Applied Evidence

How best to manage chronic cholestasis

J Fam Pract. 2018 July;67(7):E9-E15

From The Journal of Family Practice | 2018;67(7):E9-E15.

References

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Malnutrition. Many patients with cholestasis are at risk for malnutrition, which can be exacerbated in those with cirrhosis. Causes of malnutrition include poor oral intake, malabsorption, or dental problems that prevent the patient from chewing. Assess the nutritional status of every patient with chronic cholestasis, and stress the importance of multivitamin supplementation to reverse systemic alterations caused by malnutrition.³⁴

When the patient has advanced disease

Despite progress in diagnostic techniques, life expectancy and quality of life for patients with advanced cholestatic conditions remain poor. Patients routinely experience fatigue, pruritus, and complications of cirrhosis including ascites, encephalopathy, and bleeding. Cholestasis also carries the risk of life-threatening complications, partly because of comorbidities such as osteoporosis and malabsorption.

ERCP is widely employed for diagnosing and treating pancreatobiliary diseases; however, its use has dropped over the last 10 years because of the risk of complications.

Liver transplantation can improve the life expectancy of patients with advanced disease, but because of long waiting lists, candidates for transplant often die before an organ becomes available. For many patients who are not in end-stage condition, targeted therapy is crucial to slow disease progression and is recommended along with hepatitis A and B vaccinations and nutritional counseling.³⁵

Extrahepatic cholestasis is suspected? How to proceed

Computer tomography (CT) is recommended for better identification of neoplastic causes of biliary obstruction and for staging purposes. MRCP is an excellent noninvasive imaging technique for evaluating biliary ducts.³⁶

MRCP has 92% to 93% sensitivity and 97% to 98% specificity for diagnosing biliary duct stones.³⁷ MRCP also is the first-choice modality for evaluating bile ducts in patients with suspected PSC. If performed in expert centers, the diagnostic accuracy reaches that of ERCP. A meta-analysis of studies from 2000 to 2006 has shown a sensitivity of 86% and specificity of 94% for diagnosing PSC.³⁸

Endoscopic ultrasonography, which uses an ultrasonographic probe, allows clinicians to evaluate the integrity of the biliary and pancreatic ducts and is effective for diagnosing and staging cancer of the ampulla of Vater (sensitivity 93% vs 7% for abdominal ultrasonography and 29% for CT), and identifying biliary stones and biliary tree strictures.

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