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Suspected choledocholithiasis — ABIM Board MCQ

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ModerateGastroenterology/HepatologySuspected choledocholithiasisABIM Board

A 44-year-old woman is hospitalized with mild gallstone pancreatitis and improves with supportive care. She is afebrile and has no hypotension, confusion, or persistent abdominal pain. Total bilirubin is 3.2 mg/dL, and alkaline phosphatase is elevated. Right upper quadrant ultrasonography shows gallstones and a 9-mm common bile duct but no common bile duct stone. Which of the following is the most appropriate next study to evaluate for a retained common bile duct stone?

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Correct answer: B — Magnetic resonance cholangiopancreatography

The correct answer is B. This patient has intermediate-risk features for choledocholithiasis: abnormal cholestatic liver tests and a dilated common bile duct, but no cholangitis, duct stone on imaging, or bilirubin greater than 4 mg/dL. MRCP is a noninvasive confirmatory test; EUS would also be appropriate if offered. ERCP is reserved primarily for patients with high-risk findings or confirmed stones because it is invasive and can cause pancreatitis and other complications. A HIDA scan evaluates cystic duct obstruction and gallbladder function, not retained common bile duct stones. CT is less sensitive for many bile duct stones, and repeating transabdominal ultrasonography is unlikely to adequately exclude choledocholithiasis.

Reference: American Society for Gastrointestinal Endoscopy. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis, recommendations for intermediate-risk patients, 2019. https://www.asge.org/docs/default-source/guidelines/asge-guideline-on-the-role-of-endoscopy-in-the-evaluation-and-management-of-choledocholithiasis-2019-june-gie.pdf?sfvrsn=6757df52_4