The Diagnostic Pathway for Patients with Cholestatic Liver Disease

Cholestatic liver diseases comprise a heterogeneous group of disorders characterized by impaired bile formation or flow. We outline an initial assessment anchored in clinical context and biochemical cholestasis, followed by first-line imaging with abdominal ultrasound to exclude dilatation and structural lesions. We then detail targeted second-line testing based on pretest probability: autoantibody profiling, serum immunoglobulin G4 and cholangiographic evaluation with MRCP; ERCP is reserved for therapeutic or equivocal scenarios. We define the refined role of liver biopsy-when serology is negative, overlap is suspected, imaging is indeterminate, or alternative diagnoses remain plausible-and summarize indications for genetic testing in early-onset or syndromic presentations.