Basic Science 1
Basic Science 2
Clinical Presentation 1
Clinical Presentation 2
Diagnostics
100
What role does impaired gallbladder motility play in gallstone formation?
A. It increases bilirubin conjugation
B. It allows time for cholesterol crystals to form and grow
C. It reduces mucin secretion
D. It leads to increased bile acid production
E. It promotes contraction of the sphincter of Oddi
B. It allows time for cholesterol crystals to form and grow
Bile stasis provides an environment for crystal aggregation and growth into stones.
100
Which group of vitamins requires bile for proper absorption?
A. B-complex vitamins
B. Vitamin C and folate
C. Vitamins A, D, E, and K
D. Iron and zinc
C. Vitamins A, D, E, and K
These fat-soluble vitamins need bile salts for micelle formation and absorption.
100
Which laboratory value is most specific for diagnosing acute pancreatitis?
A. AST
B. ALT
C. Amylase
D. Lipase
Answer: D. Lipase
Explanation: Lipase is more specific and remains elevated longer than amylase in acute pancreatitis. A level >3x normal is diagnostic.
100
Which of the following is the most common cause of acute pancreatitis in the United States?
A. Alcohol
B. Trauma
C. Gallstones
D. Hypercalcemia
Answer: C. Gallstones
Explanation: Gallstones are the most common cause overall, followed by alcohol.
100
A 56-year-old woman presents with postprandial RUQ pain. Ultrasound shows gallstones. Labs are normal. What is the next best step in management?
A. Ursodeoxycholic acid
B. ERCP
C. Elective cholecystectomy
D. HIDA scan
Answer: C. Elective cholecystectomy
→ She has symptomatic cholelithiasis, which warrants surgical removal of the gallbladder. Delayed surgery led to complications in the case.
The classic case of symptomatic cholelithiasis is a patient with biliary colic due to gallstones, and pain waxes and wanes post-meals. There is a temporary obstruction of the cystic duct by gallstones.
Elective Laparoscopic cholecystectomy is recommended even with normal labs if the patient is symptomatic.
200
A previously healthy 37-year-old woman, gravida 3, para 2, at 29 weeks' gestation, comes to the physician because of colicky postprandial abdominal pain. Her vital signs are within normal limits. Physical examination shows a uterus consistent in size with a 29-week gestation. Ultrasonography of the abdomen shows multiple 5-mm hyperechoic masses within the gallbladder lumen. Which of the following processes is most likely involved in the pathogenesis of this patient's condition?
A. Accelerated gallbladder emptying
B. Reduced production of cholecystokinin
C. Decreased caliber of bile duct
D. Increased secretion of bile acids
E. Overproduction of bilirubin
F. Increased secretion of cholesterol
F. Increased secretion of cholesterol
Beginning in the third trimester of pregnancy, increased circulating estrogen levels result in an increased hepatic cholesterol synthesis and the formation of cholesterol-supersaturated bile. Moreover, higher progesterone levels cause smooth muscle relaxation, decreased and incomplete emptying of the gallbladder, and subsequent bile stasis. Together, cholesterol-rich lithogenic bile and gallbladder stasis predispose to gallstone formation. Similarly, hormone replacement therapy and oral contraceptive use also predispose to cholelithiasis.
200
A medical student is reviewing the process of lipid digestion. Which of the following best explains how bile salts aid in fat digestion?
A. They hydrolyze triglycerides into monoglycerides and free fatty acids
B. They increase gastric acid secretion to enhance lipid breakdown
C. They act as amphipathic molecules that emulsify fat droplets and form micelles
D. They stimulate the production of lipoproteins in the liver
E. They activate pancreatic lipase to directly digest dietary lipids
C. They act as amphipathic molecules that emulsify fat droplets and form micelles
Bile salts emulsify fats by using their amphipathic nature—hydrophobic parts interact with lipids, hydrophilic parts face outward. This allows enzymes access to fats and forms micelles for absorption.
200
A 66-year-old woman has fever, right upper quadrant pain, and jaundice. Labs show elevated ALP and bilirubin. What condition best explains this triad?
A. Gallstone pancreatitis
B. Ascending cholangitis
C. Acute cholecystitis
D. Hepatitis A
Answer: B. Ascending cholangitis
Explanation: Charcot’s triad (fever, jaundice, RUQ pain) is classic for ascending cholangitis, often caused by a bile duct obstruction from a stone.
200
Which of the following is a potential long-term risk of chronic, untreated gallstones?
A. Appendicitis
B. Gallbladder carcinoma
C. Diverticulosis
D. Peptic ulcer disease
Answer: B. Gallbladder carcinoma
Explanation: Chronic inflammation from long-standing gallstones increases the risk of epithelial dysplasia and gallbladder cancer.
200
Which of the following is the most appropriate indication for urgent ERCP in gallstone disease?
A. Gallbladder sludge
B. Biliary colic
C. Gallstone pancreatitis with obstructing CBD stone
D. Asymptomatic gallstones
C. Gallstone pancreatitis with obstructing common bile duct stone
→ The patient’s ERCP was done urgently after obstructive jaundice, elevated enzymes, and ampullary blockage.
ERCP indications include obstructive jaundice, ascending cholangitis, or gallstone pancreatitis. ERCP removes stones from the common bile duct.
Gallstones can migrate from the gallbladder into the common bile duct, blocking it at the ampulla of Vater. The backup of bile leads to elevated bilirubin while pancreatic duct obstruction leads to pancreatitis.
300
A 28-year-old man with known hereditary spherocytosis presents with episodic abdominal discomfort. He denies fever or jaundice. Ultrasound shows multiple small gallstones but no biliary duct dilation. What is the most likely composition of his gallstones?
A. Cholesterol monohydrate crystals
B. Calcium bilirubinate and calcium salts
C. Mixed cholesterol and pigment
D. Calcium salts of fatty acids and unconjugated bilirubin
E. Bile acid aggregates with cholesterol
B. Calcium bilirubinate and calcium salts
Chronic hemolysis leads to increased unconjugated bilirubin, which forms calcium bilirubinate—classic for black pigment stones formed in sterile bile in the gallbladder.
300
A 35-year-old woman eats a high-fat meal. Shortly afterward, cholecystokinin (CCK) is released into her bloodstream. Which of the following is not a function of CCK?
A. Stimulates contraction of the gallbladder to release bile
B. Promotes pancreatic enzyme secretion
C. Inhibits gastric emptying
D. Stimulates bicarbonate secretion from the pancreas
E. Enhances fat digestion via coordinated gastrointestinal activity
D. Stimulates bicarbonate secretion from the pancreas
Bicarbonate secretion is the role of secretin, not CCK. CCK's main actions include stimulating bile release, pancreatic enzyme secretion, and slowing gastric emptying to improve digestion of fats.
300
What is the most common serious complication of a gallstone lodged in the cystic duct?
A. Ascending cholangitis
B. Acute cholecystitis
C. Chronic pancreatitis
D. Gallstone ileus
Answer: B. Acute cholecystitis
Explanation: Persistent cystic duct obstruction leads to inflammation of the gallbladder (acute cholecystitis), often with fever and leukocytosis.
300
What is typically seen on ultrasound in uncomplicated cholelithiasis?
A. Echogenic foci with shadowing
B. Thickened gallbladder wall
C. Pericholecystic fluid
D. No visible gallbladder
Answer: A. Echogenic foci with shadowing
Explanation: Gallstones appear as echogenic (bright) structures with posterior acoustic shadowing and often move with patient repositioning.
300
What is the mechanism of postcholecystectomy diarrhea?
A. Loss of bile storage → excess bile acids in colon
B. Pancreatic insufficiency
C. Hypomotility of small intestine
D. Vitamin K deficiency
Answer: A. Loss of bile storage → excess bile acids in colon
→ Without the gallbladder, continuous bile flow causes secretory diarrhea in some patients.
Postcholecystectomy diarrhea affects up to 10% of patients after gallbladder removal.
After cholecystectomy, bile flows continuously from the liver into the intestines, even between meals. Excess bile acids entering the colon stimulate colonic secretion and motility, leading to water diarrhea.
400
A 34-year-old woman with Crohn disease comes to the physician because of a 4-week history of nausea, bloating, and epigastric pain that occurs after meals and radiates to the right shoulder. Four months ago, she underwent ileocecal resection for an acute intestinal obstruction. An ultrasound of the abdomen shows multiple echogenic foci with acoustic shadows in the gallbladder. Which of the following mechanisms most likely contributed to this patient’s current presentation?
A. Increased bilirubin production
B. Increased hepatic cholesterol secretion
C. Decreased biliary concentration of bile acids
D. Decreased fat absorption
E. Decreased motility of the gallbladder
F. Increased activity of β-glucuronidaseC. Decreased biliary concentration of bile acids
Bile acids are normally reabsorbed in the terminal ileum and returned to the liver for reuse via the enterohepatic circulation. Bile acid malabsorption can occur in patients with Crohn disease as they are prone to developing ileitis or complications requiring terminal ileum resection, leading to a decreased concentration of bile acids in the bile. A decreased bile acid to cholesterol ratio causes cholesterol supersaturation and predisposes to cholesterol gallstone formation, which can lead to cholelithiasis and cholecystitis.
400
A patient with newly diagnosed type 1 diabetes mellitus has elevated serum triglycerides. Which of the following best explains insulin’s role in fat metabolism?
A. Inhibits pancreatic lipase to slow fat breakdown
B. Stimulates bile secretion to facilitate lipid emulsification
C. Promotes storage of lipids in adipose tissue after digestion
D. Activates hormone-sensitive lipase in adipocytes for fat mobilization
E. Inhibits absorption of fatty acids in the intestine
C. Promotes storage of lipids in adipose tissue after digestion
Insulin facilitates fat storage by promoting uptake and esterification of fatty acids into triglycerides in adipose tissue. It’s anabolic, not involved in fat breakdown directly.
400
Which of the following is the most common complication associated with ERCP?
A. Pancreatitis
B. Perforation
C. Bleeding
D. Aspiration pneumonia
Answer: A. Pancreatitis
Explanation: Post-ERCP pancreatitis is the most common complication, occurring in up to 5–10% of cases. It is thought to result from mechanical or chemical irritation of the pancreatic duct during the procedure.
400
On ultrasound, which of the following is most specific for acute cholecystitis rather than uncomplicated cholelithiasis?
A. Mobile gallstones
B. Posterior acoustic shadowing
C. Wall thickening and pericholecystic fluid
D. Anechoic gallbladder
Answer: C. Wall thickening and pericholecystic fluid
Explanation: Gallbladder wall thickening (>3 mm) and surrounding fluid indicate inflammation, suggesting acute cholecystitis.
400
Which of the following is a relative contraindication to cholecystectomy?
A. Porcelain gallbladder
B. Hemodynamic instability
C. Gallstone pancreatitis
D. RUQ pain after fatty meals
Answer: B. Hemodynamic instability
→ Acute decompensation requires stabilization before surgery.
Hemodynamic instability refers to unstable vital signs (e.g., hypotension or tachycardia) usually due to shock, sepsis, or severe illness. In such patients, surgery should be delayed until the patient is stabilized.
500
A 60-year-old man returning from a month-long trip in China presents with fever, right upper abdominal pain, and jaundice. Imaging shows intrahepatic biliary dilation and several filling defects within the ducts. Stool exam results are shown in this image:
What is the most likely mechanism for his stone formation?
A. Cholesterol supersaturation due to increased estrogen
B. Direct precipitation of conjugated bilirubin in sterile bile
C. Increased β-glucuronidase activity leading to deconjugation of bilirubin
D. Calcium salt precipitation due to ileal bile salt loss
E. Excessive mucin secretion forming a nucleation site in the gallbladder
C. Increased β-glucuronidase activity leading to deconjugation of bilirubin
Clonorchis sinensis and other biliary infections produce β-glucuronidase, which deconjugates bilirubin, promoting brown pigment stone formation in infected bile within ducts.
500
A 37-year-old woman with a known history of gallstones presents to the emergency department with sudden onset right upper quadrant pain radiating to the back, nausea, and vomiting. She mentions the pain began after eating a large meal of fried chicken. Vitals are stable, and Murphy's sign is positive. Which of the following best explains why fatty meals should be avoided in patients with gallstones?
A. Fatty meals inhibit bile acid synthesis in the liver
B. Fatty foods increase secretion of pancreatic enzymes, irritating the gallbladder
C. Fat ingestion stimulates gallbladder contraction, potentially triggering biliary colic
D. Fat absorption requires bile pigments, leading to stone enlargement
E. Fatty meals cause bile duct sphincter spasm, preventing bile flow
C. Fat ingestion stimulates gallbladder contraction, potentially triggering biliary colic
Fatty foods stimulate CCK release, which causes gallbladder contraction. In patients with gallstones, this can obstruct the cystic duct and trigger biliary colic or complications like cholecystitis.
500
Which of the following drugs is most likely to cause acute pancreatitis?
A. Omeprazole
B. Hydrochlorothiazide
C. Metformin
D. Lisinopril
Answer: B. Hydrochlorothiazide
Explanation: Thiazide diuretics are a known drug-induced cause of pancreatitis (via hypercalcemia and idiosyncratic reactions).
500
Which component of the Revised Atlanta Classification indicates severe acute pancreatitis?
A. Peripancreatic inflammation
B. Lipase >1000 U/L
C. Persistent organ failure >48 hours
D. CT evidence of pseudocyst
Answer: C. Persistent organ failure >48 hours
Explanation: Severity is based on organ dysfunction, not enzyme elevation or radiographic changes.
500
What condition causes RUQ pain, mildly elevated bilirubin, and compression of the common hepatic duct by an impacted gallstone?
A. Mirizzi syndrome
B. Gallbladder hydrops
C. Biliary dyskinesia
D. Acute hepatitis
Answer: A. Mirizzi syndrome
→ Extrinsic compression by an impacted stone causes obstructive jaundice without CBD stones.
The stone is impacted in either the cystic duct or gallbladder neck. When the stone is stuck at the outlet of the gallbladder, it presses directly against the common hepatic duct. The external compression narrows the common hepatic duct, leading to bile buildup, mild hyperbilirubinemia, RUQ pain, and sometimes jaundice.