American Board of Internal Medicine (ABIM) Certification Practice Exam

In the presence of cholangitis or nonresolving biliary obstruction, what is typically indicated unless the patient is a surgical candidate for cholecystectomy?

1. Cholecystectomy

2. ERCP and biliary sphincterotomy

3. Conservative management

4. Open surgery

The correct answer is: ERCP and biliary sphincterotomy

In cases of cholangitis or nonresolving biliary obstruction, endoscopic retrograde cholangiopancreatography (ERCP) and biliary sphincterotomy are typically indicated due to their effectiveness in relieving the obstruction and managing the infection. ERCP is a minimally invasive procedure that allows for both diagnostic and therapeutic interventions, such as the removal of stones in the common bile duct or drainage of infected bile. The procedural approach aims to quickly alleviate the acute symptoms of cholangitis, which can be life-threatening if not treated promptly. Biliary sphincterotomy enhances bile drainage by cutting the muscle that surrounds the bile duct, further facilitating the resolution of the obstruction. While other options like cholecystectomy may be necessary in the long term for gallbladder disease, ERCP serves as a critical intervention in managing the acute condition and is often performed before any definitive surgical procedure. This method is preferred when immediate surgical intervention is not suitable or the patient is not a surgical candidate.