DISEASE

Primary Biliary Cirrhosis

OVERVIEW | CAUSES | RISK FACTORS | SYMPTOMS | COMPLICATION | DIAGNOSIS | TREATMENT | PREVENTION | REFERENCES

Primary Biliary Cirrhosis/ Cholangitis

OVERVIEW

Primary biliary cholangitis, previously called primary biliary cirrhosis, is a chronic disease in which the bile ducts in your liver are slowly destroyed. Bile is a fluid made in your liver. It aids with digestion and helps your body get rid of cholesterol, toxins and worn-out red blood cells.

When the bile ducts are damaged, bile can back up in your liver and sometimes lead to irreversible scarring of liver tissue (cirrhosis).

Primary biliary cholangitis is considered an autoimmune disease, which means your body's immune system is mistakenly attacking healthy cells and tissue. Researchers think a combination of genetic and environmental factors triggers the disease. It usually develops slowly. Medication can slow liver damage, especially if treatment begins early.

CAUSES

It's not clear what causes primary biliary cholangitis. Many experts consider it an autoimmune disease in which the body turns against its own cells.
The liver inflammation seen in primary biliary cholangitis starts when certain types of white blood cells called T cells (T lymphocytes) start to collect in the liver. Normally, these immune cells detect and help defend against germs, such as bacteria. But in primary biliary cholangitis, they mistakenly destroy the healthy cells lining the small bile ducts in the liver.
Inflammation in the smallest ducts spreads and eventually damages other cells in the liver. As the cells die, they're replaced by scar tissue (fibrosis) that can lead to cirrhosis. Cirrhosis is scarring of liver tissue that makes it difficult for your liver to work properly.

RISK FACTORS

The following factors may increase your risk of primary biliary cholangitis:

Sex. Most people with primary biliary cholangitis are women.
Age. It's most likely to occur in people 30 to 60 years old.
Genetic factors. You're more likely to get the condition if you have a family member who has or had it.
Geography. It's most common in northern Europe and North America.

Researchers think that genetic factors combined with certain environmental factors trigger primary biliary cholangitis. These environmental factors may include:

Infections caused by bacteria, fungi or parasites
Smoking
Toxic chemicals

SYMPTOMS

More than half the people with primary biliary cholangitis do not have any noticeable symptoms when diagnosed. The disease may be diagnosed when blood tests are done for other reasons. Symptoms eventually develop over the next five to 20 years. Those who do have symptoms at diagnosis typically have poorer outcomes.

Common early symptoms include:

Fatigue
Itchy skin
Dry eyes and mouth

Later signs and symptoms may include:

Pain in the upper right abdomen
Swelling of the spleen
Bone, muscle or joint (musculoskeletal) pain
Swollen feet and ankles (edema)
Buildup of fluid in the abdomen due to liver failure (ascites)
Fatty deposits (xanthomas) on the skin around the eyes, eyelids or in the creases of the palms, soles, elbows or knees
Yellowing of the skin and eyes (jaundice)
Darkening of the skin that's not related to sun exposure (hyperpigmentation)
Weak and brittle bones (osteoporosis), which can lead to fractures
High cholesterol
Diarrhea, which may include greasy stools (steatorrhea)
Underactive thyroid (hypothyroidism)
Weight loss

COMPLICATIONS

As liver damage worsens, primary biliary cholangitis can cause serious health problems, including:

Liver scarring (cirrhosis). Cirrhosis makes it difficult for your liver to work and may lead to liver failure. It indicates the later stage of primary biliary cholangitis. People with primary biliary cholangitis and cirrhosis have a poor prognosis and higher risk of other complications.
Increased pressure in the portal vein (portal hypertension). Blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. When scar tissue from cirrhosis blocks normal blood flow through your liver, blood backs up. This causes increased pressure inside the vein. Also, because blood doesn't flow normally through your liver, drugs and other toxins aren't filtered properly from your bloodstream.
Enlarged spleen (splenomegaly). Your spleen can become swollen with white blood cells and platelets because your body no longer filters toxins out of the bloodstream as it should.
Gallstones and bile duct stones. If bile cannot flow through the bile ducts, it may harden into stones, causing pain and infection.
Enlarged veins (varices). When blood flow through the portal vein is slowed or blocked, blood may back up into other — usually those in your stomach and esophagus. Increased pressure may cause delicate veins to break open and bleed. Bleeding in the upper stomach or esophagus is a life-threatening emergency that requires immediate medical care.
Liver cancer. Liver scarring (cirrhosis) increases your risk of liver cancer.
Weak bones (osteoporosis). People with primary biliary cholangitis have an increased risk of weak, brittle bones that may break more easily.
Vitamin deficiencies. A lack of bile affects your digestive system's ability to absorb fats and the fat-soluble vitamins, A, D, E and K. Because of this, some people with advanced primary biliary may have low levels of these vitamins.
Decreased mental function (hepatic encephalopathy). Some people with primary biliary cholangitis with liver failure have personality changes and problems with memory and concentration.
Increased risk of other disease. Primary biliary cholangitis is associated with metabolic or immune system disorders, including thyroid problems, limited scleroderma (CREST syndrome) and rheumatoid arthritis.

DIAGNOSIS

Your doctor will ask you about your health history and your family's health history, and perform a physical exam.

The following tests and procedures may be used to diagnose primary biliary cholangitis.

Blood tests

Cholesterol test. More than half the people with primary biliary cholangitis have extreme increases in blood fats (lipids), including total cholesterol level.
Liver tests. These blood tests check the levels of enzymes that may signal liver disease and bile duct injury.
Antibody tests for signs of autoimmune disease. Blood tests may be done to check for anti-mitochondrial antibodies (AMAs). These substances almost never occur in people without the disease, even if they have other liver disorders. Therefore, a positive AMA test is considered a very reliable sign of the disease. However, a small number of people with primary biliary cirrhosis don't have AMAs.

Imaging Tests

Imaging tests may not be needed. However, they may help your doctor confirm a diagnosis or rule out other conditions with similar signs and symptoms. Imaging tests looking at the liver and bile ducts may include:

Ultrasound. Ultrasound uses high-frequency sound waves to produce images of structures inside your body.
Magnetic resonance cholangiopancreatography (MRCP). This special magnetic resonance imaging (MRI) exam creates detailed images of your organs and bile ducts.
Magnetic resonance elastography (MRE). MRI is combined with sound waves to create a visual map (elastogram) of internal organs. The test is used to detect hardening of your liver that might be a sign of cirrhosis.
Endoscopic retrograde cholangiopancreatography (ERCP). The doctor passes a thin, flexible tube down your throat and injects dye into the area of your small intestine where your bile ducts empty. A tiny camera attached to the end of the tube provides a picture of your bile ducts. This test may be done with or instead of an MRCP. But, it's invasive and may cause complications. With advances in MRI, it's usually not needed for diagnosis.

Biopsy

If the diagnosis is still uncertain, your doctor may perform a liver biopsy. A small sample of liver tissue is removed through a small incision using a thin needle. It's examined in a laboratory, either to confirm the diagnosis or to determine the extent (stage) of the disease.

TREATMENT

Treating the disease

There's no cure for primary biliary cholangitis, but medications are available to help slow the progression of the disease and prevent complications. Options include:

Ursodeoxycholic acid (UDCA). This medicine, also known as ursodiol (Actigall, Urso), is commonly used first. It helps move bile through your liver. UDCA doesn't cure primary biliary cholangitis, but it seems to improve liver function and reduce liver scarring. It's less likely to help with itching and fatigue. Side effects may include weight gain, hair loss and diarrhea.
Obeticholic acid (Ocaliva). This is the newest medication approved by the Food and Drug Administration for primary biliary cholangitis. Studies show that when given alone or combined with ursodiol for 12 months it can help improve liver function.
Fibrates (Tricor). Researchers aren't exactly sure how this medicine works to help ease primary biliary cholangitis symptoms. But, when taken with UDCA, it has reduced liver inflammation and itching in some people. More studies are needed to determine long-term benefits.
Other medications. Many other drugs have been used or studied for treating primary biliary cholangitis with mixed results. They include methotrexate (Trexall) and colchicine (Colcrys).
Liver transplant. When medications no longer control primary biliary cholangitis and the liver begins to fail, a liver transplant may help prolong life. A liver transplant replaces your diseased liver with a healthy one from a donor. Liver transplantation is associated with very good long-term outcomes for people with primary biliary cholangitis. However, sometimes the disease comes back several years later in the transplanted liver.

Treating the symptoms

Your doctor may recommend treatments to control the signs and symptoms of primary biliary cholangitis and make you more comfortable.

Treatment for fatigue

Primary biliary cholangitis causes fatigue. But, your daily habits and other health conditions can affect how tired you feel. Researchers are investigating whether a medicine called modafinil (Provigil) may help reduce fatigue in people with primary biliary cholangitis. More research is needed.

Treatment for itching

Antihistamines such as diphenhydramine (Benadryl, others) and loratadine (Claritin, others) are commonly used to reduce itching. They may help with sleep if itching keeps you awake.
Cholestyramine (Questran) is a powder that must be mixed with food or liquids. Though cholestyramine works for most people, the taste is unpleasant.
Rifampin (Rifadin, others) is an antibiotic that may stop itching. Exactly how it does this is unknown. Researchers think it may block the brain's response to itch-inducing chemicals in the blood.
Opioid antagonists such as those containing naloxone (Bunavail, Evzio) and naltrexone (Vivitrol) may help itching related to liver disease. Like rifampin, these drugs seem to reduce the itching sensation by acting on your brain.

Treatment for dry eyes and mouth

Artificial tears and saliva substitutes, available over-the-counter or by prescription, can help ease dry eyes and mouth. Chewing gum or sucking on hard candy also can help you make more saliva and relieve dry mouth.

PREVENTION

Since the cause of the disease is not known, it is not possible to prevent PBC. However, medications may be able to slow the progression of the disease and control the symptoms.
Should a person develop PBC, all attempts should be made to prevent further potential damage. This may include limiting alcohol intake, avoiding the use of medications that contain acetaminophen (Tylenol, Panadol), and cholesterol lowering agents.