Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show: Aspartate aminotransferase 142 U/L Alanine aminotransferase 86 U/L Alkaline phosphatase 153 U/L Total bilirubin 1.5 mg/dL Direct bilirubin 1.0 mg/dL Amylase 20 U/L Which of the following is the most likely diagnosis?

Acute cholecystitis (calculous)

Many large clinics have noticed that the prevalence of primary biliary cholangitis (PBC) has increased significantly over the past 20 years. An epidemiologist is working to identify possible reasons for this. After analyzing a series of nationwide health surveillance databases, the epidemiologist finds that the incidence of PBC has remained stable over the past 20 years. Which of the following is the most plausible explanation for the increased prevalence of PBC?

Improved quality of care for PBC

Increased availability of diagnostic testing for PBC

Increased exposure to environmental risk factors for PBC

Increased awareness of PBC among clinicians

Increased average age of the population at risk for PBC

Fourteen days after a laparoscopic cholecystectomy for cholelithiasis, a 45-year-old woman comes to the emergency department because of persistent episodic epigastric pain for 3 days. The pain radiates to her back, occurs randomly throughout the day, and is associated with nausea and vomiting. Each episode lasts 30 minutes to one hour. Antacids do not improve her symptoms. She has hypertension and fibromyalgia. She has smoked 1–2 packs of cigarettes daily for the past 10 years and drinks 4 cans of beer every week. She takes lisinopril and pregabalin. She appears uncomfortable. Her temperature is 37°C (98.6° F), pulse is 84/min, respirations are 14/min, and blood pressure is 127/85 mm Hg. Abdominal examination shows tenderness to palpation in the upper quadrants without rebound or guarding. Bowel sounds are normal. The incisions are clean, dry, and intact. Serum studies show: AST 80 U/L ALT 95 U/L Alkaline phosphatase 213 U/L Bilirubin, total 1.3 mg/dL Direct 0.7 mg/dL Amylase 52 U/L Abdominal ultrasonography shows dilation of the common bile duct and no gallstones. Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangiopancreatography

Counseling on alcohol cessation

Reassurance and follow-up in 4 weeks

A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Laparoscopic removal of ovarian cysts

Intramuscular ceftriaxone followed by cephalexin

A 39-year-old woman presents to the emergency department with right upper quadrant abdominal discomfort for the past couple of hours. She says that the pain is dull in nature and denies any radiation. She admits to having similar episodes of pain in the past which subsided on its own. Her temperature is 37°C (99.6°F), respirations are 16/min, pulse is 78/min, and blood pressure is 122/98 mm Hg. Physical examination is normal except for diffuse tenderness of her abdomen. She undergoes a limited abdominal ultrasound which reveals a 1.4 cm gallbladder polyp. What is the next best step in the management of this patient?

Magnetic resonance cholangiopancreatography (MRCP)

Endoscopic retrograde cholangiopancreatography (ERCP)

A 45-year-old woman comes to the emergency department complaining of abdominal pain for the past day. The pain is situated in the right upper quadrant, colicky, 8/10, and radiates to the tip of the right shoulder with no aggravating or relieving factors. The pain is associated with nausea but no vomiting. She tried to take over-the-counter antacids which relieved her pain to a certain extent, but not entirely. She does not smoke cigarettes or drink alcohol. She has no past medical illness. Her father died of pancreatic cancer at the age of 75, and her mother has diabetes controlled with medications. Temperature is 38°C (100.4°F), blood pressure is 125/89 mm Hg, pulse is 104/min, respiratory rate is 20/min, and BMI is 29 kg/m2. On abdominal examination, her abdomen is tender to shallow and deep palpation of the right upper quadrant. Laboratory test Complete blood count Hemoglobin 13 g/dL WBC 15,500/mm3 Platelets 145,000/mm3 Basic metabolic panel Serum Na+ 137 mEq/L Serum K+ 3.6 mEq/L Serum Cl- 95 mEq/L Serum HCO3- 25 mEq/L BUN 10 mg/dL Serum creatinine 0.8 mg/dL Liver function test Total bilirubin 1.3 mg/dL AST 52 U/L ALT 60 U/L Ultrasonography of the abdomen shows normal findings. What is the best next step in management of this patient?

Reassurance and close follow up

Hepatobiliary surgery basics for USMLE Step 3: High-Yield Surgery Lessons

🗺️ Anatomy: Key structures - Liver & Biliary Atlas

Liver: Divided into 8 functional Couinaud segments, each with its own portal triad inflow, biliary drainage, and hepatic venous outflow. This allows for segmental resections.

Couinaud segments of the liver with hepatic veins

Biliary Drainage Pathway:

Key Surgical Landmarks:
- Portal Triad: Found in the hepatoduodenal ligament.
  - Proper Hepatic Artery (anterior-medial)
  - Portal Vein (posterior)
  - Common Bile Duct (anterior-lateral)
- Triangle of Calot: Critical for cholecystectomy.
  - Borders: Cystic duct, common hepatic duct, inferior liver edge.
  - Contains: Cystic artery.

⭐ The Pringle Maneuver involves clamping the hepatoduodenal ligament to control liver inflow (hepatic artery & portal vein), but does not stop bleeding from hepatic veins.

🔬 Biliary Spyglass (Cholangioscopy)

Function: A single-operator cholangioscopy system used during ERCP for direct visualization of the biliary and pancreatic ducts. Enables targeted biopsies and therapy.

Biliary Spyglass cholangioscopy of cholangiocarcinoma

Key Findings & Applications:
- Stones: Direct visualization of biliary stones; facilitates laser lithotripsy (e.g., Holmium laser) for large or impacted stones.
- Strictures: Differentiates benign from malignant.
  - Malignant (Cholangiocarcinoma): Irregular, nodular, friable mucosa with abnormal, tortuous "tumor vessels."
  - Benign: Smooth mucosa, symmetric narrowing, absence of neovascularity.
- Biopsy: Visually-guided forceps biopsy of indeterminate strictures or lesions.

⭐ Spyglass-guided biopsy significantly improves diagnostic yield for indeterminate biliary strictures over standard ERCP with brush cytology or random biopsies.

🔪 Management: Scalpel & Scope

Cholecystectomy: Laparoscopic is the gold standard for symptomatic cholelithiasis.
- 📌 Calot's Triangle: Identify cystic duct, common hepatic duct, & inferior liver edge to isolate the cystic artery.
- Open conversion for severe inflammation, adhesions, or malignancy.
ERCP: Diagnostic & therapeutic for biliary obstruction (stones, strictures).
- Procedures: Sphincterotomy, stone extraction, stenting.
- ⚠️ High risk of post-ERCP pancreatitis.
Liver Resection/Transplant: For tumors (HCC, mets) or end-stage disease. Transplant eligibility guided by MELD score (typically >15).

⭐ Critical View of Safety (CVS): Essential step in lap cholecystectomy to prevent iatrogenic bile duct injury. Requires clear identification of only two structures entering the gallbladder: the cystic duct and cystic artery.

Calot's Triangle Anatomy

💧 Complications: When Leaks Happen

Etiology: Most common after laparoscopic cholecystectomy (cystic duct stump), liver resection, or abdominal trauma.
Presentation: Occurs 2-10 days post-op. Symptoms include fever, RUQ pain, jaundice, and ↑ bilirubin/ALP. High bilious output from a surgical drain is highly suggestive.
Diagnostic Workup:
- Initial: CT or ultrasound to identify fluid collection (biloma).
- Confirmatory: HIDA scan is the most accurate non-invasive test to confirm an active leak and locate its source.
Management Flow:

⭐ ERCP with sphincterotomy +/- stenting is the cornerstone of management. It lowers intraductal pressure, creating a preferential path for bile into the duodenum, allowing the leak to heal spontaneously.

⚡ Biggest Takeaways

Asymptomatic gallstones are observed; symptomatic stones (biliary colic) require elective cholecystectomy.

Acute cholecystitis (Murphy's sign): diagnose with ultrasound, confirm with HIDA scan. Treat with cholecystectomy.

Choledocholithiasis (CBD stone) causes obstructive jaundice. Diagnose and treat with ERCP.

Ascending cholangitis (Charcot's triad/Reynolds' pentad) is an emergency requiring urgent biliary drainage (ERCP) and antibiotics.

The Pringle maneuver clamps the hepatoduodenal ligament to control hepatic inflow bleeding.

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