Review Question - QID 108816

A 37-year-old woman presents to the emergency department with right upper quadrant (RUQ) pain. She reports that the pain is not new and usually starts within half an hour of eating a meal. The pain has been previously diagnosed as biliary colic and she underwent a cholecystectomy 3 months ago for symptomatic biliary colic. Her liver reportedly appeared normal at that time. The patient dates the onset of these episodes to shortly after she underwent a sleeve gastrectomy several years ago and the episodes were more severe immediately following that surgery. Her postsurgical course was otherwise uncomplicated and she has lost 50 pounds since then. She has a past medical history of hypertension, hyperlipidemia, diabetes mellitus, osteoarthritis, and obesity. She denies alcohol or tobacco use. Her home medications are hydrochlorothiazide, enalapril, atorvastatin, and vitamin supplements. Her temperature is 98.6°F (37°C), blood pressure is 131/92 mmHg, pulse is 91/min, and respirations are 14/min. An abdominal exam reveals tenderness to palpation in the right upper quadrant. RUQ ultrasound reveals a dilated common bile duct without evidence of stones. No gallbladder is seen consistent with the prior surgical history. Magnetic resonance cholangiopancreatography (MRCP) shows no evidence of biliary compression or obstruction and endoscopic retrograde cholangiopancreatography (ERCP) shows no evidence of biliary stones or sludge. Laboratory tests are performed which reveal the following:

ALT: 47 U/L
AST: 56 U/L
Alkaline phosphatase: 165 U/L
Total bilirubin: 1.6 g/dL
Amylase: 135 U/L
Lipase: 160 U/L

Which of the following is the most appropriate treatment for this patient's condition?