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Post-cholecystectomy bile leak — USMLE Step 3 MCQ

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HardSurgeryPost-cholecystectomy bile leakUSMLE Step 3

Ten days after laparoscopic cholecystectomy, a 28-year-old woman has fever and right upper-quadrant pain. CT shows a 7-cm gallbladder-fossa collection. Percutaneous drainage yields bile, and output remains 350 mL/day. MRCP shows no complete common-duct transection or retained stone; the likely source is the cystic-duct stump. Which additional intervention is most appropriate?

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Correct answer: A — Perform ERCP with transpapillary biliary stent placement

The best answer is “Perform ERCP with transpapillary biliary stent placement”. The symptomatic biloma first needs percutaneous source control. Persistent high-output bile from a minor cystic-duct-stump leak then requires reduction of the transpapillary pressure gradient, usually by ERCP with sphincterotomy and temporary stenting. Complete major-duct transection requires specialist reconstruction, but the imaging excludes that. Drain removal or clamping before internal control risks recurrent infected collection.

Reference: WSES Guidelines: Bile Duct Injury During Cholecystectomy: https://pmc.ncbi.nlm.nih.gov/articles/PMC8190978/