Cholestatic Hepatitis

Cholestatic hepatitis was once called cholangiolitic hepatitis, which is the obstruction of bile secretion and dysfunction of bile canaliculi in the Golgi apparatus of the liver cells. During the acute stage of cholestatic hepatitis, electron microscopy and histo-chemical studies of the liver cell demonstrated that the cell apparatuses, such as the Golgi apparatus, exhibited degeneration of the smooth endoreticulum and mitochondria. These components are mainly responsible for the secretion of bile and as a result, the amount of bile excreted into duodenal intestine is greatly reduced. The components of bile (bile acid, bilirubin, cholesterol, and AKP etc.) re-enters into the blood stream, which causes a group of clinical symptoms including: jaundice, skin itch, elevation of serum AKP, bilirubin, bile acid, and albumin. Cholestatic hepatitis is commonly seen in viral, iatrogenic (drug-caused), and idiopathic cholestatic hepatitis as part of their pathology.

Viral infection is the most common cause of cholestatic hepatitis. The incidence rate of this disease in HAV, HBV, and HCV is around 1 to 2%, 2%, and 9 to 10%, respectively. It can occur during acute, chronic, or fulminant viral hepatitis and also post-hepatitis cirrhosis. Besides viral cholestatic hepatitis, there is also chronic active-, drug-, pregnant-, post-surgical-, alcoholic-, fatty-liver-, Hodgkin-disease-, congestive-heart-disease-, chronic-pancreatitis- based-cholestatic hepatitis. In icteric (jaundice) hepatitis, 2 to 8% are cholestatic hepatitis and in older age groups this proportion is much higher. In order to distinguish intra- or extra-liver bile obstruction, a B-ultrasound study is useful.  

Clinical Features

1. Jaundice: The main characteristics of this disease are similar to icteric hepatitis, and subjective symptoms are mild with jaundice being its main manifestation.  The Jaundice usually lasts longer than three weeks.
2. Skin Itch: Body itch and rashes will sometimes show at the wrist area, under the breast, or on the neck and chest or back areas. The itching is mainly caused by bile acid flooding in the skin, which over-stimulates the nerve endings.
3. Enlarged liver: The size of the liver becomes larger when the blockage of the bile is caused by extra-liver obstruction than intra-liver bile retention. There is usually no tenderness while palpating. When cirrhosis has been developed, the surface of the liver becomes uneven. A mildly enlarged spleen can be seen in viral, iatrogenic hepatitis. When the spleen is obviously enlarged, blood pressure in the portal vein is also likely to be elevated.
4. Stool and urine color change: Dark colored urine and light colored stool are very common signs.
5. Other symptoms: fatigue, and indigestion are common symptoms.

Diagnosis

1. Clinical symptoms: Jaundice is the main manifestation and it lasts longer than three weeks. Skin itch is usually more severe at night. Rashes can occur on the neck, chest, back, and wrists. Stool color becomes lighter and urine color becomes darker. Although there can be many symptoms, the patient usually will not feel extremely ill.
2. Laboratory tests: Direct bilirubin in the serum elevated and its proportion is more than 50% of the total bilirubin. Serum combined bile acid elevated to 10 to 20 times higher than the normal range. AKP, GGT, cholesterol, and 5- nucleotidase are obviously elevated, and the ALT elevation is moderate.
3. B-Ultrasound: It can distinguish intra or extra liver obstruction.

Treatments for Cholestatic Hepatitis

  General treatments:

1. Etiological therapy: For viral causes, we do not have a very effective anti-viral treatment protocol available yet. For alcoholic, drug- induced cases, the most important step is to stop the toxic chemical intake immediately. About 1/3 of cholestatic hepatitis cases are without clear causative factors so there is no etiological therapy. If it is caused by extra-liver bile duct obstruction, removal of the obstruction via surgery may be considered. 
2. Nutritional therapy: low fat, low cholesterol diet, for chronic long-term bile obstruction sufferers, use vitamin K, A, D, and ATP, Co-enzyme A, and a high protein low fat diet.
3. Symptomatic treatments: eliminating the jaundice, conventional medicine may use prednisone with about 60% efficacy, but it may cause undesired side effects and can cause the underlying disease to worsen. For the skin itch, 2% magnesium sulfate (Epsom salt) bathing can help to release the itching. Take six to ten grams of Cholestyramine daily also help to reduce the itch. Deoxycholic acid can also be used.

MCM treatment strategy

The treatment principle for this disease is heat-cleansing and toxic-resolving, bile secretion facilitating, dampness-drying. Herbs and formulas can facilitate bile secretion and excretion from the liver and increase the bile movement into the intestine. They can also help to expel small gallstones and act as anti-inflammatory agents to reduce gall bladder inflammation.