Approach to the evaluation of an asymptomatic adult with elevated alkaline phosphatase and hyperbilirubinemia

CMV: cytomegalovirus; EBV: Epstein-Barr virus; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; MRCP: magnetic resonance cholangiopancreatogram.

* Causes for intrahepatic cholestasis include drug toxicity, primary biliary cholangitis, primary sclerosing cholangitis, viral hepatitis, intrahepatic cholestasis of pregnancy, benign postoperative cholestasis, infiltrative diseases, total parenteral nutrition.

¶ If drug-induced cholestasis is suspected, elimination of the offending drug usually leads to resolution of cholestasis, although it may take months. The National Institutes of Health maintains a searchable database of drugs, herbal medications, and dietary supplements that have been associated with liver injury.

Δ The extent of testing should be informed by the patient's history and risk factors. Evaluation may include serologies for viral etiologies (hepatitis A, B, C, E, CMV, EBV) and exclusion of intrahepatic cholestasis of pregnancy (serum pregnancy test and serum bile acids) and MRCP for primary sclerosing cholangitis. Patients with unexplained cholestasis despite serologic evaluation and imaging should be referred to a hepatologist for further evaluation and consideration of a liver biopsy to rule out infiltrative disease.