Biliary drainage transiently relieves intractable pruritus in primary biliary cirrhosis
Authors: Ulrich Beuers, Guido Gerken, Thomas Pusl
Journal: Hepatology (2006)

To the Editor: We read with interest the report by Stapelbroek et al. on nasobiliary drainage inducing long-lasting relief of pruritus in benign recurrent intrahepatic cholestasis (BRIC).1 Pruritus may be a severely disabling symptom also for patients with primary biliary cirrhosis (PBC) who do not respond to standard antipruritic treatment with ursodeoxycholic acid, anion exchangers, enzyme inducers, or opiate antagonists.2 In contrast to PBC, severe intractable pruritus is rarely observed in primary sclerosing cholangitis (PSC) when adequate dilatation/short-term stenting of major bile duct strictures of the biliary tree is performed. We applied nasobiliary drainage in patients with PBC to relieve otherwise intractable severe pruritus3-5 and to exclude a component of mechanical biliary obstruction as a contributing factor. Within a period of 3 years (February 2001- February 2004), 107 patients with PBC and 82 patients with PSC were seen on a regular basis in our outpatient clinic in Munich. All patients were treated with ursodeoxycholic acid. Patients with PBC underwent endoscopic retrograde cholangiography (ERC) when severe intractable pruritus as defined by severity of pruritus ≥7 on a scale between 0 and 10 on at least 4 of 7 days despite treatment with colestyramine (≥8 g/day), rifampicin (300-600 mg/day), and naltrexone (50 mg/day), each for ≥4 weeks, was diagnosed. Endoscopic papillotomy (EPT) and nasobiliary drainage for 4 days were scheduled after written informed consent when two of three criteria for defective papillary function were observed (bile duct dilatation, lack of bile in duodenum, delayed release of contrast medium). Serum and biliary bile acid analysis was performed by gas chromatography. Three of 107 patients with PBC (stage II, serum bilirubin <2 mg/dL), but none of 82 patients with PSC regularly seen suffered from severe intractable pruritus during the observation period. All three PBC patients with severe intractable pruritus fulfilled 3 (patient A) or 2 (patients B, C) indirect criteria for papillary dysfunction. ERC, EPT, and nasobiliary drainage for (A) 7, (B) 4, and (C) 1.3 days were performed without complications. Within 24 hours, 2 of 3 patients (A,B) were completely free of pruritus and remained free for 2 weeks and 1 week, respectively, while the third (C) reported major improvement (2/10), but tolerated the nasobiliary tube only one night. Pruritus returned to pretreatment levels after 5 months (A), and 2 weeks (B, C). After a transient decrease, serum bile acids showed no association with intensity of pruritus after nasobiliary drainage, and bile acid pattern was not markedly changed (Table 1). We confirm that severe intractable pruritus is transiently relieved by biliary drainage also in PBC and that mechanical bile duct obstruction might be considered a minor contributing factor not only in PSC, but also in single cases of PBC. A direct role of bile acids in the induction of intractable pruritus in PBC may be questioned in view of a lack of association of bile acid levels and intensity of pruritus after nasobiliary drainage. The data rather favour an indirect effect of bile acids (if any) like transcriptional modulation of expression of an unidentified pruritogen in susceptible individuals. Ulrich Beuers*, Guido Gerken , Thomas Pusl*, * Department of Medicine II, Klinikum Grosshadern, University of Munich, Munich, Germany, Department of Gastroenterology, Klinikum of the University of Essen, Essen, Germany.