Applied Evidence

How best to manage chronic cholestasis

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


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. ERCP is nearly exclusively used as a therapeutic procedure for pancreatic sphincterotomy, biliary dilatations, and removing biliary stones. It also has a diagnostic role in dominant stenosis or suspected biliary malignancy using brushing cytology and sampling biopsies of the bile ducts.

Treating extrahepatic cholestasis

Treatment of the different underlying conditions that cause extrahepatic cholestasis is surgical. Thus, the potential surgical techniques that can resolve or improve an extrahepatic cholestatic condition are guided by the surgeon and beyond the scope of this article.

Treating osteopenia: A concern for intra- and extrahepatic cholestasis

Vitamin D deficiency as a consequence of reduced intestinal absorption (poor availability of bile salts) or decreased hepatic activation to 25,OH-cholecalcipherol in both intrahepatic and extrahepatic cholestasis can lead to reduced bone formation.39 However, osteopenia can occur even in early stages of the disease. Prescribing bisphosphonates, in combination with calcium and vitamin D3, to improve bone mineral density is a good practice.40


Blood tests and ultrasound imaging suggest the presence of a chronic liver disease. Other lab tests indicate that the patient has an ALP level 3 times normal. This finding, together with the other tests, points to a likely diagnosis of intrahepatic cholestatic liver disease. Serology confirms positivity for ANA (1:160) and AMA (1:640). The clinician suspects PBC, so the patient is referred to a liver specialist for further evaluation and to determine whether a liver biopsy is needed.

The liver specialist confirms the diagnosis of PBC, performs a transient elastographym, which indicates a low-grade liver fibrosis (F1 out of 4), and starts therapy with UDCA.

Ignazio Grattagliano, MD, Italian College of General Practitioners and Primary Care, Via del Sansovino 179, 50142, Florence, Italy;

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