American Board of Internal Medicine (ABIM) Certification Practice Exam

In the context of biliary obstruction, what findings typically warrant further investigation?

1. Elevated amylase levels

2. Normal liver enzyme levels

3. Persistently elevated liver enzyme levels

4. Decreased bilirubin levels

The correct answer is: Persistently elevated liver enzyme levels

Persistently elevated liver enzyme levels indicate ongoing hepatic injury or dysfunction, which could be a result of biliary obstruction. Biliary obstruction can cause a buildup of bile acids and lead to liver damage, resulting in elevated transaminases (such as AST and ALT) as well as alkaline phosphatase, which is particularly relevant in the context of cholestasis. When liver enzyme levels remain elevated over time, this suggests a chronic process that is potentially linked to obstruction of the bile ducts, gallstones, tumors, or other conditions causing biliary insufficiency. These findings warrant further investigation, as they could indicate significant underlying pathology that requires prompt management. In contrast, elevated amylase levels might suggest pancreatitis or another abdominal process, normal liver enzyme levels would not typically warrant further evaluation for biliary obstruction since they suggest that the liver is likely functioning correctly, and decreased bilirubin levels could indicate a resolution of an obstruction or no obstruction at all, thus typically not prompting further investigation in this context.