Cholestasis

Clinic

• Cholestasis is a condition where bile cannot flow from the liver to the duodenum.
• Two types
  1. Obstructive type
  2. Metabolic type
• Also there are Extrahepatic or Intrahepatic Cholestasis

Signs / Symptoms

• Abdominal pain, localized in upper right quadrant
• Cholecystitis or choledocholithiasis, which can progress to cholestasis.
• Pruritus or itching that may present with visible scratch marks as a result of scratching.
• Pruritus is often misdiagnosed as a dermatological condition, especially in patients that do not have jaundice as an accompanying symptom.
• In a typical day, pruritus worsens as the day progresses, particularly during the evening time. Overnight, pruritus dramatically improves. This cycle can be attributed to an increase in the concentration of biliary elements during the day due to food consumption, and a decline at night.
• Pruritus is mostly localized to the limbs, but can also be more generalized.

• Many patients may experience jaundice as a result of cholestasis. This is usually evident after physical examination as yellow pigment deposits on the skin, in the oral mucosa, or conjunctiva. Jaundice is an uncommon occurrence in intrahepatic (metabolic) cholestasis, but is common in obstructive cholestasis.
• The majority of patients with chronic cholestasis also experience fatigue. This is likely a result of defects in the corticotrophin hormone axis or other abnormalities with neurotransmission.
• Some patients may also have xanthomas, which are fat deposits that accumulate below the skin. These usually appear waxy and yellow, predominantly around the eyes and joints. This condition results from an accumulation of lipids within the blood.
• If gallstones prevent bile flowing from the pancreas to the small intestine, it can lead to gallstone pancreatitis.
• Physical symptoms include nausea, vomiting, and abdominal pain.
• Bile is required for the absorption of fat-soluble vitamins. As such, patients with cholestasis may present with a deficiency in vitamins A, D, E, or K due to a decline in bile flow. Patients with cholestasis may also experience pale stool and dark urine.

Causes

Common causes:

• Pregnancy
• Androgens
• Abdominal mass (e.g. cancer)
• pediatric liver diseases
• Biliary trauma
• Gallstones
• Biliary dyskinesia
• Acute hepatitis
• Cystic fibrosis

Rare causes

• Primary biliary cholangitis, an autoimmune disorder
• Primary sclerosing cholangitis, associated with IBD
• Secondary syphilis, albeit rarely