Question

A 44-year-old woman presents to the emergency department with abdominal pain. This symptom started yesterday and has been gradually worsening. The patient has a past medical history of acute cholecystitis and had her gallbladder removed 1 month ago. Her temperature is 97.7°F (36.5°C), blood pressure is 144/84 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for right upper quadrant tenderness to palpation. An ultrasound is performed demonstrating a dilated common bile duct and an absence of a gallbladder. Laboratory studies are ordered as seen below.

Hemoglobin: 13 g/dL
Hematocrit: 37%
Leukocyte count: 9,500/mm^3 with normal differential
Platelet count: 168,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.8 mEq/L
HCO3-: 25 mEq/L
BUN: 23 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.2 mg/dL
AST: 82 U/L
ALT: 100 U/L
Alkaline phosphatase: 250 U/L

Which of the following is the most appropriate next step in management?

a. CT abdomen/pelvis
b. Endoscopic retrograde cholangiopancreatography
c. Laparoscopy
d. MRI abdomen/pelvis
e. Pain control and reassurance

Answer 1

The most appropriate next step in management for a 44-year-old woman with a post-cholecystectomy dilated common bile duct and abdominal pain is an endoscopic retrograde cholangiopancreatography (ERCP), which provides both diagnostic and therapeutic options.

Step-by-step explanation:

A 44-year-old woman who recently underwent a cholecystectomy is now presenting with abdominal pain and has been found to have a dilated common bile duct on ultrasound. Given her symptoms and the ultrasound findings, the most appropriate next step in management would be endoscopic retrograde cholangiopancreatography (ERCP). This procedure allows for direct visualization and potential intervention within the biliary tree. It can help to diagnose and manage complications such as bile duct stones, strictures, or leaks, which can occur after gallbladder surgery. ERCP combines endoscopy and fluoroscopic imaging to access the biliary and pancreatic duct systems. This is preferred over CT abdomen/pelvis, laparoscopy, MRI abdomen/pelvis, or pain control and reassurance alone due to its diagnostic and therapeutic potential in this clinical scenario.