Makindo Medical Notes

Amoxicillin clavulanate is an important cause of cholestatic jaundice. If cholestatic jaundice develops with Co-Amoxiclav then it should be withdrawn, and the combination avoided in future

Aetiology

• Intrahepatic - liver Parenchymal disease like hepatitis, cirrhosis, or drug-induced liver injury.
• Extrahepatic - obstruction distal to bile canaliculi and issues outside the liver, usually due to blockages in the bile ducts from gallstones, tumours, or strictures.

Intrahepatic Causes:

• Viral Hepatitis: Hepatitis A, B, C, and E can cause liver inflammation, leading to cholestasis.
• Alcoholic Liver Disease: Chronic alcohol abuse can cause liver damage, leading to impaired bile flow.
• Primary Biliary Cholangitis (PBC): An autoimmune disorder that leads to the destruction of bile ducts within the liver.
• Primary Sclerosing Cholangitis (PSC): A chronic liver disease characterized by inflammation and scarring of the bile ducts.
• Drug-Induced Liver Injury: Certain medications, such as antibiotics, anabolic steroids, and oral contraceptives, can cause cholestasis.
• Pregnancy: Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that occurs during pregnancy, leading to impaired bile flow.

Extrahepatic Causes:

• Gallstones: Stones in the bile ducts can block the flow of bile, leading to cholestasis.
• Tumours: Tumours in the pancreas or bile ducts can obstruct the flow of bile.
• Bile Duct Strictures: Narrowing of the bile ducts due to surgery, injury, or inflammation can cause obstruction.
• Pancreatitis: Inflammation of the pancreas can lead to compression of the bile ducts.

Clinical

• Jaundice: Yellowing of the skin and eyes, the most recognizable symptom.
• Dark Urine: Due to the increased excretion of bilirubin by the kidneys.
• Pale Stools: Because bilirubin is not reaching the intestines, where it normally contributes to the brown colour of stool.
• Itching (Pruritus): A common symptom in cholestasis, often due to bile salts depositing in the skin.
• Fatigue: Generalized tiredness and weakness.
• Abdominal Pain: Particularly in the right upper quadrant, where the liver and gallbladder are located.
• Nausea and Vomiting: These gastrointestinal symptoms may accompany the condition.
• Weight Loss: Unintentional weight loss can occur, especially if the underlying cause is chronic.

Investigations

• Bloods U&E, FBC, LFT's. Elevated ALP, GGT, and Bilirubin are to be expected. Raised ALT suggests localized inflammation.
• Screen: Screen for HAV and HBV. Consider EBV, CMV, Copper studies, and Ferritin.
• USS: USS Liver and Biliary system - shows obstruction; if there is dilation of the common bile duct.
• ERCP: If there is a common bile duct stone, a sphincterotomy may be performed to release it.
• MRCP: MRCP may be considered and has largely replaced ERCP as a diagnostic test.
• Prolonged PT: Prolonged PT may suggest Vitamin K malabsorption.
• Serum autoantibodies: Serum autoantibodies for autoimmune diseases.
• Liver Biopsy: In cases where intrahepatic causes are suspected, a liver biopsy may be performed to assess the extent of liver damage.

Management of Intrahepatic Cholestasis:

• Medications: Ursodeoxycholic acid (UDCA) is often used to improve bile flow in conditions like PBC and PSC.
• Corticosteroids: Used in cases of autoimmune hepatitis.
• Avoidance of Hepatotoxic Drugs: Discontinuing medications that may cause liver damage.
• Management of Underlying Liver Disease: Treating the specific liver condition causing the cholestasis.

Management of Extrahepatic Cholestasis:

• Surgical Intervention: Removal of gallstones, tumours, or strictures causing bile duct obstruction.
• Endoscopic Procedures: ERCP + stent or sphincterotomy can be used to remove blockages in the bile ducts or place stents to keep the ducts open.
• Management of Pancreatitis: Treatment of underlying pancreatitis if it is causing bile duct compression.