Podcast: How to Screen and Diagnose Cholestatic Liver Diseases

So cholestasis is where you have impaired bile flow or formation.

And I think it's important to just recognize it and confirm the biochemical pattern and not just focus on the disease state that will come later.

And determine first, is this truly cholestatic hepatocellular or is it a mixed pattern? So what do you look for, Allison, when you have someone that comes to your practice with abnormal liver tests?

Yeah, so I think just as you mentioned, you know, it's important for us to see based on some of the preliminary testing, do we think this is intrahepatic, like it's a process going on within the liver? Do we think it's extra hepatic, something going on outside of the bile ducts? Or is it possibly something going on in the liver parenchyma itself, which, you know, is kind of where we're focusing here with cholestasis.

So typically, people who have cholestasis versus other things like a biliary obstruction or a drug-induced liver injury, the top things that these patients usually present with is itching and a lot of times can be accompanied by jaundice or a yellowing of the urine, the whites of the sclera, and sometimes the skin.

The problem is that that can also be known and found in other disease states, like patients who have a drug-induced liver injury, if it's severe or severe acute hepatitis.

But very commonly when we're talking about cholestasis, itching and the jaundice are the two things that are what we're paying attention to.

I think the most important thing Besides taking a really good history, which of course I think is probably what sets this apart from other things like, oh yes, I took an antibiotic four weeks ago and since I started the antibiotic, I started to be itchy or started to have jaundice, or paying attention to things on routine liver tests, and probably most importantly is an alkaline phosphatase.

Which in most patients would not just be a hair elevated.

In patients who have cholestatic liver disease would probably at least be two times the upper limit of normal.

What would you say is a number that you're kind of looking for, Ho-Chung, in that range?

Yeah, absolutely.

So, you know, obviously in the cholestatic pattern, you're going to have elevation and alkaline phosphatase greater than two upper limits of normal, like you said, Allison.

I think first, the one thing you have to do is kind of confirm it by insulin.

you know, you can fractionate the alkaline phosphatase because we know that there are many things that can cause that elevation and confirm the hepatic origin.

You should confirm it using the GGT to make sure that it's hepatic because you can actually have other things that cause a cholestatic picture just in the labs by like bone disease.

So helping by fractionating the alkaline phosphatase, you can kind of see, is it from the gut? Is it from the liver? Is it from the bone, right? And there are...

And there are other clinical situations like in pregnancy or, you know, if you're a pediatric person that you're growing like crazy that you can have, you know, elevated alkaline phosphate.

So you have to think about, you know, what it can be, but what it's not.

And also the most important thing when you're looking at cholestatic liver disease, you know, you want to confirm that it is normal.

hepatic in origin.

And then kind of that will then help you, you know, in addition to the symptoms that, you know, Alison talked about, but what do we do next in that workup? And what does that look like?