Primary biliary cholangitis (PBC) probably results from an autoimmune reaction.
This disorder commonly causes itchiness, fatigue, dry mouth and eyes, and jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more , but some people have no symptoms.
A blood test to measure certain antibodies can usually confirm the diagnosis.
Treatment includes relieving symptoms, slowing liver damage, and treating complications.
(See also Cirrhosis of the Liver Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more .)
Primary biliary cholangitis (PBC) is most common among women aged 35 to 70, although it can occur in men and women of any age. It tends to occur in families.
The liver produces bile, a greenish yellow, thick, sticky fluid that aids digestion. Bile also helps eliminate certain waste products (mainly bilirubin and excess cholesterol) and by-products of drugs from the body. Bile ducts are small tubes that carry bile from the liver to the gallbladder and then to the small intestine. Primary biliary cholangitis affects only the small bile ducts inside the liver and the liver cells near these bile ducts. Another inflammatory bile duct disorder, primary sclerosing cholangitis Primary Sclerosing Cholangitis Primary sclerosing cholangitis is inflammation with progressive scarring and narrowing of the bile ducts in and outside the liver. Eventually, the ducts become blocked and then obliterated.... read more , affects bile ducts inside and outside the liver.
Primary biliary cholangitis begins with inflammation of the bile ducts. The inflammation blocks the flow of bile out of the liver. Thus, bile remains in the liver cells, causing inflammation. If damage from the inflammation is mild, the liver commonly repairs itself by making new liver cells and attaching them to the web of connective tissue (internal structure) that is left when liver cells die. As inflammation spreads, a latticework of scar tissue (fibrosis Fibrosis of the Liver Fibrosis is the formation of an abnormally large amount of scar tissue in the liver. It occurs when the liver attempts to repair and replace damaged cells. Many conditions can damage the liver... read more ) develops throughout the liver. The scar tissue performs no function, and it can distort the liver's internal structure. When the scarring and distortion become widespread, cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more develops.
Causes of PBC
The cause is not clear but is probably an autoimmune reaction Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers autoimmune disorders is not known. Symptoms vary depending on... read more (in which the immune system attacks the body’s own tissues). Primary biliary cholangitis often occurs in people with autoimmune disorders, such as rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more , scleroderma Systemic Sclerosis Systemic sclerosis is a rare, chronic autoimmune rheumatic disorder characterized by degenerative changes and scarring in the skin, joints, and internal organs and by blood vessel abnormalities... read more , Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a common autoimmune rheumatic disorder and is characterized by excessive dryness of the eyes, mouth, and other mucous membranes. White blood cells can infiltrate and damage... read more , or autoimmune thyroiditis Hashimoto Thyroiditis Hashimoto thyroiditis is chronic, autoimmune inflammation of the thyroid. Hashimoto thyroiditis results when the body attacks the cells of the thyroid gland—an autoimmune reaction. At first... read more .
An autoimmune cause is also thought possible because more than 95% of people with PBC have certain abnormal antibodies in their blood. These antibodies attack mitochondria (tiny structures that produce energy in cells). However, these antibodies are not involved in the destruction of the bile ducts. Other immune cells attack the bile ducts. What triggers this attack is unknown, but it may be exposure to a virus or a toxic substance.
Symptoms of PBC
Usually, PBC starts very gradually. About half of people have no symptoms at first.
The first symptoms often include
Dry mouth and eyes
Other problems may not occur until months or years later:
The skin may become dark or nerves may be damaged (called neuropathy).
People may feel discomfort in the upper abdomen.
Fat sometimes accumulates in small yellow bumps in the skin (xanthoma) or eyelids (xanthelasma Xanthelasma Noncancerous (benign) and cancerous (malignant) growths can form on the eyelids. A yellow-white lump known as xanthelasma is seen under the eye. This finding may indicate elevated cholesterol... read more ).
As the disorder progresses, itching may disappear and the yellow bumps may shrink.
Jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more (yellowish discoloration of the skin and whites of the eyes) may develop.
Fluid can accumulate within the abdomen (called ascites Ascites Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen. Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood... read more ) or in other parts of the body, such as the ankles and feet (called edema Swelling Swelling is due to excess fluid in the tissues. The fluid is predominantly water. Swelling may be widespread or confined to a single limb or part of a limb. Swelling is often in the feet and... read more ).
Eventually, any of the symptoms and complications of cirrhosis Symptoms Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more can develop. Fats, including fat-soluble vitamins (A, D, E, and K), are often poorly absorbed. Poor absorption of vitamin D results in osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more , and poor absorption of vitamin K contributes to easy bruising and bleeding. If the body cannot absorb fats, stools may be light-colored, soft, bulky, oily-looking, and unusually foul-smelling (called steatorrhea).
The liver and spleen may enlarge. But as scarring progresses, the liver shrinks.
Diagnosis of PBC
Abnormal liver function tests
Antibodies to mitochondria
A doctor may suspect this disorder in middle-aged women who have typical symptoms such as fatigue and itchiness. However, in many people, the disorder is discovered long before symptoms appear because results of routine blood tests to evaluate the liver Liver Blood Tests Liver tests are blood tests that represent a noninvasive way to screen for the presence of liver disease (for example, hepatitis in donated blood) and to measure the severity and progress of... read more are abnormal.
During the physical examination, the doctor may feel an enlarged, firm liver (in about 25% of people) or an enlarged spleen Enlarged Spleen An enlarged spleen is not a disease in itself but the result of an underlying disorder. Many disorders can make the spleen enlarge. Many disorders, including infections, anemias, and cancers... read more (in about 15%).
If PBC is suspected, doctors do liver tests, imaging tests, and blood tests to check for antibodies to mitochondria.
Imaging tests Imaging Tests of the Liver and Gallbladder Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more are done to check for abnormalities or blockages in bile ducts outside the liver. These tests include magnetic resonance imaging (MRI) of the bile duct system (called magnetic resonance cholangiography) and often ultrasonography. If results of these tests are not clear, endoscopic retrograde cholangiopancreatography may be done. For this procedure, an x-ray is taken after a substance that can be seen on x-rays (contrast agent) is injected through a viewing tube (endoscope) inserted through the mouth into the bile ducts. Finding no blockages outside the liver means that the liver is the site of the problem and thus supports the diagnosis of PBC.
A liver biopsy Biopsy of the Liver Doctors can obtain a sample of liver tissue during exploratory surgery, but more often they obtain a sample by inserting a hollow needle through the person's skin and into the liver. This type... read more (removal of a tissue sample for examination under a microscope) is usually done to confirm the diagnosis. Biopsy also helps doctors determine how advanced the disorder is (the stage).
Prognosis of PBC
Primary biliary cholangitis usually progresses slowly, although how fast it progresses varies greatly. Symptoms may not appear for 2 years or for up to 10 to 15 years. Some people become very ill in 3 to 5 years. Once symptoms develop, life expectancy is about 10 years. Certain characteristics suggest that the disorder will progress quickly:
Rapidly worsening symptoms
Certain abnormal liver test results
When itching disappears, the yellow bumps of fat shrink, and jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more develops, death may occur within months.
Treatment of PBC
There is no known cure. Treatment includes
Drugs to relieve symptoms, primarily itching
Ursodeoxycholic acid to slow the progression of liver damage
Obeticholic acid is a new medication that was approved by the Food and Drug Administration (FDA) in 2016 for the treatment of primary biliary cholangitis (PBC). This medication is intended for use in people in whom ursodeoxycholic acid is not working well. It should be used with caution in people with advanced liver disease.
Treatment of complications
Eventually liver transplantation
No alcohol should be consumed. Drugs that may damage the liver are stopped.
Cholestyramine may control itchiness, as may rifampin, naltrexone (an opioid), sertraline, or ursodeoxycholic acid plus ultraviolet light.
Ursodeoxycholic acid, particularly if used before the disorder is advanced, reduces liver damage, prolongs life, and delays the need for liver transplantation. Obeticholic acid is a newly FDA-approved medication which has been proven to improve liver-related blood tests in many people with PBC for whom ursodeoxycholic acid alone is not effective.
Supplements of calcium and vitamin D are needed to help prevent osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more or slow its progression. Weight-bearing exercises, bisphosphonates, or raloxifene may also help prevent or slow osteoporosis. Vitamin A, D, E, and K supplements may be needed to correct vitamin deficiencies. Vitamins A, D, and E can be taken by mouth. Vitamin K is given by injection.
Liver transplantation Liver Transplantation Liver transplantation is the surgical removal of a healthy liver or sometimes a part of a liver from a living person and then its transfer into a person whose liver no longer functions. (See... read more is the best treatment when the disorder is advanced. It can prolong life. After transplantation, PBC recurs in some people, but it rarely becomes severe.