx aids,x neurostimulators)
,
intracranialx metalx clips,x andx metallicx bodiesx inx thex eye.
