To the Editor:

Stapelbroek et al.1 describe the remarkable efficacy of nasobiliary drainage in treating the pruritus associated with an incipient attack of acute cholestasis in 3 patients with benign recurrent intrahepatic cholestasis (BRIC). The rationale of such an approach is to remove the circulating bile acid pool, decrease intestinal absorption of bile acids, and thereby lower plasma bile acids. Multiple lines of evidence indicate that bile acid retention in cholestasis contributes directly or indirectly to pruritus. In their paper, the Utrecht group cites prior studies going back to 1988 that used partial biliary drainage or ileal bypass to successfully treat cholestatic pruritus, again with the same rationale.

The purpose of this letter is to point out that there are several much older studies reporting that cholestatic pruritus can be treated by biliary drainage. The utility of surgical drainage of the biliary tract as a treatment of nonobstructive cholestatic liver disease was discussed and practiced in the early 1930′s in France.2 Still, earlier B. B. Vincent Lyon proposed duodenal drainage of bile to treat liver disease3 and described several patients who appeared to benefit from the procedure. In 1947, Richard Varco, a young cardiovascular surgeon at the University of Minnesota reported that in 5 of 6 patients with cholestatic pruritus, biliary drainage by cholecystostomy or T-tube abolished pruritus.4 In 3 of 6 patients, oral bile administration induced recurrence of pruritus (Varco subsequently had a distinguished career as a cardiovascular surgeon).5 In 1957, in a French review article discussing therapy for intrahepatic cholestasis (“medical jaundice”), it was recognized that several publications had shown that external biliary drainage relieves pruritus.6 In 1970, one of us (P-M. H.), as part of his doctoral thesis under the mentorship of Jacques Caroli, often considered to be the father of French hepatology, summarized the clinical experience of the Caroli group. Huet et al. reported that in14 of 17 patients biliary drainage induced relief of pruritus.7 The paper suggested that the only established indication for biliary drainage in liver in non-obstructive cholestatic liver disease was to relieve pruritus, and this view is probably valid today.

For obstructive cholestatic liver disease, there is an extensive surgical-endoscopic literature reporting that biliary drainage either externally or internally reduces pruritus.8–10 The rationale here is different that than in intrahepatic cholestasis. In complete cholestasis caused by extrahepatic obstruction, there is no circulating bile acid pool. Presumably, biliary secretion has been down regulated by the high pressure in the biliary tree; biliary drainage increases canalicular transport function with the result that levels of bile acids (and possibly other pruritogens) are decreased.

Thus, the useful report of Stapelbroek not only confirms the much older reports showing the utility of surgical biliary drainage to treat cholestatic pruritus, but also provides valuable information in showing that such intervention can be achieved conveniently by endoscopic biliary drainage.


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  • 1
    Stapelbroek J, van Erpecum K, Klomp LW, Venneman N, Schwartz T, van Berge Henegouwen G, et al. Nasobiliary drainage induces long-lasting remission in benign recurrent intrahepatic cholestasis. HEPATOLOGY 2006; 43: 5153.
  • 2
    Mocquot P. L'intervention chirurgicale dans certains icteres par retention sans obstacle. Influence du drainage biliare externe sur les functions hepatiques. J Chir 1933; 41: 178193.
  • 3
    Lyon BBV. Value of duodenal tube drainage of the biliary system in the treatment of various diseases and disorders of the liver. J Med Soc NJ 1931; 28: 799817.
  • 4
    Varco RL. Intermittent external biliary drainage for relief of pruritus in certain chronic disorders of the liver. Surgery 1947; 21: 4345.
  • 5
    Najarian JS, Varco RL. The compleat academic surgeon. Surgery 2003; 133: 451452.
  • 6
    Cattan R, Pariente P, Cattan A. Traitement de la cholostase intrahepatique. Arch Mal Appar Dig Mal Nutr 1957; 46( Suppl): 329354.
  • 7
    Huet P-M, Rautureau M, Dhumeaux D, Caroli J. Effects du drainage biliare dans les hepatites cholestatiques. Rev Med Fr 1970; 45: 271278.
  • 8
    Rupp N. Indications and results of percutaneous transhepatic bile-duct drainage. Chirurg 1979; 50: 233238.
  • 9
    van den Brandt-Gradel V, Scheurer U, Halter F. Endoscopic insertion of endoprostheses in malignant extrahepatic bile duct stenoses. Schweiz Med Wochenschr 1985; 115: 1734178.
  • 10
    Hartmann D, Jakobs R, Schilling D, Riemann JF. Endoscopic and radiological interventional therapy of benign and malignant bile duct stenoses. Zentralbl Chir 2003: 128: 936943.

Alan F. Hofmann M.D*, Pierre-Michel Huet M.D†, * Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego, CA, † Fédération d'Hepato-Gastroentérologie, Centre universitaire de Nice, Hôpital L'Árchet 2, Nice, France.