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Biliary obstruction, autoimmune diseases of the liver

Biliary obstruction, autoimmune diseases of the liver. John J O’Leary. Learning objectives. Understand bile duct obstruction [causes and effects] Understand what is meant by the term auto-immune liver disease: Primary biliary cirrhosis [PBC] Primary sclerosing cholangitis [PSC]

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Biliary obstruction, autoimmune diseases of the liver

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  1. Biliary obstruction, autoimmune diseases of the liver John J O’Leary

  2. Learning objectives • Understand bile duct obstruction [causes and effects] • Understand what is meant by the term auto-immune liver disease: • Primary biliary cirrhosis [PBC] • Primary sclerosing cholangitis [PSC] • Autoimmune hepatitis [AIH]

  3. Biliary obstruction

  4. Pathological effects of biliary obstruction Biliary obstruction High local concentration of bile salts Inflammation Fibrosis & scarring Biliary fistula

  5. Fibrosis and scarring Biliary stasis Liver atrophy Repeated cholangitis Biliary cirrhosis & portal HTN (very late)

  6. Causes of Benign strictures

  7. Causes of Malignant strictures

  8. Symptoms and history: • Biliary colic • Obstructive jaundice • Cholangitis – Charcot’s triad • jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. – Reynold’s pentad + hypotension and an altered mental state • Past history of cholecystectomy/ other GI surgery (eventful) • History s/o pancreatitis, trauma, radiation, alcohol abuse

  9. Signs: • Icterus • s/o hepatocellular failure • Courvoisier's sign • e/o biliary fistula, peritonitis, biloma • Nutritional deficiencies • pale stools • dark urine • itchiness (pruritus)

  10. HISTOPATHOLOGY Under a microscope, the individual hepatocytes will have a brownish-green stippled appearance within the cytoplasm, representing bile that cannot get out of the cell. Canalicular bile plugs between individual hepatocytes or within bile ducts may also be seen, representing bile that has been excreted from the hepatocytes but cannot go any further due to the obstruction. When these plugs occur within the bile duct, sufficient pressure (caused by bile accumulation) can cause them to rupture, spilling bile into the surrounding tissue, causing hepatic necrosis. These areas are known as bile lakes, and are typically seen only with extra-hepatic obstruction.

  11. Strasberg classification of biliary injury & stricture

  12. Laboratory investigations • Bilirubin • Alkaline phosphatase & GGT • PT • Anemia, amylase & lipase, ESR, LDH • Tumor markers: CA 19-9, CEA, AFP

  13. Imaging studies: • Ultrasound • CT scan • MRCP • HIDA scan • ERCP • Endoscopic ultrasound • PTC • Fistulography

  14. Ultrasonography: • Detects intra/extra hepatic ductal dilatation • Less accuracy in defining etiology • Sensitivity – 94% if bilirubin > 10mg% – 47% otherwise

  15. Endoscopic ultrasound: • Extra hepatic bile duct readily visualized • Detects choledocholithiasis (>95%) • Sensitive in diagnosis & staging of malignancy

  16. CT Scan: • Highly sensitive (esp. with contrast) • Detects site & cause of obstruction • Better anatomical delineation • CT cholangiography

  17. MRI & MRCP: • Bile – high signal intensity on T2 weighted images • Visualises – biliary dilatation (97-100%), site of obstruction (87%), hepatic parenchyma & vasculature • Only diagnostic

  18. HIDA Scan[Hepatobiliary Imino-Diacetic Acid scan] • Helps in diagnosing biliary leaks • Provides functional assessment of incomplete strictures and surgical anastomosis • suggest complete biliary obstruction if the small intestine is not visualized in 60 minutes • insensitive for helping detect biliary dilatation or the site and cause of bile duct obstruction

  19. Cholangiography: • Gold standard • Endoscopic/ percutaneous • Features: • define the anatomy of the proximal biliary tree • decompression of the biliary system • Non-operative dilation of bile duct strictures • allow for the simultaneous placement of drainage catheters • of assistance with regard to surgical reconstruction

  20. Treatment: • Options: • Endoscopic or percutaneous balloon dilatation and insertion of an endoprosthesis • Surgery • Pre-procedure antibiotic prophylaxis

  21. RX of malignant strictures: • Depends on: resectability & stage general condition • Resectable (15-20%) – Radical resection with biliary enteric anastomosis • Palliative – endoscopic stenting – percutaneous transhepatic stenting • Palliative resection with surgical bypass (mortality – 33%)

  22. RX of benign strictures: • Operative management • to surgically re-establish bile flow within the biliary tree and into the proximal gastrointestinal tract in a manner that prevents cholestasis, cholangitis, sludge and stone formation, restricture, or biliary cirrhosis • Non–operative management • to correct the increased resistance to biliary flow caused by a reduction in the diameter of the lumen

  23. Autoimmune diseases of the liver

  24. Autoimmune liver disease • Primary biliary cirrhosis • Primary sclerosing cholangitis • Autoimmune hepatitis

  25. Primary biliary cirrhosis

  26. PRIMARY BILIARY CIRRHOSIS • Primary biliary cirrhosis is an autoimmune disease of the liver marked by: • the slow progressive destruction of the small bile ducts (bile canaliculi) within the liver. • when these ducts are damaged, bile builds up in the liver (cholestasis) and over time damages the tissue. • this can lead to scarring, fibrosis and cirrhosis. • it was previously thought to be a rare disease, but more recent studies have shown that it may affect up to 1 in 3-4,000 people; the sex ratio is at least 9:1 (women to men)

  27. In some areas of the US and UK the prevalence is estimated to be as high as 1 in 4000. This is much more common than in South America or Africa, which may be due to better recognition in the US and UK. First-degree relatives may have as much as a 500 times increase in prevalence, but there is debate if this risk is greater in the same generation relatives or the one that follows. After liver transplant, the recurrence rate may be as high as 18% at 5 years, and up to 30% at 10 years. There is no consensus on risk factors for recurrence of the disease

  28. The following signs may be present in PBC: • Fatigue • Pruritus (itchy skin) • Jaundice (yellowing of the eyes and skin) • Xanthelasmata (focal collections of cholesterol in the skin, especially around the eyes) • Complications of cirrhosis and portal hypertension: • Fluid retention in the abdomen (ascites) • Hypersplenism • Esophageal varices • Hepatic encephalopathy, up to coma, in extreme cases. • Association with extra-hepatic autoimmune disorder[s] such as Rheumatoid arthritis or Sjögren's syndrome (up to 80% incidence).

  29. To diagnose PBC, distinctions should be established from other conditions with similar symptoms, such as autoimmune hepatitis or primary sclerosing cholangitis (PSC). • Diagnostic blood tests include: • Abnormal liver function tests (high alkaline phosphatase, elevated AST, ALT) • Presence of certain antibodies: antimitochondrial antibody, antinuclear antibody (the M2-IgG antimitochondrial antibody is the most specific test) • Abdominal ultrasound or a CT scan is usually performed to rule out blockage to the bile ducts. Previously most suspected sufferers underwent a liver biopsy, and - if uncertainty remained - endoscopic retrograde cholangiopancreatography (ERCP, an endoscopic investigation of the bile duct). Now most patients are diagnosed without invasive investigation since the combination of anti-mitochondrial antibodies (see below) and typical (cholestatic) liver function tests are considered diagnostic. However, a liver biopsy is necessary to determine the stage of disease. • Anti-nuclear antibodies appear to be prognostic agents in PBC. Anti-glycoprotein-210 antibodies, and to a lessor degree anti-p62 antibodies correlate with progression toward end stage liver failure. Anti-centromere antibodies correlate with developing portal hypertension. Anti-np62 and anti-sp100 are also found in association with PBC.

  30. STAGES OF DISEASE • Stage 1 - Portal Stage: Normal sized triads; portal inflammation, subtle bile duct damage. Granulomas are often detected in this stage. • Stage 2 - Periportal Stage: Enlarged triads; periportal fibrosis and/or inflammation. Typically characterized by the finding of a proliferation of small bile ducts. • Stage 3 - Septal Stage: Active and/or passive fibrous septa. • Stage 4 - Biliary Cirrhosis: Nodules present; garland or jigsaw pattern.

  31. The cause of the disease is unknown at this time • an immunological basis for the disease, making it an autoimmune disorder. • most patients (>90%) have anti-mitochondrial antibodies (AMAs) against pyruvate dehydrogenase complex (PDC-E2), an enzyme complex that is found in mitochondria. • an increase in GGT could indicate presence of Primary Biliary Cirrhosis. • 57% of patients with acute liver failure have anti-transglutaminase antibodies suggesting a role of gluten sensitivity in primary biliary cirrhosis, and primary biliary cirrhosis is considerably more common in gluten sensitive enteropathy than the normal population. • in some cases of disease protein expression may cause an immune tolerance failure, as might be the case with gp210 and p62, nuclear pore proteins. Gp210 has increased expression in the bile duct of anti-gp210 positive patients. • Both proteins appear to be prognostic of liver failure relative to anti-mitochondrial antibodies.

  32. Course and cure of the disease: • no known cure, but medication may slow the progression • ursodeoxycholic acid (Ursodiol) is the most frequently used treatment. This helps reduce the cholestasis and improves blood test results (liver function tests). • to relieve itching caused by bile acids in circulation, which would normally be removed by the liver, cholestyramine (a bile acid sequestrant) may be prescribed to absorb bile acids in the gut and be eliminated, rather than re-enter the blood stream. • alcoholic beverages are contraindicated. • in advanced cases, a liver transplant, if successful, results in a favourable prognosis. • multivitamins (esp. Vitamin D) and calcium are also recommended as patients with PBC have poor lipid-dependent absorption of Vitamins A, D, E, K.

  33. Contrast-enhanced helical CT image obtained through liver during hepatic arterial phase shows several small, homogeneously enhancing lesions (arrows). Multiple lesions were seen throughout remainder of liver as well.

  34. Primary sclerosing cholangitis

  35. Primary sclerosing cholangitis (PSC) is a chronic liver disease caused by progressive inflammation and scarring of the bile ducts of the liver. The inflammation impedes the flow of bile to the gut, which can ultimately lead to liver cirrhosis and liver failure. The underlying cause of the inflammation is believed to be autoimmunity. The definitive treatment is liver transplantation.

  36. The cause(s) for PSC are unknown. It is often considered to be an autoimmune disorder. PSC is associated with inflammatory bowel disease and particularly ulcerative colitis, which coexists in approximately 70% of patients. Conversely, the prevalence of PSC in ulcerative colitis patients is ~4%. There is a 2:1 male-to-female predilection of PSC. There is an increased prevalence of HLA alleles A1, B8, and DR3 in PSC.

  37. The disease normally starts from age 30 to 60, though may begin in childhood. PSC progresses slowly, so the disease can be active for a long time before it is noticed or diagnosed.

  38. Signs and symptoms • Fatigue • Severe jaundice with intense itching • Malabsorption (especially of fat) and steatorrhea, leading to decreased levels of the fat-soluble vitamins, A, D, E and K. • Signs of cirrhosis • Ascending cholangitis, or infection of the bile duct. • Pale stools due to biliary obstruction • Dark urine due to excess conjugated bilirubin, which is water soluble, being excreted by the kidneys

  39. Diagnosis: • - imaging of the bile duct [ERCP], • - magnetic resonance cholangio-pancreatography (MRCP), • - approximately 80% of patients have perinuclear antineutrophil cytoplasmic antibodies, also called p-ANCA, however this finding is not specific for PSC. • - antinuclear antibodies and anti-smooth muscle antibodies are found in 20%-50% of PSC patients and, likewise, are not specific for the disease. • - full blood count, liver enzymes, bilirubin levels (usually grossly elevated), renal function, electrolytes. • faecal fat determination is occasionally ordered when the symptoms of malabsorption are prominent. • The differential diagnosis can include: primary biliary cirrhosis, drug induced cholestasis, cholangiocarcinoma, and HIV-associated cholangiopathy.

  40. Treatment: • ursodiol, a bile acid naturally produced by the liver, which has been shown to lower elevated liver enzyme numbers in people with PSC, but has not yet been proven effective at prolonging the life of the liver. • medication to relieve itching (antipruritics) and bile acid sequestrants (cholestyramine), antibiotics to treat infections, and vitamin supplements, as people with PSC are often deficient in vitamin A, vitamin D, vitamin E and vitamin K. • in some cases, ERCP, which may involve stenting of the common bile duct, may be necessary in order to open major blockages (dominant strictures). • - Liver transplantation is the only proven long-term treatment of PSC. Indications for transplantation include recurrent bacterial cholangitis, jaundice refractory to medical and endoscopic treatment, decompensated cirrhosis and complications of portal hypertension.

  41. PSC is associated with cholangiocarcinoma

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