A 53-year-old woman presents with fatigue and pruritus and an enlarged, non-tender liver. Lab results show alkaline phosphatase markedly elevated and gamma-glutamyltransferase markedly elevated. Which diagnosis best fits these findings?

• A. Alcoholic cirrhosis
• B. Infectious mononucleosis
• C. Intrahepatic cholestasis
• D. Viral hepatitis

Answer: (C)

High alkaline phosphatase with marked GGT points to cholestasis, a disruption of bile flow. When this disruption originates inside the liver, as in intrahepatic cholestasis, bile acids accumulate in the liver and bloodstream, leading to fatigue, an enlarged liver, and intense pruritus from skin deposition of bile acids. The enzyme pattern—predominant rise in cholestatic markers (ALP and GGT)—fits a hepatobiliary source of obstruction rather than pure hepatocellular injury, which would show a different pattern.

Alcoholic cirrhosis often presents with a more mixed enzyme pattern and signs of liver synthetic failure, with less emphasis on marked ALP and GGT elevations. Infectious mononucleosis and viral hepatitis typically produce prominent transaminase (ALT/AST) elevations rather than a dominant cholestatic pattern, and pruritus is less characteristic.