Primary sclerosing cholangitis causing intrahepatic cholestasis – morning report 7.31.2019

Today at morning report we had an interesting case of young patient with jaundice, pruritus, abdominal pain and weight loss. ANCA was positive. Following liver biopsy and MRCP the patient was diagnosed with primary sclerosing cholangitis and ultimately with Crohn’s.

We also discussed this great article from NEJM about DILI (nejmra1816149) which describes 3 patterns of liver injury which each have several phenotypes:

  • Direct which can be further differentiated to acute hepatic necrosis (acetaminophen), Sinusoidal obstruction syndrome, nodular regeneration
  • Idiosyncratic  can be further differentiated to acute hepatocellular (nitrofurantoin), cholestatic (amox-clav),  mixed, chronic hepatitis
  • Indirect which is mostly related to antineoplastic agents or monoclonal antibodies

Dr. Suneja presented his schema for biliary obstruction:

  • Extrahepatic:
    • Extrinsic from tumors, Mirizzi syndrome
    • Intrinsic from stones, autoimmune, AIDS, parasites
  • Intrahepatic:
    • Extrinsic from liver disease (viral / NASH / alcohol)
    • Intrinsic from autoimmune (PBC/PSC), infiltrative (hemochromatosis, sarcoidosis)

We also mentioned Lakshmi’s ACP vignette which described a young immigrant which presented with abdominal pain and was found to have hepatic biliary ascariasis.

 

AS

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