Internal Medicine

0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Cholestasis 307

management

What to Do First

■determine demographics, history and clinical manifestations pro-

vide important clues to a cost-effective diagnostic approach

■obtain tests: CBC, LFTs (including direct/conjugated and indi-

rect/unconjugated bilirubin) and ultrasound; this information leads

to more specific/sensitive diagnostic tests

General Measures

■avoid or discontinue hepatotoxic drugs

■appropriate treatment depends on the underlying cause

■liver transplant evaluation: decompensated chronic cholestatic dis-

orders (PBC and PSC)

specific therapy

■pruritus: oral cholestyramine, antihistamines, opiate antagonists

(naloxone and naltrexone), ursodeoxycholic acid, rifampin and phe-

nobarbitol

■malabsorption: oral supplementation of fat-soluble vitamins; in

severe cases, parenteral injections may be required; medium chain

triglycerides to improve caloric intake

■osteopenia: vitamin D and calcium supplementation, estrogen

replacement, calcitonin and biphosphonates; avoid tobacco use and

corticosteroids

follow-up

n/a

complications and prognosis

Complications

■cirrhosis and liver failure (PBC, PSC); secondary biliary cirrhosis

(extrahepatic biliary obstruction); cholangiocarcinoma (PSC); bil-

iary strictures (PSC); cholangitis (PSC, extrahepatic cholestasis)

Prognosis

■prognosis are excellent with acute cholestatic disorders: postopera-

tive jaundice, cholestasis of pregnancy, benign recurrent intrahep-

atic cholestasis, drug/TPN induced cholestasis

■PBC and PBC can recur in small number (10%) of patients after liver

transplantation