Which imaging modalities are most effective in assessing the cause of cholestasis in primary care?

Ultrasound is the most effective and practical initial imaging modality in a primary care setting to assess the cause of cholestasis. It is widely recommended for evaluating suspected gallstone disease and biliary obstruction, which are common causes of cholestasis, due to its accessibility, non-invasiveness, and ability to detect gallstones and bile duct dilation NICE CG188.

Liver function tests combined with ultrasound provide a strong initial assessment approach; abnormal liver function tests alongside ultrasound findings guide further management or referral NICE CG188.

If ultrasound is inconclusive or bile duct stones are suspected but not visualized, magnetic resonance cholangiopancreatography (MRCP) is the next step, offering detailed imaging of the biliary tree without ionizing radiation, though it is typically accessed via secondary care NICE CG188.

Transient elastography or acoustic radiation force impulse imaging may be used to assess liver fibrosis or cirrhosis in patients with chronic liver disease, which can contribute to cholestasis, but these are more specialized and less commonly performed in primary care NICE NG50.

Recent literature supports the use of ultrasound as the first-line imaging for cholestasis and highlights MRCP as the gold standard for detailed biliary imaging when ultrasound is insufficient Khoshpouri et al. 2019Pötter-Lang et al. 2021. Neonatal liver imaging literature also emphasizes ultrasound as the primary modality in early assessment Hadian et al. 2024.