II. Pathophysiology

  1. Bile salt protease release in skin and plasma

III. Causes: Cholestasis

  1. Chronic Liver Disease
  2. Pancreatic carcinoma
  3. Primary biliary Cirrhosis (Pruritus in all cases)
  4. Intrahepatic Cholestasis of Pregnancy
    1. Affects 0.5% of women in third trimester

IV. Symptoms: Pruritus

  1. Intense itching worse at night
  2. Location (initial)
    1. Hands and feet
    2. Pressure areas

V. Signs

  1. Hyperpigmentation in areas of heavy scratching
  2. Spares midback resulting in butterfly-shaped rash

VI. Management

  1. Cholestyramine (or Colestipol if Constipation limited)
    1. Has also been used in Pruritus of pregnancy
  2. Ursodeoxycholic Acid
    1. Used in primary biliary Cirrhosis (intense itch)
  3. Ultraviolet Radiation
    1. May be indicated in refractory cases
  4. Selective Serotonin Reuptake Inhibitors
    1. Mayo (2007) Hepatology 45(3): 666-74 [PubMed]
  5. Ondansetron
  6. Opiate receptor antagonist
    1. Naltrexone (Revia)
    2. Naloxone IV
    3. Nalmefene PO

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