{"id":11000,"date":"2026-09-02T00:05:27","date_gmt":"2026-09-02T08:05:27","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=11000"},"modified":"2026-08-12T14:40:15","modified_gmt":"2026-08-12T22:40:15","slug":"usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase","title":{"rendered":"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Elevated alkaline phosphatase"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_86 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 2 CK Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-elevated-alkaline-phosphatase\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Today\u2019s USMLE\u00ae Step 2 CK question of the day features a 38 -year-old woman coming in for a follow up appointment due to an <strong>elevated\u00a0alkaline\u00a0phosphatase<\/strong>\u00a0level. What\u2019s underlying condition is she experiencing and what are the next, best next steps? Let\u2019s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A&nbsp;38-year-old&nbsp;woman&nbsp;comes&nbsp;to&nbsp;the&nbsp;clinic&nbsp;for&nbsp;a&nbsp;follow&nbsp;up.&nbsp;At&nbsp;her&nbsp;initial&nbsp;visit&nbsp;a&nbsp;week&nbsp;ago,&nbsp;routine&nbsp;labs&nbsp;were&nbsp;ordered&nbsp;which&nbsp;revealed&nbsp;an&nbsp;<strong>elevated&nbsp;alkaline&nbsp;phosphatase<\/strong>&nbsp;level,&nbsp;which&nbsp;was&nbsp;then&nbsp;<strong>confirmed&nbsp;with&nbsp;repeat&nbsp;testing<\/strong>.&nbsp;Review&nbsp;of&nbsp;systems&nbsp;is&nbsp;significant&nbsp;for&nbsp;<strong>mild&nbsp;pruritus<\/strong>.&nbsp;She&nbsp;has&nbsp;no&nbsp;family&nbsp;history&nbsp;of&nbsp;liver&nbsp;disease.&nbsp;Past&nbsp;medical&nbsp;history&nbsp;is&nbsp;noncontributory.&nbsp;Vitals&nbsp;are&nbsp;within&nbsp;normal&nbsp;limits.&nbsp;Physical&nbsp;examination&nbsp;is&nbsp;unremarkable.&nbsp;Laboratory&nbsp;findings&nbsp;are&nbsp;shown&nbsp;below.&nbsp;<strong>Right&nbsp;upper&nbsp;quadrant&nbsp;ultrasound<\/strong>&nbsp;shows&nbsp;a&nbsp;<strong>normal&nbsp;appearing&nbsp;gallbladder&nbsp;and&nbsp;biliary&nbsp;tract<\/strong>.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory&nbsp;value<\/strong>&nbsp;<\/td><td><strong>Result<\/strong>&nbsp;<\/td><\/tr><tr><td colspan=\"2\"><strong>Complete&nbsp;Blood&nbsp;Count<\/strong>&nbsp;<\/td><\/tr><tr><td>Hemoglobin&nbsp;<\/td><td>13.5&nbsp;g\/dL&nbsp;<\/td><\/tr><tr><td>Leukocyte&nbsp;count&nbsp;<\/td><td>5500\/mm<sup>3<\/sup>&nbsp;<\/td><\/tr><tr><td>Platelet&nbsp;Count&nbsp;<\/td><td>200,000\/mm<sup>3<\/sup>&nbsp;<\/td><\/tr><tr><td colspan=\"2\"><strong>Serum&nbsp;Chemistry<\/strong>&nbsp;<\/td><\/tr><tr><td>Sodium&nbsp;&nbsp;<\/td><td>142&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Potassium&nbsp;&nbsp;<\/td><td>4.2&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Chloride&nbsp;<\/td><td>95&nbsp;mEq\/L&nbsp;<\/td><\/tr><tr><td>Creatinine&nbsp;&nbsp;<\/td><td>1.2&nbsp;mg\/dL&nbsp;<\/td><\/tr><tr><td>Alanine&nbsp;aminotransferase&nbsp;<\/td><td>20&nbsp;U\/L&nbsp;<\/td><\/tr><tr><td>Aspartate&nbsp;aminotransferase&nbsp;<\/td><td>21&nbsp;U\/L&nbsp;<\/td><\/tr><tr><td>Serum&nbsp;albumin&nbsp;<\/td><td>4&nbsp;g\/dL&nbsp;<\/td><\/tr><tr><td>Serum&nbsp;total&nbsp;bilirubin&nbsp;<\/td><td>0.8&nbsp;mg\/dL&nbsp;<\/td><\/tr><tr><td>Total&nbsp;protein&nbsp;<\/td><td>6&nbsp;g\/dL&nbsp;<\/td><\/tr><tr><td>Alkaline&nbsp;phosphatase&nbsp;level&nbsp;&nbsp;<\/td><td>220&nbsp;U\/L&nbsp;<\/td><\/tr><tr><td>Antimitochondrial&nbsp;antibodies&nbsp;(AMA)&nbsp;<\/td><td>positive&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Fatigue<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Cold intolerance<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Edema<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Epigastric pain radiating to the back<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Exertional chest pain<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 2 CK Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Fatigue<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct<\/strong>: See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Cold&nbsp;intolerance&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect<\/strong>:&nbsp;Cold&nbsp;intolerance&nbsp;is&nbsp;typically&nbsp;associated&nbsp;with&nbsp;<strong>hypothyroidism<\/strong>.&nbsp;While&nbsp;liver&nbsp;diseases&nbsp;can&nbsp;affect&nbsp;overall&nbsp;metabolism,&nbsp;cold&nbsp;intolerance&nbsp;is&nbsp;not&nbsp;a&nbsp;symptom&nbsp;of&nbsp;PBC.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Edema<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect<\/strong>:&nbsp;Edema&nbsp;may&nbsp;be&nbsp;a&nbsp;sign&nbsp;of&nbsp;<strong>late-stage&nbsp;liver&nbsp;disease<\/strong>&nbsp;and&nbsp;<strong>cirrhosis&nbsp;<\/strong>in&nbsp;PBC;&nbsp;however,&nbsp;this&nbsp;patient&nbsp;has&nbsp;only&nbsp;mild&nbsp;symptoms&nbsp;and&nbsp;lab&nbsp;work&nbsp;shows&nbsp;no&nbsp;evidence&nbsp;of&nbsp;significant&nbsp;liver&nbsp;damage,&nbsp;therefore&nbsp;she&nbsp;most&nbsp;likely&nbsp;has&nbsp;early-stage&nbsp;disease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Epigastric&nbsp;pain&nbsp;radiating&nbsp;to&nbsp;the&nbsp;back&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect<\/strong>:&nbsp;This&nbsp;type&nbsp;of&nbsp;pain&nbsp;is&nbsp;more&nbsp;indicative&nbsp;of&nbsp;gastrointestinal&nbsp;conditions&nbsp;like&nbsp;<strong>pancreatitis&nbsp;<\/strong>or&nbsp;<strong>peptic&nbsp;ulcer&nbsp;disease<\/strong>.&nbsp;PBC&nbsp;primarily&nbsp;affects&nbsp;the&nbsp;liver&nbsp;and&nbsp;does&nbsp;not&nbsp;typically&nbsp;cause&nbsp;this&nbsp;specific&nbsp;pattern&nbsp;of&nbsp;abdominal&nbsp;pain,&nbsp;although&nbsp;some&nbsp;patients&nbsp;may&nbsp;experience&nbsp;intermittent&nbsp;right&nbsp;upper&nbsp;quadrant&nbsp;abdominal&nbsp;pain.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">E.&nbsp;Exertional&nbsp;chest&nbsp;pain&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect<\/strong>:&nbsp;Exertional&nbsp;chest&nbsp;pain&nbsp;is&nbsp;commonly&nbsp;associated&nbsp;with&nbsp;<strong>cardiac&nbsp;conditions<\/strong>,&nbsp;such&nbsp;as&nbsp;<strong>angina&nbsp;pectoris<\/strong>,&nbsp;resulting&nbsp;from&nbsp;reduced&nbsp;blood&nbsp;flow&nbsp;to&nbsp;the&nbsp;myocardium.&nbsp;It&nbsp;is&nbsp;not&nbsp;a&nbsp;symptom&nbsp;typically&nbsp;associated&nbsp;with&nbsp;PBC,&nbsp;which&nbsp;primarily&nbsp;involves&nbsp;the&nbsp;liver&nbsp;and&nbsp;biliary&nbsp;tract.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"478\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_680d12.png\" alt=\"Osmosis.org educational illustration showing clinical features that may suggest primary biliary cholangitis (PBC) or primary sclerosing cholangitis (PSC) and prompt a focused history and physical examination. Key findings include fatigue, pruritus, right upper quadrant abdominal pain, and a history of autoimmune conditions such as inflammatory bowel disease or Sj\u00f6gren syndrome.\" class=\"wp-image-11003\" style=\"aspect-ratio:2.0397737507655727;width:381px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_680d12.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_680d12.png?resize=300,147 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_680d12.png?resize=768,377 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This&nbsp;patient&nbsp;who&nbsp;presents&nbsp;with&nbsp;an&nbsp;<strong>elevated&nbsp;alkaline&nbsp;phosphatase<\/strong>&nbsp;level&nbsp;and&nbsp;<strong>mild&nbsp;pruritus<\/strong>&nbsp;likely&nbsp;has&nbsp;<strong>cholestasis<\/strong>.&nbsp;Given&nbsp;normal&nbsp;ultrasound,&nbsp;the&nbsp;biliary&nbsp;obstruction&nbsp;is&nbsp;likely&nbsp;to&nbsp;be&nbsp;intrahepatic,&nbsp;making&nbsp;<strong>primary&nbsp;biliary&nbsp;cholangitis&nbsp;(PBC)<\/strong>&nbsp;likely.&nbsp;Patients&nbsp;with&nbsp;PBC&nbsp;can&nbsp;be&nbsp;<strong>asymptomatic<\/strong>,&nbsp;or&nbsp;they&nbsp;may&nbsp;present&nbsp;with&nbsp;<strong>fatigue<\/strong>,&nbsp;<strong>pruritus<\/strong>,&nbsp;and&nbsp;<strong>right&nbsp;upper&nbsp;quadrant&nbsp;pain<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">PBC&nbsp;is&nbsp;an&nbsp;<strong>autoimmune&nbsp;disorder<\/strong>&nbsp;that&nbsp;affects&nbsp;the&nbsp;small&nbsp;and&nbsp;medium&nbsp;intrahepatic&nbsp;bile&nbsp;ducts.&nbsp;<strong>Autoimmune&nbsp;destruction&nbsp;of&nbsp;intrahepatic&nbsp;bile&nbsp;ducts<\/strong>&nbsp;leads&nbsp;to&nbsp;<strong>cholestasis<\/strong>.&nbsp;PBC&nbsp;is&nbsp;more&nbsp;prevalent&nbsp;in&nbsp;women,&nbsp;with&nbsp;a&nbsp;female-to-male&nbsp;ratio&nbsp;of&nbsp;9:1.&nbsp;While&nbsp;it&nbsp;is&nbsp;often&nbsp;asymptomatic,&nbsp;patients&nbsp;can&nbsp;present&nbsp;with&nbsp;fatigue&nbsp;and&nbsp;pruritus.&nbsp;<strong>Fatigue<\/strong>&nbsp;is&nbsp;one&nbsp;of&nbsp;the&nbsp;<strong>most&nbsp;common&nbsp;early&nbsp;symptoms<\/strong>&nbsp;of&nbsp;the&nbsp;disease.&nbsp;As&nbsp;the&nbsp;disease&nbsp;progresses,&nbsp;patients&nbsp;may&nbsp;experience&nbsp;<strong>pruritus<\/strong>,&nbsp;which&nbsp;is&nbsp;due&nbsp;to&nbsp;the&nbsp;accumulation&nbsp;of&nbsp;<strong>bile&nbsp;salts<\/strong>&nbsp;in&nbsp;the&nbsp;skin.&nbsp;Studies&nbsp;have&nbsp;recently&nbsp;shown&nbsp;that&nbsp;the&nbsp;fatigue&nbsp;seems&nbsp;to&nbsp;stem&nbsp;from&nbsp;muscle&nbsp;mitochondrial&nbsp;dysfunction,&nbsp;due&nbsp;to&nbsp;the&nbsp;autoimmune&nbsp;destruction&nbsp;of&nbsp;mitochondria&nbsp;that&nbsp;characterizes&nbsp;the&nbsp;condition.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Physical&nbsp;examination&nbsp;findings&nbsp;in&nbsp;the&nbsp;early&nbsp;stages&nbsp;of&nbsp;PBC&nbsp;may&nbsp;be&nbsp;unremarkable,&nbsp;but&nbsp;as&nbsp;the&nbsp;disease&nbsp;progresses,&nbsp;<strong>signs&nbsp;of&nbsp;chronic&nbsp;liver&nbsp;disease<\/strong>,&nbsp;such&nbsp;as&nbsp;<strong>jaundice&nbsp;<\/strong>(yellowing&nbsp;of&nbsp;the&nbsp;skin&nbsp;and&nbsp;eyes)&nbsp;and&nbsp;<strong>hepatomegaly&nbsp;<\/strong>may&nbsp;be&nbsp;seen.&nbsp;In&nbsp;later&nbsp;stages,&nbsp;patients&nbsp;can&nbsp;have&nbsp;signs&nbsp;of&nbsp;<strong>liver&nbsp;cirrhosis<\/strong>&nbsp;like&nbsp;ascites&nbsp;and&nbsp;spider&nbsp;angiomata&nbsp;(small,&nbsp;spider-like&nbsp;blood&nbsp;vessels&nbsp;on&nbsp;the&nbsp;skin).&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Typically,&nbsp;<strong>alkaline&nbsp;phosphatase<\/strong>&nbsp;levels&nbsp;are&nbsp;elevated&nbsp;in&nbsp;PBC.&nbsp;If&nbsp;they&nbsp;exceed&nbsp;1.5&nbsp;times&nbsp;the&nbsp;upper&nbsp;limit&nbsp;of&nbsp;normal,&nbsp;a&nbsp;positive&nbsp;<strong>antimitochondrial&nbsp;antibody&nbsp;(AMA)<\/strong>&nbsp;test&nbsp;result&nbsp;can&nbsp;establish&nbsp;the&nbsp;diagnosis&nbsp;without&nbsp;the&nbsp;need&nbsp;for&nbsp;a&nbsp;liver&nbsp;biopsy.&nbsp;The&nbsp;primary&nbsp;treatment&nbsp;for&nbsp;PBC&nbsp;is&nbsp;<strong>ursodeoxycholic&nbsp;acid<\/strong>,&nbsp;which&nbsp;is&nbsp;associated&nbsp;with&nbsp;histologic&nbsp;improvement,&nbsp;increased&nbsp;survival&nbsp;rates,&nbsp;and&nbsp;reduced&nbsp;reliance&nbsp;on&nbsp;liver&nbsp;transplantation.<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"731\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_725e0e.png\" alt=\"Osmosis.org educational table summarizing primary biliary cholangitis (PBC). It describes autoimmune destruction of the intrahepatic bile ducts leading to cholestasis, common clinical features such as fatigue and pruritus, characteristic laboratory findings including elevated alkaline phosphatase and antimitochondrial antibodies, treatment with ursodeoxycholic acid or liver transplantation in advanced disease, and complications including cirrhosis, portal hypertension, hepatocellular carcinoma, vitamin deficiencies, and bone disease.\" class=\"wp-image-11004\" style=\"aspect-ratio:1.3337887818323164;width:607px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_725e0e.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_725e0e.png?resize=300,225 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_725e0e.png?resize=768,576 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Patients&nbsp;with&nbsp;<strong>primary&nbsp;biliary&nbsp;cholangitis&nbsp;(PBC)<\/strong>&nbsp;are<strong>&nbsp;<\/strong>often&nbsp;<strong>asymptomatic&nbsp;<\/strong>in&nbsp;early&nbsp;disease,&nbsp;or&nbsp;they&nbsp;may&nbsp;present&nbsp;with&nbsp;<strong>pruritus&nbsp;<\/strong>and&nbsp;<strong>fatigue<\/strong>.&nbsp;In&nbsp;later&nbsp;stages,&nbsp;they&nbsp;may&nbsp;present&nbsp;with&nbsp;<strong>jaundice&nbsp;<\/strong>and&nbsp;<strong>hepatomegaly&nbsp;<\/strong>and&nbsp;eventually&nbsp;with&nbsp;signs&nbsp;and&nbsp;symptoms&nbsp;of&nbsp;<strong>cirrhosis<\/strong>.<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:<\/strong> <a href=\"https:\/\/www.osmosis.org\/learn\/Primary_biliary_cholangitis_and_primary_sclerosing_cholangitis:_Clinical_sciences\">Primary biliary cholangitis and primary sclerosing cholangitis: Clinical sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Lleo,&nbsp;A.,&nbsp;Wang,&nbsp;G.&nbsp;Q.,&nbsp;Gershwin,&nbsp;M.&nbsp;E.,&nbsp;&amp;&nbsp;Hirschfield,&nbsp;G.&nbsp;M.&nbsp;(2020).&nbsp;<strong>Primary&nbsp;biliary&nbsp;cholangitis<\/strong>.&nbsp;<em>The&nbsp;Lancet<\/em>,&nbsp;<em>396<\/em>(10266),&nbsp;1915-1926.&nbsp;<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em><strong>Get your&nbsp;<em><a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\">f<\/a><a href=\"http:\/\/osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\">ree trial<\/a><\/em>&nbsp;of Osmosis from Elsevier today to discover why millions of clinicians and caregivers love learning by Osmosis.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A patient presents with persistent abnormal liver testing and mild pruritus despite normal biliary imaging. Can you identify the additional finding most consistent with the underlying condition?<\/p>\n","protected":false},"author":208,"featured_media":11005,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,10,20,16,1366,1370,45],"tags":[3360,1239,3362,2967,3361,489,3108,3195,3200,3177,785,3359,84,462,952],"class_list":["post-11000","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-clinical-skills","category-exam-prep","category-do","category-questions","category-step-2-questions","category-step-2","tag-alkaline-phosphatase","tag-autoimmune-disease","tag-biliary-disorders","tag-board-exam-prep","tag-cholestasis","tag-clinical-reasoning","tag-clinical-vignette","tag-gastroenterology","tag-hepatology","tag-internal-medicine","tag-liver-disease","tag-liver-function-tests","tag-medical-education","tag-osmosis","tag-usmle-step-2-ck"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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