Cholestasis of Pregnancy Case File

https://medical-phd.blogspot.com/2021/03/cholestasis-of-pregnancy-case-file.html

Eugene C.Toy, MD, William E. Seifert, Jr., PHD, Henry W. Strobel, PHD, Konrad P. Harms, MD

❖ CASE 33
A 26-year-old female at 35 weeks gestation presents to the clinic with complaints of generalized
itching. Patient reports no rash or skin changes. She denies any change in clothing detergent, soaps,
or perfumes. She denies nausea and vomiting and otherwise feels well. On physical exam, there are
no rashes apparent on her skin and only some excoriations from itching. Blood work reveals
slightly elevated serum transaminase and bilirubin levels.

◆ What is the patient’s likely diagnosis?

◆ What are treatment options?

◆ What is the cause of the patient’s generalized itching?

ANSWERS TO CASE 33: CHOLESTASIS OF PREGNANCY

Summary: A 26-year-old female at 35 weeks gestation with generalized pruritus without a rash and
slightly elevated liver transaminases and bilirubin.

◆ Diagnosis: Cholestasis of pregnancy.

◆ Treatment options: Oral antihistamines, cholestyramine, ursodeoxycholic acid.

◆ Etiology of generalized itching: Increased serum bile salts and accumulation of bile salts in the
dermis of the skin.

CLINICAL CORRELATION
Cholestasis of pregnancy is a condition in which the normal flow of bile from the gallbladder is
impeded, leading to accumulation of bile salts in the body. Generalized itching and, possibly,
jaundice may result. It is speculated that the hormones such as estrogen and progesterone, which
are elevated in pregnancy, cause a slowing of the gallbladder function, leading to this disorder.
Uncomplicated cholestasis is usually diagnosed clinically by generalized itching in a pregnant
woman, usually in the third trimester without a rash. Elevated serum levels of bile salts can help to
confirm the diagnosis. Elevated bilirubin levels or liver transaminase enzymes may also be seen.
The usual treatment includes antihistamine medications for the itching. Some experts recommend
ursodeoxycholic acid, a naturally occurring bile acid that seems to improve liver function and may
reduce the serum bile acid concentration. More severe cases may require bile salt binders such as
cholestyramine or corticosteroids.
APPROACH TO BILE SALTS

Objectives
1. Be able to describe the catabolism and metabolism of bile salts.
2. Biochemical mechanism of action of cholestyramine and ursodeoxycholic acid.

Definitions

Bile acids: The major metabolites of cholesterol, which are synthesized in the liver and stored in
the gallbladder for use as emulsifiers in the digestion of lipids. Primary bile acids are those
synthesized directly from cholesterol in the liver; Secondary bile acids are metabolites of primary
bile acids produced by the action of intestinal bacteria.

Bile salts: The ionized form of bile acids, which is the state that bile acids exist at physiologic
conditions.

Cholestyramine: A synthetic, strongly basic anion exchange resin that will strongly bind bile salts
when taken orally and prevent their reabsorption in the intestinal tract.

Conjugated bile salts: Bile salts whose carboxylate groups have been enzymatically condensed
with the amino groups of either of the amino acids glycine or taurine to form the glyco- or
tauroconjugates. This conjugation extends the pH range over which the bile salts are ionized and
therefore effective emulsifying agents.

Ursodeoxycholic acid: A naturally occurring bile acid (originally isolated from the bile of bears)
that is present in minor concentrations in the bile (approximately 1 to 10 percent). When
administered orally, it helps to dissolve cholesterol gallstones.