What are the symptoms of cholestasis?

Symptoms of Cholestasis

The hallmark symptom of cholestasis is pruritus (itching), which is often generalized but may predominantly affect the palms and soles, typically worsens at night, and characteristically occurs without an associated rash. 1

Primary Symptom: Pruritus

• Pruritus is the most characteristic and often earliest symptom of cholestasis, presenting before other clinical manifestations or even biochemical abnormalities in some cases 2
• The itching in cholestasis is typically generalized but shows predilection for the palms of the hands and soles of the feet 1
• Pruritus characteristically worsens at night, which is a distinguishing feature 1
• Importantly, cholestatic pruritus occurs without a primary rash—any skin changes observed are typically secondary excoriations from scratching, not a primary dermatologic process 1
• The intensity of pruritus can lead to excoriations or prurigo nodularis, which may be mistaken for a primary rash 1

Secondary Clinical Manifestations

Common Symptoms

• Fatigue is frequently reported in cholestatic conditions 1, 3
• Right upper quadrant abdominal pain may occur, particularly in primary sclerosing cholangitis 1
• Weight loss can develop as the disease progresses 1

Less Common Symptoms

• Jaundice (yellowing of skin and eyes) is not commonly present at initial presentation and typically indicates more advanced disease 1
• Dark urine is uncommon in early cholestasis and suggests other hepatic diseases when present 1
• Episodes of fever and chills may occur, particularly if cholangitis develops 1

Important Clinical Distinctions

Symptoms NOT Typical of Cholestasis

• Excessive fatigue, insomnia, malaise, and abdominal pain/colic are NOT common with intrahepatic cholestasis of pregnancy—their presence warrants evaluation for other causes 1
• Steatorrhea and fat-soluble vitamin malabsorption occur only with prolonged, advanced cholestasis 1

Asymptomatic Presentation

• Approximately 50% of patients with primary sclerosing cholangitis are asymptomatic at diagnosis, with cholestasis detected only through abnormal biochemical markers 1
• The majority of patients with primary biliary cirrhosis are asymptomatic at diagnosis, though some present with fatigue, pruritus, or jaundice 1

Physical Examination Findings

• Hepatomegaly and splenomegaly are the most frequent findings on clinical examination in primary sclerosing cholangitis 1
• Absence of rash is expected—the physical examination should specifically assess for excoriations, papules, plaques, or bullae to distinguish cholestasis from dermatologic conditions 1
• Jaundice on examination is uncommon in early cholestasis and suggests advanced disease or alternative diagnoses 1

Critical Timing Considerations

• In intrahepatic cholestasis of pregnancy, pruritus typically develops in the second half of pregnancy (second and third trimesters) 1
• Pruritus may precede biochemical abnormalities by weeks or even months, particularly in primary biliary cirrhosis and intrahepatic cholestasis of pregnancy 2
• Symptoms characteristically resolve after delivery in pregnancy-related cholestasis 1