A 52-year-old woman presents to her primary care physician for a routine check-up. She is asymptomatic and has no significant past medical history. Her medications include a daily multivitamin and an oral contraceptive. She has a family history of breast cancer but no known liver disease. Vital signs are within normal limits. Physical examination is unremarkable. Routine blood tests reveal the following:
An abdominal ultrasound shows normal liver parenchyma and no dilation of the biliary ducts. Given these findings, which of the following is the most appropriate next step in management of this patient?
E) Start ursodeoxycholic acid
This asymptomatic patient has elevated alkaline phosphatase with normal hepatic transaminase (ALT, AST) levels, a normal right upper quadrant ultrasound, and a positive anti-mitochondrial antibody assay. This is consistent with early primary biliary cholangitis (PBC). Approximately 50-60% of patients with PBC are asymptomatic at diagnosis and are detected because of abnormalities in liver biochemical tests obtained for other reasons. Among patients with symptoms, fatigue and pruritus are most commonly seen. Ursodeoxycholic acid (UDCA) is the drug of choice for PBC, as it can delay histologic progression and improve symptoms and possibly survival. It should be initiated as soon as the diagnosis is made, even in asymptomatic patients. Treatment is less effective in advanced disease, and many patients will go on to require liver transplantation.
Answer choice A: Discontinue oral contraceptive and repeat testing, is incorrect. Oral contraceptives are not typically associated with isolated elevated alkaline phosphatase and positive AMA.
Answer choice B: Measure serum alpha-fetoprotein level, is incorrect. Alpha-fetoprotein is used to screen for hepatocellular carcinoma, which is not the most likely etiology in this scenario.
Answer choice C: Refer for liver transplantation, is incorrect. Liver transplantation is the definitive cure for progressive PBC but is only indicated in advanced cases with severe liver damage or cirrhosis.
Answer choice D: Start glucocorticoids, is incorrect. Glucocorticoids are not recommended for the treatment of PBC, but rather used for autoimmune hepatitis, which is characterized by elevated transaminases and positive antinuclear antibody titer.
Key Learning Point
In a patient with elevated alkaline phosphatase, normal transaminases, a positive anti-mitochondrial antibody (AMA), and a liver ultrasound that shows no extrahepatic biliary obstruction, primary biliary cholangitis (PBC) is likely. Ursodeoxycholic acid (UDCA) should be started to delay disease progression and improve outcomes.
