Primary biliary cirrhosis (PBC) definition
Primary biliary cirrhosis (PBC) is a progressive disease of the liver caused
by a buildup of bile within the liver (cholestasis) that results in damage to
the small bile ducts that drain bile from the liver. Over time, this pressure
build-up destroys the bile ducts leading to liver cell damage. As the disease
progresses and enough liver cells die,
cirrhosis and liver failure occur.
Bile is manufactured in the liver and then transported through the bile ducts
to the gallbladder and intestine where it helps digest fats and fat soluble
vitamins (A,D,E,K). When bile cannot be drained from the liver, it causes
inflammation that leads to cell death. Scar tissue gradually replaces the areas
of damaged liver and then the body cannot perform necessary functions.
What are the causes of primary biliary cirrhosis?
The cause of PBC is unknown. It is most likely an autoimmune disease, where
the body’s immune system attacks its own cells. In this disease, the bile ducts
are under attack and are destroyed.
What are the risk factors for primary biliary cirrhosis?
- There may be a
genetic component to the development of PBC since a
person
with the disease is likely to have a family member also afflicted. - Women are nine times more likely than men to develop PBC. It most often
develops in the middle age between the ages of 40 to 60. - The disease is seen more often in white, northern Europeans, compared
to African-Americans.
Cirrhosis in the Liver Signs and Symptoms
Some of the more common symptoms and signs of cirrhosis include:
- Yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood
- Fatigue
- Weakness
- Loss of appetite
- Itching
- Easy bruising from decreased production of blood clotting factors by the diseased liver.
Read more about cirrhosis signs and symptoms »
What are the signs and symptoms for primary biliary cirrhosis?
Up to a quarter of patients with primary biliary cirrhosis are asymptomatic,
meaning they do not have symptoms at the time of diagnosis and the disease is
found incidentally because of
abnormal liver blood tests.
The most common initial symptoms are fatigue or a sense of being abnormally
tired and, skin that itches. Because of the intense itching and
scratching, the skin may become darkened and discolored in some areas. The
person may also complain of dry mouth and
eyes.
Because there may be liver inflammation, some people may experience right
upper quadrant abdominal pain, where the liver is located.
Should the liver damage progress, the symptoms of cirrhosis may develop.
These include muscle wasting, ascites (swelling of the abdomen due to fluid
accumulation), leg swelling, jaundice (yellow coloration of the skin),
and confusion.
QUESTION
Liver disease refers to any abnormal process that affects the liver.
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How is the diagnosis of primary biliary cirrhosis made?
The diagnosis of primary biliary cirrhosis is considered when the doctor suspects that there might be liver inflammation based upon the history and physical examination. Initially there may be few symptoms like itching or fatigue to help guide further testing
The diagnosis may be made incidentally when abnormal liver functions be found on routine blood tests drawn for another reason. Liver function tests include AST (aspartate aminotransferase), ALT (alanine aminotransferase), GGT (gamma-glutamyl transpeptidase), alkaline phosphatase and bilirubin. Blood levels tend to become elevated in liver disease and they may rise in specific patterns depending upon the underlying cause of inflammation.
Once the diagnosis is suspected, a blood test to check for antimitochondrial antibody (AMA) is usually done. This is positive in over 90% of patients with PBC.
Other blood tests may be considered including a complete blood count (CBC) and cholesterol levels.
Imaging of the abdomen by ultrasound, CT scan or MRI is often considered to look for structural changes in the liver and to search for tumors.
A liver biopsy, where a thin needle is inserted through the skin to take a piece of liver tissue, may help confirm the diagnosis. This tissue is examined under a microscope by a pathologist to look for changes consistent with PBC. It is also useful to help stage the disease, deciding its severity at the time of diagnosis.
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What is the treatment for primary biliary cirrhosis?
The only "cure" for primary biliary cirrhosis is liver transplant, but it is
only considered as a treatment option if other less aggressive treatments have
failed and the patient develops liver failure.
Ursodiol (Actigal) or ursodeoxycholic acid (UDCA) is the first line treatment
for PBC. It helps the liver transport bile into the gallbladder and intestine,
in an attempt to prevent cholestasis.
Depending upon the severity of the disease, immune suppression medications
may be prescribed, including methotrexate
(Rheumatrex, Trexall), cyclosporine and prednisone.
Itching may be intense and difficult to control. Antihistamines like
diphenhydramine (Benadryl) may be helpful but other drugs may be considered
including cholestyramine
(Questran, Questran Light), which helps bind bile and decrease the itching
associated with elevated bilirubin levels in the blood.
Complications of PBC will need to be cared for. These include cirrhosis,
portal hypertension, gastrointestinal bleeding, osteoporosis, and vitamin
deficiencies.
What are the complications of primary biliary cirrhosis?
The complications of primary biliary cirrhosis develop as the ability of the liver to function decreases. Cirrhosis describes liver scarring and failure. The liver is responsible for helping to digest food, producing proteins, blood clotting factors, and enzymes that help digest food. Some complications include the following:
Ascites: Fluid collection within the abdomen that occurs because the liver cannot produce enough albumin, a protein that helps keep fluid within the blood vessels. Ascites fluid is prone to infection and a condition called spontaneous bacterial peritonitis (peritoneum=sac that contains the abdominal organs + itis=inflammation)
Edema: Swelling of the legs may occur, again because of decreased albumin levels in the body
Easy bruising or bleeding: The liver is responsible for producing blood clotting factors. Without an adequate supply, there is an increased risk of bleeding. Patients may have a low platelet count because of an enlarged spleen causing easy bruising.
Hepatic encephalopathy: The liver also helps remove waste products from the bloodstream. Ammonia is the chemical waste product of protein metabolism and the body requires a healthy liver to metabolize it. If ammonia levels rise, confusion and lethargy (encephalopathy) may occur.
Portal hypertension: An increase in pressure within the liver can cause blood flow issues leading to portal hypertension. This may backup blood flow from other organs, causing splenomegaly, an enlarged spleen, and varices, swollen veins, especially in the esophagus and stomach that can predispose to bleeding.
Osteoporosis: PBC is also complicated by osteoporosis, difficulty in absorbing nutrients, such as fat-soluble vitamin D and calcium, from the intestine.
Cancer: Some studies show patients with PBC are at an increased risk for hepatocellular carcinoma.
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Can primary biliary cirrhosis be prevented?
Since the cause of the disease is not known, it is not possible to prevent
PBC. However, medications may be able to slow the progression of the disease and
control the symptoms.
Should a person develop PBC, all attempts should be made to prevent further
potential damage. This may include limiting alcohol intake, avoiding the use of
medications that contain acetaminophen (Tylenol, Panadol), and cholesterol
lowering agents.
What is the prognosis for someone with primary biliary cirrhosis?
PBC is a progressive disease that can be controlled but not cured. The prognosis depends upon a variety of factors including whether the patient has symptoms (especially fatigue), liver function test abnormalities, and whether the patient has undergone treatment with medication or has required liver transplantation.
Advances in treatment have extended the life expectancy in the past many years. The average survival from diagnosis for a patient with PBC who is asymptomatic is 16 years, while that of patients with symptoms is 7 1/2 years.