Need some Vater
Clinical presentations/complications
Gall of Fame (Topic: Dx, physical presentation, imaging, etc.)
Mixed Bag of Stones
Sassy Sphincters (MISC)
100
A 45-year-old man presents with 2 days of severe epigastric pain radiating to the back, nausea, and vomiting. He has a long-standing history of alcohol use disorder. On exam, he is febrile and tachycardic. Labs show:
WBC count: 15,800/mm³
Serum amylase: 190 U/L (Normal: 30–110 U/L)
Serum lipase: 380 U/L (Normal: 0–160 U/L)
ALT: 38 U/L
AST: 82 U/L
ALP: 96 U/L
Total bilirubin: 0.9 mg/dL
Abdominal ultrasound shows no gallstones. CT abdomen reveals peripancreatic fluid without necrosis.
Which of the following criteria best supports the diagnosis of acute pancreatitis in this patient?
A. Elevated AST and absence of gallstones on imaging
B. Elevated lipase >3× normal and characteristic imaging findings
C. Elevated WBC count and normal LFTs
D. Epigastric pain and peripancreatic edema on imaging
Best Answer = E
The Diagnostic Criteria for Acute Pancreatitis Requires At least 2/3 of the following factors:
1. Epigastric Pain
2. Peripancreatic edema on CT/Sonographic imaging
3. >3x Serum Lipase levels compared to the upper limit of normal (in this case; although elevated, the abnormal level starts at ~480; theirs is 380)
100
A 45-year-old woman presents with right upper quadrant abdominal pain, fever, and nausea for the past 2 days. Exam reveals a + Murphy's sign. Her liver function tests show elevated AST and ALT, and markedly increased alkaline phosphatase (ALP). Which of the following best explains the elevated ALP in this patient?
A. Hepatocellular injury from acute viral hepatitis
B. Increased osteoblastic activity from bone turnover
C. Cholestasis with primarily bile duct involvement
D. Increased ALP synthesis by the gallbladder wall
Correct Answer: C. Bile duct involvement leading to cholestasis
Explanation:
In cholecystitis, particularly when there is involvement of the biliary ducts (such as obstruction by a gallstone), ALP levels rise due to cholestasis. The bile duct epithelial cells increase ALP synthesis, and damaged cells can leak the enzyme into the bloodstream. Elevated ALP is not typically seen in isolated gallbladder inflammation unless there's associated biliary obstruction.
100
Name at least three differential diagnoses for RUQ pain.
Gastric ulcer, cholelithiasis, cholangitis, choledocholithiasis, duodenal ulcer, hepatitis, portal vein thrombosis, nephrolithiasis, peritonitis, mesenteric ischemia
100
A 45-year-old woman presents to her primary care physician with a complaint of intermittent right upper quadrant (RUQ) pain that is often worse after meals. She has a history of obesity, multiple pregnancies, and uses oral contraceptives. On examination, she is obese with a BMI of 32. An abdominal ultrasound reveals multiple, round, yellow, radiolucent stones in the gallbladder. Which of the following is the most likely mechanism leading to the formation of these stones?
A) Increased bilirubin production due to extravascular hemolysis
B) Supersaturation of cholesterol due to decreased bile acids
C) Chronic biliary tract infection with E. coli
D) Stasis of bile secondary to a dysfunctional sphincter of Oddi
E) Increased calcium concentration in the bile due to cirrhosis
Correct Answer B) Supersaturation of Cholesterol due to decreased bile acids
In this case, the patient's obesity, use of OCPs, and multiple pregnancies are risk factors for cholesterol gallstones, which form when the bile becomes supersaturated with cholesterol. This is often due to decreased bile acids or phospholipids that are needed to keep the cholesterol in solution. The yellow, radiolucent stones observed on ultrasound are characteristic of cholesterol stones.
100
A 52-year-old M presents with jaundice and severe epigastric pain radiating to the back. He reports nausea and vomiting. Exam reveals scleral icterus and tenderness in the epigastric region. Labs show elevated ALP, GGT, direct bilirubin, and markedly elevated lipase. Abdominal US reveals dilation of both the common bile duct and pancreatic duct. No gallstones are visualized in the gallbladder. What is the most likely location of the obstruction? Point to the location.
A. Cystic duct
B. Common hepatic duct
C. Ampulla of Vater
D. Intrahepatic bile ducts
E. Right main pancreatic duct
Correct Answer:
C. Ampulla of Vater
Explanation:
Simultaneous dilation of the common bile duct and pancreatic duct ("double duct sign") is characteristic of an obstruction at the Ampulla of Vater. Gallstones lodged here can block both outflow tracts, leading to jaundice, cholangitis, and acute pancreatitis.
200
A 52-year-old man with a history of chronic alcohol use presents 5 weeks after an episode of acute pancreatitis. He reports persistent upper abdominal fullness and early satiety. He has no fever or chills. His vital signs are within normal limits. CT abdomen shows a 6 cm fluid-filled collection with a well-defined, fibrous wall posterior to the stomach.
Which of the following is the most likely diagnosis?
A. Pancreatic abscess
B. Pancreatic pseudocyst
C. Pancreatic necrosis
D. Perforated posterior duodenal ulcer
E. Walled-off pancreatic necrosis (WOPN)
Correct Answer: B) Pancreatic Pseudocyst
> The pseudocyst is a walled-off collection of edema and fluid which DOES NOT have necrotic tissue or an epithelial lining; but rather a fibrous cap. This is what differentiates it from a true cyst or abscess.
Q: What is the management of this condition and what is a/are feared complication(s) a pseudocyst can lead to?
200
A 48-year-old woman presents with intermittent right upper quadrant abdominal pain that typically occurs after eating greasy meals. The pain resolves spontaneously within a few hours. She is afebrile, has a negative Murphy’s sign, and her laboratory tests—including liver enzymes and white blood cell count—are within normal limits. Which of the following is the most likely diagnosis? Point to the primary location of the presenting condition. → EXTRA… whats the treatment?
A. Acute cholecystitis
B. Gallstone ileus
C. Biliary colic
D. Choledocholithiasis
E. Gallbladder adenocarcinoma
Point to cystic duct → does not produce ALP so no elevation in labs and doesn't block liver so no elevated liver function tests
Explanation:
This presentation is classic for biliary colic, caused by temporary obstruction of the cystic duct by gallstones.
It typically occurs after fatty meals, lasts a few hours, and resolves without intervention.--> gallbladder contracting against semi blocked cystic duct
There are no signs of inflammation, such as fever, leukocytosis, Murphy's sign, or abnormal labs.
ADDITIONAL QUESTION- treatment?
Pain control (NSAIDs such as ketorolac, opioids only if pain is not relieved or patient is allergic to NSAIDs).
And Elective cholecystectomy: Done to prevent recurrence. Or oral dissolution therapy using ursodeoxycholic acid
200
Name at least three non-GI differential diagnoses for RUQ pain.
Main RUQ ddx: lower lobe pneumonia, low lobe pulmonary infarction (pulmonary embolism), empyema (pus in the pleural cavity), uretic colic, pyelonephritis
Also acceptable: sickle cell crisis, cocaine use, endometriosis, DKA, aortic dissection, abdominal aortic aneurysm
200
Brianpaul presented to your ED due to an 8 day history of nausea, vomiting, and RUQ abdominal pain. He has dark-brown urine. He has recent travel to Mexico on 3/25/25. He has a high temperature and scleral icterus. He loves eating shrimp and pasta, and he will eat it especially on vacation. On ultrasound, there is no obstruction of any biliary-related duct.
a) food poisoning
b) Acute hepatitis A
c) choledocholithiasis
He is a traveler who ate contaminated shrimp in an endemic area.
Food poisoning would have occurred within 2-6 hours after the shrimp.
Choledocholithiasis would have shown stones.
200
A 45-year-old woman presents to the emergency department with abdominal pain that began last night. She describes the pain as sharp, located in the right upper quadrant, and radiating to her right shoulder. She notes that the pain started about 45 minutes after eating a large, greasy dinner and gradually worsened before improving spontaneously after a few hours. She denies fever, chills, nausea, or vomiting. Physical exam shows a soft, non-distended abdomen with mild tenderness in the right upper quadrant. There is no guarding or rebound, and Murphy’s sign is negative. Her vitals and lab results are within normal limits. An abdominal ultrasound shows several gallstones without gallbladder wall thickening or pericholecystic fluid.
Which of the following is the most likely diagnosis?
A) Acute pancreatitis
B) Acute cholecystitis
C) Biliary colic
D) Choledocholithiasis
E) Peptic ulcer disease
Correct answer: C) Biliary colic
Explanation:
The patient’s episodic postprandial right upper quadrant pain, absence of systemic signs (e.g., fever, leukocytosis), normal labs, negative Murphy’s sign, and spontaneous resolution are classic for biliary colic. This results from transient cystic duct obstruction by gallstones, usually after fatty meals.
Why the other choices are wrong:
A) Acute pancreatitis typically presents with constant epigastric pain radiating to the back, elevated lipase/amylase, and often nausea/vomiting.
B) Acute cholecystitis presents with persistent RUQ pain, fever, leukocytosis, a positive Murphy’s sign, and gallbladder wall inflammation on imaging.
D) Choledocholithiasis involves stones in the common bile duct, typically causing jaundice and elevated liver enzymes, sometimes with cholangitis.
E) Peptic ulcer disease causes epigastric pain but is not usually triggered by fatty meals and wouldn’t show gallstones on ultrasound.
300
A 28-year-old woman presents to the ED with 12 hours of worsening abdominal pain, nausea, and vomiting. Pain is epigastric and radiates to her back. She has no significant past medical history, takes no medications, and denies alcohol use. Vital signs show T 37.8°C, HR 112, BP 98/62, RR 24. On exam, she appears uncomfortable, and there is mild periumbilical ecchymosis.
Labs show:
- WBC: 14,500/mm³
- Lipase: 950 U/L (Normal: 0–160 U/L)
- Triglycerides: 1450 mg/dL
- AST/ALT: Normal
- ALP: Normal
- Bilirubin: Normal
Abdominal ultrasound shows no gallstones, and CT confirms peripancreatic edema and a small amount of retroperitoneal fluid.
On physical exam, the patient has a facial muscle twitch when tapped directly anterior to their ear.
List the steps in the pathogenesis leading to the above sign in this patient:
1. Pancreatic lipase leaks into the interstitial space and peri-pancreatic fat due to persistent pancreatic inflammation
2. The Triglycerides are broken down by the lipase into FFAs
3. FFAs go on to form electrostatic bonds with circulating Ca2+ and Mg+ in the bloodstream
4. This leads to sequestration of free Ca2+ and thus hypocalcemia
5. Hypocalcemia produces signs of facial muscle twitching (Chvostek Sign)
300
A 60-year-old M presents to the ED with RUQ abdominal pain and jaundice. His temp is 102.4°F, BP is 118/75 mmHg, and HR is 98 bpm. Lab tests reveal elevated alkaline phosphatase, GGT, direct bilirubin, and mildly elevated AST and ALT. He is alert and oriented. Which of the following is the most likely diagnosis?
A. Acute cholecystitis
B. Biliary colic
C. Choledocholithiasis
D. Acute cholangitis
E. Gallbladder adenocarcinoma
Correct Answer:
D. Acute cholangitis
Explanation:
This patient presents with Charcot’s triad:
Fever
Jaundice
Right upper quadrant pain
These features point toward acute cholangitis, a serious infection caused by biliary obstruction (often due to choledocholithiasis) and bile stasis, leading to ascending infection.
CAN PROGRESS TO Reynolds pentad→ WHAT IS THIS?:
300
A patient comes in with these dermatological physical presentations. He has already been diagnosed with pancreatitis. What is the pathophysiology behind this presentation? For fun, use dermatological terms.
In a patient with acute pancreatitis, the presence of ecchymosis (flat, red-purple bruise > 5 mm in size) reflects a severe disease state involving retroperitoneal hemorrhage. These skin findings are caused by the autodigestion of pancreatic and surrounding tissues due to the intrapancreatic activation of digestive enzymes such as trypsin and lipase. This pathological process leads to widespread inflammation, vascular injury, and increased capillary permeability. In severe cases, it results in hemorrhagic pancreatitis, allowing blood to escape into the retroperitoneal space. The blood may then track through fascial planes to the subcutaneous tissue of the abdominal wall, manifesting as discoloration and ecchymosis in specific locations.
What is the prognosis of this patient?
What are the specific names of each?
Poor prognosis
Cullen sign (periumbilical ecchymosis)
Grey-Turners Sign (intra-abdominal hemorrhage, looks like ecchymosis or discoloration. Appears on the flank. This sign is correlated with severe pancreatitis. High mortality.)
Fox sign (ecchymosis on inguinal ligament)
300
A 70-year-old woman with a history of hypertension and diabetes mellitus presents to the emergency department with fever, chills, and right upper quadrant (RUQ) pain. She has jaundice and mild hypotension on examination. Laboratory findings show an elevated white blood cell count (WBC 18,000/µL), total bilirubin of 4.8 mg/dL, and alkaline phosphatase of 450 U/L. An abdominal ultrasound reveals a dilated common bile duct and a large brown stone in the distal common bile duct. Which of the following is a characteristic of the most likely pathogen?
A) Oxidase Positive
B) LPS Exotoxin
C) Pink on MacConkey Agar
D) Reduces H2O2
E) C and D
F) B and C
Correct Answer E): C and D (pink on macconkey and H2O2 reducing)
E Coli is the most common culprit of Ascending Cholangitis wherein Brown Pigmented Stones lodge in the Biliary Tract; allowing colonization of bacteria upstream of the obstruction.
> E coli is a Gram negative Oxidase Negative Rod which is Pink on MacConkey Agar (Lactose Fermenting), Catalase Positive (H2O2 reducing) and it does contain LPS, but LPS is an endotoxin NOT exotoxin!
300
A 54-year-old woman presents with severe epigastric pain radiating to the back, accompanied by nausea and vomiting for the past 12 hours. She has a history of gallstones. On exam, she is febrile, tachycardic, and tender in the upper abdomen without rebound or guarding. Laboratory tests show:
Elevated lipase
Elevated liver enzymes (AST, ALT, ALP)
Elevated direct bilirubin
Abdominal ultrasound shows gallstones and a dilated common bile duct.
What is the most appropriate initial step in management?
A. Start broad-spectrum IV antibiotics
B. Schedule elective cholecystectomy before discharge
C. Initiate early enteral nutrition
D. Begin IV fluid resuscitation and pain control
E. Proceed immediately to ERCP
Correct Answer:
D. Begin IV fluid resuscitation and pain control
Explanations for Incorrect Answers:
A. IV antibiotics – Not indicated unless there’s clear evidence of infection like cholangitis or infected necrosis.
B. Cholecystectomy – Needed later to prevent recurrence, but not during the acute inflammatory phase.
C. Early enteral feeding – Helpful in stable patients, but this patient needs fluids and symptom control first.
E. Immediate ERCP – Only indicated urgently if there’s cholangitis(infection) or worsening signs of biliary obstruction with infection.
If complicated by cholangitis, the ERCP should be done within 24-48 hours, along with antibiotics.
In patients without cholangitis, (TRUE OF OUR PATIENT) ERCP is indicated if the patient has ongoing biliary obstruction, dilated common biliary duct (as in our patient), or increasing liver tests prior to elective cholecystectomy.
400
A 30-year-old women presents with recurrent episodes of abdominal pain over the past 6 months. She does not drink alcohol or have prior history of gallstones. She was recently hospitalized with presumed acute pancreatitis that resolved with supportive care. Now she presents again with similar symptoms, fatigue, and 10-pound unintentional weight loss.
On exam: mild scleral icterus, RUQ tenderness, and palpable non-tender mass in the epigastric region. No rebound or guarding. Vitals show T 38.1°C, HR 94, BP 116/74, RR 22.
Labs:
Lipase: 430 U/L
Total bilirubin: 4.1 mg/dL (direct 3.5 mg/dL)
ALP: 410 U/L
AST/ALT: Mildly elevated
Total Serum IgG: 330 mg/dL (normal <135)
WBC: 12,800/mm³
ESR: Markedly Elevated
CT Abdomen: Diffusely enlarged pancreas with “sausage-shaped” contour and a hypoattenuating rim; biliary tree dilation is present.
Which of the following is the best next step in management?
A. Begin corticosteroids
B. ERCP with biliary stenting
C. CT-guided pancreatic biopsy
D. Surgically Drain, then administer IV antibiotics for suspected infected necrosis
E. Surgical resection of pancreatic head
Correct Answer A. Begin Corticosteroids
This is a case of Autoimmune Pancreatitis:
Notable Criteria:
> Recurrent Cases of Acute Hepatitis
> Diffusely enlarged Pancreas on CT imaging
> Elevated ESR and Serum IgG4** Specific Marker for AIP
400
A 58-year-old woman presents with persistent epigastric pain radiating to the back, 10 days after an initial hospitalization for gallstone-induced acute pancreatitis. She reports that her abdominal pain has not fully resolved and has now developed a low-grade fever. A follow-up CT scan reveals a well-circumscribed, fluid-filled collection adjacent to the pancreas without evidence of enhancing pancreatic necrosis. Her serum lipase is still mildly elevated. What is the most likely diagnosis?
A. Pancreatic pseudocyst
B. Necrotizing pancreatitis
C. Ascending cholangitis
D. Chronic pancreatitis
E. Hepatic abscess
A. Pancreatic pseudocyst
Explanation:
A pancreatic pseudocyst is a common delayed complication of acute pancreatitis, especially gallstone-related. It presents days to weeks later as a fluid-filled, encapsulated structure adjacent to the pancreas. It may cause persistent pain, fever, or a palpable mass. The absence of enhancing necrotic tissue distinguishes it from necrotizing pancreatitis.
B. Necrotizing pancreatitis
This condition involves nonviable pancreatic tissue, seen on imaging as non-enhancing areas on contrast CT.
It usually presents earlier (within the first week), is more severe, and often causes systemic signs of sepsis.
This patient has a well-circumscribed fluid collection and no evidence of necrosis, which is more characteristic of a pseudocyst.
C. Ascending cholangitis
Typically presents with Charcot’s triad (fever, jaundice, RUQ pain) and lab signs of cholestasis.
This patient lacks jaundice and RUQ pain and has imaging findings more consistent with a pancreatic complication, not biliary infection.
D. Chronic pancreatitis
This is a progressive, fibrosing disease often due to alcohol use, presenting with longstanding epigastric pain, malabsorption, and diabetes.
Imaging shows calcifications and ductal changes, not fluid collections. The patient’s history and imaging are more consistent with a post-acute episode.
E. Hepatic abscess
Would typically present with right upper quadrant pain, fever, and imaging showing a liver-based fluid collection.
This patient’s pain is epigastric, and imaging localizes the collection to the pancreas, making a hepatic source unlikely.
400
A 40-year-old woman presents to the emergency department with acute-onset epigastric pain radiating to the back, accompanied by nausea and vomiting. Her serum lipase is significantly elevated. Abdominal ultrasound shows gallstones within the gallbladder, but her common bile duct (CBD) measures 4.5 mm in diameter. She is discharged with plans for an elective laparoscopic cholecystectomy.
Question:
Why is the finding of a 4.5 mm common bile duct (CBD) diameter clinically relevant in this patient?
A. It indicates chronic biliary obstruction requiring immediate ERCP.
B. It confirms biliary dilation, suggesting cholangitis.
C. It is within normal limits and does not indicate biliary obstruction.
D. It suggests biliary atresia requiring further hepatobiliary imaging.
C: A CBD diameter of 4.5 mm is considered normal in a patient without prior cholecystectomy. The normal upper limit typically ranges from 4–6 mm in younger individuals, increasing slightly with age and following gallbladder removal.
Why would the diameter increase in a patient several months post-op lap chole?
It increases because the common bile duct still holds bile and needs to hold a greater volume (compensatory mechanism).
400
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Make an appraisal of uptodate.
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Con: Paid (behind firewall); it isn’t a substitute for deep, specialty-specific literature reviews; it may reflect a bias toward North American clinical practices and guidelines
400
Does this ultrasound indicate cholecystitis? Why/not?
Both the longitudinal and transverse views of the gallbladder show a thin, normal gallbladder wall and no gallstones or sludge. The gallbladder is anechoic (black) inside, meaning it's filled with bile and unobstructed.
Image from: https://radiologykey.com/the-gallbladder/ (pretty trustable, they pull from multiple sources/papers)
500
The Gila Monster, known for its slow movement and vibrant pink and black scales, prefers arid desert habitats and spends over 90% of its time underground; emerging mostly to hunt eggs and small mammals. After expressing these unnecessary details, a physician explains to their patient: "You are presenting with rare, acute pancreatitis due to one of the drugs you are taking"
Which of the following best describes the mechanism of action of the drug that caused this patients acute pancreatitis?
A) Inhibits alpha-glucosidase in the intestinal brush border
B) Inhibits dipeptidyl peptidase-4 (DPP-4) enzyme
C) Activates GLP-1 receptors to promote insulin secretion
D) Inhibits sodium-glucose cotransporter 2 (SGLT2) in the renal tubules
E) Stimulates insulin release independent of glucose levels
Correct Answer C) Activates GLP-1 receptors to promote insulin secretion
GLP-1 Agonists (notably Liraglutide and Exenatide) have been associated with increased risk of acute pancreatitis; although cases are rare.
Exenatide is a synthetic analog of the GLP-1 made by the Gila Monster (now off the market due to better alternatives such as Semaglutide)
500
A 62-year-old woman presents with right upper quadrant abdominal pain, nausea, and fever for two days. On examination, she has a positive Murphy’s sign and scleral icterus. Labs reveal:
WBC: Elevated
AST: Elevated
ALT: Elevated
ALP: Very elevated
Total bilirubin: Elevated
Abdominal ultrasound shows a thickened gallbladder wall with pericholecystic fluid and a dilated common bile duct with a possible obstructing stone. Which of the following best explains why this patient requires cholecystectomy?
A. The presence of acute cholecystitis alone
B. Evidence of gallstone pancreatitis
C. Development of gallstone ileus
D. Choledocholithiasis complicating cholecystitis
E. Isolated biliary colic
Correct Answer:
D. Choledocholithiasis complicating cholecystitis
Explanation:
This patient has signs of acute cholecystitis (RUQ pain, fever, positive Murphy’s sign) plus cholestatic lab abnormalities (↑ALP, ↑direct bilirubin) and CBD dilation with a suspected stone on imaging. This indicates choledocholithiasis (gallstones in the common bile duct), a complication of cholecystitis that elevates the severity and requires definitive management, including ERCP (for stone removal) and cholecystectomy to prevent recurrence and progression to cholangitis or pancreatitis.
A. The presence of acute cholecystitis alone
While cholecystectomy is also the treatment for uncomplicated cholecystitis, the urgency increases when complications like choledocholithiasis are present.
This case is not “uncomplicated”—the elevated bilirubin and ductal dilation point to a more serious process.
→ our patient had a dilated common bile duct
Uncomplicated cholecystitis does not require surgery → surgery is only required if theres a complication or if the patient has symptoms
Complicated cholelithiasis can include acute cholecystitis, choledocholithiasis, gallstone pancreatitis, acute cholangitis, gallstone ileus, and more.
B. Evidence of gallstone pancreatitis
Gallstone pancreatitis typically presents with epigastric pain radiating to the back, and elevated lipase or amylase, not RUQ tenderness with Murphy’s sign and primarily cholestatic lab abnormalities.
This patient’s presentation does not suggest pancreatitis.
C. Development of gallstone ileus
Gallstone ileus is a mechanical bowel obstruction caused by a gallstone passing into the intestine through a cholecystoenteric fistula.
It presents with signs of bowel obstruction (vomiting, distention, constipation), not cholestatic lab findings or gallbladder inflammation.
E. Isolated biliary colic
Biliary colic is transient pain after fatty meals with normal labs and no fever or inflammation. This patient’s findings (fever, WBC elevation, abnormal liver enzymes, CBD dilation) clearly indicate a more severe and complicated condition than simple biliary colic.
500
The representative image below shows stones. The stones cast a shadow. The “L” stands for liver and the “G” stands for the gallbladder lumen. Why do gallstones cast a shadow on ultrasound?
A. Gallstones contain air, which reflects ultrasound waves and prevents further transmission.
B. Gallstones absorb ultrasound energy, converting it to heat, which leads to signal dropout behind them.
C. Gallstones strongly reflect and absorb ultrasound waves at their surface, preventing wave penetration and creating an acoustic shadow.
C. Gallstones strongly reflect and absorb ultrasound waves at their surface, preventing wave penetration and creating an acoustic shadow.
Gallstones cast a shadow on ultrasound because they are dense and highly reflective to sound waves. When the ultrasound probe sends soundwaves through the body, those waves pass through soft tissues and fluids. When the waves hit a dense structure like a gallstone, most of the sound is either reflected back or absorbed, and very little continues beyond the stone. On the bottom of the oval are white bright echogenic gallstones, which casts a posterior acoustic shadow. The acoustic shadowing occurs because the stone blocks the passage of sound waves, confirming its solid nature.
500
A 30-year-old man with a history of sickle cell anemia presents to the emergency department with sudden-onset right upper quadrant (RUQ) pain, fever, and jaundice. He has had a few episodes of similar pain in the past, but this episode is more severe. His physical examination reveals tenderness in the RUQ, jaundice, and mild tachycardia. Laboratory findings show an elevated white blood cell count, increased alkaline phosphatase, and a total bilirubin of 3.5 mg/dL (high). A CT scan reveals a dilated common bile duct and a large black stone downstream of this. What is the most likely diagnosis?
A) Acute cholecystitis
B) Ascending cholangitis
C) Gallstone ileus
D) Choledocholithiasis
E) Biliary colic
D) Choledocholithiasis is correct
This is a classic case of hemolysis induced black pigmented bilirubin stones. In this case, the cause is SSD.
Followup Question: If this patient marries an asymptomatic women who has Sickle Cell Trait, what is the likelihood of having a child with Sickle Cell Disease?
500
Time to act! You are a doctor treating a patient who was just informed that they need to undergo ERCP (Endoscopic Retrograde Cholangiopancreatography) indicated for cholecystitis with pancreatitis. However, their insurance company denied their request to pay for the procedure. Explain this procedure to the patient and then walk them through the steps of where to go next after the insurance denial and provide them support.
Purpose: Used to diagnose and treat conditions of the bile ducts, gallbladder, and pancreatic ducts (e.g., choledocholithiasis, cholangitis, pancreatic duct strictures).
Diagnostic Component: Combines endoscopy and fluoroscopy to visualize the biliary and pancreatic ductal systems.
Therapeutic Uses:
Remove bile duct stones
Place stents to relieve obstruction
Perform sphincterotomy (cutting the sphincter of Oddi to allow drainage)
Biopsy of suspicious strictures or tumors
How it's done:
A flexible endoscope is passed through the mouth → esophagus → stomach → duodenum.
A small catheter is inserted into the ampulla of Vater.
Contrast dye is injected into the ducts, and X-ray images are taken.
Tools may be inserted to perform treatment.
Insurance:
Provide Strong Medical Documentation
Support Internal Appeals Promptly
Act as Authorized Representatives
Contribute to Expedited Reviews in Urgent Cases
Help with External Reviews
Educate Patients About Their Rights