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Akinsanya A, González IA. Liver manifestation of patients with celiac disease: A single center experience. Ann Diagn Pathol 2024; 71:152327. [PMID: 38754356 DOI: 10.1016/j.anndiagpath.2024.152327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Characterize the clinicopathologic features of liver biopsies from patients with celiac disease (CD). METHODS Single center, retrospective search for liver biopsies from patients with CD. RESULTS 36 unique patients were included, median age of 46 years (range: 2-75), including 5 pediatric patients, with an overall female predominance (25, 69 %) but in in children a male predominance was seen (p = 0.023). Most cases (75 %) had an underlying condition including autoimmune hepatitis (AIH) (11 %), AIH/primary biliary cholangitis (PBC) overlap (3 %) and PBC (3 %). The median body mass index was 28, with 4 (11 %) underweight and 22 (61 %) overweight/obese patients. The most common histologic pattern was steatosis (18, 50 %), considered severe in 5 (14 %) and in 7 (19 %) regarded as steatohepatitis. The other histologic patterns included a nonspecific portal and/or lobular inflammation ("celiac hepatitis") in 9 cases (25 %), autoimmune hepatitis (3, 8 %), chronic cholestatic pattern (3, 8 %), chronic hepatitis (1, 3 %), acute lobular hepatitis (1, 3 %) and stablished cirrhosis (1, 3 %). Additionally, 2 of the cases with steatosis show cirrhosis. CONCLUSIONS The biopsy findings from patients with CD are heterogenous and in most represent a concomitant underlying disease, particularly metabolic dysfunction-associated steatotic liver disease. Additionally, CD injury should remain in the differential diagnosis in liver biopsies with a nonspecific portal and/or lobular inflammation.
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Affiliation(s)
- Adeyinka Akinsanya
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Iván A González
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America.
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2
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Late-Onset Acute Liver Injury From Azathioprine. ACG Case Rep J 2022; 9:e00847. [PMID: 36134121 PMCID: PMC9485461 DOI: 10.14309/crj.0000000000000847] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/13/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
Azathioprine is a widely prescribed immunosuppressant. Although hepatotoxicity is rare, it commonly presents as mild asymptomatic liver enzyme elevation or acute cholestatic liver injury. We report a case of a 46-year-old woman who presented with jaundice, abdominal pain, fatigue, and elevated aminotransferases in a cholestatic pattern. Endoscopic retrograde cholangiopancreatogram demonstrated no abnormalities, and recently started medications were discontinued without improvement. Liver biopsy was performed, which was consistent with drug-induced liver injury. Despite multiple years of treatment without issue, after azathioprine was discontinued, symptoms and laboratory abnormalities resolved. This case highlights azathioprine's potential for hepatotoxicity even multiple years after initiation.
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Faragalla K, Lau H, Wang HL, Liu J. Cloxacillin-induced acute vanishing bile duct syndrome: a case study and literature review. Br J Clin Pharmacol 2022; 88:4633-4638. [PMID: 35730139 DOI: 10.1111/bcp.15445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/14/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
Ductopenia is often regarded as a chronic process where ≥50% of portal tracts lack bile ducts, which is also known as vanishing bile duct syndrome (VBDS). One etiology is drug-induced liver injury. Cloxacillin, an anti-staphylococcal penicillin, typically causes "bland" cholestasis. We present the first case of cloxacillin-induced acute ductopenia or VBDS and a review of published cloxacillin-induced liver injuries. A 66-year-old woman with no prior liver disease, but known penicillin allergy, was treated for post-carotid angioplasty staphylococcal infection with 6 weeks of cloxacillin. She presented with a two-week history of weakness and jaundice. Laboratory work-up showed elevated liver enzymes with a cholestatic pattern, hyperbilirubinemia, and eosinophilia. She required ICU transfer for hypotension and was started empirically on prednisone. Liver biopsy revealed severe centrilobular cholestasis, mild necroinflammation, and ductopenia with epithelial injury, but no ductular reaction. Two-month later, she was discharged on hydrocortisone and ursodiol with persistently elevated alkaline phosphatase and bilirubin. She was considered for liver transplantation but died of liver failure four months later. Four additional articles were found with histopathologic descriptions of cloxacillin-related liver injury. These included portal inflammation, cholestasis and mild necroinflammation. Clinical features were reported in two cases; both had mild symptoms with cholestatic liver enzymes and hyperbilirubinemia. Both patients recovered completely within 10-60 days. Cloxacillin-induced cholestasis can be secondary to acute ductopenia, which can result in worse clinical outcomes than previously described "bland" cholestasis. Liver biopsy is recommended to identify cases with acute VBDS.
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Affiliation(s)
| | - Helena Lau
- Gastroenterology, Halton Healthcare, Oakville, ON, Canada
| | - Hanlin L Wang
- Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Jimin Liu
- Laboratory Medicine, Halton Healthcare, Oakville, ON, Canada.,Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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4
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Abstract
Vanishing bile duct syndrome (VBDS) refers to a form of cholestatic liver disease with many etiologies. Vanishing bile duct syndrome is characterized by biliary ductopenia and chronic cholestasis. This is a challenging condition for clinicians because of its rarity and unclear pathophysiology. Presented is an 18-year-old woman who developed cholestatic liver injury and intrahepatic biliary ductopenia after a course of oral contraceptives and intravenous estrogen for uterine bleeding. A year later, this patient did not have significant improvement in liver biomarkers and was referred for transplantation.
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5
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Björnsson ES, Andrade RJ. Long-term sequelae of drug-induced liver injury. J Hepatol 2022; 76:435-445. [PMID: 34688732 DOI: 10.1016/j.jhep.2021.10.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) has a very variable clinical and biochemical phenotype and differs widely in severity, from mild injury to life-threatening liver failure. Chronic injury has also been reported to occur at a variable frequency, ranging from 3.4% to 39%, 6-12 months after discontinuing the implicated agent. This wide range is probably related to various definitions of chronic liver injury and variable selection of patients. The long-term sequalae of this chronic injury in terms of morbidity and mortality are unclear, although rare vanishing bile duct syndrome is associated with an unfavourable prognosis, with increased risk of chronic liver failure and need for liver transplantation. Other forms of long-term sequalae associated with DILI are progressive fibrosis, autoimmune-like hepatitis, secondary sclerosing cholangitis, sinusoidal obstruction syndrome and, as a common final stage, the development of cirrhosis, portal hypertension and its complications. Immune checkpoint inhibitors, which can cause an autoimmune-like phenotype have also recently been shown to cause sclerosing cholangitis with cytotoxic T CD8+ cell infiltration in biliary tracts. DILI has been shown to have a significant impact on health-related quality of life but very little is known about its psychological consequences in the long-term. Further investigations with structured long-term follow-up and periodic quality of life surveys are needed to assess the impact of DILI on psychological outcomes, particularly in those with chronic sequelae.
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Affiliation(s)
- Einar S Björnsson
- Faculty of Medicine, University of Iceland, Iceland; Department of Gastroenterology, Landspitali University Hospital Reykjavik, Iceland.
| | - Raul J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Malaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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6
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Jaffey JA. Canine intrahepatic biliary disease - what have we learned? J Small Anim Pract 2021; 63:167-173. [PMID: 34585753 DOI: 10.1111/jsap.13433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/08/2021] [Accepted: 09/06/2021] [Indexed: 12/07/2022]
Abstract
The intrahepatic biliary tract is essential for physiologic homeostasis. Disease that results in aberrant function can have serious deleterious consequences and result in considerable morbidity and mortality. This review aimed to summarise clinically relevant updates on intrahepatic biliary disorders in dogs including human corollaries.
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Affiliation(s)
- J A Jaffey
- Department of Specialty Medicine, Midwestern University, College of Veterinary Medicine, 19555 N 59th Avenue, Glendale, AZ, 85308, USA
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7
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Bessone F, Hernández N, Tanno M, Roma MG. Drug-Induced Vanishing Bile Duct Syndrome: From Pathogenesis to Diagnosis and Therapeutics. Semin Liver Dis 2021; 41:331-348. [PMID: 34130334 DOI: 10.1055/s-0041-1729972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The most concerned issue in the context of drug/herb-induced chronic cholestasis is vanishing bile duct syndrome. The progressive destruction of intrahepatic bile ducts leading to ductopenia is usually not dose dependent, and has a delayed onset that should be suspected when abnormal serum cholestasis enzyme levels persist despite drug withdrawal. Immune-mediated cholangiocyte injury, direct cholangiocyte damage by drugs or their metabolites once in bile, and sustained exposure to toxic bile salts when biliary epithelium protective defenses are impaired are the main mechanisms of cholangiolar damage. Current therapeutic alternatives are scarce and have not shown consistent beneficial effects so far. This review will summarize the current literature on the main diagnostic tools of ductopenia and its histological features, and the differential diagnostic with other ductopenic diseases. In addition, pathomechanisms will be addressed, as well as the connection between them and the supportive and curative strategies for ductopenia management.
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Affiliation(s)
- Fernando Bessone
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Nelia Hernández
- Clínica de Gastroenterología, Hospital de Clínicas y Facultad de Medicina, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Mario Tanno
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Marcelo G Roma
- Instituto de Fisiología Experimental (CONICET-UNR), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
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8
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Zhang XC, Wang D, Li X, Hu YL, Wang C. Idiopathic adulthood ductopenia with elevated transaminase only: A case report. World J Clin Cases 2020; 8:6524-6528. [PMID: 33392340 PMCID: PMC7760456 DOI: 10.12998/wjcc.v8.i24.6524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Idiopathic adulthood ductopenia (IAD) is a chronic cholestatic liver disease of unknown etiology that usually presents as unexplained jaundice. It is characterized by adult onset, lack of autoantibodies, inflammatory bowel disease and loss of interlobular bile ducts. CASE SUMMARY This case presents a 27-year-old woman with elevation of transaminases and alkaline phosphatase without clinical symptoms. Five years ago, the patient had abnormal transaminases but no cholestasis. Three months before admission, physical examination revealed an increase in transaminases. Oral hepatoprotective drugs did not show any significant improvement, and she was admitted to hospital for further diagnosis and treatment. Liver biopsy confirmed IAD. After about 2 wk of ursodeoxycholic acid treatment, serological and histological examination showed a significant response. CONCLUSION IAD is a manifestation of cholestasis, but also may be an abnormal increase in transaminase in the early stage.
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Affiliation(s)
- Xiao-Chen Zhang
- Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Di Wang
- Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xiang Li
- Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yu-Lin Hu
- Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Chong Wang
- Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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9
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Mohanty S, Das K, Anne Correa MM. Non Syndromic Paucity of Interlobular Bile Ducts in Children - A Clinicopathological Study. Fetal Pediatr Pathol 2020; 39:317-333. [PMID: 31437071 DOI: 10.1080/15513815.2019.1652376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Non syndromic paucity of interlobular bile ducts (NS-PILBD) constitutes a miniscule of infantile cholestasis. Method: Clinical details, investigations, surgical findings, management and outcome of cases of NS-PILBD at liver biopsy were analyzed. Specific histopathological features including bile duct to portal tract ratio were studied. Results: Eighteen cases (1993-2013) are detailed. Clinical presentation and investigations were similar to biliary atresia. Hepatic scintigraphy showed no gut excretion in 13/18 and operative cholangiogram was normal in all. Liver biopsy showed a median Scheuer fibrosis stage of 2, the mean bile duct/portal tract ratio was 0.29. The average age at last follow up of twelve cases was 54.9 months . Ten were asymptomatic and anicteric, the liver function tests had normalized over 3-15 months. Conclusion: Histopathology differentiated NS-PILBD from other causes of infantile cholestasis .The idiopathic form generally had a favorable long term outcome with medical management.
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Affiliation(s)
- Suravi Mohanty
- Department of Pathology, St. John's Medical College, Bangalore, India
| | - Kanishka Das
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, India
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10
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Douglass KM, Willner IR, Glenn DJ, Jones RM. Idiopathic Adulthood Ductopenia Causing Cirrhosis. ACG Case Rep J 2020; 7:e00349. [PMID: 32337312 PMCID: PMC7162123 DOI: 10.14309/crj.0000000000000349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 12/21/2022] Open
Abstract
Idiopathic adulthood ductopenia (IAD) is a chronic small duct cholestatic biliary disease that is characterized by the loss of interlobular bile ducts. It is diagnosed when there is biochemical evidence of cholestatic liver disease, ductopenia on liver biopsy, and no other identifiable cause of cholestasis. We present a patient with 10 days of progressive abdominal pain, jaundice, and worsening liver function tests who advanced to fulminant liver failure with no apparent underlying cause. He was found to have cirrhosis, with biopsy demonstrative of ductopenia, consistent with idiopathic adulthood ductopenia, which is a rare etiology of cirrhosis but should be considered when the typical workup yields no answer.
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Affiliation(s)
- Kevin M. Douglass
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Ira R. Willner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Douglas J. Glenn
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Ryan M. Jones
- Department of Pathology, Medical University of South Carolina, Charleston, SC
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11
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Idilman IS, Low HM, Bakhshi Z, Eaton J, Venkatesh SK. Comparison of liver stiffness measurement with MRE and liver and spleen volumetry for prediction of disease severity and hepatic decompensation in patients with primary sclerosing cholangitis. Abdom Radiol (NY) 2020; 45:701-709. [PMID: 31894383 DOI: 10.1007/s00261-019-02387-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE To compare liver stiffness measurement (LSM) with magnetic resonance elastography (MRE) and liver and spleen volumetry for prediction of disease severity and hepatic decompensation in primary sclerosing cholangitis (PSC). METHODS This retrospective study was approved by the institutional review board. Magnetic resonance imaging (MRI) and MRE studies were reviewed, and mean LSM of entire liver, right lobe and left lobe, total liver, right lobe, left lobe, caudate lobe, and spleen volumes were calculated. Qualitative evaluation of lobar atrophy or hypertrophy and presence of macronodular regeneration (MNR) was recorded. Statistical analysis was performed to evaluate correlations between LSM, volumetry measurements, and Mayo risk score. Univariate and multivariate analyses were performed to predict hepatic decompensation. RESULTS A total of 266 patients with PSC were included in the study. Lobar stiffness measures were higher in the presence of relative lobe atrophy. Mean LSM was higher in the presence of MNR. Significant correlations were observed between mean LSM and volumetry measurements with a fair correlation between LSM and spleen volume (rs = 0.526, p < 0.0001). Among the measurements, the best correlation was observed between mean LSM and Mayo risk score (rs = 0.646, p < 0.0001). In the multivariate analyses, mean LSM and Mayo risk score were significantly associated with liver decompensation (hazard ratio, 1.18; 95%CI 1.02-1.36 and hazard ratio, 1.65; 95%CI 1.08-2.53, respectively). CONCLUSION LSM with MRE performs significantly better than liver and spleen volumes for prediction of both disease severity and hepatic decompensation.
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Affiliation(s)
- Ilkay S Idilman
- Department of Radiology, School of Medicine, Hacettepe University, Ankara, Turkey
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Hsien Min Low
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Zeinab Bakhshi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - John Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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12
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Hashim A, Barnabas A, Miquel R, Agarwal K. Successful liver transplantation for drug-induced vanishing bile duct syndrome. BMJ Case Rep 2020; 13:13/1/e233052. [PMID: 31948982 DOI: 10.1136/bcr-2019-233052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Drug-induced cholestasis has a wide range of clinical presentations, and in a small number of patients, it can progress to severe ductopenia. A 63-year-old woman was referred to our department with progressive cholestasis and hyperbilirubinaemia following a course of flucloxacillin. Despite the comprehensive laboratory, imaging and genetic investigations, no other cause for the cholestasis was demonstrated. Sequential liver biopsies confirmed the development of vanishing bile duct syndrome. She developed significant cachexia and pruritus that did not respond to medical therapy, and hence she was listed for liver transplantation. She underwent liver transplantation 6 months after the initial drug-induced injury. She has remained well with good graft function at 1-year follow-up. The case highlights an extreme form of drug-induced ductopenia and underscores the need for meticulous hepatology input and consideration of liver transplantation in some patients.
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Affiliation(s)
- Ahmed Hashim
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Ashley Barnabas
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Rosa Miquel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
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Tian QJ, Zhao XY, Wang Y, Wee A, Soon GST, Gouw ASH, Li M, Yang RY, Wang L, Wang QY, Duan WJ, Wang Y, Wang XM, Kong YY, Ou XJ, You H, Jia JD. Histologic pattern is better correlated with clinical outcomes than biochemical classification in patients with drug-induced liver injury. Mod Pathol 2019; 32:1795-1805. [PMID: 31300804 DOI: 10.1038/s41379-019-0314-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/30/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022]
Abstract
Histologically, drug-induced liver injury could be classified into acute hepatitis, chronic hepatitis, acute cholestasis, chronic cholestasis, and cholestatic hepatitis. The correlation between these histologic patterns and long-term clinical outcomes has not been well established. Therefore, we conducted a retrospective cohort study to investigate the association of histologic patterns and long-term clinical outcomes defined as biochemical normalization, persistent abnormal liver biochemistry or death at designated time points. In this study, biochemical classification was determined by R-values; histologic injury pattern was determined by morphological features. Predictive ability of clinical outcomes by these two classifications was assessed using Receiver Operating Characteristic Curves. Logistic regression was performed to identify histologic factors associated with outcomes. Totally, 88 patients with drug-induced liver injury were included for final analysis. Biochemical and histologic classification were consistent in 50 (57%) cases. 53 (60%) cases showed biochemical normalization within 6 months, and a further 11 (13%), 16 (18%), and 6 (7%) cases within 1, 2, and 3 years, respectively. Compared with biochemical classification, histologic injury pattern had better predictive ability for abnormal biochemistry at 6 months (Areas under Receiver Operating Characteristic Curves 0.92 versus 0.60, P < 0.001) and 1 year (Areas under Receiver Operating Characteristic Curves 0.94 versus 0.69, P < 0.001). Interlobular bile duct loss in >25% portal areas was independently associated with abnormal biochemistry at 6 months, 1 year, and 2 years. In conclusion, histologic injury pattern is better correlated with clinical outcome at 6 months and 1 year than biochemical classification. Moderate bile duct loss is an important histologic feature associated with persistent biochemical abnormality at 6 months, 1 year, and 2 years.
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Affiliation(s)
- Qiu-Ju Tian
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xin-Yan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yan Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Aileen Wee
- Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital, Singapore, Singapore
| | | | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Min Li
- Clinical Epidemiology and Evidence-Based Medicine Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Rui-Yuan Yang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lan Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Qian-Yi Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Wei-Jia Duan
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yu Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiao-Ming Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yuan-Yuan Kong
- Clinical Epidemiology and Evidence-Based Medicine Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiao-Juan Ou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Hong You
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Ji-Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China.
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14
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Keshet N, Aricha A, Friedlander-Barenboim S, Aframian DJ, Nadler C. Novel parotid sialo-cone-beam computerized tomography features in patients with suspected Sjogren's syndrome. Oral Dis 2018; 25:126-132. [PMID: 30070035 DOI: 10.1111/odi.12946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/19/2018] [Accepted: 07/11/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Sjogren's syndrome (SjS) causes salivary gland impairment leading to oral dryness. Parotid sialo-cone-beam computerized tomography (sialo-CBCT) demonstrates ductal architecture and to a lesser extent gland activity. This study characterizes radiographic features of patients suspected for SjS and looks for a possible correlation with the diagnosis of SjS. METHODS The clinical and radiographic data of suspected SjS/dry mouth patients referred for sialo-CBCT in 2011-2014 were reviewed retrospectively. Two observers studied the scans for various radiographic features including duct morphology, level of branching, ductopenia and sialectasia. These features were analysed taking the specific clinical data and two sets of SjS criteria: The 2002 American-European Consensus Group (AECG) and the 2012 American College of Rheumatology (ACR) Group. RESULTS Sialo-CBCT scans of 67-referred patients suffering from dry mouth (115 parotid glands) were included. Intraradiographic association was found between ductopenia and all other radiographic parameters. Minimal, yet important, radiographic differences were found between left and right parotid glands. AECG-confirmed-SjS patients showed strong correlation with radiographic features, whereas ACR 2012-confirmed-SjS patients did not. CONCLUSION Sialo-CBCT demonstrates novel radiographic features which may clarify the diagnosis of SjS. Further studies are needed to determine the role of sialo-CBCT in diagnosis of SjS.
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Affiliation(s)
- Naama Keshet
- Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Sjogren's Syndrome Center, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel
| | - Adi Aricha
- Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Sjogren's Syndrome Center, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel.,Oro-Maxillofacial Imaging, Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel
| | | | - Doron J Aframian
- Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Sjogren's Syndrome Center, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel
| | - Chen Nadler
- Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Sjogren's Syndrome Center, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel.,Oro-Maxillofacial Imaging, Department of Oral Medicine, Sedation, and Maxillofacial Imaging, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel
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15
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Abstract
Patients with primary biliary cholangitis (PBC) are at risk for various harmful consequences of chronic cholestasis. These include fat-soluble vitamin deficiency, even in the setting of macronutrient sufficiency, as well as metabolic bone disease, including osteoporosis with fractures. Hyperlipidemia is often present and less commonly associated with risk of cardiovascular event; however, the long-term effect of new emerging therapies for PBC remains to be determined. Patients with PBC also have infrequent but notable risk of portal hypertension despite early-stage disease. This review discusses the background, evaluation, and practical management of these complications of chronic cholestasis.
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Affiliation(s)
- David N Assis
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06510, USA.
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16
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Tan D, Goodman ZD. Liver Biopsy in Primary Biliary Cholangitis: Indications and Interpretation. Clin Liver Dis 2018; 22:579-588. [PMID: 30259854 DOI: 10.1016/j.cld.2018.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis is a disease characterized by immune-mediated bile duct destruction, followed by inflammation, scarring, and the development of chronic cholestasis and a slow progression to cirrhosis over the course of years. Liver biopsy has traditionally been used in conjunction with clinical evaluation and serologic autoantibody testing to establish the diagnosis, but it is no longer required in typical cases with positive antimitochondrial antibodies. Biopsy remains essential, however, in antimitochondrial antibody-negative patients or suspected overlap syndrome with autoimmune hepatitis, and if an adequate biopsy is performed precise staging is possible for assessment of prognosis.
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Affiliation(s)
- Daisong Tan
- Division of Liver Pathology Research, Center for Liver Diseases, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Zachary D Goodman
- Division of Liver Pathology Research, Center for Liver Diseases, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
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17
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Kim J, Yang B, Paik N, Choe YH, Paik YH. A case of Alagille syndrome presenting with chronic cholestasis in an adult. Clin Mol Hepatol 2017; 23:260-264. [PMID: 28683534 PMCID: PMC5628001 DOI: 10.3350/cmh.2016.0057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/16/2016] [Accepted: 11/21/2016] [Indexed: 12/23/2022] Open
Abstract
Alagille syndrome (AGS) is a complex multisystem disorder that involves mainly the liver, heart, eyes, face, and skeleton. The main associated clinical features are chronic cholestasis due to a paucity of intrahepatic bile ducts, congenital heart disease primarily affecting pulmonary arteries, vertebral abnormalities, ocular embryotoxon, and peculiar facies. The manifestations generally become evident at a pediatric age. AGS is caused by defects in the Notch signaling pathway due to mutations in JAG1 or NOTCH2. It is inherited in an autosomal dominant pattern with a high degree of penetrance, but variable expressivity results in a wide range of clinical features. Here we report on a 31-year-old male patient who presented with elevated serum alkaline phosphatase and gamma-glutamyl transpeptidase, and was diagnosed with AGS associated with the JAG1 mutation after a comprehensive workup.
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Affiliation(s)
- Jihye Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bumhee Yang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Namyoung Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Björnsson ES, Jonasson JG. Idiosyncratic drug-induced liver injury associated with bile duct loss and vanishing bile duct syndrome: Rare but has severe consequences. Hepatology 2017; 65:1091-1093. [PMID: 28073177 DOI: 10.1002/hep.29040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 12/25/2016] [Indexed: 12/07/2022]
Affiliation(s)
- Einar S Björnsson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jon Gunnlaugur Jonasson
- Department of Pathology Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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19
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Bilal M, Kazemi A, Babich M. Idiopathic Adulthood Ductopenia: 'It Is Out There'. Case Rep Gastroenterol 2016; 10:95-8. [PMID: 27403109 PMCID: PMC4929362 DOI: 10.1159/000444443] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/02/2016] [Indexed: 12/21/2022] Open
Abstract
Idiopathic adulthood ductopenia (IAD) is a chronic cholestatic entity of unknown origin characterized by loss of inter-lobular bile ducts that was first described two decades ago. Although the diagnostic criteria have been described in detail, IAD continues to be a rare diagnosis. Our thorough literature search revealed less than a hundred cases of IAD reported. Here we present a 34-year-old female with no significant past history who was evaluated for persistent elevation of serum alkaline phosphate levels. Serology was negative for all viral hepatitides, and a chronic liver disease workup was unremarkable. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography did not reveal any abnormalities in the biliary tree. Finally, a liver biopsy demonstrated ductopenia involving greater than 50% of the portal triads, making a diagnosis of IAD. Since the disease can progress rapidly, close follow-up is warranted, so liver transplantation can be pursued if deemed necessary.
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Affiliation(s)
- Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny General Hospital, Pittsburgh, Pa., USA
| | - Ali Kazemi
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny General Hospital, Pittsburgh, Pa., USA
| | - Michael Babich
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny General Hospital, Pittsburgh, Pa., USA
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20
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Nakanishi Y, Saxena R. Pathophysiology and Diseases of the Proximal Pathways of the Biliary System. Arch Pathol Lab Med 2015; 139:858-66. [PMID: 26125426 DOI: 10.5858/arpa.2014-0229-ra] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Diseases of the proximal pathways of the biliary system can be divided into those that affect the interlobular bile ducts and those that affect the bile canaliculi. The former include primary biliary cirrhosis, small-duct variant of primary sclerosing cholangitis, graft-versus-host disease, and drug-induced liver injury, whereas the latter include progressive familial intrahepatic cholestasis, benign recurrent intrahepatic cholestasis, intrahepatic cholestasis of pregnancy, and drug-induced liver injury. OBJECTIVE To summarize the current state of knowledge of diseases of the proximal pathways of the biliary system, with special emphasis on clinical presentation, pathological features, and differential diagnosis. DATA SOURCES Clinicopathological information was extracted from pertinent published literature. CONCLUSIONS Care of the patient with cholestasis hinges on identifying the etiology. Diagnostic steps in cholestatic conditions comprise a thorough patient history, abdominal imaging, distinct serological studies, and liver biopsy. Primary biliary cirrhosis is characterized by distinctive serological and histological findings. The small-duct variant of primary sclerosing cholangitis is very rare and difficult to diagnose; imaging of the bile ducts is not helpful. Graft-versus-host disease is characterized by damage and loss of intrahepatic bile ducts. Drugs can cause injury variably at the level of bile canaliculus or the interlobular bile duct. Loss of bile ducts may be seen with primary biliary cirrhosis, primary sclerosing cholangitis, graft-versus-host disease, and drug-induced liver injury. Progressive familial intrahepatic cholestasis and progressive familial intrahepatic cholestasis represent 2 extreme ends of the spectrum of abnormalities in transporters responsible for bile formation. Intrahepatic cholestasis of pregnancy has a variable incidence in different parts of the world and may be due to abnormalities in transporter molecules.
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Affiliation(s)
| | - Romil Saxena
- From the Department of Pathology, Indiana University School of Medicine, Indianapolis
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21
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The Impact of Intensified Hemodialysis on Pruritus in an End Stage Renal Disease Patient with Biliary Ductopenia. Case Rep Nephrol 2015; 2015:236419. [PMID: 25821614 PMCID: PMC4364046 DOI: 10.1155/2015/236419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/25/2015] [Indexed: 11/28/2022] Open
Abstract
We report a unique observation characterized by the coexistence of idiopathic adulthood ductopenia (IAD), a rare cholestatic disease, and end stage renal failure treated by conventional hemodialysis in a patient awaiting double renal and liver transplantation. As pruritus gradually worsened, we hypothesized that intensified dialysis could alleviate the symptoms. Conventional hemodialysis following 3 hours/3 times a week regimen was initiated in December 2013. Due to increasing pruritus not responding to standard medical therapy, intensified hemodialysis following 2.5 hours/5 times a week regimen was started in May 2014. During two weeks, a temporary decrease in bilirubin levels was observed. No major changes on other liver function tests and inflammatory markers occurred. Nevertheless, a persistent improvement on pruritus and general wellbeing was obtained during the four weeks' study period. The pathogenesis of itch encompasses multiple factors, and, in our case, both uremic and cholestatic pruritus are involved, although the latter is likely to account for a greater proportion. By improving itch intensity, through better clearance of uremic and cholestatic toxins which we detail further, intensive dialysis appears to be an acceptable short-term method for patients with hepatic cholestasis and moderate pruritus not responding to conventional therapy. Additional studies are needed to assess and differentiate precisely factors contributing to pruritus of both origins.
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Kaung A, Sundaram V, Dhall D, Tran TT. A Case of mild idiopathic adulthood ductopenia and brief review of literature. Gastroenterol Rep (Oxf) 2014; 3:167-9. [PMID: 25030019 PMCID: PMC4423457 DOI: 10.1093/gastro/gou048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/21/2014] [Indexed: 01/01/2023] Open
Abstract
Mild idiopathic adulthood ductopenia (IAD) is a rare cholestatic disease of unknown cause and characterized by interlobular bile duct loss in less than 50% of the portal tracts. We describe the case of a middLe-aged male who presented with persistent elevation of transaminases and alkaline phosphatase. He had a normal biliary tree on endoscopic retrograde cholangiopathy and negative anti-mitochondrial antibody. His liver biopsy specimen showed chronic biliary disease, duct loss in 4 out of 15 portal tracts and prominent cholestasis. Based on the work-up, he likely had mild IAD. Liver transplantation would be necessary if his disease becomes progressive.
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Affiliation(s)
- Aung Kaung
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA, Center for Liver Disease and Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA, USA and Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA, Center for Liver Disease and Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA, USA and Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Deepti Dhall
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA, Center for Liver Disease and Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA, USA and Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tram T Tran
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA, Center for Liver Disease and Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA, USA and Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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24
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Abstract
The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Jüngst C, Berg T, Cheng J, Green RM, Jia J, Mason AL, Lammert F. Intrahepatic cholestasis in common chronic liver diseases. Eur J Clin Invest 2013; 43:1069-83. [PMID: 23927644 DOI: 10.1111/eci.12128] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/15/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Cholestasis represents the consequence of impaired bile formation and decrease in bile flow, generally classified as extra- and intrahepatic. Cholestasis is the pivotal hallmark of the so-called primary cholestatic liver diseases but may also emerge in other forms of chronic liver injury. The aim now was to summarise the current state of knowledge on intrahepatic cholestasis related to chronic liver diseases. METHODS For this overview on intrahepatic cholestasis in chronic liver disorders other than the 'classic' cholestatic liver diseases, selected references were retrieved by literature search in MEDLINE and textbooks were reviewed. All articles were selected that discussed pathophysiological and clinical aspects of intrahepatic cholestasis in the context of alcoholic liver disease, nonalcoholic fatty liver disease, chronic hepatitis B and C virus infections as well as drug-induced and granulomatous liver diseases. Titles referring to primary biliary cirrhosis and sclerosing cholangitis were excluded. RESULTS AND CONCLUSIONS Dependent on the aetiology, intrahepatic cholestasis is present at variable frequencies and in different disease stages in chronic liver diseases. Cholestasis secondary to chronic liver injury may denote a severe disease course and development of end-stage liver disease or specific disease variants. These findings indicate that 'secondary intrahepatic cholestasis' (SIC) can occur in the natural course of chronic liver diseases other than the primary cholestatic diseases, in particular in the setting of advanced disease progression.
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Affiliation(s)
- Christoph Jüngst
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
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26
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Peniche-Moquel P, Pérez-Hernández JL, Cordova J. Chronic cholestasis in a 20-year-old young man: a case of idiopathic adulthood ductopenia. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:628-30. [PMID: 24035738 DOI: 10.1016/j.gastrohep.2013.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/09/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Pilar Peniche-Moquel
- Unit of Gastroenterology, Mexico's General Hospital "Dr. Eduardo Liceaga", O.D., Mexico
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27
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Abstract
Cholestasis caused by drugs is an important differential diagnosis in patients presenting with a biochemical cholestatic pattern. The extent of serologic tests and radiological imaging depends on the clinical context. The underlying condition of the patient and detailed information on drug use, results of rechallenge, and the documented hepatotoxicity of the drug are important to establish a diagnosis of drug-induced liver injury (DILI). Most cases of cholestatic DILI are mild, but in rare cases, ductopenia and cholestatic cirrhosis can develop. Approximately 10% of patients with cholestatic jaundice caused by drugs develop liver failure.
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28
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Abstract
Cholestasis is defined as impairment of bile formation or bile flow. Care of the patient with cholestatic features is dependent on identifying the cause of the cholestasis, initiating appropriate treatment of reversible conditions, and the recognition and management of cholestasis-specific complications. Cholestasis may include extrahepatic ducts and intrahepatic bile ducts, or may be limited to one or the other. Jaundice and pruritus are the hallmarks of cholestasis clinically but biochemical evidence may, and often does, precede the clinical manifestations.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
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29
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Li H, Li X, Liao XX, Zhan H, Xiong Y, Hu CL, Wei HY, Jing XL. Drug associated vanishing bile duct syndrome combined with hemophagocytic lymphohistiocytosis. World J Gastrointest Endosc 2012; 4:376-8. [PMID: 22912913 PMCID: PMC3423520 DOI: 10.4253/wjge.v4.i8.376] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 03/02/2012] [Accepted: 08/08/2012] [Indexed: 02/05/2023] Open
Abstract
A 28-year-old woman with untreated autoimmune disorder, demonstrated skin rash and fever after taking Amoxicillin-clavulanate and developed progressive jaundice. A bone marrow aspiration indicated an increased number of macrophages with hemophagocytosis and liver biopsy showed pure centrilobular cholestasis with necrosis and some absence of portal bile ducts. Furthermore, a serological test for Epstein-Barr virus was positive. Under treatment by liver dialysis and administration of steroids led to rapidly defervescence and clinical improvement. However, liver enzymes were still markedly elevated with persistent anemia, even after immunosuppressive treatment. The patient is currently waiting for liver transplantation. This is the first description of vanishing bile duct syndrome combined with hemophagocytic lymphohistiocytosis, with underlying causes including infection, drug-induced factors and untreated autoimmune disorder.
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Affiliation(s)
- Hui Li
- Hui Li, Xin Li, Xiao-Xing Liao, Hong Zhan, Yan Xiong, Chun-Lin Hu, Hong-Yan Wei, Xiao-Li Jing, Department of Emergency, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
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Portmann B, Zen Y. Inflammatory disease of the bile ducts-cholangiopathies: liver biopsy challenge and clinicopathological correlation. Histopathology 2011; 60:236-48. [PMID: 21668470 DOI: 10.1111/j.1365-2559.2011.03853.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver biopsy challenge and clinicopathological correlation Liver biopsy interpretation in inflammatory diseases of the bile ducts or chronic cholangiopathies may be challenging, especially for pathologists working outside referral centres, where there is a limited exposure to relatively uncommon conditions. In view of the importance of sampling errors resulting from the patchy distribution of pathognomonic bile duct injuries and the misleading absence of cholestasis in the early stages, there is a need to recognize surrogate markers and subtle changes, in particular the early periportal deposition of copper and mild biliary interface activity. Such findings may either constitute the first indication of a primarily biliary disorder or be supportive of a clinically suspected diagnosis. Histological changes common to chronic cholangiopathies are reviewed at the variable stages of development that patients may first present to clinicians. As awareness of the protean clinical manifestations is essential for histological interpretation, the major and distinctive anatomoclinical features of primary biliary cirrhosis and primary and acquired sclerosing cholangitis are revisited, together with so-called overlapping syndromes and less common variants and associations, including more recently documented conditions, such as IgG4-related disease and the rarer multidrug resistance 3 deficiency. The review stresses the importance of evaluating histological changes in conjunction with clinical information.
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Affiliation(s)
- Bernard Portmann
- Institute of Liver Studies, King's College Hospital, London, UK.
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31
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Juricic D, Danica J, Hrstic I, Irena H, Radic D, Davor R, Skegro M, Mate S, Coric M, Marijana C, Vucelic B, Boris V, Francetic I, Igor F. Vanishing bile duct syndrome associated with azithromycin in a 62-year-old man. Basic Clin Pharmacol Toxicol 2009; 106:62-5. [PMID: 19906050 DOI: 10.1111/j.1742-7843.2009.00474.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vanishing bile duct syndrome is a severe cholestatic disease associated with toxic effects of medications. Stevens-Johnson syndrome is a hypersensitivity disorder that may also be caused by medications. We present a case of a 62-year-old male patient who developed vanishing bile duct syndrome a month after Stevens-Johnson syndrome. These adverse drug reactions were associated with the use of azithromycin (500 mg daily for 3 days). The patient was initially treated for Stevens-Johnson syndrome with steroids, antihistamines and proton pump inhibitors and fully recovered. However, a month after the beginning of Stevens-Johnson syndrome, he developed vanishing bile duct syndrome and was treated with steroids, ursodeoxycholic acid, antihistamines and tacrolimus. Unfortunately, the treatment was unsuccessful and he was listed for liver transplantation which was performed 7 months after the beginning of jaundice. This is the first case of vanishing bile duct syndrome associated with the use of azithromycin and one of few that reports vanishing bile duct syndrome and Stevens-Johnson syndrome co-occurrence.
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Affiliation(s)
- Danica Juricic
- Division of Clinical Pharmacology, Department of Internal Medicine, Zagreb University Hospital Center, Zagreb, Croatia.
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Park BC, Park SM, Choi EY, Chae HB, Yoon SJ, Sung R, Lee SK. A case of idiopathic adulthood ductopenia. Korean J Intern Med 2009; 24:270-3. [PMID: 19721865 PMCID: PMC2732788 DOI: 10.3904/kjim.2009.24.3.270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Accepted: 08/28/2007] [Indexed: 12/21/2022] Open
Abstract
Idiopathic adulthood ductopenia (IAD) is a chronic cholestatic liver disease of unknown etiology characterized by adult onset, an absence of autoantibodies, inflammatory bowel disease, and a loss of interlobular bile ducts. In the present report, a case fulfilling the IAD criteria is described. A 19-year-old man was admitted to the hospital for persistent elevation of transaminases and alkaline phosphatase without clinical symptoms. Viral hepatitis markers and autoantibodies were absent. The patient had a normal extrahepatic biliary tree and had no evidence of inflammatory bowel disease. A liver biopsy specimen showed absence of interlobular bile ducts from 58% of the portal tracts. He was diagnosed with IAD and was treated with ursodeoxycholic acid.
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Affiliation(s)
- Byeong Chool Park
- Department of Internal Medicine, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Eun Young Choi
- Department of Internal Medicine, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Hee Bok Chae
- Department of Internal Medicine, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Se Jin Yoon
- Department of Internal Medicine, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Rohyun Sung
- Department of Pathology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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MESH Headings
- Adult
- Child
- Cholangitis/diagnosis
- Cholangitis/immunology
- Cholangitis/therapy
- Cholangitis, Sclerosing/diagnosis
- Cholangitis, Sclerosing/therapy
- Cholestasis, Intrahepatic/diagnosis
- Cholestasis, Intrahepatic/etiology
- Cholestasis, Intrahepatic/prevention & control
- Cholestasis, Intrahepatic/therapy
- Cystic Fibrosis/complications
- Female
- Hepatitis, Autoimmune/diagnosis
- Hepatitis, Autoimmune/therapy
- Humans
- Immunoglobulin G/metabolism
- Infant
- Liver Cirrhosis, Biliary/diagnosis
- Liver Cirrhosis, Biliary/therapy
- Male
- Osteoporosis/etiology
- Osteoporosis/therapy
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/therapy
- Syndrome
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Gotthardt D, Runz H, Keitel V, Fischer C, Flechtenmacher C, Wirtenberger M, Weiss KH, Imparato S, Braun A, Hemminki K, Stremmel W, Rüschendorf F, Stiehl A, Kubitz R, Burwinkel B, Schirmacher P, Knisely AS, Zschocke J, Sauer P. A mutation in the canalicular phospholipid transporter gene, ABCB4, is associated with cholestasis, ductopenia, and cirrhosis in adults. Hepatology 2008; 48:1157-66. [PMID: 18781607 DOI: 10.1002/hep.22485] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED Cholestatic liver disease (CLD) is a major cause of progressive liver damage and liver failure. Several forms of biliary cirrhosis are caused by mutations in specific genes. We sought to identify a genetic defect in a family with CLD impossible to assign to a distinct pathogenic entity. Clinical and histopathological characterization of the family members, microarray-based single-nucleotide polymorphism genotyping, and analysis of candidate genes were performed. Among six of 11 siblings severely affected by idiopathic CLD in a family from a population isolate in Transylvania, three died of cirrhosis (aged 5, 7, and 43 years) and three had adult-onset disease with small duct cholangiopathy, including ductopenia. Others were mildly affected and experienced intrahepatic cholestasis of pregnancy, miscarriages, or stillbirth. Pedigree studies revealed distant parental consanguinity. Genome-wide linkage analysis and autozygosity mapping yielded a single maximal lod-score of 3.88 on chromosome 7q21.1-7q22, excluding other genomic loci. Sequencing of ABCB4 at this locus revealed a novel missense mutation c.2362C>T (p.Arg788Trp) which cosegregated with severity of disease. Bile from a mutation homozygote showed a reduced phosphatidylcholine/bile acid ratio, consistent with reduced ABCB4 phosphatidylcholine transport activity. CONCLUSION We show that a missense mutation in ABCB4 is a cause for ductopenic CLD in adulthood. Allelic status correlated with severity of liver disease ranging from intrahepatic cholestasis of pregnancy through fibrosis to cirrhosis and death in childhood and adulthood. Mutational analysis of ABCB4 should be generally considered in all patients with cholestatic liver disease of unknown etiology regardless of age and onset of disease.
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Affiliation(s)
- Daniel Gotthardt
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany.
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Abstract
Perhaps no condition associated with chronic cholestasis is less understood than vanishing bile duct syndrome, a term that refers loosely to the group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts and, ultimately, cholestasis. Although the array of insults resulting in poor bile flow is vast, most adult patients who have chronic cholestasis have either primary biliary cirrhosis (or primary sclerosing cholangitis; in some cases, however, a cause cannot be identified. This article reviews the multiple causes, postulated pathophysiology, clinical features, and treatment options for this syndrome.
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Affiliation(s)
- Nancy S Reau
- Center for Liver Diseases, Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland, MC7120, Chicago, IL 60637, USA.
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Mambelli E, Mancini E, Casanova S, Di Felice A, Santoro A. Severe Ticlopidine-Induced Cholestatic Syndrome. Blood Purif 2007; 25:441-5. [DOI: 10.1159/000111033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 07/19/2007] [Indexed: 11/19/2022]
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Li Y, Ayata G, Baker SP, Banner BF. Cholangitis: a histologic classification based on patterns of injury in liver biopsies. Pathol Res Pract 2005; 201:565-72. [PMID: 16259109 DOI: 10.1016/j.prp.2005.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammatory disorders of the biliary tract present difficult diagnostic problems in liver needle biopsies. The aim of this study was to perform a detailed histologic analysis of liver biopsies from patients with biliary tract disorders, classify them by pattern of inflammation, and determine the accuracy of the histologic classification by clinical follow-up. Percutaneous liver needle biopsies from the surgical pathology files of UmassMemorial Healthcare (UMMHC) from 2000 to 2003 with a diagnosis suggesting a biliary tract process (n = 32) and four biopsies from cases with systemic non-biliary tract disorders were analyzed for multiple histologic features and classified as one of five patterns: acute cholangitis/pericholangitis (ACP), lymphocytic cholangitis (LC), granulomatous (G), ductopenia (D), or non-specific (NS). When compared to the "gold standard" diagnosis based on all clinical data, the concordance between the histologic classification and the clinical diagnosis was: 50% for ACP and bile duct obstruction; 77% for LC and immune-mediated cholangitis NOS; 100% for G and G cholangitis; 100% for D and idiopathic adulthood D; and 50% for NS and non-biliary tract disorders. Our findings suggest that classifying biopsies by pattern of injury is helpful in guiding the subsequent clinical work-up. ACP pattern correlates with bile duct obstruction, infection, and ischemia. LC correlates with serologic studies supporting immune-mediated processes. G pattern suggests further work-up for PBC, drug, tuberculosis, or sarcoidosis. D pattern establishes the clinical diagnosis. NS pattern includes cases of primary sclerosing cholangitis, which cannot be diagnosed by biopsy alone.
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Affiliation(s)
- Yanhua Li
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Abstract
Cholestasis caused by medicinal and chemical agents is an increasingly well-recognized cause of liver disease. Clinical drug-induced cholestatic syndromes producing jaundice and bile duct injury can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis, among others. This article updates the various forms of drug-induced cholestasis, focusing on the clinicopathologic features of this form of hepatic injury and on the known or putative mechanisms by which drugs and chemicals lead to cholestasis.
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Affiliation(s)
- Raja Mohi-ud-din
- Section of Hepatology, Division of Gastroenterology, Georgetown University Medical Center, 3800 Reservoir Road, Washington, DC 20007, USA
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Abstract
Drug-induced cholestasis is a common entity, seen with numerous classes of pharmacological agents. A high index of suspicion is required for the correct diagnosis. Different clinical syndromes may be recognized, with variable degrees of hepatitis in association with cholestasis. The most important aspect of treatment is prompt discontinuation of the offending drug. Several agents have been used for symptomatic relieve of the pruritus associated with cholestasis, including cholestyramine, ursodeoxycholic acid, and opiate antagonists, with limited results. Prognosis is usually good, with few cases of prolonged cholestasis leading to vanishing bile duct syndrome. Liver failure may rarely occur if diagnosis goes unrecognized and the inciting drug is not withdrawn.
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Affiliation(s)
- Cynthia Levy
- Division of Gastroenterology and Hepatology, W 19A, Mayo Clinic and Foundation, 200 1st Street, SW, Rochester, MN 55905, USA
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Affiliation(s)
- Ali T Dural
- Department of Medicine, Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas 77030, USA
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Abstract
Several distinct conditions are characterized by a reduction in the number of small and medium-sized intrahepatic bile ducts. These diseases are associated with progressive cholestasis, which in turn leads to biliary fibrosis and ultimately cirrhosis. The best-characterized ductopenic condition in adulthood is primary biliary cirrhosis (PBC) for which there is now strong evidence of an autoimmune cause. The antigenic targets are epitopes on proteins of the 2-oxoacid dehydrogenase complex within mitochondria. Some of these proteins appear to be aberrantly expressed at the surface of cholangiocytes in PBC. The basis for the breakdown in tolerance remains uncertain, although there is recent evidence to indicate that apoptosis may play a key role at early stages in the pathogenesis of the disease. Related conditions include autoimmune overlap syndromes and AMA-negative PBC (autoimmune cholangitis). Primary sclerosing cholangitis is clinically and histologically distinct, although there is evidence that it also may have an immune-mediated cause. Ductopenia may also arise on the basis of drug-induced injury; the best example of this is progressive cholestasis complicating chlorpromazine therapy.
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Affiliation(s)
- Alastair D Burt
- Centre for Liver Research, University of Newcastle upon Tyne, Newcastle upon Tyne NE1 4LP, UK.
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Vleggaar FP, van Buuren HR, Zondervan PE, ten Kate FJ, Hop WC. Jaundice in non-cirrhotic primary biliary cirrhosis: the premature ductopenic variant. Gut 2001; 49:276-81. [PMID: 11454806 PMCID: PMC1728410 DOI: 10.1136/gut.49.2.276] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The clinical and pathological findings of four females with primary biliary cirrhosis (PBC) with an unusual and hitherto not well recognised course are reported. Patients suffered severe pruritus and weight loss with progressive icteric cholestasis which did not respond to such treatments as ursodeoxycholic acid and immunosuppressives. In all cases liver histology revealed marked bile duct loss without however significant fibrosis or cirrhosis. Further diagnostic studies and repeat biopsies confirmed the absence of liver cirrhosis as well as other potential causes of hyperbilirubinaemia. Comparison of the fibrosis-ductopenia relationship for our cases with that for a group of 101 non-cirrhotic PBC patients indicated that in the former the severity of bile duct loss relative to the amount of fibrosis was significantly higher. The proportion of portal triads containing an interlobular bile duct was 3%, 4%, 6%, and 10% compared with 45% (median; range 8.3--100%) for controls (p<0.001). Three patients received a liver transplant 6--7 years after the first manifestation of PBC because of progressive cholestasis, refractory pruritus, and weight loss, while the fourth patient is considering this option. In one case cirrhosis had developed at the time of transplantation while the others still had non-cirrhotic disease. These cases suggest that cholestatic jaundice in non-cirrhotic PBC may be secondary to extensive "premature" or accelerated intrahepatic bile duct loss. Although the extent of fibrosis may be limited initially, progression to cirrhosis appears to be inevitable in the long run. Despite intact protein synthesis and absence of cirrhotic complications, liver transplantation in the pre-cirrhotic stage for preventing malnutrition and to improve quality of life should be considered for these patients.
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Affiliation(s)
- F P Vleggaar
- Department of Gastroenterology and Hepatology, University Hospital Rotterdam, the Netherlands
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García-Jiménez ME, Quiroga JA, Gutiérrez ML, Pardo M, Carreño V. Association of HLA-DR genes with mild idiopathic adulthood biliary ductopenia. Am J Gastroenterol 2001; 96:1178-82. [PMID: 11318008 DOI: 10.1111/j.1572-0241.2001.03717.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Mild idiopathic adulthood ductopenia (MIAD) is an asymptomatic chronic cholestatic liver disease characterized by the loss of interlobular bile ducts in <50% of the portal tracts. Although the underlying cause of MIAD is unknown, the host factors may contribute to the patient's susceptibility to the disease. The aim of this work was to investigate the immunogenetics in the pathogenesis of MIAD. METHODS We prospectively studied 22 Caucasian patients with MIAD. Peripheral blood was collected, and HLA-DR typing was performed by polymerase chain reaction with sequence-specific primers followed by sequencing for subtyping. Results were compared with those from 140 age- and sex-matched controls. RESULTS There was no significant association between HLA-DRB1 alleles and the disease, although a trend was found in MIAD patients with the DRB1*1502 allele (five of 44 vs four of 280 in controls; p corrected = 0.055; chi2 = 13.9). Multiple HLA-DRB1 alleles (*04, *11, *15) showed increased frequencies in MIAD patients. Further subtyping revealed a motif (positions 25-32 of the beta1 chain) present in 17 (77.3%) patients, which was significantly associated with MIAD (p = 0.049; chi2 = 3.87). Seven patients (31.8%) and 21 (15%) controls coded for this motif in their two alleles (p = 0.068; chi2 = 3.76). Among MIAD patients, those seven had abnormal ALT levels (p = 0.017) and their gamma-glutamyltransferase and ALT values tended to be more increased. CONCLUSIONS These results provide evidence of an immunogenetic basis of susceptibility to MIAD in Caucasian individuals.
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Abstract
Primary biliary cirrhosis is the prototype of the small-duct biliary diseases which are characterized by damage or destruction of interlobular and proximal septal bile ducts. Autoimmune cholangitis differs serologically from primary biliary cirrhosis but, by current consensus, has the same pathological features. The histological findings in primary biliary cirrhosis and the staging criteria of that disease are well described and at this point can be applied to autoimmune cholangitis also. Diagnostic difficulties arise either because other small-duct biliary diseases are not considered or because tell-tale histological signs, particularly ductopenia, are not recognized. Review of all small-duct biliary diseases suggests that interlobular and adjacent septal bile ducts (1st and 2nd generation ducts) represent an immunosensitive portion of the biliary tree. Comparative studies of these unique segments may have important implications for our understanding of primary biliary cirrhosis and autoimmune cholangitis and possibly for future treatment options for these conditions.
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Affiliation(s)
- J Ludwig
- Division of Anatomic Pathology, Mayo Clinic and Mayo Foundation, Rochester, MN, 55905, USA
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Czaja AJ, Carpenter HA, Santrach PJ, Moore SB. Autoimmune cholangitis within the spectrum of autoimmune liver disease. Hepatology 2000; 31:1231-8. [PMID: 10827147 DOI: 10.1053/jhep.2000.7878] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Autoimmune cholangitis is an idiopathic disorder with mixed hepatocellular and cholestatic findings. Our goal was to characterize the disease prospectively by application of uniform diagnostic criteria. Twenty patients were identified and compared with 242 patients with conventional forms of autoimmune liver disease. Patients with autoimmune cholangitis were distinguished from type 1 autoimmune hepatitis (AIH) by lower serum levels of aspartate transaminase (AST), gamma-globulin, and immunoglobulin G; higher serum levels of alkaline phosphatase; and lower frequencies of autoantibodies. They were distinguished from primary biliary cirrhosis (PBC) by higher serum levels of AST and bilirubin, lower serum concentrations of immunoglobulin M, and greater occurrence of autoantibodies. Their female predominance, lower serum alkaline phosphatase levels, higher frequency of autoantibodies, and absence of inflammatory bowel disease differentiated them from primary sclerosing cholangitis (PSC). Laboratory findings ranged widely and did not characterize individual patients. HLA risk factors were similar to those of type 1 AIH and PBC, and different from those of PSC. Treatment responses to corticosteroids or ursodeoxycholic acid were poor. Composite histological patterns resembled mainly PBC or PSC. We conclude that autoimmune cholangitis diagnosed by prospective analysis cannot be assimilated into a single, conventional, diagnostic category. It may represent variant forms of diverse conditions, a transition stage, or a separate entity with varying manifestations.
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Affiliation(s)
- A J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Abstract
OBJECTIVE Cholestasis may result from diverse etiologies. We review chronic cholestatic disorders involving small intrahepatic bile ducts in the adult ambulatory care setting. Specifically, we discuss variant forms of primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) as well as other conditions that may present diagnostic and therapeutic difficulties. METHODS We conducted a MEDLINE search of the literature (1981-1997) and reviewed the experiences at the Mayo Clinic. All articles were selected that discussed antimitochondrial antibody (AMA)-negative PBC, small-duct PSC (formerly pericholangitis), and idiopathic adulthood ductopenia. RESULTS The most common chronic cholestatic liver diseases affecting adults are PBC and PSC. Patients without the hallmarks of either syndrome are diagnosed according to their clinical and histological characteristics. Autoimmune cholangitis is diagnosed if clinical and histological features are compatible with PBC but autoantibodies other than AMA are present. Isolated small duct PSC is diagnosed if patients have inflammatory bowel disease, biopsy features compatible with PSC, but a normal cholangiogram. If ductopenia (absence of interlobular bile ducts in small portal tracts) is found histologically in the absence of PSC, inflammatory bowel disease, and other specific cholestatic syndromes such as drug reaction or sarcoidosis, the most likely diagnosis is idiopathic adulthood ductopenia. CONCLUSIONS Based on these definitions, an algorithm for diagnosis and therapy in patients with laboratory evidence of chronic cholestasis may be constructed, pending results of further investigations into the etiopathogenesis of these syndromes.
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Affiliation(s)
- W R Kim
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Burak KW, Pearson DC, Swain MG, Kelly J, Urbanski SJ, Bridges RJ. Familial idiopathic adulthood ductopenia: a report of five cases in three generations. J Hepatol 2000; 32:159-63. [PMID: 10673081 DOI: 10.1016/s0168-8278(00)80203-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIMS Idiopathic adulthood ductopenia is a cholestatic liver disease of unknown etiology. Although most cases are sporadic, familial cases do occur. METHODS We describe a series of adult-onset bile duct depletion involving five members of an extended family spanning three generations. The proband, a 49-year-old man, presented in 1989 with asymptomatic elevation of liver enzyme tests. Investigations for chronic liver disease, including endoscopic retrograde cholangiopancreatography, were negative. Findings on liver biopsy progressed from normal in 1989 to striking loss of interlobular bile ducts in 1992. Ursodeoxycholic acid has resulted in improvement of liver enzyme tests. The proband's brother required a liver transplant at age 35 for cryptogenic cirrhosis. The proband's sister, age 42, has had intermittent jaundice and elevation of liver enzyme tests since 1971. Her liver biopsy findings progressed from normal in 1975, to striking bile duct damage by 1997. The proband's 21-year-old son has elevated liver enzyme tests and a liver biopsy consistent with idiopathic adulthood ductopenia. The proband's father had a liver biopsy at age 70 for investigation of a liver mass. It revealed extensive fibrosis and striking bile duct destruction. RESULTS/CONCLUSIONS This is the largest series of familial idiopathic adulthood ductopenia reported, and the first with multiple generations described. Genetics appears to play a role in some cases of adulthood ductopenia. Ursodeoxycholic acid may be beneficial in the treatment of this condition.
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Affiliation(s)
- K W Burak
- Department of Medicine, University of Calgary, Alberta, Canada
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50
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Abstract
Cholestasis resulting from drugs is an increasingly recognized cause of liver disease. It produces a broad clinical-pathologic spectrum of injury that includes simple jaundice, cholestatic hepatitis, and bile duct injury that can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis. Although the risk of drug-induced cholestasis leading to a fatal outcome is quite rare, knowledge and recognition of the various forms of cholestatic injury assumes an importance whenever clinicians are confronted with jaundice or other manifestations of liver disease in patients receiving medicinal or chemical agents.
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Affiliation(s)
- J H Lewis
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
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