A 42-year-old man comes to the office due to fatigue and dark urine. Medical history is insignificant and he takes no medications. He used intravenous drugs in the remote past. The patient is an ex-smoker with 25-pack-year history. His father died of colon cancer at age 52. Temperature is 37 C (98.6 F), blood pressure is 122/70 mm Hg, and pulse is 80/min. BMI is 30 kg/m². The sclera and skin are icteric. The abdomen is nondistended and nontender. Laboratory results are as follows: Which of the following is the best next step in management?

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11ec25c8_d3eb_90bc_bc81_5708a42ae0ee_MD0003_00 This patient has elevated conjugated (direct) hyperbilirubinemia along with elevated levels of alkaline phosphatase. This pattern of abnormal liver function is consistent with cholestasis in the setting of extrahepatic or intrahepatic biliary obstruction. The next appropriate step in management for patients with predominantly cholestatic pattern is to obtain an abdominal ultrasound to assess hepatic parenchyma and biliary ducts. The presence of biliary dilatation is suggestive of extrahepatic cholestasis; the absence of biliary dilatation suggests intrahepatic cholestasis. (Choice A) Endoscopic retrograde cholangiopancreatogram (ERCP) is usually performed in patients when initial ultrasonography or CT scan suggests the presence of obstruction due to cholelithiasis or malignancy. ERCP in these settings can be both diagnostic and therapeutic by relieving obstruction and facilitating biliary drainage. (Choice B) Examination of the peripheral blood smear is useful in the evaluation of patients with suspected hemolytic anemias. However, patients with hemolysis have elevated unconjugated (indirect) hyperbilirubinemia. (Choice C) Measurement of serum iron, transferrin saturation, and ferritin levels is useful in the diagnosis of iron overload syndromes, including hereditary hemochromatosis. Patients with hereditary hemochromatosis have progressive iron deposition in the liver and elevated serum aminotransferases (AST and ALT). (Choice E) Patients with acute viral hepatitis typically have marked elevation of serum aspartate and alanine aminotransferase levels. Chronic viral hepatitis can be associated with mild to moderate elevation of serum aminotransferases. This patient has normal aminotransferase levels and is unlikely to have viral hepatitis as a cause of hyperbilirubinemia. Educational objective: Elevated serum alkaline phosphatase levels are indicative of cholestasis. These patients (with or without hyperbilirubinemia) should be evaluated with right upper-quadrant ultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction.

A 42-Year-Old Man Comes to the Office Due to Fatigue