16-25: Primary Sclerosing Cholangitis

GENERAL CONSIDERATIONS

Primary sclerosing cholangitis is an uncommon disease thought to result from an increased immune response to intestinal endotoxins and characterized by diffuse inflammation of the biliary tract leading to fibrosis and strictures of the biliary system (eFigure 16–55). From 60% to 70% of affected persons are male, usually 20–50 years of age (median age 41). The incidence is nearly 3.3 per 100,000 in Asian Americans, 2.8 per 100,000 in Hispanic Americans, and 2.1 per 100,000 in African Americans, with an intermediate (and increasing) incidence in whites and a prevalence of 16.2 per 100,000 population (21 per 100,000 men and 6 per 100,000 women) in the United States.

Primary sclerosing cholangitis is closely associated with inflammatory bowel disease (more commonly ulcerative colitis than Crohn colitis), which is present in approximately two-thirds of patients with primary sclerosing cholangitis; however, clinically significant sclerosing cholangitis develops in only 1–4% of patients with ulcerative colitis. The association with inflammatory bowel disease has suggested a role for intestinal microbial dysbiosis in the pathogenesis of primary sclerosing cholangitis. Smoking is associated with a decreased risk of primary sclerosing cholangitis in patients who also have inflammatory bowel disease. Coffee consumption is also associated with a decreased risk of primary sclerosing cholangitis, and statin use is associated with improved outcomes in patients with primary sclerosing cholangitis. Women with primary sclerosing cholangitis may be more likely to have recurrent urinary tract infections and less likely to use hormone replacement therapy than healthy controls. Associations with cardiovascular disease and diabetes mellitus have been reported. Primary sclerosing cholangitis is associated with the histocompatibility antigens HLA-B8 and -DR3 or -DR4, and first-degree relatives of patients with primary sclerosing cholangitis have a fourfold increased risk of primary sclerosing cholangitis and a threefold increased risk of ulcerative colitis. A subset of patients with primary sclerosing cholangitis have increased serum IgG₄ levels and distinct HLA associations (with a poorer prognosis) but do not meet criteria for IgG₄-related sclerosing cholangitis. The diagnosis of primary sclerosing cholangitis may be difficult to make after biliary surgery.

CLINICAL FINDINGS

A. Symptoms and Signs

Primary sclerosing cholangitis presents as progressive obstructive jaundice, frequently associated with fatigue, pruritus, anorexia, and indigestion. Patients may be diagnosed in the presymptomatic phase because of an elevated alkaline phosphatase level or a subclinical phase based ...