Primary Sclerosing Cholangitis Heba Mohamed Abdella, MD Assistant Professor of Trtopical Medicine

Definitions Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease characterized by inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts, leading to the formation of multifocal bile duct strictures. PSC is likely an immune mediated, progressive disorder that eventually develops into cirrhosis, portal hypertension and hepatic decompensation, in the majority of patients.

Diagnosis of PSC It is made in patients with: Cholestatic biochemical profile, when cholangiography (e.g., MRC, ERC, percutaneous transhepatic cholangiography) shows characteristic bile duct changes with multifocal strictures and segmental dilatations, and secondary causes of sclerosing cholangitis have been excluded. Patients who present with clinical, biochemical and histological features compatible with PSC, but have a normal cholangiogram, are classified as small duct PSC.

Home Work

Small duct PSC is a disease variant which is characterized by typical cholestatic and histological features of PSC but normal bile ducts on cholangiography. PSC overlap syndromes are conditions with diagnostic features of both PSC and other immune mediated liver diseases including autoimmune hepatitis and autoimmune pancreatitis

Secondary sclerosing cholangitis (SSC) is characterized by a similar multifocal biliary stricturing process due to identifiable causes such as long-term biliary obstruction, infection, and inflammation which in turn leads to destruction of bile ducts and secondary biliary cirrhosis. Immunoglobulin G4 (IgG4)-positive sclerosing cholangitis might represent a separate entity

Differential Diagnosis of PSC

Diagnosis

I-Clinically A) Typical symptoms include right upper quadrant abdominal discomfort, fatigue, pruritus, and weight loss. Episodes of cholangitis (i.e., fever and chills) are very uncommon features at presentation, in the absence of prior biliary surgery or instrumentation such as ERC. B) Physical examination is abnormal in approximately half of symptomatic patients at the time of diagnosis; jaundice, hepatomegaly, and splenomegaly are the most frequent abnormal findings.

Many patients with PSC are asymptomatic with no physical abnormalities at presentation. The diagnosis is made incidentally when persistently cholestatic liver function tests are investigated. Approximately 60%-80% of patients with PSC have concomitant IBD, most often ulcerative colitis .

II- Serum Biochemical Tests Elevation of serum alkaline phosphatase is the most common biochemical abnormality but m.b normal . Serum aminotransferase levels are elevated in the majority of patients (2-3 times upper limits of normal), but can also be normal. Serum bilirubin is normal at diagnosis in the majority of patients. IgG serum levels are modestly elevated in approximately 60% of patients (1.5 times the upper limit of normal).

III- Autoantibodies/Serology. They have no role in the routine diagnosis of PSC including the perinuclear antineutrophil cytoplasmic antibody which is nonspecific, although it may draw attention to colon involvement in a cholestatic syndrome.

IV- Imaging Studies. A) Transabdominal ultrasound (US) is usually nondiagnostic and may even be normal, although bile duct wall thickening and/or focal bile duct dilatations are often identified. However, gallbladder abnormalities are identified in up to 41% of patients with PSC who undergo US examinations. B) The findings on computed tomography (CT) of the upper abdomen are also nonspecific. It should be noted that lymphadenopathy in the abdomen is common in PSC and should not be over interpreted as metastases or a lymphoproliferative disorder

ERC was regarded as the gold standard in diagnosis but it is an invasive procedure associated with potentially serious complications such as pancreatitis and bacterial cholangitis. It is associated with hospitalization in up to 10% of PSC patients undergoing the procedure MRC, which is non-invasive and avoids radiation exposure, has become the diagnostic imaging modality of choice when PSC is suspected.

V- Role of Liver Biopsy In general the changes at an early stage are non-specific. Periductal concentric (“onion-skin”) fibrosis is a classic histopathologic finding, but this observation is infrequent in PSC liver biopsy specimens and may also be observed in SSC. In the presence of an abnormal cholangiogram, a liver biopsy is therefore not required to establish a diagnosis of large duct PSC, although is essential in suspected small duct PSC, and for the assessment of possible overlap syndromes.

Algorithm for diagnosis

Home Work Autoimmune Pancreatitis (Immunoglobulin G4– Associated Cholangitis) and PSC. Dominant Strictures in PSC Portal Hypertension Metabolic Bone Disease Inflammatory Bowel Disease and PSC Gallbladder Disease and PSC

Recommendations for treatment: In adult patients with PSC, we recommend against the use of UDCA as medical therapy . In adult patients with PSC and overlap syndrome, we recommend the use of corticosteroids and other immunosuppressive agents for medical therapy. ???Transplantation

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