Merck Manual

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Danielle Tholey

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Reviewed/Revised Jan 2023
Topic Resources

Cholestasis is reduction or stoppage of bile flow. Bile is the digestive fluid produced by the liver.

  • Disorders of the liver, bile duct, or pancreas can cause cholestasis.

  • The skin and whites of the eyes look yellow, the skin itches, urine is dark, and stools may become light-colored and smell foul.

  • Laboratory and often imaging tests are needed to identify the cause.

  • Treatment depends on the cause, but drugs can help relieve itching.

With cholestasis, the flow of bile is impaired at some point between the liver cells (which produce bile) and the duodenum (the first segment of the small intestine). When bile flow is stopped, the pigment bilirubin (a waste product formed when old or damaged red blood cells are broken down) escapes into the bloodstream and accumulates. Normally, bilirubin joins with bile in the liver, moves through the bile ducts into the digestive tract, and is eliminated from the body. Most bilirubin is eliminated in stool, but a small amount is eliminated in urine.

Overview of Cholestasis

View of the Liver and Gallbladder

View of the Liver and Gallbladder

Causes of Cholestasis

The causes of cholestasis are divided into two groups: those originating within the liver and those originating outside the liver.

Within the liver

Outside the liver

Symptoms of Cholestasis

Jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more Jaundice in Adults , dark urine, light-colored stools, and generalized itchiness are characteristic symptoms of cholestasis. Jaundice is a yellow color of the skin and eyes that results from excess bilirubin deposited in the skin, and dark urine results from excess bilirubin excreted by the kidneys. The skin itches, possibly because bile products accumulate in the skin. Scratching can damage the skin. Stools may become light-colored because the passage of bilirubin into the intestine is blocked, preventing it from being eliminated from the body in stool. Stools may contain too much fat (a condition called steatorrhea) because bile cannot enter the intestine to help digest fat in foods. Fatty stools may be foul-smelling.

The lack of bile in the intestine also means that calcium and vitamin D are poorly absorbed. If cholestasis persists, a deficiency of these nutrients can cause loss of bone tissue. Vitamin K, which is needed for blood clotting, is also poorly absorbed from the intestine, causing a tendency to bleed easily.

Prolonged jaundice due to cholestasis produces a muddy skin color and fatty yellow deposits in the skin. Whether people have other symptoms, such as abdominal pain, loss of appetite, vomiting, or fever, depends on the cause of cholestasis.

Diagnosis of Cholestasis

  • Blood tests

  • If blood test results are abnormal, an imaging test, usually ultrasonography

  • Sometimes a liver biopsy

A doctor suspects cholestasis in people who have jaundice and tries to determine whether the cause is within or outside the liver on the basis of symptoms and the results of a physical examination.

Recent use of drugs that can cause cholestasis suggests a cause within the liver. Small spiderlike blood vessels visible in the skin (called spider angiomas), an enlarged spleen, and accumulation of fluid within the abdomen (ascites Ascites Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen. Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood... read more )—which are signs of chronic liver disease—also suggest a cause within the liver.

Findings that suggest a cause outside the liver include certain kinds of abdominal pain (such as intermittent pain in the upper right side of the abdomen and sometimes also in the right shoulder) and an enlarged gallbladder (felt during the physical examination or detected by imaging studies).

Some symptoms (such as loss of appetite, nausea, and vomiting) do not indicate whether the cause is within or outside the liver.

Typically, blood tests are done to measure levels of two enzymes (alkaline phosphatase and gamma-glutamyl transpeptidase) that are very high in people with cholestasis. However, if the level of alkaline phosphatase is very high but the level of gamma-glutamyl transpeptidase is normal, the cause of the high level of alkaline phosphatase is probably not cholestasis. A blood test that measures the level of bilirubin indicates the severity of the cholestasis but not its cause.

If the cause appears to be blockage of the bile ducts, more precise images of these ducts are usually needed. Typically, one of the following is done:

Treatment of Cholestasis

  • For bile duct blockages, surgery or endoscopy

  • For blockages within the liver, various treatments depending on the cause

  • For itching, cholestyramine

A blockage of the bile ducts can usually be treated with surgery or endoscopy (using a flexible viewing tube with surgical instruments attached).

A blockage within the liver may be treated in various ways depending on the cause. If a drug is the suspected cause, the doctor stops its use. If acute hepatitis is the cause, cholestasis and jaundice usually disappear when hepatitis has run its course. People with cholestasis are advised to avoid or stop using any substance that is toxic to the liver, such as alcohol and certain drugs.

Cholestyramine, taken by mouth, can be used to treat itchiness. This drug binds with certain bile products in the intestine, so they cannot be reabsorbed to irritate the skin.

Unless the liver is severely damaged, taking vitamin K can improve blood clotting.

Supplements of calcium and vitamin D are often taken if the cholestasis persists, but they are not very effective in preventing loss of bone tissue.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
Azasan, Imuran
Locholest , Locholest Light, Prevalite , Questran, Questran Light
Calcidol, Calciferol, D3 Vitamin, DECARA, Deltalin, Dialyvite Vitamin D, Dialyvite Vitamin D3, Drisdol, D-Vita, Enfamil D-Vi-Sol, Ergo D, Fiber with Vitamin D3 Gummies Gluten-Free, Happy Sunshine Vitamin D3, MAXIMUM D3, PureMark Naturals Vitamin D, Replesta, Replesta Children's, Super Happy SUNSHINE Vitamin D3, Thera-D 2000, Thera-D 4000, Thera-D Rapid Repletion, THERA-D SPORT, UpSpring Baby Vitamin D, UpSpring Baby Vitamin D3, YumVs, YumVs Kids ZERO, YumVs ZERO
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