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For further information, see CMDT Part 16-25: Primary Sclerosing Cholangitis

Key Features

Essentials of Diagnosis

  • Progressive jaundice, itching, and other features of cholestasis

  • Males, aged 20–50 years old

  • Often associated with ulcerative colitis

  • Diagnosis based on characteristic cholangiographic findings

  • At least 10% risk of cholangiocarcinoma

General Considerations

  • Characterized by diffuse inflammation of the biliary tract leading to fibrosis and strictures of the biliary system

  • Associated with the histocompatibility antigens HLA-B8 and -DR3 or -DR4

  • Occasional patients have clinical and histologic features of both sclerosing cholangitis and autoimmune hepatitis

  • 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 is difficult to make after biliary surgery or intrahepatic artery chemotherapy, which may result in bile duct injury

  • Primary sclerosing cholangitis must be distinguished from

    • Idiopathic adulthood ductopenia, a rare disorder affecting young to middle-aged adults who manifest cholestasis resulting from loss of interlobular and septal bile ducts yet who have a normal cholangiogram

    • Other cholangiopathies, including

      • Primary biliary cholangitis

      • Cystic fibrosis

      • Eosinophilic cholangitis

      • AIDS cholangiopathy

      • Histiocytosis X

      • Allograft rejection

      • Graft-versus-host disease

      • Ischemic cholangiopathy

      • Intra-arterial chemotherapy

      • Sarcoidosis

      • Post-COVID cholangiopathy


  • Between 60% and 70% of affected persons are male, usually 20–50 years old (median age 41)

  • Incidence

    • Nearly 3.3 per 100,000 in Asian Americans

    • ~2.8 per 100,000 in Hispanic Americans

    • ~2.1 per 100,000 in Blacks

    • Intermediate incidence in Whites (and increasing)

  • Prevalence: 16.2 per 100,000 population, 21 per 100,000 men and 6 per 100,000 women in the United States

  • Closely associated with inflammatory bowel disease (more commonly ulcerative colitis than Crohn colitis), which is present in approximately two-thirds of patients

  • However, clinically significant sclerosing cholangitis develops in only 1–4% of patients with ulcerative colitis

  • As in ulcerative colitis, smoking is associated with a decreased risk of primary sclerosing cholangitis; so is coffee consumption

Clinical Findings

Symptoms and Signs

  • Progressive obstructive jaundice, frequently associated with fatigue, pruritus, anorexia, and indigestion

  • Esophageal varices on initial endoscopy are most likely found in patients with a higher Mayo risk score based on age, serum bilirubin, albumin, and AST and a higher AST/ALT ratio

  • New varices are likely to develop in those with a lower platelet count and higher bilirubin at 2 years

  • In patients with primary sclerosing cholangitis, ulcerative colitis is frequently characterized by rectal sparing and backwash ileitis

  • Associations with cardiovascular disease and diabetes mellitus have been reported

  • Women with primary sclerosing cholangitis may be more likely to have recurrent urinary tract infections

Differential Diagnosis

  • Primary biliary cholangitis

  • Choledocholithiasis

  • Cancer of pancreas or biliary tract

  • Biliary stricture

  • Drug-induced cholestasis, eg, chlorpromazine

  • Inflammatory bowel ...

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