Efficacy of Nasobiliary Drainage for Refractory Cholestatic
Pruritus.
E.M.M. Kuiper1, R.A. de Man1, H.R. van Buuren1.
1Department of Gastroenterology and Hepatology Erasmus University Medical Center, Rotterdam.
Background and Aims:
Nasobiliary drainage (NBD) has been reported to be effective in pruritus secondary to benign recurrent
intrahepatic cholestasis (BRIC) (Stapelbroek et al. Hepatology 2006;43:51-3). The aim of this study was to
further explore the feasibility and efficacy of NBD in severe refractory pruritus associated with cholestatic
conditions of any etiology.
Methods:
We selected patients with severe cholestatic pruritus who did not respond to medical treatment including
cholestyramine, rifampicin and naltrexon. A nasobiliary drain was inserted during ERCP for 7 days. The
effect of drainage was evaluated using visual analogue scales (VAS) for pruritus and fatigue and by
laboratory studies including serum bile acids, bilirubin, ALP, AST and ALT before, during and after NBD.
Results:
6 consecutive patients (4 females, 2 males; mean age 40 yrs) were included. Causes of cholestatic
pruritus were PBC (n=1), PSC (n=1) and BRIC (n=4, based on clinical features, although negative for
ATP8B1/ABCB11 mutations). All patients experienced marked improvement of pruritus within 7 days. The
absolute difference between median pruritus VAS score before and after NBD was 5 (78%). Laboratory
tests all improved markedly (see figure). Patients were followed for a median period of 14.6 (range 2.326.2) months. Pruritus recurred in one patient with PSC immediately following removal of the drain and
recurred after 12 months in another case. Two patients developed mild post-ERCP pancreatitis.
Conclusions:
Nasobiliary drainage is an invasive procedure associated with potential complications, but may result in
long-term relief of severe, refractory cholestatic pruritus. Our results suggest that beneficial effects of NBD
cannot not only be obtained in BRIC but also in other cholestatic conditions and confirm older
observations of the utility of surgical biliary drainage to treat cholestatic pruritus.