ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Onboarding (Day One) | March 2025-Radiology Studies Case 2

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This case presents a 25-year-old man who is referred for elevated liver enzymes, detected during routine bloodwork for a disability insurance application. The patient has a history of ulcerative pancolitis, treated initially but later unmanaged due to being lost to follow-up. His symptoms include progressive generalized pruritus. Physical examinations and most lab tests appear normal, except for elevated AST, ALT, ALP, and total bilirubin (TBIL).<br /><br />The initial differential diagnosis should consider various liver conditions, emphasizing the need to explore Biliary Stricture and potential Primary Sclerosing Cholangitis (PSC), especially given the association with ulcerative pancolitis. Further diagnostic actions could include imaging via MRCP, which is non-invasive and adept at highlighting bile duct irregularities typical of PSC. <br /><br />Key investigations for this case should include viral hepatitis serologies, autoimmune markers, and possibly tumor markers given the heightened cancer risk associated with PSC. Colonoscopy is necessary due to the elevated risk of colon cancer linked with ulcerative colitis and PSC.<br /><br />Primary Sclerosing Cholangitis is an autoimmune disorder leading to bile duct inflammation and progressive fibrosis, causing obstructive complications, jaundice, and an elevated risk for cholangiocarcinoma, gallbladder, and colon cancers. Symptom management may require pharmacotherapy and possibly endoscopic procedures, while surveillance should focus on cancer monitoring.<br /><br />PSC lacks curative treatment but may slow progression with certain therapies. Regular hepatology-focused care, potentially including liver transplantation if needed, is indicated, with special caveats for PSC. The patient should undergo regular colonoscopy screenings due to increased cancer risk.<br /><br />In conclusion, this case highlights the importance of comprehensive management and surveillance in patients with suspected PSC, considering both hepatic and related oncological risks.

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John A. Martin, MD, FASGE
Katelyn Cookson, PA-C

Keywords

elevated liver enzymes

ulcerative pancolitis

Primary Sclerosing Cholangitis

biliary stricture

MRCP imaging

autoimmune disorder

cholangiocarcinoma risk

cancer surveillance

liver transplantation

colonoscopy screenings