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Answer 4
  1. Endoscopic ultrasound. The likelihood that this patient has CBD stones is low because she does not have gallstones in her resected gallbladder and her laboratory test results are normal during episodes of pain. Invasive methods to evaluate the biliary tree, such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography, thus would not be warranted. CT scan is often insensitive when looking at the biliary tree for stones or sludge. Magnetic resonance cholangiography can offer good images of the biliary system and can identify bile duct stones, but endoscopic ultrasound is regarded as superior when looking for focal bile duct stones as well as microlithiasis (ie, biliary sludge), which also could be causing this patient’s symptoms.

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