A 47-year-old woman was referred to us for follow-up of primary biliary cirrhosis (PBC).1 She reported nausea, malaise, weight loss, and new-onset jaundice. The patient had recently had an episode of melena with anemia requiring blood transfusions, but upper endoscopy and colonoscopy did not reveal a bleeding source. She reported a smoking history of 30 years and was currently smoking. The patient’s family history included rheumatoid arthritis, hyperlipidemia, and cardiovascular disease. Her medical history included fibromyalgia and treated Hashimoto thyroiditis.