A large retrospective study (M Deneau, M Perito, A Ricciuto, N Gupta et al. J Pediatr 2019; 209: 92-6) examined the outcomes/response of ursodeoxycholic acid (UDCA) for pediatric primary sclerosing cholangitis (PSC).
- “Within 10 years of diagnosis, 30% of children with PSC will require liver transplantation and 50% of children will develop complications, including biliary strictures and hypertension.”
- Because UDCA has not been shown to improve survival (& may worsen outcomes), it is not recommended in adults by the AASLD.
- In pediatrics, UDCA remains the most common treatment, used in more that 80% on long-term treatment
- 263 patients at 46 centers
- Median age 12.1 years
- UDCA median dose: 15 mg/kg/day
- Normalization of GGT (<50 IU/L) occurred in 46% of patients in the first year after diagnosis
- Patients with normalization was less likely among patients with Crohn’s disease and those with laboratory profiles indicative of more advanced hepatobiliary fibrosis (eg. lower platelet count, lower albumin, hyperbilirubinemia)
- The 5-year survival with native liver was 99% in those who achieved normalization vs 77% in those who did not
- Even in those without normalization, improvement in GGT was associated with better outcomes. “Those who had a reduction in GGT of >75% had nearly the same long-term survival as those with GGT<50 IU/L at 1 year.”
- It has previously been shown that nearly “one-third of children who are UDCA-naive have spontaneous GGT normalization by 1 year.” Thus, the number to treat with UDCA to have one additional case of GGT normalization is four.
- In a previous study, one-third of patients with GGT normalization on UDCA therapy for 1 year, maintained GGT <29 after withdrawal of UDCA for 12 weeks.
The authors note that “patients who do not achieve normalization could reasonably stop UDCA as they are likely not receiving clinical benefit.”
My take: This study shows that patients who have improvement/normalization of GGT with UDCA therapy have improved outcomes. The retrospective design of the study limits conclusions about whether UDCA therapy actually improves long-term outcomes, particularly since UDCA at higher doses has been associated with detrimental affects in adults with PSC.
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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
A recent retrospective study (P-Y Boelle et al. Hepatology 2019; 69: 1648-56, associated editorial 1379-81) examines a large cohort of 3,328 patients with cystic fibrosis and pancreatic insufficiency (born after 1985) who were followed into a longitudinal “French CF Modifier Gene Study.”
Background from editorial:
- Cystic fibrosis liver disease (CFLD) has been thought to occur mainly before puberty with ~40% of patients developing biochemical or ultrasonographic signs of liver involvement by age 12 years.
- Registry studies have shown slow progression of liver disease with the development of cirrhosis and portal hypertension in 5-10% of patients. Due to difficulty identifying those at high risk for disease progression and the long time course, it has been impractical to complete definitive clinical trials to establish whether any therapies alter the natural history.
- Ursodeoxycholic acid (UDCA) is the only current treatment available for CFLD; UDCA has been shown to have beneficial effects on biochemistries and liver stiffness, but effects on survival or need for transplantation are unknown.
- Concerns have been raised about the potential for toxic UDCA metabolites (eg. lithocholic acid) in part based on unfavorable results of high-dose UDCA with primary sclerosing cholangitis
Key findings of this current study:
- The incidence of CFLD increased “by approximately 1% every year, reaching 32.2% by age 25”
- The incidence of severe CFLD increased “only after age 5, reaching 10% by age 30.”
- Risk factors for CFLD and severe CFLD: male sex, CFTR F508del homozygosity, and history of meconium ileus.
- Earlier introduction of UDCA (over the last 20 years) “did not change the incidence of severe CFLD.”
My take: This study confirms a previous study showing that CFLD occurs also in adulthood (Koh C et al. Hepatology 2017; 66:591-601) and adds further doubt about whether UDCA is beneficial.
Related article: AJ Freeman et al. “A Multidisciplinary Approach to Pretransplant and Posttransplant Management of Cystic Fibrosis-Associated Liver Disease” Liver Transplantation 2019; 25: 640-57.
Related blog posts:
Peonie in Sandy Springs
A recent study (C Colombo et al. J Pediatr 2016; 177: 59-65) examined 20 patients with cystic fibrosis-associated liver disease (CFLD) who were receiving ursodeoxycholic acid (UDCA) for at least 2 years. Specifically, they wanted to focus on the extent of biotransformation of UDCA to its hepatotoxic metabolite, lithocholic acid. The possibility that long-term UDCA therapy could be detrimental was propelled by a primary sclerosing cholangitis study (K Lindor et al. Hepatology 2009; 50: 808) which indicated that high doses of UDCA resulted in worse outcomes despite better “liver function tests.”
Dosing of UDCA: 20 mg/kg/day
Key findings: UDCA became the predominant serum bile acid; 2 hours after UDCA administration, “both UDA and chenodeoxycholic acid significantly increase (P< .01), but no significant changes in serum lithocholic acid concentrations were observed.”
What does this study prove?
Well, not very much. There are other potential mechanisms for UDCA toxicity and as the editorial notes, “we still lack the necessary endpoints in CF liver disease with which to assess the efficacy of UDCA or any therapy that is on the horizon.”
My take: Because our surrogate markers are unreliable for CFLD, there really is no way to know with certainty whether UDCA therapy is beneficial.
Schwarz et al. JPGN 2016; 62: 93-96. This study showed that all 21 children who had achieved a sustained virological response with PEG-interferon/ribavirin maintained an SVR during followup of 4.4-7.0 years. Hopefully, new direct-acting highly effective oral agents will be approved in pediatrics and make this study less relevant.
U.S. Food and Drug Administration approved Zepatier (elbasvir and grazoprevir) Jan 28, 2016
Anderson et al. JPGN 2016; 62: 110-17. Participants (n=2612) from a large longitudinal study with prospectively collected data were followed. “The adolescents who are more active in late childhood have lower risk of ultrasound scan fatty liver and lower ϒ-gluamyl transferase levels.” In addition, they showed that more activity was correlated with lower fat mass in adolescence.
Saki et al. JPGN 2016; 62: 97-100. In a double-blind randomized clinical trial of 80 neonates with unconjugated hyperbilirubinemia, treatment with added ursodeoxycholic acid (5 mg/kg/dose BID) resulted in improved clearance of bilirubin compared to phototherapy alone. At 12, 24 and 48 hours, total bilirubin in the treatment group was 12, 10 and 9.8 respectively compared with 14.4, 12.5, and 10.1 for the control group. Furthermore, the mean time for phototherapy to decrease bilirubin to <10 was 15.5 hours in the treatment group compared with 44.6 hours in the control group. This study, if confirmed, could result in shorter hospital stays.
Old Town, San Juan
Progressive Familial Intrahepatic Cholestasis, type 2, (PFIC2) is due to decrease (or absent) function of the bile salt export pump (BSEP) encoded by ABCB11 has been treated mainly in a symptomatic manner with medicines like ursodeoxycholic acid and sometimes biliary diversion. PFIC2 has been associated with increased risk for hepatocellular carcinoma (HCC).
A recent study (E Gonzales, et al. Hepatology 2015; 62: 558-66) indicates that newer therapies targeting the specific mutation may be effective.
In this study, treatment with oral 4-phenylbutyrate (4-PB) in four patients improved pruritus, serum bile acid concentrations, and liver function tests. 4-PB is considered a chaperone drug and may partially correct mistrafficking.
The associated editorial (pg 349-50) notes that 4-PB has an unpleasant taste and requires ingestion of a large number of pills. In addition, patients with complete loss of BSEP, 4-PB will not be effective. Finally, even in patients with a clinical response, it is unclear if this will lower the risk of HCC.
A second study (S Varma et al. Hepatology 2015; 62: 198-206) retrospectively studied 22 children with PFIC2. “Children with late-onset presentation, lower ALT, and intracellular BSEP expression are likely to respond, at least transiently, to nontransplant treatment.” Nontransplant treatment in this cohort included ursodeoxycholic acid in 19 (10 mg/kg thrice daily) and partial biliary diversion in 3. Higher ALT values were considered to be >165 IU/L. Another point in this study: response to treatment can be slow and take many months.
My take: These studies provide useful information about which patients with PFIC2 respond medically and introduce a new therapy, 4-PB.
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Perhaps next week the story will be: man with venomous snakes says they make great pets?
While previous studies of ursodeoxycholic acid (UDCA) at high doses (28-30 mg/kg/day) have been shown to have detrimental effects, a number of randomized controlled trials (RCTs) have shown that low-dose UDCA has been associated with biochemical improvements but no differences in endpoints like death, liver transplantation or cholangiocarcinoma. Given this conflicting information, a new study (Hepatology 2014; 60: 931-40, editorial 785-88) has examined the effects of withdrawal of low-dose UDCA.
In this cohort, the median age was 34 years, “62% were male, 69% had IBD, 19% had cirrhosis, and the baseline UDCA dose was 10-15 mg/kg/day.”
- “At 3 months, discontinuation of UDCA in patients with PSC causes significant deterioration in liver biochemistry and influences concentrations of bile acid metabolites.”
- Alkaline phosphatase increased 75.6%, GGT increased 117.9%, bilirubin increased by 50%, aspartate aminotransferase increased by 45.0%, and alanine amiontransferase increased by 63.9%
- The Mayo Risk Score for PSC (associated with PSC prognosis) also increased 0.5 points from baseline.
Conclusion (from editorial): “there may still be a role for judicious use of UDCA in patients with well-compensated disease.” A suggested “yet unproven” algorithm for use of UDCA is noted in Figure 1 pg 787 and considers UDCA for patients with alkaline phosphatase >1.5x ULN and/or PSC-associated symptoms like pruritus. If no clinical improvement within 6 months, then stopping UDCA is recommended.
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A recent study reviews the King’s College experience for managing pruritus associated with cholestasis in patients with Alagille syndrome (AGS) (JPGN 2013; 57: 149-54).
This retrospective study examined 62 patients (1995-2010). 82% (n=51) had pruritus. Most common treatments:
- Ursodeoxycholic acid in 40 patients. 1st line Rx in 31. Efficacy was rated as good in 20% and some efficacy in 67.5%.
- Rifampicin in 39 patients. 1st line Rx in 8. Efficacy was rated as very good/good in 49% and some efficacy in 46%.
- Cholestyramine in 18 patients. 1st line Rx in 9. Efficacy was rated as very good in 17% and some efficacy in 67%.
- Naltrexone in 14 patients. Efficacy was rated as good in 43% and some efficacy in 36%.
- Alimemazine in 13 patients
- Nonsedating antihistamines in 7 patients
- Ondansetron in 5 patients
- Phenobarbital in 1 patient.
Despite these medications, pruritus was controlled by medication in 41% (n=21). 16 patients were referred for liver transplantation and 11 of these patients have been transplanted. These 11 patients make up 55% of those who had permanent resolution of their pruritus.
The authors proposed an algorithm for treatment:
- 1st line: ursodeoxycholic acid 10-20 mg/kg/day divided in 2 doses or cholestyramine 240 mg/kg/day divided into 3 doses
- 2nd line: (if needed) Add/substitute rifampicin 5-10 mg/kg/day divided into 2 doses (max 600 mg/day)
- 3rd line: (if needed) Add/substitute naltrexone 0.25-0.5 mg/kg/day (max 50 mg/day)
- 4th line: (if needed) Add/substitute ondansetron max 8 mg/day divided into 2 doses per day (or phenobarbital 5-10 mg/kg/day divided into 2 doses.
- If none of these are helpful, options could include MARS (molecular adsorbent recirculation system), partial external biliary diversion, or liver transplantation.
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A recent article provides a useful review for primary sclerosing cholangitis (PSC) (Clin Gastroenterol Hepatol 2013; 11: 898-907).
This blog has previously discussed PSC (links below); however, the above reference is succinct and covers the key issues. A couple of points that I found particularly helpful:
- Cholangiocarcinoma (CCA): recommends “consider annual imaging (MRCP or Ultrasound) along with serum CA19-9 levels” to monitor for cholangiocarcinoma. If there is a dominant stricture, proceed with ERCP with brushings. In pediatrics, the age to start screening is less clear, usually not presenting until beyond the late teen years, though CCA has been diagnosed in one case report at 14 years of age (NEJM 2003; 348: 1464).
- Gallbladder cancer (30-40-fold higher risk than general population): If gallbladder polyp identified that is ≥0.8 cm, recommends cholecystectomy. If smaller, may also want to remove if normal synthetic function; otherwise repeat imaging in 3-6 months.
- Colon cancer: colonoscopy every 1-2 years in those with coexistent IBD (70% of patients with PSC have IBD).
Diagnosis: 44-56% of patients are asymptomatic at time of diagnosis, picked up due to abnormal serum liver tests or on cross-sectional imaging.
Small-duct PSC: occurs in the setting of features of PSC (histology, biochemistry) without abnormal cholangiogram. This represents 11-17% of PSC patients and is difficult to identify in patients without IBD. Over time, 25% will develop large-duct PSC. Small-duct PSC does not appear to result in increased risk of CCA.
Overlap syndrome with autoimmune hepatitis: patients with typical PSC but with 5- to 10-fold aminotransferase elevations should be suspected of having an overlap syndrome and may benefit from treatments directed at autoimmune hepatitis. Other features often include histology with an interface hepatitis and the presence of auto-antibodies. This situation is more common in children and young adults.
Immunoglobulin G4-Related sclerosing cholangitis: this occurs most commonly in conjunction with autoimmune pancreatitis. Since steroids can be effective, IgG4 levels should “be tested in all patients with suspected PSC, and, if elevated to consider an evaluation for IgG4-related disease.”
Medical management: “to date, there are no medical therapies that have been proven to alter the natural course of PSC.” The discussion notes that standard doses of ursodeoxycholic acid (UDCA) may have protective effects against colorectal cancer in patients with coexisting IBD. Higher doses of UDCA have been associated with a 2-fold risk of increased disease progression. Specific treatments for dominant strictures, pruritus, metabolic bone disease, and malabsorption are discussed. In patients with cholestasis, monitoring fat-soluble vitamins is important.
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A retrospective study from the Netherlands showed that timely surgery and postoperative antibiotics were associated with better outcomes in Biliary Atresia (BA) (J Pediatr 2012; 160: 638-44). While these results are not surprising, due to the length of the study period (1987-2008) and the number of patients (n=214), the study offers insight into a number of unresolved issues with regard to BA.
The type of BA in this series:
- type I 14 (6.5%)
- type II 27 (12.6%)
- type III 172 (80.4%)
- undetermined 1 (0.9%)
Other notable findings:
- 10% of their patients had splenic malformations; no significant change in outcome was noted in this subgroup.
- 18% received high-dose corticosteroids –no benefit was identified in this subgroup. The authors state that previous studies are inconclusive; a large US trial of prednisolone (4 mg/kg/day initially) is pending.
- 31% received ursodeoxycholic acid –no benefit was identified in this subgroup.
- Overall survival improved a little during the study period, mostly due to increased availability of liver transplantation. 4-year transplant-free survival was 46% and 4-year overall survival was 73%. Table II (pg 641) in their study lists six other international studies. Recent studies in some countries have reported 4-year survivals of 82-91%.
- Antibiotic usage (most commonly co-trimoxazole) was associated with improved outcomes, presumably due to less frequent bouts of cholangitis. Yet, in this study the reported incidence of cholangitis was not lower. The authors do not have an explanation for this finding.
Age at time of Kasai:
- ≤45 days 19%
- 46-60 days 37%
- 61-89 days 36%
- ≥90 days 8%
- Median was 59 days. Authors note that Netherland guidelines call for all infants with jaundice at 3 weeks to have a fractionated bilirubin.
Related blog entries:
Minimizing malnutrition in Biliary Atresia
The heart connection
MicroRNAs and biliary atresia
- -JPGN 2010; 51: 631. n=91. Operation w/in 100 days. Data suggesting that 60 day cutoff is not valid. (Hong Kong)
- -J Pediatr Surg 2003; 38: 997-1000. n=735. 90 day cutoff was key with 5-yr & 10-yr survival. (Japan)
- -JPGN 2010; 51:61. Canadian experience. n=230. Center size did not affect outcome. Overall 39% at 4yrs had survival with native liver.
- -Liver transplantation 2009; 15: 829, 876. With combo of Kasai & Tx, >95% exteneded survival (previously 100% fatal). >80% will need a liver Tx at some point –~50% before age 2. Increased fibrosis & genes for fibrosis may increase risk for poor outcome.
- -JPGN 2009; 48: 72. Review of 13 year experience. n=91.
- -Pediatrics 2008; 121: e1438. Single center (Australia?) noted longer delay in dx of BA over 15-year period from 48.5 days (1990-94) to 59.5 (95-99) to 69 days (2000-2004).
- -JPGN 2008; 46: 238, 299. More data on age of dx of BA and outcomes from Sweden.
- -J Pediatr 2006; 149: 393. Long term outcome of BA -28yrs in England. 7/56 survived long term with native liver; 5-yr native liver survival was 46%, 10-yr was 32%.
- -J Pediatr 2006; 148: 467, 432.. Outcome of BA in US. Avg age of referral was 53 days and HPE avg at 61 days. one-third will survive to age 10 with native liver; overall 90% survival with kasai/hpe & Tx; 50-60% clear jaundice p Kasai. yellow alert campaign: www.childliverdisease.org/jaundice
- -Clin Gastro & Hep 2006; 1411. BA with choledochal cyst. Nice pics of types of BA. Japanese pathologic classification: Type 1 with atresia after gallbladder (CBD), type II atresia of common hepatic duct/CBD/GB c normal intrahepatic ducts, Type III atresia of entire ductal system.
- -Pediartics 2006; 117: 1147. Usefulness of stool color cards for screening program.
- -J Pediatr 2005; 147: 142 & 180-5. 23% c BA survive c native liver for more than 20 yrs; 88% survival for 3 yrs p-OLT; risk factors for poor outcome discussed including poor nutrition & age <5 months.
- -J Pediatr 2004; 144: 123-5. severity of fibrosis at time of Kasai inversely correlated with survival
- -JPGN 2003; 37: 430-33. Residual fibrosis/cirrhosis noted in 54%/40% respectively of pts with normal labs, median age 13 yrs.
- -JPGN 2003; 37: 4-21. Review of BA
Although primary sclerosing cholangitis (PSC) is an infrequent liver problem in pediatrics, it remains important. PSC accounts for 2-3% of pediatric liver transplant cases. A recent report updates some of the challenges for pediatric hepatologists (Shneider BL. Liver Transplantation 2012: 18: 277-81).
First the article examines some of the salient differences between children and adults. The approach in adults may not apply well to children. Some inherited diseases and immunologic defects may produce a similar clinical picture. Specific differences include the following:
- Defects in the adenosine triphosphate-binding cassette B4 (ABCB4 gene) (multidrug resistance protein 3) may cause a number of small-duct PSC in children
- Cystic fibrosis can have a similar appearance
- Overlap syndrome with autoimmune hepatitis is more common in children
- Children with PSC often have higher alanine aminotransferase enzyme values than adults
- Cholangiocarcinoma is rare in childhood, with 17 being the youngest reported case
Diagnosis usually requires, in addition to blood tests, cholangiography (eg MRCP), liver biopsy or both. ERCP may not be needed depending on MRCP results.
Management: Pruritus may be managed with ursodeoxycholic acid (UDCA), bile acid binding resins, and rifampin. Bone disease needs to be monitored along with fat soluble vitamin status.
- While pruritus may improve with UDCA, high-dose UDCA (28-30mg/kg/day) has been associated with increased likelihood of negative endpoints. It is not clear whether there may be detrimental effects at lower doses.
- What about immunosuppression? This (corticosteroids/thiopurines) is accepted in cases with AIH overlap. Of course, what constitutes overlap is not certain. So, in many cases, a trial of corticosteroids is considered.
- Antibiotics? Oral vancomycin has been tried in a small number with preliminary success.
As noted above, liver transplantation is a needed treatment in some cases. One concern with this approach has been recurrent PSC in about 10% at an average of 18 months after liver transplantation.
- -Am J Gastro 2011; 106: 1638. Use of high dose Urso increases risk of colonic neoplasia. n=150.
- -Hepatology 2011; 54: 1842. Guidelines on surveillance for PSC. IF IBD yearly scope. **Yearly U/S + CA 19-9 or yearly MRI.
- -Liver Transplantation 201; 17: 925-933. n=79 pediatric pts. 49% w IBD prior to OLT (46% w UC, 3%) & 9.8% developed IBD p OLT. 1 & 5yr survival for OLT 99% & 87%. Recurrence in 9.8%.
- -Clin Gastro & Hepatology 2011; 9: 434. 37% of PSC pts with CA 19-9 >129U/mL do NOT have cholangiocarcinoma. n=7.
- -Hepatology 2010; 51: 660-678. update on dx/mgt.
- -Gastroenterology 2010; 138: 1102. genome associations with PSC.
- -Hepatology 2009; 50: 808, 671 (ed). Use of urso ~30/kg associated w WORSE outcome @5yrs. n=76 (& 74 controls)
- -Clin Gastro & Hep 2009; 7:239. n=47 children w PSC. 59% w IBD, 25% w overlap syndrome
- -JPGN 2008; 47: 61. Use of oral vancomycin, 50mg/kg/day in patients with PSC/IBD was effective. n=14.
- -Liver Tx 2008; 14: 735. Review. 5 yr OLT survival 85% ReTx rate higher (9.6% vs 4.9%).
- -Hepatology 2008; 47: 9494-57. Asymptomatic PSC common in AIH –might be higher than 10%.
- -Gastroenterology 2008; 134: 975. Natural hx/o small duct PSC in 83 pts (compared to controls). Not likely increase in cholangiocarcinoma unless also large duct involvement.
- -Gastroenterology 2008; 134: 706. IAC is similar; IAC=IGG4 Associated Cholangitis
- -Hepatology 2008; 47: 949. 8/79 w AIH also had PSC.
- -J Pediatr 2007; 151: 255, 230. association of CFTR mutations in PSC (26%); also present in disease control group with IBD (43%).
- -Clin Gastro & Hep 2007; 5: 32. Review vis-a-vis possible cholangiocarcinoma.
- -Hepatology 2006; 44: 1063. Review along w secondary causes.
- -Liver Transplantation 2006; 12: 1813. Recurrence post Tx 22% AIH, 18% PBC, 11% PSC. (Review of 43 studies).
- -Gastroenterology 2005; 129:1464. High-dose actigall ineffective in 5 yr randomized controlled study.
- -Gastroenterology 2003; 125: 1364. Incidence of PSC.
- -JPGN 2003; 37: 345 (57A). Use of vanco 50/kg/day x 4-6weeks in PSC, n=10, (56A) some pts c normal cholangiograms.
- -Gastroenterology 2003; 124: 889. Urso prevents colon ca.
- -Am J Gastro 2001; 96: 1558-62. High dose UDCA, 25-30/kg/day may help long-term outlook
- -JPGN 2001; 33:296. PSC-IBD.
- -NEJM 2002; 346: 271-277. case c Crohn’s. PSC assoc c UC, celiac dz, pancreatic insufficiency.
- -Ann Intern Med 2001; 134: 89-95. Urso decreases colonic neoplasia in pts c UC & PSC.
-NEJM 1997; 336: 691. Ursodeoxycolic acid & PSC.
- -Gregorio et al. Autoimmune hepatitis/sclerosing cholangitis overlap syndrome in childhood: a 16-year prospective study. Hepatology 2001;33:544-553
NASPGHAN 2010 Pointers:
I. -“STOPSC criteria”: 2 of 3 diagnostic criteria needed:
1) elev GGT or alk phos
2) intra and/or extrahepatic bile duct irregularities on cholangiography (i.e. PTC, MRCP, ERCP) c/w PSC
3) liver biopsy abnormalities c/w chronic biliary injury
AND no evidence of a secondary cause of sclerosing cholangitis
II. SUMMARY OF KEY CLINICAL FEATURES:
- -Sclerosing cholangitis is associated with IBD, autoimmune and connective tissue disorders, abnormalities of immune function (i.e. immunodeficiencies, GvHD), infiltrative disorders (i.e. Langerhans cell histiocytosis, lymphoma).
- -PSC may sometimes affect only small intrahepatic bile duct (“small duct PSC”), which may have a better outcome based on adult studies
- -PSC may have overlapping features of AIH (“autoimmune sclerosing cholangitis”)
- -IgG4 –associated cholangitis: patients appear to have PSC with elev IgG4. They seem to respond very well to steroid therapy in adult studies
- -No therapy of proven benefit for PSC (ursodiol, antibiotics), some case series have suggested antibiotics may help PSC
- -5 times higher rate of Colorectal Ca when UC pt has PSC. Consider yearly endoscopy