0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
306 Cholestasis■palmar erythema, spider nevi, bruising, gynecomastia, parotid
enlargement, Dupuytren’s contracture, firm/hard/irregular liver
edge suggests cirrhosis
■splenomegaly suggests portal hypertension
■abdominal pain (viral hepatitis); abdominal pain with arthral-
gia (autoimmune hepatitis); abdominal with backache (pancreatic
cancer); abdominal pain with fever rigors (cholangitis or hepatic
abscess)
■marked weight loss with jaundice a concern for malignancytests
Laboratory
■alkaline phosphatase out of proportion to aminotransferases
■when aminotransferases normal, confirm hepatic source of alkaline
phosphatase with GGT or 5′-nucleotidase level
■AMA are present in 95% of patients with PBC
■serum bilirubin level typically normal in early cholestatic disorders
■when hyperbilirubinemia present, determine if unconjugated
(hemolysis, Gilbert’s syndrome, and heart failure) or conjugated
(hepatocellular diseases and extrahepatic biliary obstruction)
■hemolysis: associated with increased reticulocyte count, decreased
serum haptoglobulin, and peripheral blood smear showing sphero-
cytes and fragmented cells
■hyperlipidemia
Imaging
■ultrasonography: to exclude extrahepatic biliary obstruction or gall-
stones
■CT scan: when malignancy is suspected
■ERCP: diagnostic for PSC; to obtain brushings from strictures; for
decompression of biliary tract in cholangitis
■magnetic resonance cholangiopancreatography (MRCP): less inva-
sive than ERCP, but lacks therapeutic options
■liver biopsy: usually diagnostic in PBC and alcoholic hepatitis,
and often helpful in the diagnosis of PSC, viral and drug-induced
hepatitis; severity (grade and stage) of liver diseases can be deter-
mined
differential diagnosis
■primary differential: obstructive from nonobstructive biliary tract
disease