In July, this blog reviewed a recent big study of primary sclerosing cholangitis (PSC) in adults with more than 7000 patients. A recent study in the pediatric age group enrolled 781 children from 36 institutions: MR Deneau et al. Hepatology 2017; 66: 518-27 (Congratulations to Nitika Gupta and Miriam Vos -in-town colleagues and contributing authors to this study.)
This retrospective study’s key findings:
- Median age 12 years at diagnosis; 39% were female
- Autoimmune hepatitis (overlap) was present in 33%
- Small-duct PSC was present in 13%
- Inflammatory bowel disease (IBD) was present in 76%
- PSC-IBD and Small-duct PSC (normal cholangiograms) had more favorable prognosis with hazard ratio of 0.6 of developing complications
- Portal hypertensive and biliary complications were noted in 38% and 25% respectively. After developing these complications, the median survival with native liver was 2.8 years and 3.5 years respectively
- Survival with native liver was noted in 70% at 5 years and 53% at 10 years
- Elevations in bilirubin, GGT, and AST-to-platelet count ratio were associated with highest risk of progressive disease.
- Cholangiocarcinoma (CCA) developed in 1% (median, 6 years after diagnosis)
The discussion notes that while pediatric PSC is a progressive disease, complications were slower to develop compared with adult-onset PSC. 10-year survival with native liver is typically lower in adults ~60% (vs 70% in this study). “Up to one third of adults with PSC may have esophageal varices within a year of diagnosis” compared with only 13% in this cohort. Dominant strictures are more common in adults, occurring in the majority within 5 years whereas this occurred in 16% of this cohort.
With regard to CCA, the authors note that current recommendations suggest starting to screen for CCA in patients over age 18 years with ultrasound and CA 19-9 at 6-12 month intervals. These studies “could reasonably be extended to PSC patients aged 15 and above and [for those requiring dilatation] of biliary strictures.”
My take: This large pediatric PSC study provides more clarity on the outcomes of patient’s with PSC and the associated conditions.
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This blog has reviewed multiple publications on primary sclerosing cholangitis (see blog posts below). Now, a study from 37 centers with 7121 patients with PSC has been published: TJ Weismuller et al. Gastroenterol 2017; 152: 1975-84. Given the relative infrequency of PSC, this retrospective report offers more insight into the predictors of the clinical course of PSC.
- Most of the patients in the study had large duct PSC (89.8%); 3.6% had small duct disease and 6.6% had overlapping PSC/autoimmune hepatitis.
- Mean age of cohort at diagnosis was 38.5 yrs.
- 70% of PSC patients developed IBD with ulcerative colitis (UC) about 5-times more common than Crohn’s disease.
- 37% of patients met the primary endpoint of either liver transplantation or death
- Individuals with small duct PSC had a favorable outcome; only one of 254 (0.4%) developed cholangiocarcinoma (CCA). Risk of primary endpoint was much lower in small duct PSC compared with classical PSC with an adjusted hazard ratio of 0.23.
- Individuals with PSC/AIH variant also had a reduced risk of primary endpoint compared with classical PSC with an adjusted hazard ratio of 0.73.
- Overall, CCA occurred in 594 patients (8.3%); the incidence of CCA changed markedly with the age of the patient. In the youngest group (<20 years), the rate was 1.2 per 100 patient-years, it was 6.0 in 21-30 yr-olds, 9.0 for 31-40 yr-olds, 14.0 fr 41-50 year olds, 15.2 for 51-60 yr-olds, and 21.0 per 100 patient-years in those older than 60 years.
- The absence of IBD, particularly UC, was associated with a lower risk PSC clinical course. Patients with UC had increased liver disease progression compared with patient’s with Crohn’s disease, with a HR of 1.56.
- The median transplant-free survival time was 14.5 years; the estimated survival was approximately 21 years in the entire cohort
It is noted that an important limitation is that the cohort is from specialist centers and may not reflect a more typical population-based cohort; that is, this patient population is likely to be severely affected.
My take: Patients with small-duct PSC have a much lower risk of disease progression.
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A recent review (Full text: LJ Saubermann et al. JPGN 2017; 64: 639-52) discusses the hepatic issues and complications associated with inflammatory bowel disease.
- Primary Sclerosing Cholangitis (PSC)
- Autoimmune Hepatitis (AIH)
- Autoimmune Sclerosing Cholangitis (ASC)
- Portal Venous Thrombosis/hypercoagulability
- Cholelithiasis (more common in Crohn’s disease if diseased terminal ileum)
- Viral hepatitis
- Drug-Induced Liver Disease
- Fatty Liver disease
Many of these topics have been discussed previously on this blog. A couple of pointers in this review:
- Greater risk of colorectal carcinoma
- IBD-PSC patients are at higher risk for pouchitis
- GGT of >252 U/L “was highly sensitive (99%) and had good specificity (71%) for PSC” [or ASC]
- The authors recommend “screening all newly diagnosed patients with IBD with ALT and GGT
- Immunosuppressive therapy is NOT effective
- Vancomycin therapy is currently being tested (clinical trials: NCT02137668 & NCT01802073)
- Less frequent in IBD patients than PSC
- Most common treatment is prednisone/azathioprine
- 40-80% of children have cirrhosis at AIH diagnosis, but “progression to end-stage liver disease is rare and …with appropriate treatment, 80% of patients achieve remission.”
- ASC is an overlap syndrome between AIH and PSC
- “It is important that children with IBD and apparent AIH are routinely investigated for evidence of biliary disease with MRCP”
- “ASC responds to the same immunosuppressive combination therapy used for AIH”
- HAV vaccination is effective in patients with IBD…although the rate [seroconversion] was significantly lower” in patients receiving anti-TNF therapy (92.4% vs 99.1% in one study).
- In those needing HBV immunization: “One strategy evaluated to improve HBV immunity in adults with IBD is an accelerated course with double vaccine doses at 0, 1, and 2 months.”
- “The extent of histological features of hepatotoxicity secondary to long-term MTX use in IBD has been infrequently described; however, the inicdence of significant abnormal histological findings appears to be rather low.”
My take: This article is a good starting point for liver-related issues in IBD. For concerns regarding medications, the NIH livertox website is more useful and much more comprehensive.
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Last week, I posted an blog referencing new guidelines for peanut introduction. A more detailed explanation of these guidelines: New Guidelines: Early Introduction of Peanut to Prevent Peanut Allergy from David Stukus (Thanks to Kipp Ellsworth for sharing this information)
A recent study (PL Valentino et al. JPGN 2016; 63: 603-09) follows “the largest reported pediatric PSC cohort” to determine the natural history.
This retrospective study followed 120 children (1-21 yrs) with a median age of 14 years. 27% had autoimmune sclerosing cholangitis (ASC), 63% had PSC; 24% (n=29) of entire cohort had exclusive small duct PSC. Median followup was 3.7 years.
- 81% of PSC patients had inflammatory bowel disease; most (72/97) had ulcerative/indeterminant coliits. 40/72 had pancolitis.
- PSC-IBD was more common than ASC-IBD (85% vs 68%).
- 10-year transplant-free survival in this cohort was 89%; there were 6 liver transplants.
- The rate of cirrhosis was lower in the group who had IBD preceding PSC (15% vs 31%,P=0.05).
- PSC is clinically silent in the majority of patients; 64% presented with abnormal chemistries and no other symptoms.
- ERCP therapeutic intervention was low, 3% for stenting and 7% for balloon dilatation.
The authors speculate that one reason for milder PSC-IBD disease could relate to the fact that IBD patients undergo frequent chemistries. In those without IBD, subacute PSC could be present for a much longer period before detection. The authors note that PSC in children presents as a milder disease with only 10% having cirrhossi compared with 30% in studies with adult patients.
My take: We have a lot to learn about PSC including which patients are likely to develop clinically significant liver disease and whether most patients benefit from treatment.
Related blog post: Should we care about subclinical PSC? (This post has links to others related to PSC)
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A recent study (AK Lunder et al. Gastroenterol 2016; 151: 660-69, editorial 590-3) provides more information about the prevalence of subclinical primary sclerosing cholangitis (PSC) in the setting of long-term inflammatory bowel disease. From a cohort of 756 Norwegian patients in the “IBSEN” cohort of patients with inflammatory bowel disease, the authors analyzed 327 patients with magnetic resonance cholangiography (MRC).
- 24 (7.5%) of 327 patients who had been followed for 20 years were found to have PSC lesions. Only 7 (2.2%) were known to have PSC based on biochemical or clinical features. Subsequently, a missed case of small-duct PSC was recognized increasing the rate to 8.1%.
- Subclinical PSC, interestingly, was detected more often in Crohn’s patients (9.0%) compared with ulcerative colitis (6.8%)
- Extensive colitis, high prevalence of colectomy, and refractory IBD symptoms were more common in patients with suspected PSC compared with those without PSC features (P= .029, P= .002, and P= .012 respectively)
The natural history of these subclinical cases of PSC is unclear. Studies have shown that patients with PSC with normal alkaline phosphatase values have an excellent outlook. Yet, there should be some concern. PSC has been associated with 400-fold higher chance of cholangiocarcinoma and 5-fold increased risk of developing colorectal cancer. This could indicate the need for more intensive surveillance in these patients –though the exact risks in those with subclinical disease is unknown.
My take: Until we know more, I doubt looking for subclinical PSC makes sense outside research protocols.
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Though this blog has reviewed primary sclerosing cholangitis (PSC), it has been a while since I’ve posted much. As such, I thought I would place a post of a recent review (KN Lazaridis, NF LaRusso. NEJM 2016; 375; 1161-70).
- Strongly associated with inflammatory bowel disease with 70-80% of PSC patients having IBD
- Median age at diagnosis 41 years with ~6-% male
- Insidious disease in most. “About half the patients with this condition do not have symptoms but receive a diagnosis after liver-function tests are found to be abnormal.”
- Diagnostic criteria include increased alkaline phosphatase for more than 6 months
- In adults, a liver biopsy is not need for diagnosis
- Tends to be slowly progressive
- Bacterial cholangitis is reported as initial presentation in ~6% and can be recurrent and intractable
- Colon cancer is more frequent in patients with PSC. “Colonoscopy is warranted in all patients who have received a new diagnosis”
- Classic subtype (90%) involves the entire biliary tree
- ~5% have only small intrahepatic bile duct involvement
- ~5% of adults have overlap syndrome with autoimmune hepatitis. In children, overlap syndrome is present in ~35%.
- There are numerous “secondary” PSC causes including AIDS-related cholangiopathy, amyloidoiss, eosinophilic cholangiopathy, histiocytosis X, IgG4-associated cholangitis, and sarcoidosis (most extensive list -see Table 1)
- The exact reasons remain unclear. There are associations with environmental triggers but these have not been proven to be causally related. For example, patients with PSC are more likely to consume steak or hamburger compared with controls and less likely to consume similar amounts of fish.
- Due to its association with IBD, there are “microbiota hypothesis” to account for the aberrant cholangiocytic response.
- “As of this writing, no effective medical therapy exists.”
- The authors detail eight potential treatments that are being studied: obeticholic acid, simtuzumab, 24-nor-ursodeoxycholic acid, an apical sodium-dependent bile acid transporter inhibitor (LUM001), a human monoclonal antibody that targets vascular adhesion protein 1 (BTT1023), oral vancomycin (NCT01802073 -pediatric trial), and fecal microbiota transplantation.
- Management: includes managing varices in those with cirrhosis, following for benign and malignant biliary strictures, following for gallbladder disease (eg. polyps or masses), colon cancer surveillance (typically yearly screening), and managing metabolic bone disease.
Briefly noted: M Bramuzzo et al. JPGN 2016; 63: 259-64. Using an Italian Pediatric IBD registry, the authors noted 6.8% of 677 patients had autoimmune liver disease: 61% with PSC and 33% with overlap syndrome.
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“The monoclonal antibody vedolizumab may reduce biliary inflammation in patients with primary sclerosing cholangitis and comorbid inflammatory bowel disease, according to early, open-label study findings reported at the meeting sponsored by the European Association for the Study of the Liver” –according to GIHepNews: Biliary inflammation reduced by IBD drug
“Vedolizumab given to 27 patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) resulted in a 50% reduction or normalization of serum alkaline phosphatase levels in 17 cases (63%).”
This was an open-label, proof-of-concept study involving 27 patients aged 25-30 years with PSC and comorbid IBD.
My take: This is interesting but needs a lot more study.
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