The initial assessment of the cholestatic patient is based on the history, physical examination, and standard liver chemistries. Ultrasonography of the liver is an inexpensive, relatively accurate, noninvasive screening test that should be performed if there is any doubt in the initial diagnosis. If dilated bile ducts are present percutaneous transhepatic cholangiography followed by biliary drainage would be the logical course to pursue. However, if ultrasonographic evidence of mechanical obstruction is lacking but clinical suspicion of bile duct obstruction is high, endoscopic retrograde cholangiography with or without a therapeutic maneuver would be indicated. Finally, when mechanical obstruction of the biliary tree has been ruled out, liver biopsy may help resolve the differential diagnosis of the cholestasis.
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