History (focus on medication/drug exposure)

Physical examination
Lab tests: Bilirubin with fractionation, ALT, AST, alkaline phosphatase, prothrombin time, and albumin

Inherited disorders

Dubin-Johnson syndrome
Rotor's syndrome

Viral serologies


Hepatitis A IgM
Hepatitis B surface antigen and core antibody (IgM)
Hepatitis C RNA


Toxicology screen


Acetaminophen level


Ceruloplasmin (if patient <40 years of age)
ANA, SMA, LKM, SPEP

Hepatitis A IgM
Hepatitis B surface antigen and core antibody (IgM)
Hepatitis C RNA

Acetaminophen level

Results negative

Additional virologic testing

CMV, DNA, EBV capsid antigen
Hepatitis D antibody (if indicated)
Hepatitis E IgM (if indicated)

Results negative

Liver biopsy

Ultrasound

CT/ERCP

Serologic Testing

AMA
Hepatitis serologies
Hepatitis A, CMV, EBV

Review drugs (See Table: 48-3)

MRCP/Liver biopsy

Liver biopsy

End

Isolated elevation of the bilirubin

Bilirubin and other liver tests elevated

Drugs

Rifampicin
Probenecid

Inherited disorders

Gilbert's syndrome
Crigler-Najjar syndromes

Hemolytic disorders
Ineffective erythropoiesis

Dilated ducts
Extrahepatic cholestasis

Ducts not dilated
Intrahepatic cholestasis

Results negative

AMA positive

Indirect hyperbilirubinemia (Direct <15%) (see Table 48-1)

Direct hyperbilirubinemia (Direct >15%) (see Table 48-1)

Hepatocellular pattern: ALT/AST elevated out of proportion to alkaline phosphatase (see Table 48-2)

Cholestatic pattern: Alkaline phosphatase out of proportion ALT/AST (see Table 48-3)