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ERCP & Related Biliary Conditions:: MSRA MCQs

Updated: Aug 12

  1. A 44-year-old woman presents with severe epigastric pain, jaundice, and vomiting. Bloods show ALT 340 IU/L, ALP 430 IU/L, and bilirubin 120 µmol/L. Lipase is >3× ULN. Ultrasound shows gallstones and a dilated CBD.

    What is the most appropriate next step?

Choose the correct answer

  • A. Start antibiotics and observe

  • B. Elective laparoscopic cholecystectomy

  • C. ERCP within 72 hours

  • D. Emergency laparotomy


✅ Answer: C. ERCP within 72 hours

This is gallstone pancreatitis with biliary obstruction (jaundice + CBD dilation + ALT >150)


  1. A 62-year-old man presents with fever, confusion, jaundice, and RUQ pain. He is hypotensive and tachycardic. LFTs show a cholestatic pattern. Ultrasound shows gallstones and a dilated common bile duct.

    What is the most appropriate next step?

Choose the correct answer

  • A. MRCP

  • B. Start fluids and monitor

  • C. ERCP immediately

  • D. CT abdomen


✅ Answer: C. ERCP immediately

 This is classic acute cholangitis (Charcot's or Reynolds pentad) — ERCP is life-saving.



  1. A 50-year-old woman presents with upper abdominal pain and jaundice. Ultrasound shows borderline CBD dilation. She is afebrile and stable. You want to confirm whether a stone is present in the duct.

    What is the most appropriate next investigation?

Choose the correct answer

  • A. ERCP

  • B. MRCP

  • C. CT abdomen

  • D. Diagnostic laparoscopy



✅ Answer: B. MRCP

 MRCP is the non-invasive test of choice for diagnosing CBD stones. Use ERCP only if intervention is required.


  1. A 38-year-old woman has mild gallstone pancreatitis. She is clinically improving, has no jaundice or fever, and her LFTs are normal. Ultrasound shows gallstones but no duct dilation.

    What is the most appropriate plan?

Choose the correct answer

  • A. ERCP within 72 hours

  • B. MRCP to confirm CBD stones

  • C. Conservative management and early cholecystectomy

  • D. Laparotomy



✅ Answer: C. Conservative management and early cholecystectomy

 No signs of obstruction or cholangitis = ERCP not needed.



  1. A patient with obstructive jaundice from pancreatic head cancer is cachectic and inoperable. LFTs show cholestasis, and ultrasound shows biliary dilation.

    What is the most appropriate intervention?

Choose the correct answer

  • A. Start high-dose steroids

  • B. Refer for ERCP and stent placement

  • C. Surgical bypass

  • D. Watchful waiting



✅ Answer: B. Refer for ERCP and stent placement

 ERCP provides palliative biliary decompression in malignant obstruction.



  1. Which of the following best supports gallstone aetiology in acute pancreatitis?

Choose the correct answer

  • A. AST > ALT

  • B. ALT >150 IU/L

  • C. Elevated CRP >150

  • D. Normal lipase



✅ Answer: B. ALT >150 IU/L

 Highly predictive of gallstone pancreatitis (specificity ~90%).



  1. A 37-year-old woman presents with acute epigastric pain radiating to the back. Lipase is >600 IU/L. She denies alcohol use. ALT is 220, bilirubin is 70, and ultrasound shows gallstones.

    What is the most likely cause?

Choose the correct answer

  • A. Autoimmune pancreatitis

  • B. Alcohol-induced pancreatitis

  • C. Gallstone pancreatitis

  • D. Idiopathic



✅ Answer: C. Gallstone pancreatitis

 ALT >150 + gallstones + no alcohol = strong gallstone clue.



  1. A 58-year-old woman presents with painless jaundice and dark urine. She is afebrile, with a mildly dilated CBD on ultrasound. LFTs show cholestatic pattern. No fever, pain, or hypotension.

    What is the most appropriate next investigation?

Choose the correct answer

  • A. ERCP

  • B. MRCP

  • C. CT scan of abdomen

  • D. Diagnostic laparoscopy



✅ Answer: B. MRCP

 Rationale: In stable, painless jaundice without infection, use MRCP to evaluate for ductal obstruction.



  1. A 65-year-old man with necrotising pancreatitis becomes septic on day 6. CT shows gas bubbles in a non-enhancing pancreatic region. Blood cultures are pending.

    What is the best next step?

Choose the correct answer

  • A. Emergency necrosectomy

  • B. ERCP

  • C. Start IV antibiotics and plan percutaneous drainage

  • D. Repeat CT in 72 hours



✅ Answer: C. Start IV antibiotics and plan percutaneous drainage

 Rationale: Gas + necrosis = infected necrosis → treat with antibiotics + drainage (step-up approach). ERCP is not helpful unless there's concurrent biliary obstruction.



  1. A 40-year-old man had mild gallstone pancreatitis and recovered well. Lipase has normalised. There’s no jaundice or fever.

    What is the best long-term management?

Choose the correct answer

  • A. Watch and wait

  • B. MRCP in 1 month

  • C. Laparoscopic cholecystectomy during same admission

  • D. Elective ERCP after discharge



✅ Answer: C. Laparoscopic cholecystectomy during same admission

 Rationale: NICE guidelines recommend early cholecystectomy to prevent recurrence in mild gallstone pancreatitis.

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