A 65-year-old man comes to the clinic complaining of abdominal pain for the past 2 months. He describes the pain as a dull, aching, 6/10 pain that is diffuse but worse in the right upper quadrant (RUQ). His past medical history is significant for diabetes controlled with metformin and a cholecystectomy 10 years ago. He reports fatigue and a 10-lb weight loss over the past month that he attributes to poor appetite; he denies fever, nausea/vomiting, palpitations, chest pain, or bowel changes. Physical examination is significant for mild scleral icterus and tenderness at the RUQ. Further workup reveals a high-grade malignant vascular neoplasm of the liver. What relevant detail would you expect to find in this patient’s history?

Prior occupation in a chemical plastics manufacturing facility

Heavy ingestion of acetaminophen

Infection with the hepatitis B virus

A 48-year-old woman with a history of obesity presents with acute onset of diffuse epigastric pain that began a few hours ago and then localized to the right upper quadrant. Further questioning reveals that the pain has been exacerbated by eating but has otherwise been unchanged in nature. Physical exam reveals severe right upper quadrant pain that is accompanied by arrest of respiration with deep palpation of the right upper quadrant. Which of the following symptoms is associated with the most likely etiology of this patient's presentation?

Pain radiating to the right shoulder

Crunching sound upon heart auscultation

Pain with passive right leg raising

A 41-year-old G3P3 woman presents with acute on chronic right upper quadrant abdominal pain. She says that her current symptoms acutely onset 8 hours ago after eating a large meal and have not improved. She describes the pain as severe, sharp and cramping in character, and localized to the right upper quadrant. She also describes feeling nauseous. The patient says she has had similar less severe episodes intermittently for the past 2 years, usually precipitated by the intake of fatty foods. She denies any history of fever or jaundice. Vital signs are stable. Physical examination is unremarkable, and laboratory findings show normal liver function tests and normal serum bilirubin and serum amylase levels. Ultrasonography of the abdomen reveals multiple stones in the gallbladder. The patient is managed symptomatically for this episode, and after a few months, undergoes elective cholecystectomy, which reveals multiple stones in her gallbladder as shown in the figure (see image). Which of the following best describes these gallstones?

They are formed due to bile supersaturated with cholesterol.

These are usually radiopaque on X-ray imaging.

They are formed due to elevated uric acid in the blood.

These are seen in patients with chronic hemolysis.

They are formed due to the release of beta-glucuronidase from infecting bacteria.

A 44-year-old woman presents to the emergency department with severe, fluctuating right upper quadrant abdominal pain. The pain was initially a 4/10 but has increased recently to a 6/10 prompting her to come in. The patient has a past medical history of type II diabetes mellitus, depression, anxiety, and irritable bowel syndrome. Her current medications include metformin, glyburide, escitalopram and psyllium husks. On exam you note an obese woman with pain upon palpation of the right upper quadrant. The patient's vital signs are a pulse of 95/min, blood pressure of 135/90 mmHg, respirations of 15/min and 98% saturation on room air. Initial labs are sent off and the results are below: Na+: 140 mEq/L K+: 4.0 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L AST: 100 U/L ALT: 110 U/L Amylase: 30 U/L Alkaline phosphatase: 125 U/L Bilirubin Total: 2.5 mg/dL Direct: 1.8 mg/dL The patient is sent for a right upper quadrant ultrasound demonstrating an absence of stones, no pericholecystic fluid, a normal gallbladder contour and no abnormalities noted in the common bile duct. MRCP with secretin infusion is performed demonstrating patent biliary and pancreatic ductal systems. Her lab values and clinical presentation remain unchanged 24 hours later. Which of the following is the best next step in management?

Analgesics and await resolution of symptoms

A 35-year-old female presents to her primary care physician complaining of right upper quadrant pain over the last 6 months. Pain is worst after eating and feels like intermittent squeezing. She also admits to lighter colored stools and a feeling of itchiness on her skin. Physical exam demonstrates a positive Murphy's sign. The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?

Increased prothrombin time and easy bleeding

Liver, gallbladder and biliary tree for USMLE Step 3: High-Yield Anatomy Lessons

Gross Anatomy - The Right-Sided Giant

Location: Right upper quadrant (RUQ), deep to ribs 7-11.
Lobes (Anatomical):
- Large right lobe, smaller left lobe.
- Posterior: caudate & quadrate lobes.
Ligaments:
- Falciform: Attaches liver to anterior abdominal wall.
- Ligamentum Teres (Round Ligament): Remnant of fetal umbilical vein.
- Coronary & Triangular: Attach superior liver to diaphragm.
Dual Blood Supply:
- Hepatic Artery Proper (30%): Oxygenated blood.
- Portal Vein (70%): Nutrient-rich blood from GI tract.

⭐ Exam Favorite: The functional division of the liver is based on blood supply, not the falciform ligament. Cantlie's line, from the IVC fossa to the gallbladder fossa, separates the true right and left functional lobes.

Vasculature & Biliary Tree - The Hepatic Highway

Dual Blood Supply:
- Portal Vein (75%): Nutrient-rich blood from the gut.
- Proper Hepatic Artery (25%): Oxygen-rich blood.
Venous Drainage: Central vein → Hepatic veins → Inferior Vena Cava (IVC).
Portal Triad: Contained within the hepatoduodenal ligament; consists of the proper hepatic artery, hepatic portal vein, and common hepatic duct.

⭐ Triangle of Calot: A critical surgical landmark for cholecystectomy. Its boundaries are the cystic duct, common hepatic duct, and the inferior border of the liver. The cystic artery is typically found within this triangle.

Gallbladder & Friends - Bile's Waiting Room

Gallbladder, biliary tree, and Calot's triangle anatomy

Function: Stores & concentrates bile produced by the liver.
Anatomy:
- Pear-shaped sac in a fossa on the liver's visceral surface.
- Parts: Fundus, Body, Neck (continuous with cystic duct).
Bile Flow:
- Cystic Duct + Common Hepatic Duct → Common Bile Duct (CBD).
- CBD joins the main pancreatic duct, emptying into the duodenum via the Ampulla of Vater, regulated by the Sphincter of Oddi.
Neurovascular:
- Artery: Cystic a. (from Right Hepatic a.).
- Innervation: Vagus (contracts), Sympathetics (relax).

⭐ Calot's Triangle: Critical surgical landmark for cholecystectomy. Boundaries: Cystic duct (inferiorly), common hepatic duct (medially), and inferior liver edge (superiorly). Contains the cystic artery.

Clinical Correlations - When Plumbing Fails

Cholelithiasis (Gallstones): Often asymptomatic. Can cause biliary colic (RUQ pain). Risk factors (📌 4 F's): Female, Fat, Fertile, Forty.
Cholecystitis: Gallbladder inflammation from cystic duct obstruction.
- Presents with steady RUQ pain, fever, ↑ WBC.
- Positive Murphy's sign.
Ascending Cholangitis: Biliary tree infection from obstruction (e.g., choledocholithiasis).
- Charcot's Triad: Jaundice, Fever, RUQ Pain.

⭐ Most gallstones (~80%) are cholesterol stones, which are radiolucent on X-ray.

Biliary tree anatomy & gallstone obstruction sites

High‑Yield Points - ⚡ Biggest Takeaways

The portal triad (hepatic artery, portal vein, common bile duct) runs within the hepatoduodenal ligament.

Calot's triangle (cystic duct, common hepatic duct, liver edge) is the surgical landmark for the cystic artery.

Gallbladder inflammation refers pain to the right shoulder via the phrenic nerve (C3-C5).

The common bile duct joins the main pancreatic duct at the ampulla of Vater.

Liver's dual blood supply: portal vein (~75%) and hepatic artery (~25%).

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