A 52-year-old woman recently had cholecystectomy and now has elevated urea, bilirubin, and AST with a normal abdominal ultrasound. What is the most likely diagnosis and next step?

• A. Bile duct leak s/t cholecystectomy; ERCP
• B. Acute pancreatitis; CT scan
• C. Small bowel obstruction; CT
• D. Hepatic artery thrombosis; MRI

Answer: (A)

After cholecystectomy, a bile duct leak or injury is a key possibility when there are rises in bilirubin and liver enzymes, even if the abdominal ultrasound looks normal. A leak or ductal injury can cause cholestasis and inflammation that elevate bilirubin and AST, and ultrasound may miss the problem because it doesn’t always visualize ductal leaks or transected ducts clearly.

The best next step is an endoscopic evaluation with ERCP. This test directly images the biliary tree, can identify the site of a leak or obstruction, and also provides immediate treatment options such as sphincterotomy or placement of a stent to divert bile flow and promote healing. MRCP could also visualize ductal anatomy, but ERCP is both diagnostic and therapeutic, which is why it’s the preferred choice in this scenario.

Other conditions don’t fit as well. Acute pancreatitis would typically show pain and access to lipase elevations with imaging that supports pancreatic inflammation. Small bowel obstruction presents with vomiting and abdominal distension with different imaging findings. Hepatic artery thrombosis would cause hepatic ischemia with a different pattern of liver injury and imaging results.