Safety and efficacy of long-term nasobiliary drainage to treat intractable pruritus in cholestatic liver disease

Abstract

IntroductionCholestasis related pruritus, secondary to intrahepatic and/or extrahepatic biliary obstruction is a common manifestation in chronic liver disease. Pruritus is difficult to treat, and results are often suboptimal. A stepwise medical approach is usually employed, followed by a trial molecular adsorbents recirculation system in medication resistant cases. Pruritus resulting in reduced quality of life is a variant syndrome eligible for liver transplantation in the setting of preserved synthetic function.AimThis case series describes the use of long-term (LT) nasobiliary drainage (NBD) in three patients with intractable pruritus. This case series tests the hypothesis that LT-NBD could be successfully used to alleviate cholestasis related pruritus, and prevent or delay the need for liver transplantation.MethodLT-NBD was carried out in three female patients (mean age 43 years) with intractable pruritus secondary to primary biliary cirrhosis (PBC) (n=2), and benign recurrent intrahepatic cholestasis (n=1). NBD was carried out through the endoscopic placement of a 6 French Cook Medical nasobiliary catheter into the common bile duct.ResultsSymptomatic relief of pruritus was described by all three cases within 24 h of NBD placement. LT-NBD was stopped in the patient with benign recurrent intrahepatic cholestasis after 8 weeks due to complete resolution of pruritus. In one patient with PBC, LT-NBD was undertaken over 12 months, with complete resolution of pruritus. In the second patient with PBC, LT-NBD was carried out over 14 months, with complete resolution of pruritus.DiscussionThis case series supports the efficacy of LT-NBD in the treatment of intractable pruritus. We propose that NBD offers an accessible modality for the treatment of intractable pruritus in liver disease, potentially avoiding the need for liver transplantation.

The safety and efficacy of nasobiliary drainage in the treatment of refractory cholestatic pruritus: a multicentre European study

“…11 Similarly, Beuers et al reported that following a mean 4.1 days of NBD in three PBC patients, two were completely free of pruritus within 24 h. 12 following 7 days of NBD in six patients with intractable pruritus secondary to viral hepatitis A, B and E. 13 More recently, a UK single centre report of three patients (2 PBC, 1 BRIC) has suggested long-term NBD is successful in maintaining remission of pruritus. 14 In comparison to previous studies, our study is unique since it is a multicentre study and to the best of our knowledge, it is the largest retrospective study describing the utility of NBD in cholestatic pruritus. In addition to adding evidence to the reported advantages of NBD, our study attempts to answer some of the previously unanswered questions and uncertainties about NBD.…”

“…reported complete remission of pruritus following 7 days of NBD in six patients with intractable pruritus secondary to viral hepatitis A, B and E . More recently, a UK single centre report of three patients (2 PBC, 1 BRIC) has suggested long‐term NBD is successful in maintaining remission of pruritus …”

“…The positive impact of NBD on liver biochemistry may have implications on patients with chronic cholestasis. In this regard, it has been suggested that long‐term NBD in PBC patients achieves sustained remission from pruritus and improvement in liver biochemistry …”

“…In this regard, it has been suggested that long-term NBD in PBC patients achieves sustained remission from pruritus and improvement in liver biochemistry. 14 There are conflicting data on the effect of NBD on TBS with two studies showing significant reduction 11,13 and one study showing only transient decrease 12 in TBS following NBD. We did not observe significant change in the levels of TBS and the percentage change in TBS levels did not correlate with the percentage change in pruritus VAS.…”

“…More recently long‐term NBD (i.e. continuous biliary drainage by leaving the NBD catheter in situ for few months) has also been suggested to be safe and effective . These results are encouraging but inference is limited since they are single centre reports with small sample size and include patients with one specific disease aetiology.…”