1. Cholestatic Pruritis
Ahmad Abid Abas 07-5-2
http://emedicine.medscape.com/article/1098029-overview#a0104
2. Pathophysiology
• Deposition of bile salts into the skin..?
• Indirect hyperbilirubinemia ..?
• Elevated venous histamine levels.
• Retention of pruritogenic intermediates in bile
salt synthesis.
• High hepatic concentrations of bile salts
resulting in hepatic injury (somewhat proven)
3. Pathophysiology
• Accumulation of endogenous opioids
modulate pruritis increase opiodergic tone
in the brain. (recent interest)
• Perhaps combination of the pruritogenic
substances ( bile salts,histamine,opioids)
induces cholestatic pruritis.
4. Etiology of Cholestatic Pruritis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Chronic hepatitis C
Choledocholithiasis
Obstructive carcinoma of the pancreas/biliary
system
Cholestasis of pregnancy
End-stage liver disease of any cause.
5. Presentation
• Characterized by an intermittent, mild, and
insidious onset that may be generalized or
localized pruritis.
• Site - typically worse on the hands and feet
and in areas under tight-fitting clothing.
• Associated fatigue in PBC.
• Associated IBD in PSC.
6. Presentation
• Signs of liver disease include jaundice, spider
angiomata, Dupuytren contractures, white
nails, gynecomastia in men, xanthelasma,
splenomegaly, and ascites.
8. Pathophysiology
• Theory still controversial.
• Iron deficiency hasn’t proved to be the cause of pruritis.
The variety of metabolic paths did.
• Patient with pruritis and iron deficiency doesn’t show
anemia sometimes.This is a prove that pruritus is
related to iron not hemoglobin.
• Iron deficiency induced-pruritis responds to iron
supplementation.
9. Presentation
• Generalized pruritis; however, it may be
localized, especially to the perianal and vulvar
regions.
• Patients with iron deficiency may have pallor
if they have anemia; they might also have
glossitis and angular cheilitis.
