《2009EASL临床实践指南：胆汁淤积性肝病的治疗》内容预览

Careful patient history and physical examination are essential in the diagnostic process and may provide valu-able information so that an experienced clinician can pre-dict the nature of cholestasis in many cases . Presence of extrahepatic diseases has to be recorded. A thorough occupational and drug history is imperative and any med-ications taken within 6 weeks of presentation may be incriminated (and discontinued); this includes herbal medicines, vitamins and other substances. A history of fever, especially when accompanied by rigors or right upper quadrant abdominal pain is suggestive of cholangi-tis due to obstructive diseases (particularly choledocholi-thiasis), but may be seen in alcoholic disease and rarely, viral hepatitis. A history of prior biliary surgery also increases the likelihood that biliary obstruction is present. Finally, a family history of cholestatic liver disease sug-gests a possibility of a hereditary disorder. Some chole-static disorders are observed only under certain circumstances (e.g., pregnancy, childhood, liver trans-plantation, HIV-infection), and may require specific investigations that are not relevant in other populations.

Abdominal ultrasonography is usually the first step to exclude dilated intra- and extrahepatic ducts and mass lesions because it is rather sensitive and specific, non-invasive, portable and relatively inexpensive. Its disadvantages are that its findings are operator-depen-dent and abnormalities of bile ducts such as those observed in sclerosing cholangitis may be missed. Fur-thermore, the lower common bile duct and pancreas are usually not well depicted. Computed tomography of the abdomen is less interpreter-dependent, but is asso-ciated with radiation exposure and may be not as good as ultrasound at delineating the biliary tree.

If bile duct abnormalities are present, further work-up depends on the presumed cause. From a purely diagnostic perspective, magnetic resonance cholangiopancreatogra-phy (MRCP) is a safe option to explore the biliary tree. Its accuracy for detecting biliary tract obstruction approa-ches that of endoscopic retrograde cholangiopancreatog-raphy (ERCP) when performed in experienced centres with state-of-the-art technology. Endoscopic ultrasound (EUS) is equivalent to MRCP in the detection of bile duct stones and lesions causing extrahepatic obstruction and may be preferred to MRCP in endoscopic units.

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