Which procedure is used to evaluate suspected primary sclerosing cholangitis in a patient with ulcerative colitis?

• A. Abdominal ultrasound
• B. MRCP
• C. Colonoscopy
• D. Endoscopic cholangiography

Answer: (D)

In suspected primary sclerosing cholangitis, you want a detailed view of the biliary tree and the ability to obtain tissue or intervene if needed. Endoscopic cholangiography (ERCP with cholangiography) directly images the intrahepatic and extrahepatic ducts, revealing the multifocal strictures and the characteristic beading pattern of PSC. It also allows brushing of the ducts for cytology or biopsies when there’s a suspicion of cholangiocarcinoma, and it enables therapeutic interventions like dilation of dominant strictures or stent placement if needed.

While MRCP is a noninvasive imaging option that can show ductal abnormalities, it does not provide tissue samples and cannot be used for definitive therapeutic management. In a patient with ulcerative colitis and suspected PSC, endoscopic cholangiography offers the most actionable information and potential treatment during the same procedure, making it the best choice in this context.