Cholestasis Commonly Presents with Pruritus

Yes, pruritus is a characteristic symptom of cholestasis and affects the majority of patients with cholestatic conditions. 1

Pruritus in Cholestasis: Clinical Presentation

Pruritus is one of the hallmark symptoms of cholestatic liver disorders, affecting up to two-thirds of patients during the course of their disease 2
In intrahepatic cholestasis of pregnancy (ICP), pruritus is a defining characteristic that typically occurs in the second and third trimesters 1
The itch in cholestasis is often generalized but predominantly affects the palms and soles of the feet, and is typically worse at night 1
Unlike other pruritic conditions in pregnancy, cholestatic pruritus is generally not associated with a rash, though excoriations may develop due to scratching 1
In primary sclerosing cholangitis (PSC), pruritus affects the majority of patients and can dramatically impair quality of life, sometimes even leading to suicidal ideations in severe cases 1

The molecular pathogenesis of cholestatic pruritus has not been fully elucidated, though significant insights have been gained in recent years 1, 3
Lysophosphatidic acid (LPA) and its forming enzyme autotaxin (ATX) have been identified as key elements in the pathogenesis of cholestatic pruritus 2, 4
Contrary to traditional belief, total bile acids or bilirubin conjugates are unlikely to have a dominant role in causing cholestatic pruritus 3
Other candidate pruritogens include certain lysophospholipids and sulfated progesterone metabolites 3

In intrahepatic cholestasis of pregnancy, the incidence ranges from 0.3% to 15% in various populations, with most estimates between 0.3% to 0.5% 1
In primary sclerosing cholangitis, approximately 50% of patients experience pruritus, with 40% reporting mild, 39% moderate, and 21% severe itch 5
Pruritus is less common in small duct PSC compared to large duct PSC 5
Hispanic ethnicity has been associated with higher frequency of pruritus in PSC 5
Younger patients with PSC tend to experience more severe pruritus 5

For intrahepatic cholestasis of pregnancy, ursodeoxycholic acid is recommended as first-line treatment for maternal symptoms 1, 3
In primary sclerosing cholangitis and other fibrosing cholangiopathies, bezafibrate or rifampicin are recommended as first-line pharmacological treatments for moderate to severe pruritus 1
Rifampicin (150-300 mg daily) has been considered effective but carries a risk of drug-induced hepatitis after 4-12 weeks in up to 12% of cholestatic patients 1
Cholestyramine, a bile acid sequestrant, has been traditionally used but has limited evidence in sclerosing cholangitis compared to primary biliary cholangitis 1, 6
Non-pharmacological approaches include using emollients to prevent skin dryness, avoiding hot baths or showers, using cooling gels (e.g., menthol gels), and keeping nails short 1

In patients with suspected cholestasis presenting with pruritus, measurement of serum bile acid and liver transaminase levels is recommended 1
A detailed history and physical examination are essential to differentiate cholestatic pruritus from other causes of pruritus without rash 1
In pregnancy, cholestatic pruritus must be distinguished from other pruritic conditions such as atopic eruption of pregnancy, polymorphic eruption of pregnancy, and pemphigoid gestationis 1

While cholestasis poses little risk to pregnant women, it confers significant risk to the fetus, including preterm delivery, meconium-stained amniotic fluid, and stillbirth 1
In non-pregnant patients with cholestatic conditions, severe pruritus can lead to sleep deprivation, loss of daytime concentration, and significantly impaired quality of life 7, 3
In most cases of intrahepatic cholestasis of pregnancy, the condition is self-limited and resolves after delivery 1