HY USMLEQ#13 Gastroenterology Step 2CK
Level: Step 2 CK/3 (inspired from Uworld step 3)
A 57-year-old man is brought to the emergency room due to excruciating abdominal pain and vomiting for the last 24 hours. The patient's abdominal pain began abruptly, and he describes it as a stabbing sensation radiating to his back. He has also developed chills, nausea, malaise, and multiple episodes of vomiting. The patient's medical history includes hyperlipidemia, hypertension, and gout. Medications include atorvastatin, allopurinol, and chlorthalidone. He occasionally drinks alcohol and smoked half a pack of cigarettes a day for 20 years. Temperature is 39.2 °C, blood pressure is 104/57 mmHg, pulse is 112/min, and respiration is 19/min. BMI is 29 kg/m2. Physical examination shows a middle-aged male in moderate distress. The patient has scleral icterus. The abdomen is soft and tender to palpation over the midepigastrium and right upper quadrant.
Complete Blood Count:
Leukocytes = 18,000/mm3 ( N = 4,500- 11,000/mm3)
Hemoglobin = 14.5 g/dl ( N = 13.5 to 17.5 g/dl )
Hemocrit = 40% ( N = 41 to 53%)
Platelets = 440,000/mm3 ( 150,000 mm3 to 400,000 mm3)
Liver function studies:
Total protein 8.3 g/dl ( 6.0 - 7.0 g/dl)
Albumin 4.3 g/dl (3.5 - 5.5 g/dl)
Total Bilirubin 5.2 mg/dl (0.1 - 1.0 mg/dl)
Direct bilirubin 3.2 mg/dl (0.0 - 0.3 mg/dl)
Alkaline phosphatase 310 U/L (25 - 100 U/L)
Asparate aminotransferase 116 U/L (12 - 38 U/L)
Asparate aminotransferase 140 U/L ( 10 to 40 U/L)
Lipase 1,116 U/L ( normal 0 to 160)
Abdominal ultrasound reveals multiple small gallbladder stones and common bile duct dilation. No stones are visualized in the biliary tree. The panceas is not very well visualized due to the gastric shadow. The patient is admitted and treated with intravenous fluids and antibiotics. Blood cultures are drawn. Which of the following is the most appropriate next step in the management of this patient ?
A. Laparoscopic Cholecystectomy
B. CT scan of the abdomen without contrast
C. Endoscopic retrograde cholangiopancreatography
D. Haptobiliary scintigraphy
E. Percutaneous Cholecystomy
✅ Correct answer C = Endoscopic retrograde cholangiopancreatography. The above patient has acute cholangitis, which can complicate gallstone pancreatitis, which is characterized by fever, abdominal pain, and jaundice. Urgent endoscopic retrograde cholangiopancreatography is a key medical step for the diagnosis and treatment of biliary drainage.
❌ A. Laparoscopic Cholecystectomy --> Cholecystecomy will eventually be needed in this patient. It is not needed acutely.
❌ B. CT scan of the abdomen without contrast --> used to diagnose acute pancreatitis in patients with typical symptoms and without elevations in serum lipase or amylase. It is not necessary in patients with classic symptoms and elevations in their serologic markers.
❌ D. Hepatobiliary scintigraphy --> this is a useful test in the evaluation of acute cholecysitis as it can help visualize the patency of the cystic and common bile ducts; however, it has no role in the evaluation of gallstone pancreatitis or acute cholangitis. Also, if acute cholecystitis is on the differential, then it would not explain the elevated lipase or hyperbilirubinemia.
❌ E. Percutaneous Cholecystomy --> Cholecystecomy will eventually be needed in this patient. It is not needed acutely. Urgent biliary decompression is needed and is best accomplished with ERCP. Biliary drainage with percutaneous cholecystostomy is an acceptable alternative in patients who have contraindications to ERCP ( for example, hemodynamic instability, neurologic impairment) or when it is unavailable.
