{"id":3475,"date":"2021-05-26T20:03:00","date_gmt":"2021-05-26T20:03:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3475"},"modified":"2025-10-01T11:42:40","modified_gmt":"2025-10-01T19:42:40","slug":"usmle-step-2-question-of-the-day-gallstones","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Gallstones"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#C_Intermittent_gallbladder_obstruction_with_black_pigment_gallstones\" >C. Intermittent gallbladder obstruction with black pigment gallstones<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#A_Acalculous_inflammation_of_the_gallbladder\" >A. Acalculous inflammation of the gallbladder&nbsp;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#B_Intermittent_common_bile_duct_obstruction_with_brown_pigment_gallstones\" >B. Intermittent common bile duct obstruction with brown pigment&nbsp;gallstones&nbsp;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#D_Spasm_of_the_biliary_tracts_secondary_to_cholesterol_stone_obstruction\" >D. Spasm of the biliary tracts secondary to cholesterol stone obstruction<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#E_Fibrotic_and_calcified_gallbladder\" >E. Fibrotic and calcified gallbladder<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#Major_takeaway\" >Major takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;<strong><em>Today&#8217;s case involves a 22-year-old man with abdominal pain.&nbsp;<\/em><\/strong><\/em><\/strong><strong><em><strong><em>Which of the following is the most likely cause of this patient\u2019s condition?<\/em><\/strong><\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 22-year-old man comes to the clinic complaining of a 6-week history of intermittent abdominal pain. The patient states the pain is located mainly in the right upper quadrant and typically occurs after meals. The patient denies any past medical history. He states his father had his spleen removed at a young age but is unsure of the details. His vital signs are within normal limits. Physical examination shows mucosal pallor and scleral icterus. There is no pain on palpation of the abdomen. The spleen tip is palpable. Laboratory results are as follows:<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory value<\/strong><\/td><td><strong>Result<\/strong><\/td><\/tr><tr><td><strong>Hematologic<\/strong><\/td><td><\/td><\/tr><tr><td>Leukocyte count<\/td><td>&nbsp;6,000\/mm3<\/td><\/tr><tr><td>Platelet count<\/td><td>175,000\/mm<sup>3<\/sup><\/td><\/tr><tr><td>Hemoglobin<\/td><td>10.1 g\/dL<\/td><\/tr><tr><td>Mean corpuscular volume (MCV)<\/td><td>84 fL<\/td><\/tr><tr><td>Mean corpuscular hemoglobin concentration (MCHC)<\/td><td>40 g\/dL<\/td><\/tr><tr><td>Red cell distribution width (RDW)<\/td><td>15%<\/td><\/tr><tr><td>Reticulocyte count<\/td><td>8.1%<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following is the most likely cause of this patient\u2019s condition?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Acalculous inflammation of the gallbladder&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Intermittent common bile duct obstruction with brown pigment gallstones&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Intermittent gallbladder obstruction with black pigment gallstones<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Spasm of the biliary tracts secondary to cholesterol stone obstruction<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Fibrotic and calcified gallbladder<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-rich is-provider-embed-handler wp-block-embed-embed-handler wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Osmosis.org at the University of Vermont\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/QumqCo4-3aw?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_Intermittent_gallbladder_obstruction_with_black_pigment_gallstones\"><\/span><strong>C. Intermittent gallbladder obstruction with black pigment gallstones<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t A, B, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Acalculous_inflammation_of_the_gallbladder\"><\/span><strong>A. Acalculous inflammation of the gallbladder&nbsp;<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Acalculous&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Acute_cholecystitis\" target=\"_blank\" rel=\"noreferrer noopener\">cholecystitis<\/a>&nbsp;is an acute inflammatory disorder of the gallbladder that is most commonly seen in conditions that cause biliary stasis, such as in critically ill patients (e.g., multiorgan failure, post-surgery, trauma) or those on prolonged total parenteral nutrition (TPN). Patients typically present with fever and persistent right upper quadrant pain, neither of which are seen in this patient. &nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Intermittent_common_bile_duct_obstruction_with_brown_pigment_gallstones\"><\/span><strong>B. Intermittent common bile duct obstruction with brown pigment&nbsp;<\/strong><strong><a href=\"https:\/\/www.osmosis.org\/learn\/Gallstones\" target=\"_blank\" rel=\"noreferrer noopener\">gallstones<\/a><\/strong><strong>&nbsp;<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Brown pigment stones are associated with bacterial (e.g.&nbsp;<em><a href=\"https:\/\/www.osmosis.org\/learn\/Escherichia_coli\" target=\"_blank\" rel=\"noreferrer noopener\">E. coli<\/a><\/em>) or parasitic (e.g. liver fluke) infections of the biliary system. Brown pigment stones are prevalent in Asian countries but are rarely seen in patients in the United States. Additionally, this patient\u2019s underlying condition predisposes him to a different type of stone composition.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_Spasm_of_the_biliary_tracts_secondary_to_cholesterol_stone_obstruction\"><\/span><strong>D. Spasm of the biliary tracts secondary to cholesterol stone obstruction<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Spasm of the biliary tract secondary to obstruction of the common bile duct is seen in patients with choledocholithiasis. Although cholesterol gallstones are the most common stones found in the gallbladder, this patient\u2019s underlying condition predisposes him to a different type of stone composition.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_Fibrotic_and_calcified_gallbladder\"><\/span><strong>E. Fibrotic and calcified gallbladder<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Porcelain gallbladder refers to a fibrotic and calcified gallbladder that occurs after recurrent episodes of&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Chronic_cholecystitis\" target=\"_blank\" rel=\"noreferrer noopener\">cholecystitis<\/a>. Although this patient\u2019s current condition may predispose him to develop a porcelain gallbladder, it most commonly presents much later in life (usually around the 6th decade). &nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This young adult, who presents with complaints of postprandial right upper quadrant (RUQ) pain and laboratory results showing anemia and elevated mean corpuscular hemoglobin concentration (MCHC), likely has&nbsp;<strong>black pigment&nbsp;<\/strong><strong><a href=\"https:\/\/www.osmosis.org\/learn\/Gallstones\" target=\"_blank\" rel=\"noreferrer noopener\">gallstone<\/a><\/strong><strong>&nbsp;formation<\/strong>&nbsp;secondary to&nbsp;<strong>hereditary spherocytosis<\/strong>&nbsp;(HS).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Black pigment gallstones<\/strong>&nbsp;form when the bile contains a high concentration of unconjugated bilirubin in the bilirubin tree, such as in patients with&nbsp;<strong>chronic extravascular red cell hemolysis<\/strong>. This can be seen in patients with&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Sickle_cell_disease_(NORD)\" target=\"_blank\" rel=\"noreferrer noopener\">sickle cell disease<\/a>&nbsp;or&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Hereditary_spherocytosis\" target=\"_blank\" rel=\"noreferrer noopener\">hereditary spherocytosis<\/a>. Brown pigment stones, on the other hand, can precipitate when the biliary tract is infected by certain microbes (e.g., E. coli,&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Clonorchis_sinensis\" target=\"_blank\" rel=\"noreferrer noopener\">Clonorchis sinensis<\/a>) that produce \u03b2-glucuronidase, an enzyme that unconjugates previously conjugated bilirubin. Unconjugated bilirubin is water insoluble and combines with calcium to form brown pigment stones.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">However, the most common gallstones are cholesterol stones. Bile formation is the only significant pathway for the body to eliminate excess cholesterol, either as free cholesterol or as bile salts. Cholesterol becomes water-soluble when combined with bile salts; therefore, when cholesterol concentrations exceed the solubility capacity of bile salts (supersaturation), cholesterol stones can form. Conditions that&nbsp;<strong>increase cholesterol synthesis<\/strong>&nbsp;(e.g., obesity, medications such as fibrates) or&nbsp;<strong>decrease bile salt formation<\/strong>&nbsp;(e.g. malabsorptive conditions) predispose individuals to forming gallstones. Additionally,&nbsp;<strong>hypomotility<\/strong>&nbsp;of the gallbladder results in bile stasis, which also promotes gallstone formation (e.g., pregnant women, patients on total parenteral nutrition). This patient did not have risk factors for cholesterol stones. Instead, his physical exam and laboratory values suggested a risk for pigment stones.<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Gallstones (cholelithiasis) - an Osmosis Preview\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/j35rj5rb6Ns?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_takeaway\"><\/span><strong>Major takeaway<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Black pigment gallstones can be seen in patients with chronic hemolytic conditions, whereas brown pigment gallstones are formed in patients with an infection of the biliary tree. Cholesterol gallstones precipitate in the gallbladder in conditions that cause increased cholesterol synthesis or decreased bile salt formation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span><strong>References<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27121416\/\" target=\"_blank\" rel=\"noreferrer noopener\">Gallstones<\/a><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em><br><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;Try Osmosis today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e3431e.png\" alt=\"Ace your clerkships with clinical practice videos on Osmosis. Watch now.\" class=\"wp-image-3477\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e3431e.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_e3431e.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;s case involves a 22-year-old man with abdominal pain.&nbsp;Which of the following is the most likely cause of this patient\u2019s condition? A 22-year-old man comes to the clinic complaining of a 6-week history of intermittent abdominal pain. The patient states the pain is located [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":3476,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1370,45],"tags":[],"class_list":["post-3475","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Gallstones - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-gallstones\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Gallstones - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;s case involves a 22-year-old man with abdominal pain.&nbsp;Which of the following is the most likely cause of this patient\u2019s condition? A 22-year-old man comes to the clinic complaining of a 6-week history of intermittent abdominal pain. 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