Answer 2. E
In a child with cholestasis due to extrahepatic biliary obstruction by gallstones clearly visualized on ultrasound, it is most appropriate to pursue evaluation with ERCP, which not only provides excellent images of the intrahepatic and extrahepatic biliary tree but also allows for endoscopic interventions including stone removal.
CT is useful for 3-dimensional imaging of the hepatobiliary tree but exposes the patient to ionizing radiation and does not offer the therapeutic opportunity that ERCP does. A liver biopsy is useful for evaluation of microscopic hepatic structure and would not be useful for this patient with biliary obstruction of known cause. PTC allows visualization of the biliary tract by transhepatic injection of contrast into the ductal system and is useful especially for visualization of ducts not accessible by ERCP; it does not offer therapeutic intervention as ERCP does. HIDA scan is useful in evaluating infants with cholestatic liver disease or gallbladder structure and function in older individuals.
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