Perplexing Severe Cholestasis in the Postpartum Period

A 36-year-old postpartum woman with prior intrahepatic cholestasis of pregnancy and gallstone pancreatitis presented with right upper quadrant pain, jaundice, and elevated liver enzymes. Initial workup suggested drug-induced liver injury, but laboratory results worsened after antibiotics were discontinued. Imaging and liver biopsies revealed cholestasis and progressive fibrosis. Endoscopic retrograde cholangiopancreatography finally confirmed primary sclerosing cholangitis, though overlap with pregnancy-related liver conditions delayed diagnosis. This case highlights the diagnostic challenges of postpartum cholestasis and illustrates how primary sclerosing cholangitis may emerge in temporal association with pregnancy despite initially nondiagnostic imaging and histology.