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Helgadottir H, Folvik G, Vesterhus M. Improvement of cholestatic episodes in patients with benign recurrent intrahepatic cholestasis (BRIC) treated with rifampicin. A long-term follow-up. Scand J Gastroenterol 2022; 58:512-520. [PMID: 36369734 DOI: 10.1080/00365521.2022.2143725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Patients with benign recurrent intrahepatic cholestasis (BRIC) suffer from recurrent episodes of cholestatic jaundice. Treatment options remain limited and are mainly symptomatic. In case reports rifampicin, plasmapheresis, and nasobiliary drainage have been reported to be effective. In this case series, we present long-term experience indicating disease-modifying effects of non-invasive treatment with rifampicin for recurrent cholestasis in BRIC type 1 (BRIC1). MATERIALS AND METHODS We included all adult BRIC1 patients diagnosed and followed up at a single centre in Bergen, Norway. Data regarding clinical and biochemical features during BRIC attacks with and without rifampicin treatment were retrieved from medical journals and a data registry. RESULTS Five males with BRIC1 were included. Median age at diagnosis was 22 years (range 15-41). Together they had suffered from 65 cholestatic attacks (including four documented abortive attacks). Twenty-eight attacks were treated with rifampicin alone over the last 12 years; all cases showed symptomatic relief and reduction in the levels of bilirubin and alkaline phosphatase in blood. The attacks treated with rifampicin seemed to have shorter duration and were less likely to result in complications or hospitalization compared to attacks prior to the introduction of rifampicin. No side effects attributable to rifampicin were noted. CONCLUSIONS Episodic treatment of recurrent BRIC1 attacks with rifampicin seems to ameliorate severity and shorten the duration of attacks. Timely diagnosis and effective treatment are of major importance in BRIC, not only to decrease complications but also improving patients' quality of life.
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Affiliation(s)
- Holmfridur Helgadottir
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Norwegian PSC Research Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Geir Folvik
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Mette Vesterhus
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Norwegian PSC Research Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Kornitzer GA, Alvarez F. Case Report: A Novel Single Variant TJP2 Mutation in a Case of Benign Recurrent Intrahepatic Cholestasis. JPGN Rep 2021; 2:e087. [PMID: 37205944 PMCID: PMC10191565 DOI: 10.1097/pg9.0000000000000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/23/2021] [Indexed: 05/21/2023]
Abstract
Benign recurrent intrahepatic cholestasis (BRIC) is a disease on the spectrum of familial intrahepatic cholestasis caused by homozygous ABCB11 or ATP8B1 mutations. In recent years, genetic testing has allowed for discovery of a variety of homozygous or compound heterozygous TJP2 mutations associated with progressive familial intrahepatic cholestasis and intrahepatic cholestasis of pregnancy. To our knowledge, no cases of BRIC caused by a single variant mutation of TJP2 have been reported. We describe a 15-year-old female presenting with recurrent episodes of jaundice, vomiting, with intense pruritus, anorexia, and weight loss. Blood work revealed elevated serum conjugated bilirubin and liver enzymes but normal gamma-glutamyl transferase, consistent with BRIC. A genetic panel identified a not previously described single allele mutation in TJP2 of unknown functional significance. This is the first reported case of a clinical entity resembling BRIC with a heterozygous mutation in TJP2, without associated mutations in other cholestasis-related genes.
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Affiliation(s)
- Gaël A. Kornitzer
- From the Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Division of Gastroenterology, Hepatology and Nutrition, CHU Sainte-Justine, Montreal, QC, Canada
| | - Fernando Alvarez
- From the Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Division of Gastroenterology, Hepatology and Nutrition, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
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3
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Gupta S, Ali IA, Abreo E, Gujju V, Hayat M. The Mystery of Episodic Recurrent Jaundice in a Young Male: Cholestasis With a Normal Gamma-Glutamyl Transferase. Cureus 2021; 13:e13834. [PMID: 33854852 PMCID: PMC8036134 DOI: 10.7759/cureus.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Benign recurrent intrahepatic cholestasis (BRIC) is a very rare autosomal recessive genetic disorder which presents with recurrent jaundice. We report the case of a young male with a history of methamphetamine use who presented with recurrent episodes of right upper quadrant abdominal pain, vomiting, dark urine, and pale stools. These symptoms always resolved within four weeks of presentation. During these episodes, the patient had a cholestatic pattern derangement of liver function tests with a normal gamma-glutamyl transferase (GGT). Workup for abnormal transaminases was unremarkable. A percutaneous liver biopsy obtained on the third visit was notable for a parenchymal lobule that exhibited slight Kupffer cell hyperplasia and subtle evidence of canalicular cholestasis. There was no evidence of cirrhosis, steatosis, hepatitis, or malignancy. Thus, a diagnosis of BRIC was made, and the patient was managed conservatively. Recognition of this rare entity is critical since its benign natural history is reassuring for the patient, and physicians can refrain from repetitive expansive and costly workups.
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Affiliation(s)
- Samiksha Gupta
- Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Ijlal Akbar Ali
- Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Eleanor Abreo
- Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Veena Gujju
- Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Maham Hayat
- Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, USA
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Schreiner P, Stieger B, McLin V, Rougemont AL, Keitel V, Dröge C, Müllhaupt B. A rare cause of a cholestatic jaundice in a North African teenager. Liver Int 2019; 39:2036-2041. [PMID: 31021034 DOI: 10.1111/liv.14122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/18/2019] [Accepted: 03/31/2019] [Indexed: 02/06/2023]
Abstract
We report an unusual case of intermittent episodes of cholestasis in a young patient. The cholestatic attacks were preceded in each case by an infection and subsequent antibiotic therapies. After ruling out many possible causes of cholestatic hepatitis, the differential diagnoses were a benign recurrent intrahepatic cholestasis or a drug-induced liver injury. We discuss here the diagnostic approach and interpretation of the genetic analysis.
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Affiliation(s)
- Philipp Schreiner
- Division of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Bruno Stieger
- Division of Clinical Pharmacology and Toxicology, University of Zurich, Zurich, Switzerland
| | - Valérie McLin
- Swiss Pediatric Liver Center, University Hospitals Geneva, Geneva, Switzerland
| | - Anne-Laure Rougemont
- Diagnostic Department, Division of Clinical Pathology, University Hospitals Geneva, Geneva, Switzerland
| | - Verena Keitel
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carola Dröge
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Beat Müllhaupt
- Division of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
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5
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Narchi H, Alhefeiti S, Althabahi F, Hertecant J, Knisely AS, Souid AK. Intrahepatic cholestasis in two omani siblings associated with a novel homozygous ATP8B1 mutation, c.379C>G (p.L127V). Saudi J Gastroenterol 2017; 23:303-305. [PMID: 28937026 PMCID: PMC5625368 DOI: 10.4103/sjg.sjg_178_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report two Omani brothers with intrahepatic cholestasis that resolved with supportive care. In one, cholestasis began in infancy; in the other, only at the age of 18 months. Whole exome sequencing identified a novel homozygous variant, c.379C>G (p.L127V) in ATP8B1. Those attending patients with cholestasis from the Arabian peninsula should be aware of this mutation and of the variation in its phenotypic effects.
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Affiliation(s)
- Hassib Narchi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, United Arab Emirates,Address for correspondence: Dr. Hassib Narchi, Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain PO Box 17666, United Arab Emirates. E-mail:
| | - Suhailah Alhefeiti
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, United Arab Emirates
| | - Fatmah Althabahi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, United Arab Emirates
| | - Jozef Hertecant
- Department of Pediatrics, Tawam Hospital, United Arab Emirates
| | - A. S. Knisely
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, England, United Kingdom,Institut für Pathologie, Medizinische Universität Graz, 8036 Graz, Austria
| | - Abdul-Kader Souid
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, United Arab Emirates
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Hayashi H, Naoi S, Hirose Y, Matsuzaka Y, Tanikawa K, Igarashi K, Nagasaka H, Kage M, Inui A, Kusuhara H. Successful treatment with 4-phenylbutyrate in a patient with benign recurrent intrahepatic cholestasis type 2 refractory to biliary drainage and bilirubin absorption. Hepatol Res 2016. [PMID: 26223708 DOI: 10.1111/hepr.12561] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM Benign recurrent intrahepatic cholestasis type 2 (BRIC2) is caused by mutations in ABCB11, a gene encoding the bile salt export pump (BSEP) that mediates biliary bile salt secretion, and presents with repeated intermittent cholestasis with refractory itching. Currently, no effective medical therapy has been established. We previously provided experimental and clinical evidence suggesting the therapeutic potential of 4-phenylbutyrate (4PB) for the cholestatic attacks of BRIC2. METHODS After examining the potential therapeutic use of 4PB treatment by in vitro studies, a patient with BRIC2 was treated p.o. with 4PB at gradually increasing doses (200, 350, and 500 mg/kg per day) for 4 months. Biochemical, histological and clinical data were collected. RESULTS The patient was diagnosed with BRIC2 because he had non-synonymous mutations (c.1211A>G [p.D404G] and 1331T>C [p.V444A]) in ABCB11, reduced hepatocanalicular expression of BSEP and low biliary bile salt concentrations. In vitro analysis showed that 4PB treatment partially restored the decreased expression of BSEP caused by p.D404G mutation. During the first 2 months of 4PB therapy at 200 and 350 mg/kg per day, the patient had no relief from his symptoms. No beneficial effect was observed after additional treatment with bilirubin absorption and endoscopic nasobiliary drainage. However, after starting treatment at a dose of 500 mg/kg per day, the patient's liver function tests and intractable itching were markedly improved. No apparent side-effects were observed during or after 4PB therapy. The symptoms relapsed within 1.5 months after cessation of 4PB therapy. CONCLUSION 4PB therapy would have a therapeutic effect on the cholestatic attacks of BRIC2.
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Affiliation(s)
- Hisamitsu Hayashi
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Sotaro Naoi
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Yu Hirose
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Yusuke Matsuzaka
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Ken Tanikawa
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Koji Igarashi
- Bioscience Division, Reagent Development Department, TOSOH, Ayase, Japan
| | - Hironori Nagasaka
- Department of Pediatrics, Takarazuka City Hospital, Takarazuka, Japan
| | - Masayoshi Kage
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiroyuki Kusuhara
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
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Ołdakowska-Jedynak U, Jankowska I, Hartleb M, Jirsa M, Pawłowska J, Czubkowski P, Krawczyk M. Treatment of pruritus with Prometheus dialysis and absorption system in a patient with benign recurrent intrahepatic cholestasis. Hepatol Res 2014; 44:E304-E308. [PMID: 24164717 DOI: 10.1111/hepr.12262] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 10/10/2013] [Accepted: 10/21/2013] [Indexed: 02/08/2023]
Abstract
Benign recurrent intrahepatic cholestasis (BRIC) is an autosomal recessive liver disorder characterized by recurrent episodes of jaundice and itching. Episodes of cholestasis last variously from 1 week to several months, may start at any age and usually resolve spontaneously. No effective treatment has been found as yet. We report a case of genetically proven BRIC in a male patient who developed three episodes of pruritus and jaundice at the age of 14, 16 and 19 years. During the third episode, he did not respond to pharmacological medical therapy, and fractionated plasma separation and absorption (FPSA, Prometheus) was performed to manage intractable pruritus. The treatment immediately alleviated pruritus, lowered serum bilirubin concentration and induced sustained remission in the 5-year follow up. FPSA seems to be a safe and effective way of treatment for BRIC in patients with severe pruritus and prolonged jaundice.
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Stindt J, Ellinger P, Weissenberger K, Dröge C, Herebian D, Mayatepek E, Homey B, Braun S, Schulte am Esch J, Horacek M, Canbay A, Schmitt L, Häussinger D, Kubitz R. A novel mutation within a transmembrane helix of the bile salt export pump (BSEP, ABCB11) with delayed development of cirrhosis. Liver Int 2013; 33:1527-35. [PMID: 23758865 DOI: 10.1111/liv.12217] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/11/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS The bile salt export pump (BSEP, ABCB11) is essential for bile salt secretion at the canalicular membrane of liver cells. Clinical phenotypes associated with BSEP mutations are commonly categorized as benign recurrent intrahepatic cholestasis (BRIC-2) or progressive familial intrahepatic cholestasis (PFIC-2). METHODS The molecular basis of BSEP-associated liver disease in a sibling pair was characterized by immunostaining, gene sequencing, bile salt analysis and recombinant expression in mammalian cells and yeast for localization and in vitro activity studies respectively. RESULTS Benign recurrent intrahepatic cholestasis was considered in a brother and sister who both suffered from intermittent cholestasis since childhood. Gene sequencing of ABCB11 identified the novel missense mutation p.G374S, which is localized in the putative sixth transmembrane helix of BSEP. Liver fibrosis was present in the brother at the age of 18 with progression to cirrhosis within 3 years. Immunofluorescence of liver tissue showed clear canalicular BSEP expression; however, biliary concentration of bile salts was drastically reduced. In line with these in vivo findings, HEK293 cells showed regular membrane targeting of human BSEP(G374S), whereas in vitro transport measurements revealed a strongly reduced transport activity. CONCLUSIONS The novel mutation p.G374S impairs transport function without disabling membrane localization of BSEP. While all other known BSEP mutations within transmembrane helices are associated with PFIC-2, the new p.G374S mutation causes a transitional phenotype between BRIC-2 and PFIC-2.
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Affiliation(s)
- Jan Stindt
- Department of Gastroenterology, Hepatology and Infectiology, University Hospital, Düsseldorf, Germany; Institute of Biochemistry, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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El Sherrif Y, Potts JR, Howard MR, Barnardo A, Cairns S, Knisely AS, Verma S. Hepatotoxicity from anabolic androgenic steroids marketed as dietary supplements: contribution from ATP8B1/ABCB11 mutations? Liver Int 2013; 33:1266-70. [PMID: 23750872 DOI: 10.1111/liv.12216] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 05/05/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Though possession of androgenic anabolic steroids (AAS) is illegal, non-prescription use of AAS persists. METHODS We describe two Caucasian males (aged 25 and 45 years) with cholestatic hepatitis following ingestion of the dietary supplement Mass-Drol ('Celtic Dragon') containing the AAS 2α-17α-dimethyl-etiocholan-3-one,17β-ol. RESULTS Despite substantial hyperbilirubinaemia peak gamma-glutamyl transferase (GGT) remained normal. Besides 'bland' intralobular cholestasis, liver biopsy in both found deficiency of canalicular expression of ectoenzymes as seen in ATP8B1 disease. In the older patient, bile salt export pump marking (encoded by ABCB11) was focally diminished. We hypothesized that AAS had either induced inhibition of normal ATP8B1/ABCB11 expression or triggered initial episodes of benign recurrent intrahepatic cholestasis (BRIC) type 1/or 2. On sequencing, ATP8B1 was normal in both patients although the younger was heterozygous for the c.2093G>A mutation in ABCB11, a polymorphism previously encountered in drug-induced liver injury. CONCLUSION AAS marketed as dietary supplements continue to cause hepatotoxicity in the UK; underlying mechanisms may include unmasking of genetic cholestatic syndromes.
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Affiliation(s)
- Yasser El Sherrif
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals, Brighton, UK
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Wakui N, Fujita M, Oba N, Yamauchi Y, Takeda Y, Ueki N, Otsuka T, Nishinakagawa S, Shiono S, Kojima T. Endoscopic nasobiliary drainage improves jaundice attack symptoms in benign recurrent intrahepatic cholestasis: A case report. Exp Ther Med 2012; 5:389-394. [PMID: 23403701 PMCID: PMC3570127 DOI: 10.3892/etm.2012.814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 11/13/2012] [Indexed: 11/15/2022] Open
Abstract
A 66-year-old male with unbearable pruritus and jaundice was admitted for detailed examination. Blood tests on admission showed increased bilirubin with a dominant direct fraction. Ultrasonography and computed tomography performed subsequent to admission showed no narrowing or distension of the bile ducts. As the jaundice symptoms were not improved by the oral administration of ursodeoxycholic acid (300 mg/day) that had been started immediately after admission, endoscopic retrograde cholangiopancreatography (ERCP) was performed on hospital day 14. This also showed no abnormalities of the bile ducts. After considerating its potential effects for improving jaundice, endoscopic nasobiliary drainage (ENBD) was performed on the same day and was followed by immediate improvements in pruritus and jaundice. Detailed examinations were performed to identify the cause of the jaundice, which was suspected to be viral hepatitis, autoimmune hepatitis or drug-induced liver injury, however, there were no findings suggestive of any of these conditions. Following a further increase in bilirubin levels, confirmed by additional blood tests, a liver biopsy was performed. Histological findings were consistent with the histological features of benign recurrent intrahepatic cholestasis (BRIC). Although ursodeoxycholic acid is used as a first-line treatment in most cases of BRIC, ENBD should also be considered for patients not responding to this treatment.
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Affiliation(s)
- Noritaka Wakui
- Departments of Internal Gastroenterology, Tokyo Rosai Hospital, Tokyo 143-0013, Japan
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