1. A patient presents to the bariatric surgeon 5 months status post LRYGB. He now has a BMI of 34…

1. A patient presents to the bariatric surgeon 5 months status post LRYGB. He now has a BMI of 34. He complains of right upper quadrant abdominal pain and vomiting for the past 3 days. USG shows stones in the common bile duct (CBD) and none in the gallbladder. Erect X ray shows multiple air fluid levels and no free air under the diaphragm. Labs show elevated direct bilirubin and alkaline phosphatase (ALP) of 300. Which of the following is NOT appropriate? A. Do a CT scan as internal hernia is also suspected. B. Use a laparoscopic approach to treat this patient’s problems. C. Do endoscopic retrograde cholangiopancreatography (ERCP) first as his obstruction can be treated conservatively for 24 hours. D. Do a magnetic resonance cholangiopancreatography (MRCP) with concomitant MRI of abdomen.

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