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Adolescent depression — USMLE Step 3 MCQ

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HardPediatrics (Well-child / Chronic Management)Adolescent depressionUSMLE Step 3

A 76-year-old woman has fever, jaundice, right-upper-quadrant pain, confusion, and hypotension. Ultrasound shows a dilated common bile duct with a distal stone. After cultures, intravenous antibiotics, fluids, and norepinephrine, hypotension persists. Which intervention is most appropriate next?

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Correct answer: E — Perform urgent ERCP for biliary decompression while resuscitation and antibiotics continue

The best answer is “Perform urgent ERCP for biliary decompression while resuscitation and antibiotics continue”. Severe acute cholangitis with persistent shock is a source-control emergency. ERCP provides prompt biliary decompression and is preferred over delayed diagnostic imaging or antibiotic-only treatment. Cholecystectomy addresses the gallbladder but does not first relieve an obstructed infected common duct in an unstable patient. Resuscitation and antibiotics occur concurrently, not as substitutes for drainage.

Reference: ASGE Guideline on Management of Cholangitis: https://www.asge.org/home/resources/publications/guidelines/asge-guideline-on-the-management-of-cholangitis