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ABSITE – Biliary Questions and Answers
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A 37-year-old woman with BMI 30kg/m2 presents with unremitting RUQ pain lasting several days. She has experienced 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...

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  • August 28, 2024
  • 49
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • absite biliary questions and answers

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  • ABSITE
  • ABSITE

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1
Elscores: Aug. 27, 24- 2024/2025

ABSITE – Biliary Questions and Answers
A 37-year-old woman with BMI 30kg/m2 presents with unremitting RUQ pain lasting several

days. She has experienced 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 guarding and rebound. Ultrasound of the RUQ shows

gallbladder wall thickness of 5 mm and mild pericholecystic fluid. What is the diagnosis?




A. Acute cholecystitis

B. Cholelithiasis

C. Acute cholangitis

D. Chronic cholecystitis

E. Biliary dyskinesia


 :-- 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.




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, 2
Elscores: Aug. 27, 24- 2024/2025



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

thickening.




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 agents 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




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, 3
Elscores: Aug. 27, 24- 2024/2025

 :-- 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 according 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 positive Murphy's sign. Labs reveal elevated bilirubin, alkaline

phosphatase, and WBC. His troponins are negative and EKG demonstrates normal sinus

rhythm. His disease process is most likely caused by which organism?




A. Staphylococcus aureus

B. Staphylococcus epididymis

C. Streptococcus pneumonia

D. Clostridium perfringens

E. Klebsiella pneumonia


 :-- E. Klebsiella pneumoniae

Correct.




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, 4
Elscores: Aug. 27, 24- 2024/2025

The patient is suffering from acute cholangitis, which is most commonly caused by E. coli,

Klebsiella 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 with a stent. She is on clopidogrel. Her vitals are T 36.5°C, HR 75 bpm, BP

135/74 mmHg, RR 16 breaths/min, 100% on RA. She is jaundiced and has RUQ tenderness to

deep palpation. Her total bilirubin is 4.0 mg/dL, direct bilirubin 3.2 mg/dL, and alkaline

phosphatase 200 IU/L. Her WBC is normal and serum troponins are not elevated. EKG

demonstrates normal sinus rhythm. An ultrasound of the RUQ reveals 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)


 :-- 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 endoscopic retrograde


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