Fnu Sadarat, MD1, Konstantin Boroda, MD2, Hilary Hertan, MD2
1Montefiore Medical Center, Bronx, NY; 2Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY
Intrahepatic cholestasis of pregnancy (ICP) is a common clinical problem evident in approximately 1% of pregnancies in the United States. The incidence is more common in Chilean and Swedish ethnic groups. Due to the pathognomonic
early symptom of severe pruritus, most patients are diagnosed and treated promptly. However, the risk of fetal demise is high, ranging from 2-11%. In very rare cases patients may present with atypical symptoms that can delay diagnosis and appropriate management.
A 40 year old woman, gravida 4 para 2, presented in her 20th week of gestation with severe right upper quadrant pain radiating to the epigastric region for 3 days. Initial workup showed elevated total bilirubin of 4.3 mg/dl with a direct bilirubin of 3.7mg/dl; Alanine aminotransferase of 39U/L and aspartate aminotransferase of 27U/L. Initial ultrasound of the abdomen showed an enlarged liver with the right hepatic lobe measuring up to 21 cm in length, status post cholecystectomy and normal caliber proximal common bile duct. Patient’s bilirubin trended up and she became jaundiced, so MRCP without contrast was obtained. It showed no choledocholithiasis and no biliary ductal dilatation. Hepatitis A, B, C, and E virus PCR, cytomegalovirus IgM, anti-mitochondrial antibody, anti-smooth muscle antibody were all negative as well. The patient never developed pruritus, however, bile acids were checked and found to 190 µmol/L and eventually peaked at 290 µmol/L. She later developed intense pruritus 1 week after initial presentation and abdominal pain had completely resolved. She was started on ursodiol and cholestyramine. The bile acid level eventually decreased to 39 µmol/L 1 month later and her pruritus improved. She continued to follow with maternal-fetal medicine and gastroenterology, there was no harm to the fetus.
ICP usually presents with pruritus of the hands and feet due to elevated bile acid levels in the blood during 2nd and 3rd trimester of pregnancy. Our patient’s only symptom was acute right upper quadrant pain with no pruritus, which is very atypical for ICP. There are no case reports of this disorder presenting solely with abdominal pain.
It is important to recognize abdominal pain as a possible presenting symptom of ICP in order to diagnose the condition early.
Citation: Fnu Sadarat, MD; Konstantin Boroda, MD; Hilary Hertan, MD. P0058 - ATYPICAL PRESENTATION OF INTRAHEPATIC CHOLESTASIS OF PREGNANCY. Program No. P0058. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.