Patients with primary biliary cirrhosis can be asymptomatic or may present with jaundice, pruritus, and fatigue. Asymptomatic patients are incidentally diagnosed when they are found to have abnormal liver chemistry during evaluation for some other cause. Jaundice is secondary to cholestasis. Pruritus occurs in about 20% to 70% of patients, which is thought to be the neurocutaneous effect of retained bile salts. Another recent theory for pruritus is the association of elevated levels of lysophosphatidic acid, which is a product of circulating phospholipase and autotaxin, the levels of which are elevated in the case of cholestasis. Patients typically complain of worsening pruritus at night, in hot and humid weather, and when the skin is dry. Few patients may complain of vague right upper quadrant pain and mild cognitive impairment. Malabsorption and steatorrhea have also been reported in the case of primary biliary cirrhosis, which is thought to be related to the deficiency of fat-soluble vitamins.

Patients with primary biliary cirrhosis have various clinical findings on physical exam, which usually correlate with the stage of disease at presentation. About 40% of patients have skin complaints such as dry skin, hyperpigmentation, xanthelasma, xanthomas, jaundice, dermatographism, and fungal infection of feet. Due to dry skin and pruritus, excoriations from scratching are common in primary biliary cirrhosis patients. Hepatomegaly can be seen in both asymptomatic patients and at the later stage of the disease. Splenomegaly is common more at the later disease state. Stigmata of chronic liver disease such as spider nevi, ascites, edema, proximal, and temporal muscle wasting is more common as the liver disease progresses and patients are cirrhotic. Patients with primary biliary cirrhosis can have other autoimmune conditions such as Hashimoto thyroiditis, CREST syndrome, Sjogren syndrome, rheumatoid arthritis, telangiectasias, and celiac disease. Osteoporosis, renal tubular acidosis, various skin conditions (lichen planus, discoid lupus, pemphigoid) are also commonly associated with primary biliary cirrhosis.

The diagnostic criteria for Primary biliary cirrhosis include an absence of any other liver disease, no evidence of extrahepatic biliary obstruction on imaging and at least 2 out of 3 of the following:

1. Elevation of alkaline phosphatase (ALP) at least 1.5 times upper limit of normal (ULN)
2. Presence of antimitochondrial antibody (AMA) with a titer of 1:40 or higher
3. Histopathological evidence of primary biliary cirrhosis (nonsuppurative destructive cholangitis or "florid duct lesion" and destruction of interlobular bile ducts with a predominance of lymphocytic infiltration).

Liver biopsy is not required for diagnosis but is helpful in disease prognosis and staging.[10][11]

Asymptomatic patients with abnormal liver chemistry, especially abnormal alkaline phosphatase, should be evaluated for primary biliary cirrhosis. Patients who present with vague right upper quadrant pain, unexplained pruritus, fatigue, jaundice, skin hyperpigmentation, and unexplained weight loss should also be evaluated for primary biliary cirrhosis.

Patients who are suspected of having primary biliary cirrhosis should undergo a right abdominal ultrasound, magnetic resonance cholangiopancreatogram (MRCP) or endoscopic retrograde cholangiopancreatogram (ERCP) to rule out the extrahepatic biliary obstruction. Once the extrahepatic obstruction is ruled out, AMA should be obtained. In some instances, IgM is elevated.

In cases of atypical disease presentation with elevated ALP but normal AMA, alternative diagnosis, and liver biopsy should be considered for diagnosis. However, with typical clinical features of primary biliary cirrhosis and positive AMA, but normal ALP liver biopsy is not required.

Patients with primary biliary cirrhosis also have deranged lipid profile due to cholestasis. Fifty percent of patients have elevated cholesterol, which clinically manifests as xanthomas and xanthelasmas. Primary biliary cirrhosis patients also have iron deficiency anemia due to chronic blood loss secondary to portal hypertensive gastropathy. Primary biliary cirrhosis patients who have already developed cirrhosis may have coagulopathy (elevated prothrombin time), thrombocytopenia, and leukopenia in addition to anemia.

The goal of therapy in primary biliary cirrhosis is the prevention of disease progression and the management of symptoms and complications related to chronic cholestasis.[11][12][13]

The only medication approved by the Food and Drug Administration for the treatment of primary biliary cirrhosis is ursodeoxycholic acid (UDCA). It is a hydrophilic bile salt, which stabilizes hepatocyte membranes against toxic bile salts and inhibits apoptosis and fibrosis. The recommended dose is 13 mg/kg to 15 mg/kg per day. Patients benefit most when UDCA is started at an earlier stage, which has been shown to delay the progression of the disease and the development of cirrhosis. UDCA also leads to histological improvement.

In patients who do not respond to UDCA, obeticholic acid (OBCA) can be administered with UDCA. OBCA is a farnesoid X receptor agonist, that helps to reduce ALP, GGT, and transaminase levels due to its antifibrotic and choleretic properties. However, it does not improve survival or disease-related symptoms.

Complications of chronic cholestasis

Bone disease: Osteoporosis and pathologic fracture is the most common bone disease in cholestatic liver disease such as primary biliary cirrhosis. Hence, it is recommended that the Dexa scan be obtained at the diagnosis of primary biliary cirrhosis. This can be prevented by daily oral vitamin D and calcium supplementation and daily exercise. Estrogen therapy in a postmenopausal patient with primary biliary cirrhosis has shown to prevent loss of bone mass or bone mineral density.

Fat-soluble vitamin deficiency: Deficiency of fat-soluble vitamins A, D, E, and K are secondary to malabsorption due to decreased amounts of bile salts in the intestinal lumen. Levels of these vitamins should be checked periodically and supplemented accordingly.

Hyperlipidemia: About 85% of patients with primary biliary cirrhosis have deranged lipid profile. As the disease progress, HDL decreases, and LDL increases. Statins are recommended and have not shown to have a deleterious effect on liver function. In addition, patients with primary biliary cirrhosis and abnormal lipid profile have not shown to have elevated risk for myocardial infarction and strokes.

Pruritus: The actual cause of pruritus is understood poorly in primary biliary cirrhosis. Nonetheless, various agents have shown to provide symptomatic relief. These are cholestyramine, rifampin UDCA, naltrexone, and antihistamines like diphenhydramine and hydroxyzine.

Steatorrhea: The cause for steatorrhea in primary biliary cirrhosis is thought to be secondary to a decreased level of bile acid in the small intestine. Patients who have other coexisting autoimmune diseases such as celiac disease and scleroderma, small intestinal bacterial overgrowth (SIBO) can be the cause for steatorrhea as well. It is essential to find out the cause for steatorrhea and treat it accordingly. In patients who do not have sufficient bile acids in the small intestine, the medium-chain triglycerides (TGs) should be substituted for long-chain TGs in the diet, and total fat intake should be reduced. In the case of SIBO, intermittent broad-spectrum antibiotics can be used.

Liver transplant: Liver transplant is the standard gold treatment for Primary biliary cirrhosis. Patients with primary biliary cirrhosis will develop complications related to cirrhosis (hepatic encephalopathy, recurrent ascites, severe portal hypertensive gastropathy, bleeding, or hemorrhage secondary to gastric or esophageal varices). They will also have disabling symptoms such as fatigue, intractable pruritus, and severely deranged bilirubin level in the absence of liver cancer. These patients should be evaluated for a liver transplant.

The differential diagnoses of primary biliary cholangitis are comprised of all the diseases which result in cholestasis, pruritis, and deranged liver profile. All middle-aged women presenting with pruritis and jaundice must be evaluated in the context of primary biliary cholangitis. Some of the more significant differentials are given below:

• Biliary obstruction/stricture
• Primary sclerosing cholangitis
• Hepatitis
• Drug-induced liver disease

The staging system devised by Scheuer is as follows:

• Stage 1: Portal stage associated with bile duct changes, and/or portal inflammation
• Stage 2: Periportal fibrosis and/or inflammation with dilated but intact portal tracts
• Stage 3: Septal stage: Septal fibrosis with active inflammation and/or paucicellular septa
• Stage 4: Cirrhotic: Variously sized nodules and varying degrees of inflammation

The most reliable indicators of a patient's prognosis suffering from primary biliary cholangitis are the rise in serum bilirubin level and the Mayo risk score. On the basis of bilirubin levels the prognosis can be determined as follows:

• Bilirubin constantly above 2 - mean survival is 4 years
• Bilirubin constantly above 6 - mean survival is 2 years
• Bilirubin constantly above 10 - mean survival is 1.4 years

In a study, it was determined that fatigue levels may also be a prognostic indicator of primary biliary cholangitis.[14]

The following complications may arise from primary biliary cholangitis:

• Osteoporosis
• Malabsorption
• Hyperlipidemia
• Esophageal motility dysfunction
• Renal tubular acidosis
• Liver cancer
• Autoimmune thrombocytopenia
• Hypoglycemia
• Myelopathy

Primary biliary cirrhosis can recur after a liver transplant. The rate of recurrence has been reported in transplant centers from 0% to 35%. Recurrence of primary biliary cirrhosis typically has been found to be anywhere from 3 to 6 years after transplant. Tacrolimus-based immunosuppression is thought to be the strongest risk factor for the recurrence of primary biliary cirrhosis. The AMA may persist after transplant; so this cannot be accounted for the recurrence of the disease. The diagnosis of primary biliary cirrhosis recurrence post-transplant is made histologically.

The management of PBC is best done through an interprofessional team approach. The disorder has no cure and carries high morbidity and mortality. The aim of treatment is to slow down the disease progression and improve the quality of life. Besides the physicians, the nurse, mental health counselor, pharmacist, and physical therapist play a critical role in the management of these patients. The nurse should educate the patient on the management of itching and the use of moisturizers. The dietitian should educate the patient on a healthy diet to prevent osteoporosis and deficiency of fat-soluble vitamins. The pharmacist should educate the patient on the Sicca syndrome and how to avoid dry eyes and mouth. Because of extreme fatigue, the patient should enroll in a physical therapy program or some type of physical activity. Finally, the patient should see a mental health counselor as the disorder can result in premature death. The patient should be urged to join a support group and closely follow up with the healthcare provider. [15][16](Level V)

Outcomes

In patients with low serum albumin, survival can range from 3-6 years. However, if the bilirubin levels are consistently high, the survival is significantly reduced with an average survival of 1.7 years. Almost all patients with PBC develop moderate-to-severe fatigue, which persists even after a liver transplant. Universally, once patients develop symptoms, the outcome is grim. [17](Level V)