Abstract | December 16, 2022

Management of Hyperlipidemia Induced by Primary Biliary Cholangitis

Presenting Author: Ange Mele A., MD, MS, Internal Medicine Resident PGY2, Department of Medicine, Northeast Georgia Medical Center, Gainesville, GA

Coauthors: Riaz Mahmood, DO, PGY4, Northeast Georgia Medical Center, Gainesville, GA; Jason Fombi, MD, Attending Physician, Northeast Georgia Medical Center, Gainesville, GA

Learning Objectives

  1. Learning how to manage hyperlipidemia induced by Primary Biliary Cholangitis

Introduction: Primary biliary cholangitis (PBC) is a chronic and progressive cholestatic autoimmune liver disease characterized by the destruction of intrahepatic bile ducts with portal inflammation and scarring. It frequently occurs in middle-aged women and may present with pruritus, jaundice, and right upper quadrant pain. In the setting of cholestasis, there is reduced bile acid production and consequently decreased intestinal absorption of cholesterol. This results in the endogenous synthesis of cholesterol in the liver and the secretion of very low-density lipoprotein. Mixed hyperlipidemia can be difficult to manage and the association with increased cardiovascular events remains unclear.

 

Case Presentation: A 46-year-old female with a past medical history significant for recurrent UTIs with MDR organisms, DM type II, autoimmune hepatitis, SLE, and primary biliary cirrhosis presented to the ED with a chief complaint of dysuria. In the ED, vitals were significant for hypertension, BP of 141/73. Her physical examination revealed xanthoma of the eyelids and infraumbilical abdominal pain. Lab workup revealed hemoglobin of 9.6, WBC of 30.2, AST 119, ALT 105, ALP 825, total cholesterol of 689, triglycerides 301, LDL of 342, and HDL less than 20. Urine culture showed ESBL E. coli. The patient was admitted under hospital medicine. CT abdomen and pelvis showed evolving bilateral pyelonephritis. She completed a 14-day course of ertapenem. She was discharged home with PCP and Urology follow-ups.

 

Management: The management of hyperlipidemia is challenging in PBC, given the risks of hepatotoxicity associated with cholesterol-lowering medications. The risk of cardiovascular complications is low in the absence of metabolic syndrome. We suggest initiating moderate-intensity statins in the presence of diabetes or pre-existing CVD and close monitoring PBC in patients with pre-existing CVD, diabetes, or primary hypercholesterolemia.

 

Follow-up: The patient continued to have ongoing infection issues. She was admitted to the hospital with sepsis secondary to pelvic wall abscess approximately 1.5 years from admission, as discussed in the case presentation. Her hospital course was complicated by multiorgan failure, and she passed away.

References:

  1. https://gastroenterology.acponline.org/archives/2021/05/28/5.htm

 

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