Endoscopic management of PSC, management of Pruritus in PSC

 Source: British society / UK-PSC guidelines - 10.1136/gutjnl-2018-317993



ERCP in PSC

1) All patients should receive broad-spectrum antibiotics for 3-5 days

2) Dominant stricture (clinically significant stricture) is defined as a stricture causing functional narrowing - either 1) biochemically (cholestatic LFT), 2) radiologically (upstream dilatation), 3) symptomatically (pruritius). The BSG guideline doesnt mention size criteria for definition of dominant stricture.

3) Obtain cytology from dominant strictures (sensitivity 50%) every time

4) Balloon dilatation of stricture is thought to retard progression of liver disease by reducing cholestatic injury

5) Stenting is associated with high rates of cholangitis / stent occlusion, as well as pancreatitis. All guidelines recommend against routine stenting in patients with PSC. Dominant stricutre need management with periodic balloon dilatation only without stenting


Other things PSC:

British guidelines suggest: Annual ultrasound of GB in PSC. Refer to surgeons if polyps identified

Liver biopsy is only useful for diagnosis of small duct PSC. In large duct (traditional) PSC, biopsy shows non-specific features of cholestasis, and the classic appearance of peri-ductal fibrosis (onion skinning) is not seen on liver biposy specimens.

In cholestatic liver diseases, look out for fat-soluble vitamin deficiency (ADEK) and Ostoeporosis, especially in patients >50 years of age, and advanced liver disease


Management of Pruritus in PSC

1) Colestyramine / Colsevelam / Colestipol

2)  Rifampicin / Naltrexone



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