Cholestasis pruritus

Treatment of icteric episodes with phenobarbital (3 x 20-60 mg/day) together with phototherapy (430-470 nm, 8-12 hr/day) and/or plasmapheresis is indicated. Cholestyramine (3x4 g/day) or cholestipol (3x5 g/day) may be used to treat pruritus. Qther recommended effective antipruritics are naloxone (2-3 x 0.4 mg/day, i.v.) or naltrexone (2-4 x 25-50 mg/day), which act as opi-oidergic neurotransmitters. (69) It is also possible to use the 5-HT3 antagonist ondansetron (3 x 4.8 mg/day, i.v. or orally). (64) Refractory cholestasis pruritus has recently been treated successfully with dronabinol (50) and also with sertraline. Administration of ursodeoxycholic acid (22, 53), medium-chain fatty acids, PUFA (65) and fat-soluble vitamins (especially vitamin K) is recommended. (s. pp 6, 47) (s. tab. 13.11)... 

Antithyroid drags have several side effects. The most frequent side effects are maculopapular rashes, pruritus, urticaria, fever, arthralgia and swelling of the joints. They occur in 1-5% of patients [1, 2]. Loss of scalp hair, gastrointestinal problems, elevations of bone isoenzyme of alkaline phosphatase and abnormalities of taste and smell are less common. The incidence of all these untoward reactions is similar with MMI and PTU. Side effects of MMI are dose-related, whereas those of PTU are less clearly related to dose [1]. PTU may cause slight transient increases of serum aminotransferase and y-glutamyl transpeptidase concentrations but also severe hq atotoxicity whereas methimazole or carbimazole can be associated with cholestasis. The side... 

Herbal remedies that have been reported to be he-patotoxic include chaparral (Larrea tridentata), germander (Teucrium chamaedrys), and life root (Senecio aureus) [18]. Cases reported patients developing jaundice, fatigue, pruritus, markedly elevated serum liver enzyme levels, severe cholestasis, hepatitis, and hepatocellular injury or necrosis documented by serial liver biopsies [19-21]. Signs and symptoms may occur as early as 3 weeks to as late as 7 months following ingestion [20,21]. 

Prurims is also common in disease which is not primarily dermatological many endocrine diseases can produce pruritus cholestasis is another cause, like kidney- and blood-diseases. Infections and malignant tumours can also give rise to pruritus. 

Jaundice as a result of oral contraceptive treatment has been repeatedly described. Whereas in the Swedish population figures between 1 100 and 1 4000 were published when the early high-dose formulations were still in use (213), the overall incidence was estimated in 1979 at about 1 10 000 (9), and the current incidence is certainly further reduced. When such hepatic symptoms occur, they usually do so within the first month of medication (214), and jaundice may be accompanied by anorexia, malaise, and pruritus. Very few cases arise after the third month of medication and those reported are regarded by some as unlikely to be due to oral contraceptives. Microscopic examination of the liver shows intrahepatic cholestasis. When medication is stopped, symptoms usually disappear rapidly and the reaction does not seem to leave any sequelae (215). Genetic components seem to be important for the development of the reaction women who have experienced jaundice or severe pruritus in late pregnancy seem to be especially susceptible to jaundice or gallbladder disease when using... 

This is an autosomal dominant hereditary disorder characterised by a progressive loss of the bile ducts within the liver and narrowing of the bile ducts outside the liver. It is also associated with congenital heart disease, and in particnlar pulmonary stenosis. Symptoms are related to chronic cholestasis and include jaundice, pruritus, pale loose stools and poor growth within the first three months of life. The majority of children have a benign course and many cases go undetected however, there is an overall mortality of 20-30% due to progressive liver disease with the development of cirrhosis, cardiac disease or intercnrrent infection. 

Patient 1 has been gradually becoming more cholestatic over the last few weeks. Her results suggest that because of the cholestasis the absorption of lipid-soluble drugs and the elimination of biliary cleared drugs may be affected. She has pruritus associated with the cholestasis, so drugs that cause itching are best avoided. 

O Donohue JW, Pereira SP, Ashdown AC, et al. (2005) A controlled trial of ondansetron in the pruritus of cholestasis. Aliment Pharmacol Ther 21 1041-1045. 

As acipimox and niacin are not highly protein bound and are not lipophilic, cholestasis should not affect their disposition. They are largely excreted in the urine. Neither has been reported to cause cholestasis. Both may cause pruritus, from which this patient suffers. 

There is evidence that pre-existing cholestasis increases the risk of jaundice and pruritus with hormonal contraceptives consequently, CHCs and probably POCs would be contraindicated in this patient. 

This chronic cholestatic liver disease affects 1 in 4000 people in the United Kingdom. Pruritus is a common early symptom, and can be helped by colestyramine. Qu-onic cholestasis leads to malabsorption of fat-soluble vitamins, particularly vitamin D, and deficiency of which must be corrected to avoid osteomalacea. 

Fully developed pruritus is found above all in cases of cholestasis and biliary cirrhosis due to CDNC as well as... 

Dysfunction in the metabolism of bile acids (= cholestasis) is often combined with an additional dysfunction in bilirubin metabolism (= jaundice). The rise in bilirubin is the main biochemical and clinical symptom of jaundice it is based on a disorder of bilirubin metabolism. Thus cholestasis is related not directly but indirectly to jaundice. Depending on the constellation of the biochemical and clinical findings, the term jaundice with cholestasis or cholestasis with jaundice can be applied, (s. tabs. 12.1, 12.2, 12.4 13.1) The main clinical sign of advanced cholestasis is pruritus. 

Careful anamnesis (with meticulous precision and detailed detective work) allows important information to be gathered for the distinction between intrahepatic and extrahepatic cholestasis. Questions about medication and hormone intake, chemicals (occupation, hobbies, house and garden), alcohol, teas (containing alkaloids), cosmetics, etc. as well as about fever, arthralgia, pruritus and discolouration of the stools or urine are mandatory in this context, (s. tab. 12.5) (s. p. 76)... 

Pruritus can occur at a very early stage - perhaps as a first sign of a cholestasis that has hitherto gone unnoticed. It is more pronounced at night and in wintertime. With a chronic course of disease, this can become excruciatingly painful and may occasionally culminate in a suicidal tendency on the part of the patient. 

It is justified to assume that cholestatis-related pruritus is caused by substances that are normally excreted in the bile. Nevertheless, it has not been possible to detect a specific causative substance up to now. Under experimental and clinical conditions, raised bile acid levels in the serum or in the skin are found both with and without pruritus - but no adequate correlation could be established. Recent findings point to an increased tonus of the opioid system in the CNS (endorphins) as being of prime importance in the pathogenesis of cholestasis-related pruritus. Endogenous lipophilic bile acids possibly effect the release of hitherto unknown prurito-... 

Pruritus is accompanied by scratch marks (s. pp 85, 232), which the tormented patient inflicts, often with great intensity, on all accessible parts of the body (f as long as it bleeds, it doesn t itch any more ). Fresh scratch marks on the skin alternating with older, blood-encrusted sites are characteristic of the body surface of a patient suffering from chronic cholestasis, such as primary biliary cholangitis, (s. fig. 13.3)... 

Fig. 13.3 Scratch marks resulting from pruritus in recurrent intrahepatic cholestasis...

Bergasa, N.V., Ailing, D.W., Talbot, T.L., Wells, M.C., Jones, E.A. Oral nalmefene therapy reduces scratching activity due to the pruritus of cholestasis a controlled study. J. Amer. Acad. Derm. 1999 41 431 -434... 

Jones, E.A., Neuberger, J., Bergasa, N.V. Opiate antagonist therapy for the pruritus of cholestasis the avoidance of opioid withdrawal-like reactions. Quart. J. Med. 2002 95 547—552... 

Macia, M., Aviles, J., Navarro, J., Morales, S., Garcia, J. Efficacy of molecular adsorbent recirculating system for the treatment of intractable pruritus in cholestasis. Amer. J. Med. 2003 114 62-64... 

Schirrmacher, S., Blnmenstein, I., Stein, J. Pathogenesis and treatment of pruritus in patients with cholestasis (review). Zschr. Gastroenterol. 2003 41 259 -262... 

Terg, R., Coronel, E., Sorda, J., Munoz, A.E., Findor, J. Efficacy and safety of oral naltrexone treatment for pruritus of cholestasis, a cross-ovei double bhnd, placebo-controlled study. J. Hepatol. 2002 37 717-722... 

Yernshalml, B., Sokol, R.J., Narkewicz, M.R., Smith, D., Karrer, F.M. Use of rifampin for severe pruritus in children with chronic cholestasis. J. Pediatr. Gastroenterol. Nutr. 1999 29 442-447... 

Idiopathic childhood ductopenia The same criteria as established by J. Ludwig et al. for ductopenia in adulthood also apply to ductopenia in childhood. There is no clinical or biochemical difference between this form and the one found in infants. Chronic progressive cholestasis can occur in children as well, accompanied by pruritus, and sometimes by jaundice or xanthomas. 

The pharmacological effects and therapeutic uses of SAMe in hepatology are discussed in a detailed review. (169) The impressive outcome of various experiments led to numerous clinical studies, which, however, also included negative results. (165, 169, 174-176) On the whole, there was a significant decrease in bilirubin, bile acids, alkaline phosphatase and transaminases. Pruritus, a frequent symptom in cholestasis, also showed regression. 

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