Pruritus of chronic cholestasis

Pruritus is a challenging clinical problem which often complicates chronic cholestatic liver disease. For practical purposes, cholestasis may be defined as impaired hepatocellular secretion of bile and is a feature of a wide variety of liver diseases. Cholestasis is usually suspected clinically when a patient presenting with jaundice or pruritus is found to have an elevation in serum alkaline phosphatase activity disproportionate to increases in serum aminotransferase levels. Early imaging by ultrasonography, computerized tomography, or cholangiography is important to address the possibility of remediable biliary tract obstruction. The majority of patients who develop problematic pruritus due to chronic cholestasis will have one of several diseases: primary biliary cirrhosis, primary sclerosing cholangitis, drug-induced cholestasis, autoimmune chronic active hepatitis, or alcoholic liver disease. Specific aetiological diagnosis is usually possible when history and physical examination are complemented, as appropriate, by serological testing, hepatobiliary imaging, and liver biopsy. This review does not address issues in diagnosis, but concentrates upon the management of pruritus, a potentially disabling complication of prolonged cholestasis.