Primary Biliary Cirrhosis

Primary biliary cirrhosis is most common among women aged 35 to 70, although it can occur in men and women of any age. This again tends to occur in families. The cause is not clear but is probably an autoimmune reaction (in which the immune system attacks the body's own tissues—About 95% of people with primary biliary cirrhosis have antibodies against mitochondria (tiny structures that produce energy in cells) in their blood. This disorder often occurs in people with autoimmune disorders, such as rheumatoid arthritis, scleroderma, Sjögren's syndrome, or autoimmune thyroiditis. Primary biliary cirrhosis affects only small bile ducts inside the liver and the nearby liver cells. Another inflammatory bile duct disorder, primary sclerosing cholangitis, affects bile ducts inside and outside the liver.

Primary biliary cirrhosis begins with the inflammation of the bile ducts. The inflammation blocks the flow of bile (a greenish yellow digestive fluid) out of the liver. Thus, toxic bile products become retained in the liver cells and spill over into the bloodstream. As inflammation spreads from the bile ducts to the rest of the liver, a latticework of scar tissue develops throughout the liver.

Symptoms

Usually, primary biliary cirrhosis starts gradually. Some people may have no symptoms at first.The progression of primary biliary cirrhosis varies greatly but usually is slow. Symptoms may not appear for 2 years or up to 10 to 15 years. Some people become very ill in 3 to 5 years. Once symptoms develop, life expectancy is about 10 years. When itching disappears, xanthomas shrink, and jaundice develops, the disorder is advanced.

The first symptoms often include itchiness, fatigue, and a dry mouth and eyes. Others have jaundice (a yellowish discoloration of the skin and whites of the eyes). Other problems may not occur until months or years later. Some people have enlarged fingertips (clubbing), osteoporosis, nerve damage (that is, neuropathy), and kidney abnormalities. People may sometimes feel discomfort in the upper abdomen. Retained fats accumulate as small yellow deposits of fat in the skin (xanthoma) or eyelids (xanthelasma).

Eventually, any of the symptoms and complications of cirrhosis can develop. If bile is not able to reach the small intestine, then fat absorption is impaired, including the absorption of fat-soluble vitamins (A, D, E, and K). Fat malabsorption results in osteoporosis, easy bruising and bleeding, and stools that are greasy and foul-smelling (steatorrhea). The liver and spleen may sometime enlarge. But as scarring progresses, the liver shrinks.

Diagnosis

A doctor may suspect this disorder generally in middle-aged women who have typical symptoms such as fatigue and itchiness (pruritus). However, in many people, the disorder is discovered well before any symptoms appear because abnormalities in liver function are detected during routine blood testing.

During the physical examination, the doctor might sometimes feel an enlarged, firm liver (in about 50% of people) or an enlarged spleen (in maybe 25%).
Ultrasonography or magnetic resonance imaging (MRI) of the bile duct system (called magnetic resonance cholangiography) is then done to check for abnormalities or obstruction of bile ducts outside the liver. Finding no obstruction outside the liver supports the diagnosis of primary biliary cirrhosis because it identifies the liver as the site of the problem. A blood test is done to measure antibodies against mitochondria. This test is highly accurate for the diagnosis. A liver biopsy (removal of a tissue sample for examination under a microscope— may be done to confirm the diagnosis. Biopsy also helps doctors determine just how advanced the disorder is (the stage).

Treatment

No cure is yet known. Treatment focuses on relieving symptoms, slowing liver damage, and then treating complications. Ursodeoxycholic acid appears to reduce liver damage, prolong life, and then delay the need for liver transplantation. No alcohol should be consumed. Drugs that may damage the liver are stopped. Supplements of calcium and vitamin D are needed to help prevent osteoporosis or slow its progression. Weight-bearing exercises, bisphosphonates, or raloxifene may also help prevent or slow osteoporosis. Vitamin A, D, E, and K supplements may be needed to correct vitamin deficiencies. Vitamins A, D, and E can be taken by mouth in a water-soluble form. Vitamin K is usually given by injection.