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How Best to Manage Chronic Cholestasis

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How Best to Manage Chronic Cholestasis ONLINE EXCLUSIVE Ignazio Grattagliano, MD; How best to manage Annarosa Floreani, MD; Enzo Ubaldi, MD; Piero Portincasa, MD chronic cholestasis Italian College of General Practitioners and Primary Care, Florence, Italy (Drs. Here’s how to maximize your use of lab work and Grattagliano and Ubaldi); Department of Surgery, imaging techniques to identify the source of your Oncology, and Gastroenterology, University patient’s cholestasis and provide prompt treatment. of Padua, Italy (Dr. Floreani); Section of Internal Medicine, Department of Biomedical Sciences and Human Oncology (DIMO), University of Bari, Italy (Dr. Portincasa) CASE u PRACTICE studiomedico@grattagliano. A 44-year-old nurse describes persistent fatigue and itching over RECOMMENDATIONS it the last 2 months. She is taking ramipril 5 mg/d for hypertension ❯ Suspect intrahepatic The authors reported no and has a family history of rheumatic disease. Lab tests reveal a cholestasis in a patient potential conflict of interest recurrent moderate elevation of gamma glutamyl-transpeptidase relevant to this article. with pruritus, normal transaminases, and mildly (gGT; 75 U/L) associated with, on some occasions, mild elevation elevated gamma glutamyl- of alanine aminotransferase (ALT) levels (100 U/L) of unknown transpeptidase and alkaline origin. She has no history of hepatitis virus infection, hepatotoxic phosphatase levels. A medications, or alcohol intake. She is overweight with a body 2 ❯ Use ultrasonography mass index of 28.5 kg/m and a waist circumference of 99 cm as a first-line diagnostic (39 inches). Liver ultrasonography detects an enlarged liver with tool for cholestasis. A diffuse echostructure dishomogeneity, but no signs of cirrhosis or portal hypertension. The patient’s biliary tree is not dilated. Strength of recommendation (SOR) How would you proceed with the care of this patient? A Good-quality patient-oriented evidence B Inconsistent or limited-quality holestasis is characterized by the alteration of bile flow patient-oriented evidence through any part of the biliary system, from the hepa- C Consensus, usual practice, tocyte basocellular membrane to the duodenum. The opinion, disease-oriented C evidence, case series condition is classified as intrahepatic when the cause is a de- fect of hepatocellular function or obstruction of the biliary tree within the liver. The extrahepatic form includes all conditions obstructing bile flow in the main biliary tract (choledochus, common bile duct). The key to successfully managing cholestasis lies in the early identification of subtle signs and symptoms before serious complications can arise. In the review that follows, we provide guidance for evaluating laboratory and imaging results that are vital to the accurate diagnosis of intrahepatic and extrahepatic cholestasis. We also detail treatment recommendations. Clues—subtle and otherwise— of cholestasis Clinical features of cholestasis include fatigue and itching all over the skin. The latter likely is caused by induction of MDEDGE.COM/JFPONLINE VOL 67, NO 7 | JULY 2018 | THE JOURNAL OF FAMILY PRACTICE E9 TABLE 1 What these serum parameters can tell you8 Alkaline phosphatase (ALP) ALP elevation follows accumulation of bile salts within biliary canalicula with a consequent solubili- zation of the enzyme bound to the canalicular membranes. ALP also is present in other tissues (eg, bone, kidney, gut, placenta), meaning that an isolated increase of ALP could be caused by extrahe- patic conditions. The simultaneous elevation of ALP and gGT (0.5-2.5 times the upper normal limit or 60-300 U/L and 19-95 U/L, respectively) strongly suggests a cholestatic condition. Gamma-glutamyltranspeptidase (gGT) A microsomal enzyme of hepatocytes, gGT is induced by several medications such as barbiturates and cyclosporine, chronic alcohol intake, and cholestasis. An isolated increase of gGT could suggest non- alcoholic fatty liver disease, excessive alcohol intake, or hepatotoxic drug use. Bilirubin Bilirubin is a later indicator of cholestasis. In conditions of biliary obstruction, plasma levels could reach values 30 to 50 times higher than normal levels (≤15 mg/dL). At very high levels (>20 mg/dL), bilirubin is toxic to the blood and brain. Suspect the enzyme autotaxin, which produces the ALP levels appear to be associated with more intrahepatic neuronal activator lysophosphatidic acid. aggressive disease and predict risk of liver cholestasis in Retention of pruritogenic substances that transplantation or death in patients with pri- a patient with normally are excreted into bile might contrib- mary biliary cholangitis (PBC).5,6 Lowering chronic itching, ute to pruritus as well.1 Jaundice, dark urine, ALP levels is associated with improved dis- normal and pale and fatty stools occur with advanced ease outcomes, including transplant-free transaminases, disease. However, a cholestatic condition can survival rates.5,7) and mildly be detected in asymptomatic patients with el- Elevated serum aminotransferase elevated gamma evated biochemical markers. levels (aspartate aminotransferase [AST] glutamyl- ❚ Mildly elevated gGT and/or alkaline >0.5 times the UNL or 17.5 U/L; ALT >0.5 times transpeptidase. phosphatase (ALP) (0.5-2.5 times the up- the UNL or >18 U/L) and bilirubin (>1.1 mg/ per normal limit [UNL] or 19-95 U/L and dL), with predominance of the conjugated 60-300 U/L, respectively2) in the presence of form (TABLE 18), suggest possible cholestasis. normal transaminase levels (<20 U/L) in an In light of such findings, a clinician’s next step asymptomatic patient can indicate chronic should be to distinguish intrahepatic from liver disease. Signs suggestive of significant extrahepatic conditions. (For a detailed list liver disease have been reported in many pa- of the causes of intra- and extrahepatic cho- tients with gGT or ALP elevation with good lestasis, see TABLES 24 and 3.9) sensitivity (65%) and specificity (83%) for a diagnosis of intrahepatic cholestasis.3 How- Patient’s history can provide ever, because abnormal gGT values are com- important clues mon and often resolve spontaneously, family A thorough patient history is especially im- physicians (FPs) may pay little attention to portant when cholestasis is suspected. Details this finding, thus missing an opportunity for about the patient’s occupation, environment, early identification and treatment. and lifestyle are key, as are the specifics of That’s why it’s important to schedule prescribed or over-the-counter medications follow-up testing within 6 months for asymp- and supplements that could be hepatotoxic tomatic patients with abnormal laboratory (TABLE 410). A number of exogenous sub- findings. Persistent elevation of gGT alone or stances can cause liver injury, and the use of accompanied by ALP and ALT elevation (ALT some herbal products (senna, black cohosh, >0.5 times the UNL or >18 U/L) is the most greater celandine, kava) have been linked to common feature of a chronic (>6 months) hepatitis and cholestasis.11 Ask patients about cholestatic condition.4 (In particular, elevated alcohol use and history of conditions associ- E10 THE JOURNAL OF FAMILY PRACTICE | JULY 2018 | VOL 67, NO 7 CHRONIC CHOLESTASIS TABLE 2 TABLE 3 Causes of intrahepatic Causes of extrahepatic cholestasis in adults4 cholestasis in adults9 Hepatocellular causes Intraductal causes Alcoholic and nonalcoholic steatohepatitis Benign obstruction: Post-surgical, post- traumatic, biliary stones Amyloidosis, sarcoidosis Choledocholithiasis Hepatic cirrhosis Infections: Tuberculosis Medications (See TABLE 4) Malignant obstruction: Cholangiocarcinoma, Paraneoplastic syndromes cancer of ampulla of Vater Parenteral nutrition Parasites: Ascaris Secondary cancers Primary sclerosing cholangitis Vascular conditions: Budd-Chiari syndrome, Extraductal causes congestive heart failure Chronic hypertrophic pancreatitis Viral hepatitis with cholestatic features Enlargement of lymph nodes in the hilum Cholangiocyte causes Mirizzi syndrome (biliary stone wedged in the Anatomical alterations: Caroli syndrome cystic duct) Abdominal Cystic fibrosis Pancreatic cancer ultrasonography Graft-versus-host disease Secondary neoplasms from gastrointestinal is a first-line IgG4-associated cholangitis cancers diagnostic tool for cholestasis. Intrahepatic cholestasis during pregnancy Medications ization of an enlarged choledochus (>7 mm) Primary biliary cholangitis or common hepatic duct (>5 mm) and an Primary sclerosing cholangitis intrahepatic bile duct diameter that is more than 40% larger than adjacent branches of Sclerosing cholangitis secondary to infections the portal vein.13 However, ultrasonography (AIDS) or ischemia (vasculitis) has a low diagnostic sensitivity for many con- AIDS, acquired immune deficiency syndrome. ditions (eg, 15% to 89% for detecting common bile duct stones),14 requiring other diagnostic ated with liver disease, such as diabetes, hy- procedures, such as endoscopic retrograde perlipidemia, and thyroid disorders. cholangiopancreatography (ERCP) or mag- netic resonance cholangiopancreatography Indicators pointing to cholestasis? (MRCP), before reaching a diagnosis. It’s time for ultrasonography ❚ For asymptomatic patients with cir- While biopsy is considered the gold standard rhosis or those at an early stage of liver for diagnosing and staging chronic cholestatic disease, ultrasound at 6-month intervals liver disease and can exclude an extrahepatic combined with serum liver function tests can obstruction, it should be employed only if be useful to track
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