Cholestasis, bile stasis, biliary congestion, or cholestasis syndrome is a pathological disorder of the bile’s drainage pathways. It results in a buildup of bodily toxins produced by the liver that must be eliminated through the intestines. A typical sign of cholastasis is jaundice. Furthermore, there is brown coloration of urine and stool discoloration. Abdominal pain and itching are also common accompanying symptoms. Cholestasis should be quickly examined and treated by a physician.
What is cholestasis?
Bile is produced in the liver and then stored in the gallbladder. When needed (primarily by food stimuli), the digestive juice is now released into the duodenum via the bile ducts. The close proximity to the pancreas is also clinically relevant. If a congestion now occurs in the area of the bile outflow, the physician speaks of a cholestasis or bile stasis. This bile stasis can be detected early in the laboratory (by the so-called cholestasis parameters gamma-GT, alkaline phosphatase (AP) and the yellow blood pigment bilirubin). Symptoms do not appear until much later.
Causes
The most common cause of cholestasis is an obstructed gallstone. This usually originates in the gallbladder and can then migrate. If this lodges in a bile duct, cholestasis occurs in addition to the typical colicky pain. Risk factors are the often cited “5xF”: women (female), around 40 years old (forty), overweight (fat), fertile (fertile) and fair complexion or blond (fair). Unfortunately, painless cholestasis is often the result of a malignant tumor of the pancreas. Since this cancer usually grows in the upper area, it then purely mechanically obstructs the bile ducts and thus leads to bile stasis. Other causes are less common. Examples include inflammatory diseases (e.g., primary sclerosing cholangitis, which is usually associated with rheumatic or chronic inflammatory bowel disease), scarring adhesions after surgery (e.g., after gallbladder removal), or tumors of the biliary system (e.g., the so-called Klatskin tumor with an extremely poor prognosis).
Symptoms, complaints, and signs
Depending on the cause, cholestasis can cause various symptoms and complaints. Cholestasis is initially manifested by the typical signs of jaundice – yellowish skin, sweating, dark circles under the eyes, and tremors. These external symptoms are accompanied by gastrointestinal discomfort. As a result of impaired kidney function, flatulence and abdominal pain occur, for example, and a feeling of fullness often sets in. The pressure on the surrounding organs can also lead to sudden vomiting. The lack of bile salts leads to chronic, usually agonizing itching. This is usually accompanied by other skin irritations. Some patients suffer from unusual redness or eczema on the skin, which increases in intensity as the disease progresses. If cholestasis occurs as a result of tumor disease, it is usually painless. However, as it progresses, jaundice and the other symptoms mentioned at the beginning may appear. If not treated, cholestasis results in perforation of the gallbladder. Rupture of the gallbladder is manifested by acute, cramping pain and severe nausea. As the gallbladder empties into the abdominal cavity, the peritoneum becomes inflamed. In addition, pancreatitis and other severe diseases may occur, which in turn are associated with symptoms and discomfort.
Course
Depending on the cause, cholestasis may be accompanied by massive pain, for example, when the bile duct is suddenly obstructed (especially by gallstones). In contrast, cholestasis due to tumors (which obstruct the duct for a prolonged period) is usually painless. Regardless of the cause, cholestasis causes bile to back up into the liver. Bile salts can now no longer be released via the bile, which are deposited in the skin. This leads to excruciating itching. The bilirubin, which gives bile its color, is now alternatively excreted via the kidneys (dark brown urine) and no longer via the stool (light yellow to white stool). Under the circumstances, the liver can also only perform its function to a limited extent. Further disorders (for example in the area of blood coagulation or protein balance) can occur as a result.
Complications
Cholestasis is usually associated with various complications and risks. First, the backlog of bile causes an overload of the liver, which in extreme cases can lead to permanent liver damage or liver failure. Cholestasis is also usually accompanied by inflammation of the bile ducts and surrounding organs, which increases the risk of perforation, gallstones or tumors. If the outflow of bile into the small intestine is also disturbed in cholestasis, a so-called gallbladder hydrops may subsequently occur, which in turn may lead to perforation of the gallbladder. Severe complications are to be expected when the gallbladder ruptures. For example, emptying into the abdominal cavity often leads to inflammation of the peritoneum, pancreatitis and other serious diseases, which in turn are associated with various complaints and risks. During treatment, complications may arise due to gallbladder removal. For example, abdominal discomfort, gastric and intestinal ulcers, or gastritis sometimes occur as part of postcholescystectomy syndrome, which can lead to further discomfort if undetected. However, early clarification of gallbladder complaints can reliably prevent the development of most complications.
When should you see a doctor?
Cholestasis is a very serious disorder that absolutely must be clarified promptly by a physician. In the more harmless cases, an obstructed gallstone is the trigger for the bile stasis. This particularly frequently affects women around the age of 40 who are still fertile, suffer from obesity and often have a very light skin color. Since an obstructed gallstone can cause very painful cholices in addition to bile stasis, patients who belong to this risk group should consult a doctor at the first sign of biliary symptoms. If cholestasis is not accompanied by pain, a visit to the doctor is all the more urgent, as the trigger may then be a malignant tumor of the pancreas. The earlier this is treated by a specialist, the better the prognosis for the affected patient. If cholestasis is not treated in time, bile often backs up into the liver, regardless of the cause of the disorder. The bile salts, which can no longer be excreted, then begin to accumulate in the skin, which is associated with unbearable itching. Patients can usually avoid this by consulting a doctor in good time. The first point of contact when cholestasis is suspected is the family doctor. In the case of acute cholestasis, the nearest hospital can also be visited immediately.
Treatment and therapy
The causal therapy of cholestasis or biliary obstruction depends on the underlying disease. In the case of gallstones, for example, the outlet into the duodenum is dilated (papillotomy) so that the stone can pass. If this is not sufficient, the stone is retrieved endoscopically using a basket. In the course, the gallbladder should be removed as the culprit. If a pancreatic tumor is present, it can be surgically removed (so-called Whipple operation). In many cases, however, the tumor is already inoperable when the first symptoms appear. Life-prolonging (but not curative) chemotherapy can be administered. Similar therapeutic approaches are used for a bile duct tumor. Antibiotics and steroids can be used successfully for inflammatory causes. However, symptomatic therapy is also important. For example, patients suffer primarily from excruciating itching. Urea-containing lotions and cool washes can provide relief here. The disturbed fat digestion can be supported by digestive enzymes in the form of a tablet or capsule.
Outlook and prognosis
Depending on the cause, the course of cholestasis can be quite different. In principle, cholestasis has a positive prognosis. If treatment is initiated early, symptoms disappear after a few days. As a rule, there are no long-term consequences of cholestasis. However, if the symptoms are due to a serious condition such as a tumor, the prognosis is less positive. A tumor disease is always associated with certain risks, for example metastasis, chronic pain and the consequences of radiation treatment.The biliary obstruction itself can be relieved with the help of medication and conservative measures such as rest and bed rest, but the cause usually requires further investigation and treatment. The prognosis is positive if the biliary obstruction is simply due to an obstructed gallstone, obesity, or swelling. In these cases, the symptoms subside as soon as the underlying condition has receded. If the complaints are based on a Klatskin tumor or even a malignant tumor of the pancreas, the prognosis is poor. Life expectancy is usually greatly reduced. The success of treatment depends on the patient’s constitution, the chosen form of therapy, and numerous other factors.
Follow-up
Because cholestasis itself is only a symptom, follow-up care is primarily based on the existing cause. If there is only a temporary obstruction caused by a tumor, for example, the biliary obstruction will regress after surgical removal. In the following months, patients should have their liver values, inflammation parameters and cholestasis markers determined in the blood at regular intervals in consultation with the treating physician. This allows the regeneration of the liver parenchyma and any irreversible damage to be assessed. If the cholestasis is due to gallstones, regular ultrasound examinations should be performed to directly detect newly forming stones. If the cause of the cholestasis could not be removed, the cholestasis can lead to symptoms and problems again and again. The predominant symptom is jaundice and the associated itching. This can be treated with on-demand medication. Even after an acute phase, patients should take care of their liver. Large amounts of alcohol and drugs that damage the liver should be avoided. This also includes painkillers such as paracetamol. In addition, attention should be paid to a balanced, low-fat diet. Every patient should be educated about warning signs of liver damage and cholestasis in order to recognize them. These include, for example, yellowing of the skin and sclerae, increased susceptibility to infection, or an increased tendency to bleed.
What you can do yourself
Recommended behavior in everyday life and self-help measures that can be applied in case of cholestasis or bile stasis depend on the causes of the disease. At the first signs of bile stasis, which usually manifests itself in jaundice-like symptoms, a specialist should definitely be consulted. He can usually clarify the causes. In most cases, it is gallstones blocking the bile ducts and causing a very painful cholestasis. In less common cases, the bile ducts can gradually become painlessly obstructed by a tumor of the pancreas. This means that a painless bile duct obstruction requires particularly rapid clarification because of the suspicion of an aggressive pancreatic tumor, which is only operable in the initial phase. Accompanying therapy aimed at eliminating the cause of the cholestasis, the application of lotions containing urea to the skin and cooling compresses or poultices can relieve the severe itching that is usually present. The itching is caused by accumulated bile salts, which are excreted into the skin in the form of tiny crystals. In parallel, a low-fat diet and the intake of digestive enzymes can alleviate the effects of impaired fat digestion as further self-help measures. Any self-help measures should only ever take place in parallel. Of elementary importance is the elimination of the cause of the bile stasis in order to limit the potential harmful effects.
