A 49-year-old female is evaluated for fatigue, pruritus, dry eyes, and dry mouth. Her symptoms have been present for about four months and have progressively worsened. She denies any fever, chills, or weight changes. She has hyperlipidemia for which she takes atorvastatin. She has no other medical problems. Her vital signs are normal, and body mass index (BMI) is 24 kg/m2. Her physical exam is notable for excoriations on her arms, legs, chest, and back; otherwise unremarkable. Her alanine transaminase (ALT) is 76 U/L, aspartate aminotransferase (AST): 55 U/L, alkaline phosphatase (ALP): 356 U/L, total bilirubin: 1.3 mg/dL, and direct bilirubin: 0.7 mg/dL Her right-upper-quadrant ultrasound is normal. Which of the following is the most likely diagnosis? The best option is indicated below. Your selections are indicated by the shaded boxes.
A. Cirrhosis
B. Crigler-Najjar syndrome
C. Gilbert syndrome
D. Primary biliary cholangitis (PBC)
E. Wilson disease