Cholestatic Pruritis

Ahmad Abid Abas 07-5-2

http://emedicine.medscape.com/article/1098029-overview#a0104

Pathophysiology

• Deposition of bile salts into the skin..?• Indirect hyperbilirubinemia ..?• Elevated venous histamine levels.• Retention of pruritogenic intermediates in bile

salt synthesis.• High hepatic concentrations of bile salts

resulting in hepatic injury (somewhat proven)

Pathophysiology

• Accumulation of endogenous opioids modulate pruritis increase opiodergic tone in the brain. (recent interest)

• Perhaps combination of the pruritogenic substances ( bile salts,histamine,opioids) induces cholestatic pruritis.

Etiology of Cholestatic Pruritis

Primary biliary cirrhosisPrimary sclerosing cholangitis Chronic hepatitis C Choledocholithiasis Obstructive carcinoma of the pancreas/biliary system Cholestasis of pregnancyEnd-stage liver disease of any cause.

Presentation

• Characterized by an intermittent, mild, and insidious onset that may be generalized or localized pruritis.

• Site - typically worse on the hands and feet and in areas under tight-fitting clothing.

• Associated fatigue in PBC.• Associated IBD in PSC.

Presentation

• Signs of liver disease include jaundice, spider angiomata, Dupuytren contractures, white nails, gynecomastia in men, xanthelasma, splenomegaly, and ascites.

Hematologic Pruritis (Iron Deficiency Induced Pruritis)

Ahmad Abid Abas 07-5-2

http://emedicine.medscape.com/article/1098029-overview#a0104

Pathophysiology

• Theory still controversial.

• Iron deficiency hasn’t proved to be the cause of pruritis. The variety of metabolic paths did.

• Patient with pruritis and iron deficiency doesn’t show anemia sometimes.This is a prove that pruritus is related to iron not hemoglobin.

• Iron deficiency induced-pruritis responds to iron supplementation.

Presentation

• Generalized pruritis; however, it may be localized, especially to the perianal and vulvar regions.

• Patients with iron deficiency may have pallor if they have anemia; they might also have glossitis and angular cheilitis.