Cholestasis during pregnancy is a disorder of the liver . In this condition, the flow of bile- a dark greenish or brownish-yellow fluid made by the liver gets blocked between the liver cells and the upper part of the small intestine or duodenum. Bile is the substance that aids in the digestion of lipids. When the normal flow of bile is impaired bilirubin starts to build up in the bloodstream.
Bilirubin is a yellowish substance that is actually a waste material that is formed during the breaking down of red blood cells. In normal circumstances, bilirubin, along with the bile, travels from the liver into the digestive tract before being expelled from the body. However, during the pregnancy the high level of this Bilirubin can lead to severe problems for the fetus development.
Types of Cholestasis
- Intrahepatic Cholestasis
- Extrahepatic Cholestasis
Intrahepatic Cholestasis occurs within the liver itself, and its major triggers are:
- An illness
- Any infection
- Use of drugs
- Genetic issues
- Effects of hormones on the flow of bile
Apart from these, being pregnant also increases the risk of developing Intrahepatic Cholestasis.
Extrahepatic Cholestasis is brought on by blockages to the bile ducts. The blockages can occur due to the presence of gallstones, tumors, and cysts.
Causes of Cholestasis
Sometimes the causes of Cholestasis occur within the liver itself, and sometimes they occur outside of it. Let’s take a closer look at its causes.
These include people having chronic Hepatitis, a liver condition due to excess consumption of alcohol, primary biliary cholangitis in which there is scarring and inflammation of the bile ducts. Additionally, the causes also include viral hepatitis B or C induced cirrhosis, sometimes certain drugs like chlorpromazine, azathioprine, oral contraceptives, and amoxicillin/clavulanate also cause Cholestasis. Apart from that, hormonal effects on the bile ducts during pregnancy and cancer that have metastasized are also some of its causes.
The causes that occur outside the liver include any sort of blockages in the bile duct due to stones, cancer in the bile duct, pancreatic cancer, and swelling of the pancreas or pancreatitis.
Symptoms of Cholestasis
Some of the signs and symptoms of Cholestasis are:
- Dark-colored urine which is because of the excess bilirubin being expelled by the kidneys.
- Light-colored stools are also experienced as bilirubin is not able to enter the digestive tract due to blockages. Since bile digests fats, in Cholestasis it cannot enter the intestines, and as a result, there is sometimes too much fat content in the stools since the body is not able to digest them. This condition is called Steatorrhea.
- Jaundice is also seen in individuals with Cholestasis as a result of the build-up of bilirubin in the skin and the eyes.
- Individuals with Cholestasis also complain of extreme itchiness as a result of the accumulation of bilirubin in the skin. Excessive scratching can also damage the skin.
Cholestasis is mostly common in pregnant women, and in their case, they suffer from intense and excessive itching. They normally itch in the palms of their hands and soles of their feet while, for some, the itchiness is everywhere. Itching is mostly seen in pregnant women during the third trimester and gets worse as the due date gets nearer. However, within a few days of delivery, the itchiness disappears on its own.
When there is a lack in the usual amounts of bile in the intestine, people have difficulty in the proper absorption of vitamin K and calcium. In the absence of these, a person might suffer bone tissue loss, and their skin is bleeding easily.
Diagnosis of Cholestasis
Cholestasis can be determined via a blood test. If the blood test results are not clear, the doctor suggests a follow up with ultrasonography. Sometimes a biopsy of the liver is also recommended.
Since Cholestasis is normally seen in people with jaundice, on the basis of test results, a doctor usually tries to determine if the cause is within the liver or outside it. Within the liver, causes can be determined by the recent use of some drugs, spider angiomas, or tiny blood vessels that look like spiders on the skin surface, ascites, or the build-up of fluid in the abdominal area and the swelling of the spleen.
Outside the liver, causes take into consideration pain in the upper right-hand side of the abdominal area or pain in the right shoulder and an inflamed gallbladder, which can be ascertained after a physical check-up or through ultrasonography.
Excessive alcohol consumption, nausea, loss of appetite are some of its causes that do not come under either within or outside the liver causes.
When the doctor asks a patient to get a blood test done, it is usually to measure the levels of two different enzymes, namely alkaline phosphatase and gamma-glutamyl transpeptidase. The level of these two enzymes are very high in people with Cholestasis. The blood test also helps detect the level of bilirubin which, if it is high, indicates how severe the case of Cholestasis is; however, it does not reveal its cause.
If the blood test result is not clear, the doctor recommends alkaline ultrasonography as well. In addition to that, a CT or Computed tomography and MRI or magnetic resonance imaging is also done. If the tests reveal that the cause stems from the liver, a liver biopsy is also advised.
In case the causes are outside the liver, namely certain blockages of the bile ducts, the following tests are recommended:
Endoscopic retrograde cholangiopancreatography or ERCP: In this, a patient is made to swallow an endoscope with a radiopaque contrast agent since this agent is visible in X-rays when it enters the bile ducts and the pancreas. The X-rays are then taken in which affected areas can easily be seen.
Magnetic resonance cholangiopancreatography or MRCP: Through this test, the secretions of the bile ducts are made to look brighter than its surrounding tissues and organs.
Endoscopic ultrasonography: these images are taken via an ultrasound probe that is fitted on the tip of an endoscope. The endoscope is inserted through the mouth that goes to the small intestines.
Treatment for Cholestasis
For Cholestasis that is caused due to certain elements within the liver, the doctor prescribes certain drugs. If a certain type of drug is not working, then the doctor might prescribe a different drug. If Cholestasis is caused due to Hepatitis, both Cholestasis and jaundice disappear on their own when the Hepatitis is cured. Apart from that person with Cholestasis should avoid harmful substances that can damage their liver further like certain drugs and alcohol.
For causes outside of the liver like bile duct blockages due to stones, surgery is recommended.
For itching, a drug known as Cholestyramine is prescribed that hinders the absorption of bile in the body. For pregnant women experiencing intense itching due to obstetric Cholestasis the condition usually goes away on its own after a few days of giving birth. However, these women are kept under observation post-delivery.
For calcium and vitamin, K deficiency supplements are prescribed, especially if the Cholestasis persists. But these calcium supplements cannot prevent bone tissue loss.
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Cholestasis is fairly common and affects all individuals, both men and women, regardless of age. Its recovery highly depends on the overall level of severity of the disease before its diagnosis. If the cause of Cholestasis lies outside the liver like gallstone blockages, then a simple surgery that removes these can completely cure the disease. However, if the problem lies within the liver itself, recovery may get harder.
There are some ways in which Cholestasis can be avoided, namely:
- Getting vaccinated for Hepatitis
- By avoiding excessive consumption of alcohol
- By avoiding the use of drugs via needles
As with any disease, the sooner it gets diagnosed and treated, the better are the chances of early recovery. The same is the case with Cholestasis as well. So it gets very important to see a doctor as soon as one feels like they have Cholestasis.