A 58 year old male presented to the emergency department with worsening jaundice and icteric sclerae. His other symptoms included pruritis, dark urine, yellow colored stool, and fatigue. Review of systems included a ten-pound weight loss over two weeks. The patient denied excessive alcohol or drug use. Pertinent exam findings included diffuse jaundice, icteric sclerae, and hepatosplenomegaly. Laboratory findings showed elevated alkaline phosphate (935), total bilirubin (23.7), and direct bilirubin (18.2); as well as decreased total protein (5.2) and albumin (1.8). Transaminase levels were relatively unremarkable — mildly elevated AST (74) and normal ALT (66). Extensive work up for other etiologies was unremarkable except for elevated ferretin (1191) and CA 19-9 (113). Abdominal ultrasound, CT, and MRCP were also unremarkable and non-diagnostic for PSC. A liver core needle biopsy demonstrated histologic features consistent with PSC. Colonoscopy showed no evidence of IBD, and biopsy samples were negative for malignancy.
Fayerberg, Eugene and Peggy Beeley. "Clinical vignette: Importance of liver biopsy in diagnosing small duct primary sclerosing cholangitis." (2014). http://digitalrepository.unm.edu/hostpitalmed_pubs/22