• A 37 year old lady presented with history of fatigue, generalized itching and weight loss of 2 kilos since  2 month
  • Past History- Grave’s disease 1 year back and had been on propylthiouracil (PTU) since then
  • Examination – unremarkable
  • Blood tests –
  • CBC :– normal,T. Bilirubin:- 1.4mg/dl, SGOT:- 40, SGPT: – 36, ALP: -334, GGT :– 425
  • Serum electrophoresis :– Normal, AMA:- Negative, P-anca :- Negative
  • USG Abdomen – NAD
  • CT Abdomen – NAD
  • Radiological Imaging Studies –
  • Provisional diagnosis- Propylthiouracil induced cholestasis
  • Patient was treated with Ursodeoxycholic acid 8mg/kg/day in divide doses and PTU stopped
  • Liver biopsy- minimal bile plugs but no ductopenia, eosinophils or lymphocytes
  •  Follow up examination- No symptomatic improvement after 3 months
  • Blood tests: – ALP – 463, GGT – 499, SGOT – 41, SGPT – 38, Bilirubin – 1.5mg/dl
  • MRCP – Dominant stricture in the right hepatic duct with features consistent with PSC
  • ERCP – MRCP findings confirmed, brushing taken and 10 French stent placed.
  • Final diagnosis- Primary Sclerosing Cholangitis

Expert comments-

  • MRCP is a far superior investigation in unexplained cholestasis than CT abdomen
  • Liver biopsy should have at least 10-12 portal tracts for accurate diagnosis

Take home message –

  • Drugs must be considered as the causative agent although if withdrawal does not resolve the liver biochemistry an alternative diagnosis should be sought
  • Drug induced liver injury (DILI) can often persist beyond six months
  • Most cases of PSC are associated with concurrent ulcerative colitis and annual screening colonoscopies are mandatory to rule out colorectal cancer.

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