ROSH Gastrointestinal Practice Exam

Which of the following is the most likely diagnosis for a woman with fatigue, pruritus, and elevated alkaline phosphatase levels?

1. Acute pancreatitis

2. Pancreatic cancer

3. Polycythemia vera

4. Primary biliary cholangitis

The correct answer is: Primary biliary cholangitis

The symptoms presented—fatigue, pruritus (itchiness), and elevated alkaline phosphatase levels—are highly indicative of primary biliary cholangitis (PBC). This chronic autoimmune liver disease primarily affects women and is characterized by the progressive destruction of the small bile ducts within the liver, leading to cholestasis and eventually liver damage. Fatigue is a common and often debilitating symptom in PBC, while pruritus results from the accumulation of bile acids in the bloodstream due to impaired bile flow. The elevation of alkaline phosphatase levels in this context reflects cholestasis, which is a hallmark feature of PBC. This enzyme is released when there is an obstruction or impaired flow of bile, which occurs in cholestatic liver diseases. The other options do not align as well with the symptom profile. Acute pancreatitis typically presents with severe abdominal pain and may affect enzyme levels like lipase rather than alkaline phosphatase. Pancreatic cancer may also elevate alkaline phosphatase levels but is more commonly associated with weight loss, jaundice, and abdominal pain. Polycythemia vera primarily presents with increased blood viscosity, headaches, and possibly pruritus due to increased histamine release, but does not characteristically cause elevated