Pruritus cholestasis-associated

Cholestasis-associated pruritus may respond to cholestyramine (Questran, others see Chapter 35), ursodeoxycholic acid (achgall, others see Chapter 37), ondansetron (zofran see Chapter 37), or rifampin (see Chapter 47). Recently, nalmefene (revex) (20 mg twice per day) has been shown to be effective in cholestatic pruritus. 

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... 

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. 

Hepatitis A is caused by a 27-nm RNA picornavirus. It has four capsid proteins (VP 1-4), but only one serotype has been identified. The virus is not cytopathic to hepatoctyes, but causes liver injury by stimulating both cellular and humoral immune responses. Hepatitis A occurs in sporadic and epidemic forms, with an incubation period of 15 to 50 days. The clinical course of acute hepatitis A is usually that of a mild fiulike iUness that lasts for a few days to a few weeks. There is no chronic form of hepatitis A, but cholestasis (manifested by several weeks of jaundice and pruritus) may occur in some adults. Although a rare occurence, relapse in up to 5% of patients has been known to happen 1 to 3 months after the acute illness. It resembles the acute illness and is associated with viremia, hut recovery always ensues. 

Cholangiocarcinoma, or primary carcinoma of the bile ducts, can arise at any point in the biliary tree, including the small intrahepatic bile duct radicals. This lesion is typically associated with underlying liver disease, such as (1) PSC, (2) congenital cystic lesions, or (3) chronic infestation with Clonorchis sinensis. The clinical picture presentation is that of cholestasis, including jaundice, dark urine, tan-colored stool, and pruritus. Differentiation from other cholestatic diseases is made by visualizing the biliary tree. 

Cholestyramine is indicated as adjunctive therapy to diet for the reduction of elevated serum cholesterol in patients with primary hypercholesterolemia (elevated low-density lipoprotein [LDL] cholesterol) who do not respond adequately to diet. Similarly, it is indicated for the relief of pruritus associated with partial biliary obstruction. Cholestyramine is not absorbed but binds to bile acids in the intestine, whereupon it is eliminated. To replenish the lost bile acid, cholesterol is then converted to bile acid, and this lowers the level of cholesterol (see Figure 34). Cholestyramine has also been used in the treatment of cholestasis to control the intense pruritis. It reduces the LDL level in 4 to 7 days, and the maximum effect is seen in 14 days. 

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