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.