Chapter 32 CHOLESTASIS AND JAUNDICE
Cholestasis and jaundice are common clinical occurrences which flag the presence of an underlying disease process. Diseases of the liver and biliary tree are a significant cause of morbidity and mortality and an important indication for liver transplantation in certain settings. This chapter outlines an approach to dealing with this common problem.
Cholestasis can broadly be divided into that caused by mechanical obstruction, and that caused by non-obstructive or hepatocellular causes. Table 32.1 lists the causes of cholestasis. Mechanical obstruction may develop in either the extrahepatic biliary tree or the smaller intrahepatic bile ducts. Non-obstructive intrahepatic cholestasis may arise from parenchymal disease affecting the small bile ducts and canaliculi or conditions affecting the hepatocytes directly (causing an excess of bile products to be formed). Considering the possible underlying causes of cholestasis will guide the history, examination and investigation of a patient with cholestasis. Important causes to consider include the following.
Fatigue is the most common symptom of chronic cholestasis. Other symptoms include jaundice, pruritis and steatorrhoea. There may be a history of haemorrhage due to poor vitamin K absorption or bone pain and fractures due to poor vitamin D and calcium absorption (in cases of chronic cholestasis resulting in hepatic osteodystrophy or osteoporosis).