EDUCATION PRACTICE Primary Sclerosing Cholangitis: Patients With a Rising Alkaline Phosphatase at Annual Follow-up

Clinical Scenario A 45-year-old man with chronic ulcerative colitis of 10 ears’ duration and primary sclerosing cholangitis (PSC) is eferred for elevated alkaline phosphatase level, detected in a outine blood test performed by the primary care physician. eview of a chemistry group from 2 years previously showed hat the alkaline phosphatase level had doubled. The patient is oncerned about the risk of cholangiocarcinoma in the setting f PSC with an increase in the level of alkaline phosphatase. The iagnosis of PSC was established about 3 years earlier when he ad abnormal liver biochemical test results and cholangioraphic findings consistent with disease. He had been on urodeoxycholic acid at a daily dosage of 13 mg/kg. Regular ollow-up surveillance colonoscopies showed no evidence of ysplasia. The patient is active at work and asymptomatic. He enies pruritus, fatigue, abdominal pain, fever, or bleeding. He as had substantial weight loss since starting an exercise and ietary modification program. Physical examination reveals a iver span of 8 cm. There are no spider angiomas, splenomegaly, scites, or peripheral edema. Laboratory evaluation shows ALT f 72 U/L (normal, 10 – 40 U/L), AST of 54 U/L (normal, 12–31 /L), alkaline phosphatase of 480 U/L (normal, 90 –234 U/L), lbumin of 3.8 g/dL, and total bilirubin of 0.9 mg/dL. A omplete blood count and coagulation parameters are normal. How should you counsel this patient with PSC and chronic lcerative colitis regarding progression of PSC and the effect of rsodeoxycholic acid therapy on his liver? What should be the trategy to diagnose or exclude cholangiocarcinoma in this atient? Specifically, is there a role for serum markers for iagnosis of cholangiocarcinoma in PSC patients, and what is he accuracy of the various radiologic modalities and endocopic methods available for the detection of cholangiocarcioma complicating PSC? Do biliary brush cytology, advanced ytologic techniques, and endobiliary biopsy add significantly o the diagnosis of cholangiocarcinoma in patients with PSC?