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Cholestasis (cholestasis) is a situation where the flow of bile is blocked. Bile produced by liver cells is essential for the digestion of food, especially fats, and for the absorption of fat-soluble vitamins. Cholestasis is its pathology.
In what situations do we deal with cholestasis, how is it diagnosed and treated – these questions are answered bow. med. Ewa Godziemba-Maliszewska, gastrologist from the Department of Internal Diseases and Gastroenterology of the Food and Nutrition Institute in Warsaw
— Doctor, what is the path of bile in the body?
– The bile duct system that carries bile out of the liver is like a very thin tube system. Those with the smallest diameter then merge into larger ducts: the left hepatic duct and the right hepatic duct. They, in turn, connect with the duct of the gallbladder into the common bile duct, which carries bile into the duodenum at a place called the hepatopancreatic bulb. After bile enters the duodenum and the further part of the small intestine, it is involved in the metabolism of fats.
Why does bile flow sometimes stop?
– There are many reasons. There are two types of cholestasis. There may be intrahepatic (impaired bile production) and extrahepatic (impaired bile drainage) cholestasis. All the factors that damage liver cells contribute to the occurrence of intrahepatic cholestasis, thus disrupting the production of bile and its normal composition. Alcoholic and non-alcoholic fatty liver is also one of the diseases associated with cholestasis. One should also not forget about all kinds of infections and sepsis (systemic infection), which disturb the process of bile production and transport by impairing the functions of protein transport systems. However, these are less common causes of cholestasis.
Extrahepatic cholestasis affects the biliary tract. Any disease of the bile ducts, i.e. cholelithiasis, biliary neoplasm, pancreatic diseases: chronic pancreatitis, pancreatic head cancer, pressure on the bile ducts – all of this can be a cause of obstruction of the outflow of bile and its retention in the liver, i.e. cholestasis.
– What symptoms may suggest cholestasis?
– Patients very often complain of generalized itching of the skin, which intensifies especially when the body is warmed up in the evening, which leads to sleep disorders and significantly impairs the quality of life. In patients with such symptoms, laboratory tests often show elevated levels of bilirubin, increased levels of alkaline phosphatase (ALP) and gamma-glumyltranspeptidase (GGTP). These are enzymes produced by the liver cells that show increased activity in people with cholestatic liver disease. Sometimes the activity of transaminases (ALT, AST) is also increased.
Additional symptoms, caused by a lack of bile, may be enlarged liver, sometimes spleen, stool discoloration. Normally, stools tend to be yellow or brown. If it is white, it may suggest disturbances in bile outflow, its stagnation, because it is bile that makes the stool darker. Of course, with a deficiency of bile, various digestive disorders occur, especially in the absorption of fat and fat-soluble vitamins: A, D, E, K.
– What are the causes of cholestasis during pregnancy and can it endanger the baby?
– In the third trimester of pregnancy, women may have a so-called gestational cholestasis. Hormonal factors (higher concentration of estrogens and progesterone), genetic and environmental factors (nutritional deficiencies of certain elements, e.g. selenium) play an important role. It is also taken into account that the child in the womb is already large at this time, the uterus is rapidly enlarging, it can put pressure on the liver, especially in a person who gained significant weight during pregnancy. Laboratory tests show elevated levels of bilirubin, parameters of cholestasis. These symptoms disappear after the baby is born. Gestational cholestasis is not life threatening to the mother. It is also rarely a serious threat to the fetus. Most often, children of mothers who develop symptoms of gestational cholestasis develop normally. It is primarily a mother’s disease. A baby may be at risk of neonatal jaundice, but this is a completely different problem. A child of a woman who has cholestasis does not have to have jaundice, and vice versa. The woman may not have gestational cholestasis and the baby may have neonatal jaundice postpartum.
– How should we react to non-allergic chronic itching of the skin?
– Any persistent itching of the skin needs to be explained. You should see a doctor and perform laboratory tests, the so-called liver tests, as well as ultrasound of the abdominal cavity. This research will help us clarify whether we are dealing with cholestasis as the cause of itchy skin. If, for example, ultrasound reveals small stones in the gallbladder, especially deposits in the bile ducts, there is a high probability of cholestasis because the bile outflow may be blocked by the deposits. Ultrasonography can also reveal possible damage to the pancreas – chronic pancreatitis and in the course of it enlargement of the pancreas head or find a focal lesion of the pancreatic head, most often cancer. These changes can narrow the bile ducts and cause impaired bile outflow, i.e. cause cholestasis. Sometimes the cause of cholestasis is pancreatic cysts, which can put pressure on the common bile duct. In conclusion, we can say that anything that causes damage to the bile ducts and anything that causes damage to the liver can cause cholestasis.
– What is the treatment of cholestasis?
– It depends on the cause of cholestasis. If there are deposits or bile mud in the bile ducts, endoscopic surgery is currently the most common method. We insert the endoscope into the gastrointestinal tract, come to the Vater’s nipple, incise it, insert a special “brush” and clean the common bile duct. If the cause of cholestasis is a pancreatic head tumor that does not infiltrate blood vessels, we treat it surgically. If it is an advanced cancer of the pancreas, infiltrating other organs, we insert a special tube (stent) into the bile ducts endoscopically to facilitate the outflow of bile. When cholestasis is caused by any liver disease, we treat the liver disease. It is also advisable to take care of the correct composition of bile. Above all, you should drink a lot so as not to thicken your bile. You can take medications that dilate the bile ducts or increase the flow of bile through the bile ducts, the so-called choleretic drugs. Of the other drugs, only ursodeoxycholic acid is administered. This is called tertiary bile acid. The liver produces primary bile acids. They enter the intestines, where secondary bile acids and tertiary bile acid – ursodeoxycholic acid are produced. The name of this compound comes from the fact that it was first isolated from bear bile. This synthesized acid acts as a drug, the only specific drug used in the treatment of certain types of cholestasis. It has the ability to dissolve cholesterol deposits (but only 40 percent). It is also considered to be the only drug that helps with autoimmune liver diseases such as primary biliary cirrhosis or primary sclerosing cholangitis. This drug has been shown to reduce cholestasis and can prevent bile stasis if the cause is inside the liver and cells in this organ. There are no medications for the extrahepatic causes of cholestasis.
– Can cholestasis be prevented in any way?
– To some extent, it is prevented by the so-called healthy lifestyle: preventing obesity, preventing the occurrence of metabolic syndrome, not abusing alcohol, which contributes to fatty liver disease, its inflammation and, consequently, cirrhosis of the liver. Alcohol also causes chronic pancreatitis, the enlargement of which puts pressure on the bile duct. Women who use hormonal contraception and hormone replacement therapy must take into account the risk of gallstone disease, which is one of the most common causes of cholestasis. It is definitely worth monitoring the level of lipids in the blood and performing an ultrasound of the abdominal cavity from time to time, which allows early detection of changes in the liver and pancreas. You can then start treatment at an early stage of the disease.
Supporting the production of bile and its flow, it affects, among others Artichoke and Helichrysum. Try the EKO liver supporting tea, the composition of which includes, among others artichoke herb. We also recommend drying Helichrysum inflorescence for making tea. You can also take advantage of the chamomile flower, which has a supportive effect in the case of bile stagnation.
Text: Barbara Skrzypińska