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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Class Summary

Ursodeoxycholic acid is a naturally occurring bile acid used successfully in the dissolution of gallstones, microlithiasis, and in primary biliary cirrhosis. Some benefit may exist in patients with Caroli disease.

Ursodiol (Actigall)

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Decreases cholesterol content of bile and bile stones probably by reducing the secretion of cholesterol from the liver and the amount reabsorbed by intestines. It is also used for PBC since it displaces endogenous bile acids from the enterohepatic circulation, stabilizes hepatocellular membranes, and reduces the abnormal expression of HLA class I and II molecules on the hepatocytes.

Class Summary

The farnesoid X receptor (FXR) is a nuclear receptor expressed in the liver, intestine, kidney, and adipose tissues that regulates a wide variety of target genes critically involved in the control of bile acid synthesis and transport, lipid metabolism, and glucose homeostasis.

Obeticholic acid (Ocaliva)

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Farnesoid X receptor (FXR) agonist. FXR activation suppresses de novo synthesis of bile acids in hepatocytes as well as increases the transport of bile acids out of hepatocytes, thereby reducing exposure of the hepatocytes to bile acid. It is indicated for primary biliary cholangitis (PBC) in combination with ursodeoxycholic acid (UDCA) in adults with an inadequate response to UDCA for at least 1 y or as monotherapy in adults unable to tolerate UDCA.

Class Summary

Alleviation of itching associated with excessive bile acid levels.

Cholestyramine (Questran)

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Forms a nonabsorbable complex with bile acids in the intestine, which in turn inhibits the enterohepatic reuptake of intestinal bile salts.

Rifampin (Rifadin)

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Antimycobacterial agent noted to alleviate pruritus in 79% of patients with primary biliary cholangitis. This effect may be a result of changed metabolism of liver bile acids or by altered bacterial metabolism by intestinal bacteria.

Naloxone (Narcan)

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Opioid antagonist useful in the treatment of pruritus.

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Media Gallery

A normal postcholecystectomy cholangiogram.
Biliary disease. In a patient with persistent elevation of liver-associated enzymes, the contrast medium entering the biliary ductal system preferentially enters the cystic duct.
Biliary disease. Even when the catheter is advanced to the proximal common hepatic duct, contrast dye preferentially fills the cystic duct and gallbladder rather than allowing visualization of the intrahepatic ductal system (same patient as in previous image).
Biliary disease. In this image, the common bile duct is occluded with a balloon-tipped catheter. Contrast material fills the intrahepatic ductal system to reveal diffuse intrahepatic sclerosing cholangitis.
Biliary disease. Common bile duct stones are among the most frequent problems occurring in the biliary system. In this cholangiogram, the stones line up like peas in a pod.
Biliary disease. After a biliary sphincterotomy, a balloon-tipped catheter is used to remove the stones one by one.
Biliary disease. This clearing cholangiogram shows a common bile duct free of filling defects and good flow into the duodenum. The stones are visible as filling defects in the duodenal bulb.
Biliary disease. A patient with pancreatic cancer developed jaundice during his treatment. The cholangiogram shows a stricture in the distal common bile duct.
Biliary disease. A patient with pancreatic cancer developed jaundice during his treatment (same patient as in previous image). To palliate the jaundice, the biliary stricture is dilated and stented with a 10F plastic stent. Note the contrast dye flowing down the stent.
Biliary disease. This computed tomography scan of the abdomen shows a large tumor mass in the head of the pancreas. The brightly colored object within the mass is the biliary stent placed by endoscopic retrograde cholangiopancreatography.
Biliary disease. This abdominal computed tomography scan shows mild intrahepatic biliary ductal dilatation.
Biliary disease. Abdominal computed tomography scanning in a patient with jaundice revealed polycystic liver disease.
Biliary disease. Findings on this endoscopic retrograde cholangiopancreatogram exclude extrahepatic biliary obstruction but demonstrate that the intrahepatic biliary ductal system is splayed by multiple hepatic cysts.
Biliary disease. This cholangiogram shows a choledochal cyst. Fusiform dilatation of the entire extrahepatic bile duct is present.
A 92-year-old woman had recurrent abdominal pain and jaundice. A right upper quadrant ultrasonogram showed a dilated biliary duct with no stones. She had a previous Roux-en-Y surgery that made endoscopic retrograde cholangiopancreatography impossible. Critical aortic stenosis increased the risk of most interventions. This percutaneous cholangiogram, performed under conscious sedation in the operating room, revealed a large stone missed by the ultrasonogram. It was removed successfully with percutaneous choledochoscopy and electrohydraulic lithotripsy.
Biliary disease. This cholangiogram shows a stone too large to deliver through a standard biliary sphincterotomy.
Biliary disease. Here, a mechanical lithotripter is used to grab a stone too large to deliver through a standard biliary sphincterotomy and crush it into small pieces (same patient as in previous image). The smaller pieces then are removed with a balloon-tipped catheter.
Biliary disease. A patient had malignant strictures of the biliary system palliated with metal mesh stents. Unfortunately, the tumor grew through the metal mesh to reobstruct the biliary system.
Biliary disease. A patient had malignant strictures of the biliary system that were palliated with metal mesh stents, but the tumor grew through the metal mesh to reobstruct the biliary system (same patient as in previous image). In this image, after a wire was passed through the lumen, a balloon-dilating catheter was passed into the metal mesh stents and inflated to enlarge the lumen.
Biliary disease. A patient had malignant strictures of the biliary system that were palliated with metal mesh stents, but the tumor grew through the metal mesh to reobstruct the biliary system (same patient as in previous image). After a wire was passed through the lumen, a balloon-dilating catheter was passed into the metal mesh stents and inflated to enlarge the lumen. In this image, two plastic stents were passed into the intrahepatic ductal system to again palliate the obstruction.

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Author

Annie T Chemmanur, MD Attending Physician, Metrowest Medical Center and University of Massachusetts Memorial Hospital, Marlborough Campus

Annie T Chemmanur, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jeanette G Smith, MD Fellow, Department of Gastroenterology-Hepatology, University of Connecticut School of Medicine

Jeanette G Smith, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Public Health Association

Disclosure: Nothing to disclose.

George Y Wu, MD, PhD Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, Association of American Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Ronnie Fass, MD, FACP, FACG Chief of Gastroenterology, Head of Neuroenteric Clinical Research Group, Southern Arizona Veterans Affairs Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine

Ronnie Fass, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Neurogastroenterology and Motility Society, American Society for Gastrointestinal Endoscopy, Israeli Medical Association

Disclosure: Received grant/research funds from Takeda Pharmaceuticals for conducting research; Received consulting fee from Takeda Pharmaceuticals for consulting; Received honoraria from Takeda Pharmaceuticals for speaking and teaching; Received consulting fee from Vecta for consulting; Received consulting fee from XenoPort for consulting; Received honoraria from Eisai for speaking and teaching; Received grant/research funds from Wyeth Pharmaceuticals for conducting research; Received grant/research funds f.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Paul Yakshe, MD, to the development and writing of this article.

Biliary Disease Medication

Medication Summary

Gallstone dissolution agents

Class Summary

Ursodiol (Actigall)

Ursodiol (Actigall)

Farnesoid X Receptor Agonist

Class Summary

Obeticholic acid (Ocaliva)

Obeticholic acid (Ocaliva)

Antipruritics

Class Summary

Cholestyramine (Questran)

Cholestyramine (Questran)

Rifampin (Rifadin)

Rifampin (Rifadin)

Naloxone (Narcan)

Naloxone (Narcan)

Biliary Disease Medication

Medication Summary

Gallstone dissolution agents

Class Summary

Ursodiol (Actigall)

Ursodiol (Actigall)

Farnesoid X Receptor Agonist

Class Summary

Obeticholic acid (Ocaliva)

Obeticholic acid (Ocaliva)

Antipruritics

Class Summary

Cholestyramine (Questran)

Cholestyramine (Questran)

Rifampin (Rifadin)

Rifampin (Rifadin)

Naloxone (Narcan)

Naloxone (Narcan)

References

Tables

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