NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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August 26, 2025
MKSAP 18 Gastroenterology & Hepatology, Question 20
A 36-year-old woman is evaluated 3 days after being hospitalized for gallstone pancreatitis. An abdominal ultrasound showed multiple gallstones in the gallbladder and a normal-diameter common bile duct. She was treated with intravenous hydration and pain medication. Over the course of 3 days, she tolerated eating and her pain subsided.
On physical examination, vital signs are normal; BMI is 32. Minimal tenderness to palpation is noted on abdominal examination. All other findings are unremarkable.
All laboratory studies have returned to baseline normal values.
Which of the following is the most appropriate treatment?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy before discharge from the hospital
C. Laparoscopic cholecystectomy 4 weeks after discharge from the hospital
D. MR cholangiopancreatography
E. Ursodeoxycholic acid
Responses Received from Members (721 Responses):
The Correct Answer is: B. Laparoscopic cholecystectomy before discharge from the hospital
Educational Objective:
Treat gallstone pancreatitis with prompt cholecystectomy.
Laparoscopic cholecystectomy before discharge from the hospital is the most appropriate treatment. Gallstone acute pancreatitis can be diagnosed based on elevated liver transaminases on presentation, a lipase level elevated to more than three times the upper limit of normal, characteristic severe abdominal pain, and ultrasonographic evidence of cholelithiasis. This patient showed clinical improvement within 3 days of hospitalization. Her laboratory values have normalized, suggesting spontaneous passage of a gallstone through the common bile duct, which occurs in most patients with gallstone pancreatitis. In a multicenter randomized controlled trial, same-admission cholecystectomy reduced rates of gallstone-related complications compared with interval cholecystectomy 25 to 30 days after hospital discharge for patients with mild gallstone pancreatitis.
Endoscopic retrograde cholangiopancreatography (ERCP) is indicated urgently for patients with acute pancreatitis and ascending cholangitis (fever, abdominal pain, and jaundice) due to choledocholithiasis. If there is evidence of ongoing biliary obstruction in patients hospitalized with acute pancreatitis, ERCP may be indicated to remove a retained gallstone from the common bile duct. This patient's symptoms and laboratory abnormalities resolved quickly, which supports the spontaneous passage of a gallstone without evidence of ongoing biliary obstruction.
MR cholangiopancreatography (MRCP) can be used to identify causes of biliary obstruction. MRCP is not needed in this patient because she has normal-caliber bile ducts on abdominal ultrasonography and normal liver chemistry test results, indicating that a biliary obstruction is unlikely.
Ursodeoxycholic acid has been used to medically dissolve small cholesterol gallstones in patients who are not candidates for surgery. The medication works slowly and may take longer than 1 year to dissolve small stones, leaving patients at risk for recurrent attacks of gallstone pancreatitis or other gallstone-related complications. This patient is young and without comorbidities, making surgery a more appropriate treatment.
Key Point
Same-admission cholecystectomy reduces rates of gallstone-related complications compared with cholecystectomy after hospital discharge for patients with mild gallstone pancreatitis.
Bibliography
da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, et al; Dutch Pancreatitis Study Group. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015;386:1261-8. PMID: 26460661 doi:10.1016/S0140-6736(15)00274-3
Copyright 2018, American College of Physicians.
August 12, 2025
MKSAP 19 Infectious Disease, Question 95
A 40-year-old man presents to the emergency department with a 2-day history of diarrhea occurring six times daily that developed 1 week after completing a course of amoxicillin-clavulanate for diverticulitis. Medical history is unremarkable, and he takes no medications.
On physical examination, temperature is 38.3 °C (100.9 °F); other vital signs are normal. Bowel sounds are present; palpation elicits tenderness but no guarding.
Laboratory studies show a leukocyte count of 17,000/µL (17 × 109/L) and serum creatinine level of 1.6 mg/dL (141 µmol/L).
Stool testing for Clostridioides difficile is positive.
Which of the following is the most appropriate treatment?
A. Intravenous metronidazole
B. Oral fidaxomicin
C. Oral vancomycin and rectal vancomycin
D. Tapered and pulsed vancomycin
Responses Received from Members (816 Responses):
The Correct Answer is: B. Oral fidaxomicin
Educational Objective:
Treat a first episode of severe Clostridioides difficile infection.
This patient has an initial episode of severe Clostridioides difficile infection (CDI), which should be treated with oral fidaxomicin therapy (Option B). Antibiotic use is the strongest risk factor for CDI. It is most highly associated with antimicrobial agents that have activity against anaerobic colonic flora but are not effective against C. difficile (such as clindamycin). Antibiotic-associated diarrhea in these cases is thought to occur by suppression of the intestinal microbiota, with resultant overgrowth of C. difficile organisms and production of toxin (toxins A and B). In all cases of CDI, the culprit antibiotic should be stopped if possible. All patients with confirmed CDI require antimicrobial treatment, but optimal management depends on whether the episode represents an initial infection or first or second recurrence and on the severity of disease (nonsevere, severe, fulminant). Severe CDI is defined by a leukocyte count of 15,000/µL (15 × 109/L) or greater or a serum creatinine level of 1.5 mg/dL (133 µmol/L) or greater. The 2021 Infectious Diseases Society of America and Society for Healthcare Epidemiology of America clinical practice guideline for CDI recommends either oral fidaxomicin (preferred) or oral vancomycin (alternative) for patients with nonsevere or severe CDI.
Intravenous metronidazole monotherapy (Option A) is not an indicated treatment for any degree of CDI severity or initial or recurrent disease status. Intravenous metronidazole therapy combined with oral vancomycin is an indicated regimen for fulminant CDI which is associated with hypotension, shock, ileus, or megacolon. Patients with fulminant disease also warrant surgical evaluation.
Another option for fulminant CDI infection is combined oral vancomycin, intravenous metronidazole, and rectal vancomycin when ileus is present (Option C). This patient does not have fulminant CDI; therefore, this combination therapy is not indicated.
Tapered and pulsed vancomycin therapy (Option D) consists of oral vancomycin, 125 mg four times daily for 10-14 days, then 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, then 125 mg every 2 or 3 days for 2 to 8 weeks. Tapered and pulsed vancomycin therapy is an indicated therapeutic option for first and subsequent CDI recurrences if the initial episode was treated with standard therapy consisting of vancomycin or fidaxomicin.
Key Point
Severe CDI is defined by a leukocyte count of 15,000/µL (15 × 109/L) or greater or a serum creatinine level of 1.5 mg/dL (133 µmol/L) or greater.
Oral fidaxomicin or vancomycin is recommended to treat an initial episode of nonsevere or severe Clostridioides difficile infection.
Bibliography
Johnson S, Lavergne V, Skinner AM, et al. Clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 focused update guidelines on management of Clostridioides difficile infection in adults. Clin Infect Dis. 2021;73:755- 757. PMID: 34492699 doi:10.1093/cid/ciab718
Copyright 2019, American College of Physicians.