What is the role of pruritus in the pathophysiology of cholestasis?

Updated: Aug 09, 2017
  • Author: Hisham Nazer, MBBCh, FRCP, DTM&H; Chief Editor: Carmen Cuffari, MD  more...
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One very common clinical consequence of cholestasis is pruritus. Several links to its pathogenesis have been proposed, including the role of bile acids, endogenous opioid and serotonins, and lysophosphatidic acid. The mechanism of pruritus in liver disease is not entirely understood, and major debate concerns its relationship to the retention of bile salts. The serum or tissue concentrations of bile salts do not correlate well with the degree of pruritus, although all patients with pruritus related to liver disease have significant elevations of serum bile salts. Therapeutic approaches that reduce pruritus generally also reduce serum bile salt concentrations.

Newer theories suggest that patients have differing sensitivities to elevated bile salt concentrations, which act on peripheral pain afferent nerves to produce the sensation of itching. This stimulation involves opiate-mediated pathways, and opiate antagonists can block cholestasis-associated itching. Itching does not appear to be associated with histamine release, and antihistamine therapy is generally ineffective. Ultraviolet B phototherapy has been successfully used to treat pruritus.

Decock et al have reported that ultraviolet B phototherapy appears to be a promising and well-tolerated treatment for cholestasis-associated pruritus. [6]

For patients with cholestasis, pruritus may be a minimal problem, or it may seriously impair the quality of life. Scratching is the most measurable effect of pruritus. The degree of pruritus can be quantitated by clinical findings related to scratching, which has been useful in monitoring patient response to therapy.

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