Makindo Medical Notes

⚠️ Key Exam Tip: Amoxicillin–clavulanate (Co-Amoxiclav) is a well-known cause of cholestatic jaundice. If cholestasis develops, the drug should be stopped immediately and avoided in the future.

🧾 Aetiology

• Intrahepatic: Parenchymal liver disease (hepatitis, cirrhosis, drug-induced liver injury).
• Extrahepatic: Obstruction beyond the canaliculi → usually due to gallstones, tumours, or strictures in the bile ducts.

🔬 Intrahepatic Causes

• Viral hepatitis (A, B, C, E)
• Alcoholic liver disease 🍺
• Primary Biliary Cholangitis (PBC) – autoimmune destruction of small bile ducts
• Primary Sclerosing Cholangitis (PSC) – progressive inflammation and fibrosis of intra/extrahepatic bile ducts
• Drug-induced (e.g. antibiotics, anabolic steroids, oral contraceptives)
• Pregnancy – intrahepatic cholestasis of pregnancy (ICP)

🚧 Extrahepatic Causes

• Gallstones in the common bile duct (choledocholithiasis)
• Pancreatic or biliary tumours
• Bile duct strictures (postsurgical, inflammatory)
• Pancreatitis causing compression

🩺 Clinical Features

• Jaundice (yellow sclera/skin)
• Dark urine (↑ conjugated bilirubin)
• Pale stools (lack of stercobilin)
• Pruritus (bile salt deposition in skin) 🪳
• Fatigue, malaise
• Right upper quadrant discomfort
• Nausea, vomiting, weight loss

📑 Investigations

• Bloods: FBC, U&E, LFTs (↑ ALP, ↑ GGT, ↑ bilirubin; ALT↑ if inflammatory). Prolonged PT = vitamin K malabsorption.
• Screen: Viral hepatitis, EBV, CMV, copper, ferritin.
• Autoantibodies: AMA (PBC), ANCA (PSC), SMA/ANA (AIH).
• USS Liver/Biliary: First-line for duct dilation/obstruction.
• MRCP: Non-invasive gold standard for biliary tree anatomy.
• ERCP: Diagnostic + therapeutic (stone removal, stenting).
• Liver biopsy: If intrahepatic cause suspected and diagnosis uncertain.

💊 Management – Intrahepatic Cholestasis

• Ursodeoxycholic acid (UDCA) to improve bile flow (PBC, PSC).
• Corticosteroids in autoimmune hepatitis.
• Stop hepatotoxic drugs (e.g. Co-Amoxiclav, anabolic steroids).
• Treat underlying liver disease specifically.

🔧 Management – Extrahepatic Cholestasis

• ERCP with stone extraction or stenting.
• Surgical resection or bypass for tumours/strictures.
• Manage pancreatitis if causing duct compression.