ACCME/Disclosures. PBC and PSC Revisited 4/6/2016. Primary Biliary Cirrhosis Cholangitis (PBC)

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1 ACCME/Disclosures The USCAP requires that anyone in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Dr. Marcela Salomao declares she has no conflict(s) of interest to disclose. Primary Biliary Cirrhosis Cholangitis (PBC) PBC and PSC Revisited Marcela Salomao, MD USCAP Annual Meeting, MFMER slide MFMER slide-4 1

2 Beuers U, Gershwin ME, Gish RG, Invernizzi P, Jones DE, Lindor K, Ma X, Mackay IR, Parés A, Tanaka A, Vierling JM, Poupon R. J Hepatol Nov;63(5): Gastroenterology Nov;149(6): Gut Nov;64(11): Hepatology Nov;62(5): Clin Gastroenterol Hepatol Nov;13(11): Am J Gastroenterol Nov;110(11): Dig Liver Dis Nov;47(11): Clin Res Hepatol Gastroenterol Oct;39(5):e57-9. Shimoda S, Tanaka A. Nihon Shokakibyo Gakkai Zasshi. 2016;113(1): MFMER slide-5 Sheila Sherlock, MD Hans Popper, MD Chronic intrahepatic ambiguous obstructive term jaundice Chronic nonsuppurative misnomer destructive cholangitis Sherlock S. Gastroenterology 1959 Rubran E. Am J Pathol MFMER slide-6 Name change initiative for PBC Driven by patients correct the inaccuracy remove the cirrhosis stigma Primary biliary cholangitis PBC Pathogenesis T-cell mediated immune attack of bile duct epithelial cells Break of B/T cell tolerance to biliary epithelial cells Anti-mitochondrial autoantibodies (PDC-E2 ) - Xenobiotics - Bacterial molecules - Genetic predisposition 2016 MFMER slide-7 Ala A, et al. Hepatology McNally RJK et al. Am J Epidemiol MFMER slide-8 2

3 PBC Diagnosis Two of the following 3 criteria (AASLD Recommendation): Elevated alkaline phosphatase AMA +, >90% pts Histologic evidence of nonsuppurative destructive cholangitis affecting interlobular bile ducts 2016 MFMER slide MFMER slide MFMER slide MFMER slide-12 3

4 Stage 3 Fibrosis and mild duct loss Ductular prolifearation and bile duct atrophy 2016 MFMER slide MFMER slide-14 Challenges Sampling error Less common variants: Overlap syndrome (PBC/AIH) Premature ductopenic variant AMA-negative PBC 2016 MFMER slide MFMER slide-16 4

5 AMA-negative PBC Differential Diagnosis of PBC 5-10% pts (by IF) AMA-M2 may be identified by EIA or Western blot Anti-nuclear antibodies, 30-50% pts subtypes specific to PBC Antibody Prevalence Anti-gp % Anti-centromere % Anti-sp % Anti-chromatin % Anti-kelch-like % Anti-hexokinase % Sarcoidosis Infections Granulomas PSC and SSC Drug-induced cholangitis/vds Hodgkin s lymphoma (posttreatment) Idiopathic adulthood ductopenia Infantile/childhood disease CR or GVHD Ductopenia HBV HCV Chronic hepatitis Lindor KD et al. Hepatology Bizzaro N et al. Clin Rev Allergy Immunol Sclair S et al. Clin Transl Gastroenterol MFMER 2015 slide MFMER slide-18 Sarcoidosis Drug-induced bile duct injury Vanishing bile duct syndrome amoxicillin/clavulanate other penicillins fluoroquinolones sulfonamides antifungal agents NSAIDs phenothiazines tricyclic antidepressants aromatic anticonvulsants 2016 MFMER slide MFMER slide-20 5

6 PBC Disease Progression and Complications UDCA therapy slows disease progression in 2/3 of patients HCC 2015: Global PBC Study Group, 4500 patients 3.4 cases per 1000 patient years Increased risk: biochemical non-responders Cholestasis and bile duct injury Ductopenia without fibrosis Clinical history 2016 MFMER slide-21 Trivedi et al. Gut 2015 Lammers WJ et al. Gastroenterology MFMER slide-22 Primary Sclerosing Cholangitis (PSC) PSC Pathogenesis PSC-associated HLA molecules Gut-primed T cells, NK cells TGFβ fibrosis - Genetic predisposition (MHC risk loci) - Gut microbiota PAMP - Innate immune system 2016 MFMER slide MFMER slide-24 6

7 PSC Diagnosis Labs are non-specific p-anca positive (80%) Cholangiography is diagnostic: MRCP recommended as first-line imaging: short, annular strictures alternating with dilated segments (beaded appearance). Liver biopsy: staging, small duct PSC, exclusion of other entities (overlap PSC-AIH) MFMER slide MFMER slide-26 Distinctive histologic features of PSC Carrasco-Avino G, et al. Am J Clin Pathol MFMER slide MFMER slide-28 7

8 Challenges Sampling error Posttransplantation biopsies PSC variants: Overlap syndrome (PSC-AIH) Small duct PSC 2016 MFMER slide MFMER slide-30 Small Duct PSC 6-16% of PSC cases Clinical and laboratorial features of PSC with normal cholangiography Slower progression, better survival rates and less Cca 20% progress to large duct PSC in median 7.4 yrs Differential Diagnosis of PSC Obstructive Tumors Stones Surgical complications Inflammatory IgG4-associated cholangitis PBC Vascular Ischemic cholangiopathy AIDS-related cholangiopathy 2016 MFMER slide MFMER slide-32 8

9 IgG4-associated cholangitis (IAC) vs. PSC IAC vs. PSC HISORt and specific features on liver biopsies Portal infiltrates: spared bile ducts (halo) with perivenular accentuation (50%) Lobular inflammation Fibroinflammatory nodules (50%) More than 10 IgG4+ cells/hpf (60% cases) IgG MFMER slide-33. Figure from Deshpande et al. Arch Pathol Lab Med MFMER slide-34 Ischemic cholangiopathy vs. PSC Liver transplantation (HA thrombosis, ABO incompatible) Hepatic intra-arterial chemotherapy (FUdR) Thrombotic disorders and systemic vasculitis Severely ill patients Histology: periductal fibrosis, ductopenia Cancer Surveillance in PSC 72% 5-yr survival in early stage hilar cholangiocarcinoma treated with neoadjuvant chemotherapy and transplant ERCP for dominant strictures Brushing cytology/biopsy low sensitivity FISH Most specific: high-grade dysplasia (73%) and positive FISH (82%) Deltenre P, Valla DC. Semin Liv Dis (Review) Gelbmann CM, et al. Am J Gastroenterol MFMER slide-35 Murad SD et al. Gastroenterology 2012 Salomao M et al. Cancer Cytopathol 2015 Boberg KM et al. J Hepatol MFMER slide-36 9

10 Summary PBC Nomenclature change cirrhosis to cholangitis AMA-negative PBC: role of PBC-specific ANA antibodies, may affect prognosis PSC Liver biopsy: staging and exclusion of variants Fibrointimal hyperplasia novel feature Consider IgG4AC and IC No treatment role of transplantation Thank you! 2016 MFMER slide MFMER slide-38 10