Liver cells produce bile, which, in a healthy body, flows from the liver into the first section of the small intestine, the duodenum. Cholestasis occurs when something blocks or slows this transport. Multiple conditions can cause cholestasis, resulting in similar symptoms but varying treatments and outlooks.
Causes Within the Liver
Cholestasis originating in the liver is called intrahepatic cholestasis. Multiple conditions cause it, including alcoholic liver disease, bacterial abscesses, extended use of IV or parenteral nutrition, lymphoma, cirrhosis, pregnancy, hepatitis, tuberculosis, certain medications, or serious infections in the bloodstream. Primary or metastatic liver cancer can also cause this type of cholestasis.
Causes Outside the Liver
Extrahepatic cholestasis results from something outside the liver. Conditions that affect the common bile duct are likely to cause this type, including stones, strictures or narrowing, and bile duct tumors. Pressure on the duct from a nearby tumor or mass can cause it, as can pancreatitis or a pancreatic tumor.
Jaundice
Jaundice is the main symptom of cholestasis. Because bile does not freely flow into the duodenum, the excess bilirubin it contains accumulates in the skin, turning it yellow. The whites of the eyes may appear yellow as well. Jaundice also causes the skin to itch, likely from too much bile in the skin.
Other Symptoms
In cholestasis, the lack of bile may cause stools that are light in color. Fatty stool may also result because bile is not flowing into the small intestine to help digest it. Urine may be dark, as the kidneys are excreting excess bilirubin. If cholestasis continues for an extended period, the lack of bile can cause malabsorption of calcium and vitamin D, leading to bone loss. Depending on the cause, people with cholestasis may experience vomiting, fever, abdominal pain, and loss of appetite. Fatigue is another common symptom and may be quite profound.
Lab Tests
Blood tests for cholestasis may show elevated bilirubin and alkaline phosphatase, particularly if the condition continues untreated. Bilirubin is what gives bile its yellow color and is also made by the liver. Alkaline phosphatase is a protein enzyme found in high levels in the bile ducts and liver.
Imaging
When bilirubin and alkaline phosphatase levels are abnormal, imaging is the next step. Doctors will almost always perform an ultrasound and, in some cases, they will also order a CT or MRI scan to gather more information. If the cause is intrahepatic, a liver biopsy can provide a definitive diagnosis for what is causing the cholestasis.
ERCP
An endoscopic retrograde cholangiopancreatography (ERCP) can give doctors a more precise image of the bile ducts. During this procedure, the physician inserts a thin, flexible tube into the mouth, through the esophagus and stomach, and into the small intestine to inject contrast dye into the bile and pancreatic ducts. The contrast is visible on x-ray, allowing for visualization of the ducts.
Treatment
Treatment of cholestasis depends on the cause. Endoscopy can treat blockages in the bile ducts; the surgeon inserts through the mouth a flexible tube with a camera and surgical instruments attached. Blockages in the liver are usually treated surgically. People with cholestasis should also avoid alcohol or medications that are hard on the liver.
Prognosis
The prognosis for cholestasis depends on the underlying cause. In some cases, doctors place stents to open narrowed or blocked areas of the bile duct. If stones are the cause, they can be removed and the cholestasis cured. If medication caused the liver damage, the condition often goes away when the person stops taking the drug.
Complications
Cholestasis can lead to several complications, especially if it continues for an extended period. Itching from jaundice can be quite severe, and scratching can cause sores on the skin. Poor absorption in the small intestine can lead to malnutrition and weak bones over time. If sepsis occurs due to an infection, organ failure can result.