GI - USMLE Step 1/2CK Question
USMLE Step 1/2CK Management
Today’s question will test your knowledge of an often-tested, high-yield USMLE Step 1/2CK concept around medical management. The question is followed by a breakdown of the answer choices and a detailed explanation of the correct answer. Good luck!
A 46-year-old woman with a history of recurrent biliary colic presents to the emergency department with severe right upper quadrant abdominal pain for the past 24 hours. The pain is colicky in nature, radiates to her right shoulder, and is associated with nausea and vomiting. She also reports that her urine has become dark, and she has noticed pale stools. Her vital signs show blood pressure 130/85 mmHg, heart rate 110/minute, respiratory rate 20/minute, and temperature 37.5°C (99.5°F). Physical examination reveals right upper quadrant tenderness with a positive Murphy's sign. Laboratory studies show the following:
• Total bilirubin: 3.2 mg/dL (N: 0.2-1.2 mg/dL)
Indirect bilirubin: 0.5 mg/dL
• Alanine aminotransferase: 185 U/L (N: 7-55 U/L)
• Alkaline phosphatase: 230 U/L (N: 45-115 U/L)
An abdominal ultrasound reveals a dilated common bile duct with evidence of a 1 cm stone. The most appropriate next step in the management of this patient is:
A) Schedule an elective laparoscopic cholecystectomy
B) Administer intravenous fluids and antibiotics and observe the patient
C) Perform an endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy
D) Proceed with percutaneous transhepatic cholangiography and stone extraction
E) Administer ursodeoxycholic acid for dissolution of the stone
Scroll down for the breakdown ⏬
ANSWER + QUESTION BREAKDOWN
The Mental Model for this week’s question:
Step 1. Identify the goal of the question (next step in mgmt).
Step 2. Make a diagnosis.
Step 3. Ask yourself the best next step in mgmt.
Step 4. Look for your answer in the answer choices.
GENERAL ANALYSIS
This question involves a 46-year-old woman with a history of recurrent biliary colic presenting with severe right upper quadrant abdominal pain, dark urine, and pale stools. The clinical presentation, laboratory findings, and imaging suggest obstructive jaundice due to a common bile duct stone. The task is to determine the most appropriate next step in the management.
ANSWER CHOICES:
ANSWER CHOICE A: Schedule an elective laparoscopic cholecystectomy
Laparoscopic cholecystectomy is the definitive treatment for gallbladder stones and is typically performed electively.
ANSWER CHOICE B: Administer intravenous fluids and antibiotics and observe the patient
IV fluids and antibiotics are important for initial stabilization, especially if there is suspicion of cholangitis.
ANSWER CHOICE C: Perform an endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy
ERCP is a minimally invasive procedure used to diagnose and treat bile duct stones by removing the obstruction. It is often followed by laparoscopic cholecystectomy to prevent recurrence.
ANSWER CHOICE D: Proceed with percutaneous transhepatic cholangiography and stone extraction
PTC is an alternative method for biliary drainage, typically used when ERCP is not feasible.
ANSWER CHOICE E: Administer ursodeoxycholic acid for dissolution of the stone
Ursodeoxycholic acid is used to dissolve cholesterol gallstones over time.
FINAL VERDICT…
The patient presents with symptoms and signs of obstructive jaundice, including severe right upper quadrant pain, dark urine, pale stools, and elevated bilirubin levels. The ultrasound findings of a dilated common bile duct with a stone confirm the diagnosis of choledocholithiasis.
The most appropriate next step is to perform an ERCP. This procedure allows for visualization of the biliary tree and removing the obstructing stone, thus relieving the obstruction. ERCP is the gold standard for both the diagnosis and treatment of bile duct stones, especially in the context of acute obstruction. Following successful biliary decompression with ERCP, laparoscopic cholecystectomy is typically performed to prevent future episodes of biliary colic and choledocholithiasis.
FINAL ANSWER: C: Perform an endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy
That’s it for today!
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