Treatment of patients with benign recurrent intrahepatic cholestasis

Benign recurrent intrahepatic cholestasis: review and long-term follow-up of five cases

OBJECTIVE

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive inherited disorder characterized by intermittent episodes of cholestatic jaundice. For the patients, the disease is a physical and psychological challenge. There is no curable treatment, but symptomatic relief is described following treatment with rifampicin or plasmapheresis.

MATERIAL AND METHODS

Five patients suffering from BRIC followed up for 17 years by one consultant are described. Two patients were treated with rifampicin and plasmapheresis, two with rifampicin alone, and one with plasmapheresis.

RESULTS

The treatments showed symptomatic relief, effect on biochemical parameters, and earlier clinical remission compared with no treatment or treatment with other substances like cholestyramine, antihistamines, and ursodeoxycholic acid.

CONCLUSIONS

Both rifampicin and plasmapheresis represent important therapeutic options of acute cholestatic attacks in patients with BRIC. As a noninvasive treatment, rifampicin may be the first choice.

Benign recurrent intrahepatic cholestasis

Benign recurrent intrahepatic cholestasis is a rare autosomal recessive disorder characterized by repeated episodes of intense pruritus, profound elevations in serum alkaline phosphatase and bilirubin, with normal or nearly normal values for serum gamma-glutamyl transferase. Attack lasts from several weeks to months and resolve spontaneously. Between attacks patients remain asymptomatic for months to years. The disorder does not lead to progressive liver injury and is not fatal. Genetic studies have demonstrated that the disorder is the result of a mutation in ATP8BI, a gene that codes for the FIC1 (familial intrahepatic cholestasis) protein, which is also affected in other forms of familial intrahepatic cholestasis. It is believed this protein plays a role in bile acid secretion, in aminophospholid transport, and in maintaining fluidity of the cell membrane. Therapy is supportive and aimed at relieving pruritus and other complications of severe cholestasis until the episode resolves spontaneously.

[Ursodeoxycholic acid treatment shortens the course of cholestasis in two patients with benign recurrent intrahepatic cholestasis]

INTRODUCTION

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal-crecessive or sporadic disorder, characterized by repeated episodes of unexplained cholestasis followed by prolonged asymptomatic periods.

CASE REPORT

We present two male patients aged 12 and 15 years old who initially presented cholestasis and who had no family history of liver or biliary disease. Typically, alkaline phosphatase and bilirubin levels were elevated, with a slight increase in transaminases and gamma-glutamyltransferase. In both patients biliary tract disease was ruled out by endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiography while no significant abnormalities of the liver parenchyma were found on liver biopsy. Early treatment with ursodeoxycholic acid (UDCA) reduced the duration of the cholestasis episode compared with that of other episodes in which the patient had received other treatment or the treatment was late (1 or 2 months vs 4 months in patient 1 and 1-3 months vs 5 months in patient 2, respectively).

DISCUSSION

Consensus is lacking on the treatment of BRIC although several treatment have been used. UDCA could be effective in increasing bile acid secretion and in reducing serum bilirubin levels. In the two patients described, the initial dosage was 15 mg/kg/day, which was subsequently maintained at 6 mg/kg/day, which was subsequently maintained 6 mg/kg/day until biochemical parameters returned to normal. Nevertheless, larger studies are required to confirm that UDA shortens episodes of cholestasis in BRIC.

Benign recurrent intrahepatic cholestasis progressing to progressive familial intrahepatic cholestasis: low GGT cholestasis is a clinical continuum

Benign recurrent intrahepatic cholestasis (BRIC) is an autosomal recessive liver disease, characterised by intermittent attacks of cholestasis, which can start at any age and last for several weeks to months. Characteristically serum GGT activity is low and normal liver structure is preserved. Progressive familial intrahepatic cholestasis (PFIC) is another liver disease, characterised by severe cholestasis, starting almost invariably before 6 months of age. All patients progress to cirrhosis, liver failure and death, unless a liver transplantation is performed. We now identified four patients who presented in childhood with recurrent attacks of cholestasis, while in the course of the disease the cholestasis gradually became permanent. Although liver biopsies performed in the early stages of the disease showed normal liver architecture, late stage biopsies revealed evident fibrosis with porto-portal septa formation. In conclusion, the disease of these patients started with the clinical and histopathological characteristics of BRIC but progressed to PFIC.

Benign recurrent intrahepatic cholestasis

Benign recurrent intrahepatic cholestasis is a rare autosomal recessive disorder characterized by repeated episodes of intense pruritus and jaundice. Each attack lasts from several weeks to months before resolving spontaneously. Patients are completely asymptomatic for months to years between symptomatic periods. The disorder does not lead to progressive liver disease. Although attacks seem to be associated with a viral prodrome, an inciting viral agent or toxin has not been defined. Genetic studies have mapped the defect of this disorder to the long arm of chromosome 18 and a gene that codes for a P-type ATPase, which appears to be involved in aminophospholipid transport. Therapy during symptomatic periods is supportive and aimed at relief of severe pruritus until the episode resolves spontaneously.

Bile acid transport

Bile acids undergo a unique enterohepatic circulation, which allows them to be efficiently reused with minimal loss. With the cloning of key bile acid transporter genes in the liver and intestine, clinicians now have a detailed understanding of how the different components in the enterohepatic circulation operate. These advances in basic knowledge of this process have directly led to a rapid and highly detailed understanding of rare genetic disorders of bile acid transport, which usually present as pediatric cholestatic disorders. Mutations in specific bile acid or lipid transporters have been identified within specific cholestatic disorders, which allows for genetic tests to be established for specific diseases and provides a unique opportunity to understand how these genes operate together. These same transporters may also prove useful for development of novel drug delivery systems, which can either enhance intestinal absorption of drugs or be used to target delivery to the liver or biliary system. Knowledge gained from these transporters will provide new therapeutic modalities to treat cholestatic disorders caused by common diseases.

Autosomal-recessive inheritance of benign recurrent intrahepatic cholestasis

Benign recurrent intrahepatic cholestasis (BRIC) is a rare disorder characterized by recurrent episodes of cholestasis without permanent liver damage. Familial and sporadic cases have been described. Based on existing evidence, both autosomal-recessive and autosomal-dominant inheritance have been considered. We describe a large Dutch pedigree with 4 patients, strongly suggesting autosomal-recessive inheritance.

Therapy with ursodeoxycholic acid in cholestatic liver disease

Ursodeoxycholic acid (UDCA) has beneficial effects on symptoms, liver biochemistry and, possibly, liver histology in primary biliary cirrhosis and other cholestatic liver diseases. UDCA may exert these beneficial effects by a direct hepatoprotective effect, by influencing the enterohepatic circulation of endogenous bile salts, by enhancing bile flow through a cholehepatic shunt mechanism or by immune modulation. In the present article, established and potential indications for UDCA are reviewed.

Ursodeoxycholic acid in chronic liver disease

The hydrophilic bile acid ursodeoxycholic acid has recently been shown to reduce biochemical markers of both cholestasis and hepatocellular damage in patients with chronic liver diseases. The most compelling evidence available is for chronic cholestatic liver diseases, in particular primary biliary cirrhosis, primary sclerosing cholangitis, and cholestasis associated with cystic fibrosis. The effects may be less beneficial in patients with advanced liver disease from these conditions. Data from placebo controlled trials are now available in support of earlier uncontrolled observations, but it is not yet clear whether short term benefit results in an improvement in longterm prognosis. The mechanism of action of the compound seems to reside in its displacement of toxic hydrophobic bile acids from both the bile acid pool and hepatocellular membranes. There may be an independent effect on bile flow, which could be of particular importance in cystic fibrosis, and possibly an effect on the immune system. Ursodeoxycholic acid should now be regarded as occupying a central place in the medical management of chronic cholestatic liver diseases, in particular primary biliary cirrhosis, because it improves cholestasis and reduces hepatocellular damage and it is not toxic. Research should now be targeted on whether treatment with ursodeoxycholic acid, initiated early in cholestatic liver conditions, improves the long-term outcome.